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

Expert consensus on the attributes and competencies required for rural and remote junior physicians to work effectively in isolated indonesian communities

Indonesian physicians working in rural and remote areas must be equipped not only with generic competencies but also with the attributes and skills necessary to provide health care services without compromising quality. This study sought to reach a consensus on the attributes and competencies that are viewed as essential and important for working effectively as an early career doctor in rural and remote practice in Indonesia. A two-round Delphi study was conducted by reference to 27 consenting physicians working in rural and remote Indonesia. Forty-three items covering 9 attributes and 34 competencies were sent to these physicians to be rated on a Likert scale ranging from 1 to 5 in terms of their importance for effective rural and remote practice. Nine attributes and 29 competencies progressed to Round 2. All nine attributes and 29 competencies were identified as essential or important for junior physicians' ability to be effective in their practice. The essential attributes included professional quality related to prioritising the rural community. The essential competencies included medical skills, professional behaviour, interprofessional skills, health promotion and connection to the rural community. The consensus thus reached on these essential and important attributes and competencies can inform curriculum development for the undergraduate and postgraduate training of junior rural and remote physicians.

Exploring recent trends (2014-21) in preferencing and accepting Queensland medical internships in rural hospitals

BACKGROUND

Medical internship is a key transition point in medical training from student to independent (junior) doctor. The national Regional Training Hubs (RTH) policy began across Australia in late 2017, which aims to build medical training pathways for junior doctors within a rural region and guide students, interns and trainees towards these. This study aims to explore preferencing and acceptance trends for rural medical internship positions in Queensland. Moreover, it focuses on internship preference and acceptance outcomes prior to and following the establishment of RTHs, and their association with key covariates such as rural training immersions offered by medical schools.

METHODS

Data from all applicants to Queensland Health intern positions between 2014-2021 were available, notably their preference order and location of accepted internship position, classified as rural or metropolitan. Matched data from Queensland's medical schools were added for rural training time and other key demographics. Analyses explored the statistical associations between these factors and preferencing or accepting rural internships, comparing pre-RTH and post-RTH cohorts.

RESULTS

Domestic Queensland-trained graduates first preferencing rural intern positions increased significantly (pre-RTH 21.1% vs post-RTH 24.0%, p = 0.017), reinforced by a non-significant increase in rural acceptances (27.3% vs 29.7%, p = 0.070). Rural interns were more likely to have previously spent ≥ 11-weeks training in rural locations within medical school, be rurally based in the year applying for internship, or enrolled in the rural generalist pathway.

CONCLUSIONS

The introduction of the RTH was associated with a moderate increase of graduates both preferencing and accepting a rural internship, though a richer understanding of the dominant reasons for and against this remain less clear. An expansion of graduates who undertook longer periods of undergraduate rural training in the same period did not diminish the proportion choosing a rural internship, suggesting there remains an appetite for these opportunities. Overall, domestic graduates are identified as a reliable source of intern recruitment and retention to rural hospitals across Queensland, with entry to the rural generalist pathway and extended rural placement experiences enhancing uptake of rural practice.

A Post-Fellowship Support Framework for Rural Doctors: the Queensland experience

Background

International workforce shortages have prompted many initiatives to recruit, train and retain rural doctors, including Australia's emerging National Rural Generalist Pathway. This project explored an important component of retention, rural doctors' post-Fellowship support needs, to develop and validate a post-Fellowship support framework. There has been considerable international attention on social accountability in medical education and how medical schools and other institutions can address the needs of the communities they serve. The recognition that rural and remote communities globally are underserved has prompted numerous educational approaches including rurally focused recruitment, selection, and training. Less attention has been paid to the support needs of rural doctors and how they can be retained in rural practice once recruited.

Methods

The project team reviewed international and Australian rural workforce and medical education literature and relevant policy documents to develop a set of guiding principles for a post-Fellowship support framework. This project utilised a mixed methods approach involving quantitative and qualitative methodologies. A range of rural doctors, administrators, and clinicians, working in primary and secondary care, across multiple rural locations in Queensland were invited to participate in interviews. Thematic analysis was undertaken.

Results

The interviews validated ten interconnected guiding principles which enabled development of a grounded, contextually relevant approach to post-Fellowship support. This framework provides a blueprint for a retention strategy aiming to build a strong, skilled, and sustainable medical workforce capable of meeting community needs.

Conclusions

The ten principles were designed in the real-world context of a mature Queensland Rural Generalist Pathway. Four themes emerged from the inductive thematic analysis: connecting primary and secondary care; valuing a rural career; supporting training and education; and valuing rural general practice. These themes will be used as a basis for engagement and consultation with rural stakeholders to develop appropriate retention and support strategies.

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.

Unsalaried health workers in Sierra Leone: a scoping review of the literature to establish their impact on healthcare delivery

BACKGROUND

The World Health Organisation (WHO) estimates a 10 million health worker shortage by 2030. Despite this shortage, some low-income African countries paradoxically struggle with health worker surpluses. Technically, these health workers are needed to meet the minimum health worker-population ratio, but insufficient job opportunities in the public and private sector leaves available health workers unemployed. This results in emigration and un- or underemployment, as few countries have policies or plans in place to absorb this excess capacity. Sierra Leone, Liberia and Guinea have taken a different approach; health authorities and/or public hospitals 'recruit' medical and nursing graduates on an unsalaried basis, promising eventual paid public employment. 50% Sierra Leone's health workforce is currently unsalaried. This scoping review examines the existing evidence on Sierra Leone's unsalaried health workers (UHWs) to establish what impact they have on the equitable delivery of care.

