Factors associated with increasing rural doctor supply in Asia-Pacific LMICs: a scoping review

Policy perception, job satisfaction and intentions to remain in rural area: evidence from the National Compulsory Service Programme in China

BACKGROUND

Exploring factors that may influence general practitioners (GPs)' intentions to remain in rural area is necessary to inform the training and placement of future medical workforce in rural area. However, little is known about how GPs' perception towards the National Compulsory Service Programme (NCSP) and job satisfaction impact their turnover intention. This paper explores GPs' intentions to remain in rural China and how their policy perception and job satisfaction predict the intentions.

METHODS

We conducted a cross-sectional, online survey from December 2021 to February 2022 to investigate GPs' perception towards NCSP, job satisfaction, and intentions to remain in rural area. Eligible participants were GPs who were required to provide health services as part of NCSP at township health centres of 9 provinces which could represent all NCSP GPs in China. Multinomial logistic regression analyses were performed to explore the associations between policy perceptions, job satisfaction, and intentions to remain.

RESULTS

Of 3615 GPs included in the analysis, 442 (12.2%) would like to remain in rural area and 1266 (35.0%) were unsure. Results of the multinomial logistic regression analyses showed that compared with GPs who would leave, GPs with higher perception scores for the restriction on taking postgraduate exam (RRR: 1.93, 95% CI 1.72, 2.16) and the commitment to work for six years (RRR: 1.53, 95% CI 1.31, 1.78) were more likely to remain. In contrast, GPs who had higher perception scores for completing standardised residency training (RRR: 0.75, 95% CI 0.64, 0.88) and passing National Medical Licensing Examinations (RRR: 0.74, 95% CI 0.62, 0.87) were more likely to leave. GPs who were satisfied with the freedom of choosing work methods (RRR: 1.52, 95% CI 1.25, 1.84) and chances of promotion (RRR: 1.60, 95% CI 1.32, 1.94) were more likely to remain.

CONCLUSIONS

This study highlights the significance of policy perception and job satisfaction on GPs' intentions to remain in rural area. Factors such as career advancement and the empowerment of GPs to build on and use their skills and abilities should be taken into account when designing rural placement programmes.

Working as a Healthcare Professional at Island Primary Care: An Exploratory Qualitative Study on the Cyclades Islands, Greece

Improving the quality of and access to healthcare services in rural areas is fundamental to developing sustainable healthcare systems. This research aims to explore the motivations of healthcare professionals to work and settle in rural island areas of Greece with limited access to secondary and tertiary care. The study suggests practical ways to encourage self-motivation and attract more health workers in rural areas. An exploratory qualitative research approach was employed, involving semi-structured interviews with 16 healthcare professionals working in primary-care units that lack direct hospital or hospital-health centre access. The research was conducted specifically in the rural islands of the Cyclades. Thematic analysis was conducted to identify common themes and unique insights from the participants. The analysis revealed three thematic categories. Τhe «attraction» thematic was influenced by personal factors, random selection, origin, accommodation factors, professional factors, and obligatoriness. The «recruitment» thematic was associated with understaffing, special care issues, an unstable working environment, educational and organisational aspects, and an insular lifestyle. The thematic of «retention» highlighted personal issues, accommodation difficulties, economic and work-related issues, and unique challenges posed by an insular lifestyle. This research provides valuable insights into the motivations that drive healthcare professionals to settle, work, and remain in remote island units, as well as the challenges they encounter in making this decision. The study proposes strategies to motivate and attract more healthcare professionals to rural areas. These findings should be considered when formulating or reviewing primary healthcare empowerment policies to ensure equitable healthcare access for all individuals.

Teledermatology to Improve Access to and Quality of Skin Care in Eastern Indonesia

Skin diseases are a major public health concern in Indonesia, although access to specialized care in remote areas is limited. We initiated a low-cost teledermatology service in Sumba, a remote island in eastern Indonesia. Eighteen healthcare workers (HCWs) at five primary healthcare centers received training to manage common skin diseases and submit clinical cases beyond their expertise to an online platform. Submitted cases were reviewed by at least one dermatologist. Diagnostic agreement between HCWs and dermatologists was calculated. The HCWs participated in a satisfaction survey 2 years after project initiation. Since October 2020, of 10,384 patients presenting with skin complaints in a 24-month period, 307 (3%) were submitted for a teledermatology consultation. The most frequent skin diseases were infections and infestations (n = 162, 52.8%) and eczematous (85, 27.7%) and inflammatory (17, 5.5%) conditions. Fifty-three patients (17.3%) were diagnosed with a neglected tropical skin disease, including leprosy and scabies. Dermatologist advice was provided within a median of 50 minutes (interquartile range, 18-255 minutes), with 91.9% of consultations occurring within 24 hours. The diagnostic agreement level between HCWs and dermatologists significantly improved over time, from 46.9% in the first 6-month period (κ = 0.45; 95% CI, 0.37-0.54) to 77.2% in the last 6-month period (κ = 0.76; 95% CI, 0.67-0.86; global P < 0.001). The HCWs reported that the teledermatology service was extremely/very useful in supporting daily practice (100%) and improved their knowledge of skin diseases tremendously/a lot (92%). Teledermatology can improve accessibility and quality of skin services in medically underserved areas, providing opportunities for scalability and knowledge transfer to frontline HCWs.