METHODS

A scoping review was conducted using Joanna Briggs Institute guidance. Medline, PubMed, Scopus, Web of Science were searched to identify relevant literature. Grey literature (reports) and Ministry of Health and Sanitation policy documents were also included.

RESULTS

36 texts, containing UHW related data, met the inclusion criteria. The findings divide into two categories and nine sub-categories: Charging for care and medicines that should be free; Trust and mistrust; Accountability; Informal provision of care, Private practice and lack of regulation. Over-production of health workers; UHW issues within policy and strategy; Lack of personnel data undermines MoHS planning; Health sector finance.

CONCLUSION

Sierra Leone's example demonstrates that UHWs undermine equitable access to healthcare, if they resort to employing a range of coping strategies to survive financially, which some do. Their impact is wide ranging and will undermine Sierra Leone's efforts to achieve Universal Health Coverage if unaddressed. These findings are relevant to other LICs with similar health worker surpluses.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Rural medical workforce pathways: exploring the importance of postgraduation rural training time

BACKGROUND

Inadequate distribution of the medical workforce in rural regions remains a key global challenge. Evidence of the importance of postgraduation (after medical school) rural immersion time and subsequent rural practice, particularly after accounting for other key factors, remains limited. This study investigated the combined impact of three key training pathway factors: (1) rural background, (2) medical school rural immersion, and (3) postgraduation rural immersion, and duration time of each immersion factor on working rurally.

METHODS

Data from a cross-sectional national survey and a single university survey of Australian doctors who graduated between 2000 to 2018, were utilised. Key pathway factors were similarly measured. Postgraduation rural training time was both broad (first 10 years after medical school, national study) and specific (prevocational period, single university). This was firstly tested as the dependent variable (stage 1), then matched against rural practice (stage 2) amongst consultant doctors (national study, n = 1651) or vocational training doctors with consultants (single university, n = 478).

RESULTS

Stage 1 modelling found rural background, > 1 year medical school rural training, being rural bonded, male and later choosing general practice were associated with spending a higher proportion (> 40%) of their postgraduation training time in a rural location. Stage 2 modelling revealed the dominant impact of postgraduation rural time on subsequent rural work for both General Practitioners (GPs) (OR 45, 95% CI 24 to 84) and other specialists (OR 11, 95% CI 5-22) based on the national dataset. Similar trends for both GPs (OR 3.8, 95% CI 1.6-9.1) and other specialists (OR 2.8, 95% CI 1.3-6.4) were observed based on prevocational time only (single university).

CONCLUSIONS

This study provides new evidence of the importance of postgraduation rural training time on subsequent rural practice, after accounting for key factors across the entire training pathway. It highlights that developing rural doctors aligns with two distinct career periods; stage 1-up to completing medical school; stage 2-after medical school. This evidence supports the need for strengthened rural training pathways after medical school, given its strong association with longer-term decisions to work rurally.

Attracting, Recruiting, and Retaining Medical Workforce: A Case Study in a Remote Province of Indonesia

Indonesia, one of the Asia Pacific low-and middle-income countries (LMICs), has suffered from a chronic medical workforce shortage. However, there are limited published studies describing the approaches implemented by the Indonesian government regarding the recruitment and retention of the medical workforce. This case study aimed to understand the current practices for recruitment and retention of the medical workforce in Indonesian rural and remote provinces. We conducted a case study of the Maluku Province of Indonesia with a document analysis and key informant interviews with officials responsible for medical workforce recruitment and retention. We used the World Health Organization's (WHO) guidelines as an analytical matrix to examine the recruitment and retention practices under the four domains of (i) educational, (ii) regulatory, (iii) financial, and (iv) professional and personal development and classified them into either University/Medical School level or Government/Non-government level. Our findings suggest that Indonesia implemented most of the WHO-recommended medical workforce recruitment and retention strategies. However, implementation is still problematic; hence, the aim of establishing an adequate, sustainable medical workforce has not been reached. Nationwide government intervention in educational aspects is important to magnify the impact of regional medical school initiatives. Relevant programmes must be re-evaluated and re-enforced concerning significance, comprehensiveness, and effectiveness for a sustainable rural and remote medical workforce.

Commitments, Conditions and Corruption: An Interpretative Phenomenological Analysis of Physician Recruitment and Retention Experiences in Indonesia

Complex factors influence physicians’ decisions to remain in rural and remote (RR) practice. Indonesia, particularly, has various degrees of poor governance contributing to physicians’ decisions to stay or leave RR practice. However, there is a paucity of literature exploring the phenomenon from the perspective of Indonesian RR physicians. This study explores physicians’ lived experiences working and living in Indonesian RR areas and the motivations that underpin their decisions to remain in the RR settings. An interpretative phenomenological analysis was utilised to explore the experiences of 26 consenting voluntary participants currently working in the RR areas of Maluku Province. A focus group discussion was undertaken with post-interns (n = 7), and semi-structured interviews were undertaken with junior (n = 9) and senior physicians (n = 10) working in district hospitals and RR health centres. Corruption was identified as an overarching theme that was referred to in all of the derived themes. Corruption adversely affected physicians’ lives, work and careers and influenced their motivation to remain working in Indonesia’s RR districts. Addressing the RR workforce shortage requires political action to reduce corruptive practice in the districts’ governance. Establishing a partnership with regional medical schools could assist in implementing evidence-based strategies to improve workforce recruitment, development, and retention of the RR medical workforce.

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.