Overview of Retention Strategies for Medical Doctors in Low- and Middle-Income Countries and Their Effectiveness: Protocol for a Scoping Review

BACKGROUND

The global shortage and maldistribution of health care workers, especially medical doctors, pose a significant threat to achieving the United Nations' sustainable development goal 3 of ensuring well-being and healthy lives for all. Low- and middle-income countries (LMICs) are disproportionately affected by this crisis, with a high rate of brain drain from rural to urban areas, as well as to high-income countries. Various retention strategies have been implemented in different settings and organizations. However, their effectiveness remains underexplored, particularly in LMICs.

OBJECTIVE

We aim to review the available retention strategies for medical doctors in LMICs and to determine the effectiveness of the various strategies. This review aims to compile relevant research findings on this issue to generate a thorough summary of all the retention strategies practiced in LMICs and, more importantly, to provide the current state of evidence of the effectiveness of these strategies in retaining medical doctors in countries with limited resources and high disease burden.

METHODS

The structured framework given by Arksey and O'Malley will serve as the basis for conducting this scoping review. A comprehensive search strategy will be conducted across 4 electronic databases (PubMed, EBSCOHost, Scopus, and ScienceDirect). A systematic approach following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines will be executed to search, screen, review, and extract data from studies that meet predefined inclusion criteria. Data encompassing bibliographical information, study location, retention strategies, influencing factors, and outcomes (effectiveness) will be obtained from the selected studies using standardized data extraction. Endnote and Microsoft Excel will be used for reference management and removal of duplicate studies. A narrative synthesis will be performed after categorizing and analyzing all the extracted data to identify recurrent themes.

RESULTS

This ongoing review will generate a comprehensive compilation of retention strategies implemented in LMICs to prevent brain drain among medical doctors. Data extraction is currently in progress, and completion is expected by early 2024. Themes regarding the types of strategies, influencing factors, and outcomes will be synthesized. The findings will highlight effective retention strategies, gaps, and challenges in implementation for the benefits of future research. By identifying common barriers and facilitators, this review will provide insights into enhancing the policies and initiatives for doctor retention in LMICs.

CONCLUSIONS

This scoping review explores the retention strategies practiced in LMICs and attempts to identify effective strategies from existing research. By evaluating the barriers and challenges that influence the effectiveness of these strategies, policymakers and health care leaders can strive to obtain balanced and optimal health human resources in their respective organizations and countries.

TRIAL REGISTRATION

Malaysian National Medical Research Register (NMRR) ID-23-01994-OGW; https://nmrr.gov.my/research-directory/ac4f5b88-8619-4b2b-b6c7-9abcef65fdcd.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52938.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

The COVID-19 Pandemic and Coronary Heart Disease: the Next Surge

PURPOSE OF REVIEW

In this narrative review, we highlight different ways in which the COVID-19 pandemic has impacted coronary heart disease (CHD) burden and how a surge in morbidity and mortality may be expected in the near future. We also discuss potential solutions, and the direction subsequent research and corrective actions should take.

RECENT FINDINGS

COVID-19 has been implicated in the development and worsening of CHD via acute and chronic mechanisms in the form of plaque rupture, destabilization, and sustenance of a chronic inflammatory state leading to long COVID syndrome and increased rates of myocardial infarction. However, indirectly the pandemic is likely to further escalate the CHD burden through poor health behaviors such as tobacco consumption, reduced physical activity, economic devastation and its associated sequelae, and regular cardiac care interruptions and delays. COVID-19 has increased the total CHD burden and will require extensive resource allocation and multifaceted strategies to curb future rise.

Learning from the COVID-19 pandemic: health care disturbances and telemedicine as an alternative rheumatology practice in Indonesia

BACKGROUND

Coronavirus disease 2019 (COVID-19) affects health care services. Our aim was to assess health care disruptions, treatment interruptions, and telemedicine reception regarding autoimmune rheumatic diseases (ARDs) in Indonesia.

METHOD

A cross-sectional population online-based questionnaire was conducted in Indonesia from September to December 2021.

RESULTS

A total of 311 ARD patients were included, of whom 81 (26.0%) underwent consultations via telemedicine during the COVID-19 pandemic. The respondents showed increased concern about their susceptibility to COVID-19 (score of 3.9/5). Approximately 81 (26.0%) avoided hospital visits, and 76 (24.4%) stopped taking the medication without medical advice. Respondents' concerns correlated with their social distancing behaviors (p value 0.000, r 0.458). Respondent concerns, behaviors, and blocked access to the hospital during the pandemic were associated with avoiding hospital visits (p value 0.014; 0.001; 0.045; 0.008). Sex was associated with stopping medication (p value 0.005). In multivariate analysis, blocked access and sex remained significant. Approximately 81 (26%) respondents who used telemedicine services during the COVID-19 pandemic as an alternative medical consultation method showed high satisfaction (3.8/5).

CONCLUSION

Health care disruptions and treatment interruptions were affected by patients' internal and external factors during the COVID-19 pandemic. Telemedicine may be the best option to address barriers to health care access in Indonesia's rheumatology practice during and after the pandemic situation.

The global burden of disease attributable to metabolic risks in 204 countries and territories from 1990 to 2019

AIM

Our study aimed to survey the burden of disease attributed to metabolic risks (MRs) and secondary MR from 1990 to 2019.

METHODS

Using methodological framework of the Global Burden of Disease Study 2019, we reported the global number, age-standardized rate and population attributable fraction of deaths and disability adjusted life years related to MRs and secondary MR. Furthermore, we analyzed the global burden caused by MRs and secondary MR in detail by gender, age, region, country, disease and Socio-demographic Index level.

RESULTS

The number (million) of deaths and DALYs caused by MRs was 18.6 and 462.8 in 2019, with an increase of 43.6 % and 75.0 % since 1990. However, the ASR of deaths and DALYs attributed to MRs had a decrease of 23.3 % and 17.0 % since 1990. The burden caused by MRs and secondary MR raised with age, and the burden was the heaviest in low - and middle-income countries, especially in Middle East & North Africa. For diseases, the heaviest burden attributed to MRs was observed in ischemic heart disease, followed by stroke.

CONCLUSION

The burden of disease attributed to MRs has continued to rise in the past 30 years, particularly for men and low-middle SDI regions. Therefore, the government should take corresponding actions to reduce the impact of MRs on population health.

What are the impacts of setting up new medical schools? A narrative review

BACKGROUND

The growth of the UK's population together with an aging society with increasingly complex health and social care needs has placed a greater demand on statutory care services. In view of this emerging landscape, the UK Government has sought to increase its medically trained workforce in order to better respond to the demands placed on the health service. Five universities were announced as homes to new medical schools offering undergraduate places to boost the numbers of doctors training in England. The aim of this narrative review was to explore how new medical schools could improve the health outcomes of the local population and evaluate the potential contribution it may make to the local economy, workforce and to research and innovation.

METHODS

A narrative review was undertaken using a systematic approach for the search literature strategy. The articles were evaluated by undertaking a critical assessment evaluating the fitness of a paper for review according to results, methods used to test the hypothesis, conclusions and impact and limitations. Thematic analysis was employed to organise and summarise the findings across a heterogeneous body of literature included in the review. The analysis was developed in an inductive manner and there were not any predefined themes to guide data extraction and analysis.

RESULTS

Thirty-six articles were selected for inclusion for this narrative review. The review identified six key themes: influence of prior rural exposure, medical school environment and rural enrichment programmes, workforce, health outcomes of local populations, social accountability, economic contribution of medical schools to communities and impact on rural research.

CONCLUSIONS

The studies included found a wealth of information on a wide-range of topics on the expansion of undergraduate education and its implications on the future medical workforce. It was shown that medical schools can have a positive effect on the health, social, economic and research activity of a region, but this literature tended to be heterogeneous in focus without consideration of the inter-connections between the wider societal and economic impacts arising from long-term sustainable change being brought to a region.

Strategies to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review

BACKGROUND

Medical workforce shortages in rural and remote areas are a global issue. High-income countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs.

METHODS

The Arksey and O'Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates.

RESULTS

Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in HICs, with only eight studies from LMICs. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce.

CONCLUSION

This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.

Access to Surgical Treatment for Breast Cancer in the Philippines

Female breast cancer is the most commonly diagnosed cancer worldwide; however, while high-income countries have the highest incidence rates, lower-middle income countries have the highest mortality rates. In this article, we describe the landscape of disparities in access to surgical care for patients with breast cancer in the Philippines, a lower-middle income country in Southeast Asia. We describe the payment landscape that allows access to care for patients with non-metastatic disease, and draw attention to the fact that despite some degree of insurance for most Filipinos, great barriers to access remain in the form of a low number of surgical providers, geographic disparities, and persistent socioeconomic barriers. Lastly, we suggest steps forward to improve equity in access to surgical care for Filipino patients with breast cancer.

Improving allocative efficiency from network consolidation: a solution for the health workforce shortage

BACKGROUND

Public hospitals are facing a critical shortage of health workers. The area-based network consolidations could be the solution to increase the system capacity for human resources by improving local allocative efficiency.

METHODS

This study develops counterfactual simulations for area-based network allocations for the health workforce in 10500 public hospitals in Thailand and examines improvements in allocative efficiency from the health workforce redistribution at different administrative levels such as sub-districts, districts, provinces, and health service areas. The workload per worker is calculated from the output measured by numbers of outpatient and inpatient cases and the input measured by numbers of health workers. Both output and input are weighted with their economic values and controlled for heterogeneity through regression analysis. Finally, this study compares the workload per worker and economic valuation of the area-based networks or ex-ante scenarios with the hospital-level or status quo scenario.

RESULTS

Network consolidations of the sub-district primary-level hospitals within the same district could reduce workload per worker by seven percentage points. Another practical policy option is to consolidate similar hospital levels such as primary, first-level secondary, and mid-level secondary hospitals altogether within the same province which could result in the reduction of the workload per worker by 6-7 percentage points. The total economic value gained from consolidating similar hospital levels within the same province is about 15-18 percentage points of total labor cost in the primary hospitals.

CONCLUSION

This study illustrates the improvement in allocative efficiency of the health workforce in public hospitals from the area-based network consolidations. The results provide an insightful example of economic gains from efficiently reallocating the medical workforce within the same local areas. Major reforms are required such that the health care delivery units can automate their resources in corresponding to the population's health needs through a strengthening gatekeeping system.

Doctor Placement’s Policy and Its Implications in Indonesia: Legal Qualitative Study

BACKGROUND: Remote, Underdeveloped Areas, Frontiers, and Islands (RUAFI) in Indonesia have a less equal distribution of doctors compared to other more developed areas, causing a decline in healthcare service quality in RUAFI and the health degree of the overall population. AIM: This research aims to describe the policy and the implication of doctor distribution in Indonesia and to provide a proportional justice-based doctor distribution policy concept. METHODS: This is a mixed qualitative research of juridical-normative and literature review. The laws that regulate the distribution of doctors in Indonesia are the 1945 Constitution, Law No. 36 of 2009, Law No. 26 of 2014, Governmental Decree No. 67 of 2019, Presidential Decree No. 72 of 2012, and the Decree of the Minister of Health No. 16 of 2017. RESULTS: The unequal doctor distribution is mainly caused by the low motivation for recruitment and retention in RUAFI. The affecting factors include disparity of incentives between doctors, low regional government involvement in the healthcare system in RUAFI, and the lack of career development for doctors being placed in RUAFI. CONCLUSION: The concept of proportional justicebased policy proposed is as follows: (a) Intensive proportionality between doctors and other types of health workers, (b) a direct regional government function of control, and (c) providing career and educational prospects.

Are return-of-service bursaries an effective investment to build health workforce capacity? A qualitative study of key South African policymakers

Return-of-service schemes (RoS) or bursaries are used in South Africa and other nations to publicly fund the training of skilled health professionals in return for the beneficiary agreeing to return to serve in their local provinces on a year-for-year basis. This study aimed to understand insights of key policymakers in South African provinces to identify barriers and solutions to implementation of RoS schemes used to recruit and retain skilled health professionals. This research draws on the insights of 16 key South African policymakers from eight of its nine provinces through semi-structured, qualitative interviews. The respondents were interviewed through Microsoft Teams virtual platform, either in pairs (ten) or as individuals (six). Data were analysed using inductive, thematic analysis in NVIVO. The study was reported according to the consolidated criteria for reporting qualitative research. Respondents reported that the schemes had resulted in an increase in the number of skilled health professionals and had provided opportunities for study and employment for previously marginalised groups. Formal evaluations of the impact of the schemes were not reported, however, a number of shortcomings with current schemes were identified that were likely limiting their effectiveness. Respondents reported a lack of foresight in the scheme implementation including a bias in the selection of beneficiaries towards medical professionals at the expense of other health workers. Furthermore, failure to plan for practice location when beneficiaries finished training limited the capacity of the schemes to meet the needs of local populations. Monitoring of recipients was limited by loopholes in contract design, decision-making and poor coordination between departments. Between 1 and 30% of beneficiaries were reported to default their contracts with some not completing their studies, some not returning after completing their internship and others terminating their services before concluding their contracts. Return-of-service schemes have helped in overcoming health professional shortages. However, they haven't been formally evaluated. Several planning and implementation shortcomings were identified which can be improved to enhance access to healthcare in South Africa.

Factors affecting retention in the Philippine National Rural Physician Deployment Program from 2012 to 2019: a mixed methods study

BACKGROUND

To address the maldistribution of healthcare providers and the shortage of physicians in geographically isolated and disadvantaged areas of the Philippines, the Philippine National Rural Physician Deployment Program, or more commonly known as the Doctors to the Barrios (DTTB) program was established in 1993. However, as of 2011, only 18% of the DTTBs chose to stay in their assigned municipalities after their two-year deployment, termed retention. This study aims to identify the individual, local, work, national, and international factors affecting the retention of DTTBs in their assigned communities after their two-year deployment.

METHODS

A descriptive, mixed-methods, explanatory design was used. For the quantitative part, the modified and updated Stayers Questionnaire was given to all current DTTBs present in a Continuing Medical Education session in the Development Academy of the Philippines. Descriptive statistics were then presented. For the qualitative part, individual, semi-structured key informant interviews were conducted in-person or via phone with current and alumni DTTBs from 2012 to 2019. Proceedings of the interviews were transcribed, translated, and analyzed thematically.

RESULTS

102 current DTTBs participated in the quantitative part of our study, while 10 current and former DTTBs participated in the interviews. Demographic factors and location, personal beliefs, well-being, friends and family dynamics, and perceptions about work were the individual factors identified to affect retention. Social working conditions, career development, and infrastructure, medical equipment, and supplies were among the work factors identified to affect retention. Geography, living conditions, local social needs, and technology were among the local factors identified to affect retention. Compensation, the recently signed Universal Healthcare Law, and Safety and Security were identified as national factors that could affect retention. International factors did not seem to discourage DTTBs from staying in their communities.

CONCLUSIONS

A host of individual, work-related, local, national, and international factors influence the DTTB's decision to be retained in different, complex, interconnected, and dynamic ways. We also identified implementation issues in the DTTB program and suggested interventions to encourage retention.

Interventions for health workforce retention in rural and remote areas: a systematic review

BACKGROUND

Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention.

METHODS

The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case-control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit.

RESULTS

Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments.

CONCLUSION

Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.

The regulation of healthcare professions and support workers in international context

BACKGROUND

The objective of this paper is to outline and compare the regulation of paid healthcare professions and associated support workers in international context, bringing out the lessons to be learned as appropriate. Modern neo-liberal societies have sought to enhance healthcare through greater professional regulation, albeit in different ways and at variable pace. This general trend is illustrated with reference to medicine in the UK. However, although such reforms have helpfully cascaded to other health professions, government policy in high-income countries has not yet adequately regulated the interrelated group of non-professionalised health support workers who form the largest and least recognised part of the workforce. Nonetheless, in low- and middle-income (LMIC) countries-aside from the greater need for regulation of health professions-there is even more of an imperative to regulate the disparate, largely invisible support workforce.

METHODS

With reference to existing studies of the medical and wider health professions in the UK and selected other higher income societies, the importance of health professional regulation to the public is underlined in the Global North. The larger gap in the regulation of support workers in modern neo-liberal countries is also emphasised on a similar basis, with an increasingly ageing population and advances in healthcare. It is argued from the very limited patchwork of secondary literature, though, that policy-makers may want to focus even more on enhancing regulation of both the professional and non-professional workforce in LMIC societies centred mainly in the Global South, drawing on lessons from the Global North.

RESULTS/CONCLUSIONS

Efforts to reform health professional regulatory approaches in more economically developed countries, while needing refinement, are likely to have had a positive effect. However, even in these societies there are still substantial shortfalls in the regulation of health support workers. There are even larger gaps in LMICs where there are fewer health professional staff and a greater dependence on support workers. With higher rates of morbidity and mortality, there is much more scope here for reforming health regulation in the public interest to extend standards and mitigate risk, following the pattern for healthcare professions in the Global North.