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Mabunda SA, Durbach A, Chitha WW, Phiri H, Phalane M, Moaletsane O, Angell B, Joshi R. Effectiveness of return-of-service schemes for human resources for health retention: a retrospective cohort study of four Southern African countries. BMJ Glob Health 2023; 8:e013687. [PMID: 37879653 PMCID: PMC10603424 DOI: 10.1136/bmjgh-2023-013687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Governments use return-of-service (RoS) schemes to train, employ and retain health professionals in the public sector. We determined the effectiveness of RoS schemes in four Southern African countries. METHODS This retrospective cohort study used databases of RoS beneficiaries from South Africa, Botswana, Eswatini and Lesotho. We ascertained the period of funding for beneficiaries between 2000 and 2010, study programme, selection criteria, study country and if they completed their studies. Records were sought to track beneficiaries' service and fulfilment of their RoS obligations. Data were sought at the provincial level in South Africa and nationally for the other three countries. Binomial logistics regression and Kaplan-Meier survival estimates were used to determine risk factors and predictors of defaulting. RESULTS Most beneficiary enrolment (eg, decision on why they were funded, socioeconomic status, disability status, high school results) and service data (eg, health facilities where they worked, how long they worked at each health facility, movement between health facilities) were not available. A total of 5616 beneficiaries were drawn from the four countries' databases. Of those with full data available, 21.7% (229/1056) were retained/served beyond their obligatory period and 20.2% (213/1056) were still serving. A total of 24.3% (95% CI: 21.7% to 26.9%; n=257/1056) of beneficiaries in the final subanalysis of two South African provinces fulfilled their contractual obligations. Only 32.2% (277/861) of beneficiaries undertook internship within their funding provinces. Governments needed to fund six beneficiaries to have one beneficiary complete their contractual obligation if they undertook internship outside their province. CONCLUSION Record keeping in all countries was poor, hampering the effectiveness of RoS schemes. Of the units with full data available, the retention rate was below 25%, and internship being undertaken outside the funding province was associated with higher defaulter rates, calling for a policy overhaul.
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Affiliation(s)
- Sikhumbuzo A Mabunda
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
- George institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea Durbach
- Australian Human Rights Institute, University of New South Wales - Kensington Campus, Sydney, New South Wales, Australia
| | - Wezile W Chitha
- Health Systems Enablement and Innovation Unit, University of the Witwatersrand, Johannesburg, South Africa
- Public Health, Walter Sisulu University, Mthatha, South Africa
| | - Hawor Phiri
- Mpumalanga Department of Health, Mbombela, South Africa
| | | | - Oduetse Moaletsane
- Pharmacovigilance and Clinical Trials, Botswana Medicines Regulatory Authority, Gaborone, Botswana
| | - Blake Angell
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Rohina Joshi
- School of Population Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
- George Institute for Global Health, Delhi, India
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Johnson O, Sahr F, Sevdalis N, Kelly AH. Exit, voice or neglect: Understanding the choices faced by doctors experiencing barriers to leading health system change through the case of Sierra Leone. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:None. [PMID: 36531296 PMCID: PMC9748299 DOI: 10.1016/j.ssmqr.2022.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/09/2022] [Accepted: 07/02/2022] [Indexed: 06/17/2023]
Abstract
This paper presents a study from Sierra Leone that explored the experiences of doctors as they endeavored to improve the health care systems in which they worked. Twenty-eight interviews were conducted with doctors in Sierra Leone, complemented by long-standing experience of national health provision and research by the authors. Drawing on Hirschman's theory of 'exit, voice and loyalty', the paper's framework analysis elaborates the doctor's career decisions and choices under systematic political and economic constraints, and in particular, the specter of retribution, including posting to undesirable jobs and withholding of salaries. This retribution was considered a driver of exit by doctors from the system, and few examples were given of doctors successfully advocating for change through advocacy ('voice'). We suggest that the relevance of Hirschman's theory to this setting is in drawing attention to the critical themes of retribution, opportunity, loyalties, and partial exits, ones often neglected in efforts to reduce emigration of doctors and strengthen their leadership. Ultimately, this paper critiques the overemphasis of mechanistic 'capacity building' in global health and recommends that health system strengthening must be viewed as a jointly political as well as technical exercise.
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Affiliation(s)
- Oliver Johnson
- Centre for Implementation Science, Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
- Centre for Health Policy, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Foday Sahr
- Department of Microbiology, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
- Military Hospital, Wilberforce, Sierra Leone
| | - Nick Sevdalis
- Centre for Implementation Science, Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Ann H. Kelly
- Department of Global Health & Social Medicine, School of Global Affairs, Faculty of Social Science & Public Policy, King's College London, London, United Kingdom
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Saha L, Dey AC, Talukder HK. Selection of right medical students to combat rural shortage of doctors: could it be a solution? In perspective of Bangladesh. MEDEDPUBLISH 2021; 10:161. [PMID: 38486586 PMCID: PMC10939572 DOI: 10.15694/mep.2021.000161.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. This comparative cross-sectional study was conducted to find the association between duration of service in rural health facilities and physicians' background factors to redress geographic imbalances in physician distribution. Among 6898 participants, information of 989 were retrieved from Directorate General of Health Services (DGHS), Minsitry of Health and Family Welfare (MOHFW), Bangladesh, through systematic sampling. Physicians who worked in rural health facilities for less than 3 years were labelled as group A, and those worked 3 years or more in rural places were put in group B. Background factors of two groups were compared and proportion of doctors living and working in rural areas was sorted. Among the participants, eighty percent were working in urban facilities and 50% worked in rural areas for less than three years. Proportion of females was about 30% and there was no significant differences between male and female in terms of duration of stay in rural areas in both groups (p=0.07). The association between place of completion of secondary school certificate (SSC) examination and duration of services in the rural areas were found statistically significant (p=0.003). Apart from this, no other background factors were found to be significantly associated.
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Engaging future healthcare professionals for rural health services in South Africa: students, graduates and managers perceptions. BMC Health Serv Res 2021; 21:220. [PMID: 33706769 PMCID: PMC7953823 DOI: 10.1186/s12913-021-06178-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 02/15/2021] [Indexed: 12/03/2022] Open
Abstract
Background The shortage of healthcare professionals (HCP) negatively affects health services in rural areas in many parts of the world, as is the case in South Africa. Innovative programs designed to improve the recruitment strategies for health system in a rural area are essential. They need support with a scholarship and mentorship programme for young people from rural areas to study for health science degrees, with the aim that they would take up a post at the hospital in their community, once qualified. This paper reports the perceptions and experiences of the students and graduates sponsored by the foundation, and those of managers from the facilities where the students were ultimately placed, in order to gauge whether such a programme can make a sustainable contribution to address the shortage of health personnel in rural areas and to what extent this is happening. Methods The authors used qualitative methods, combining semi-structured in-depth interviews and focus groups and the data were analyzed thematically. Results The results provide information on students interviewed who appreciated the financial and socio-emotional support that they received. On the other hand, graduates value the availability of jobs in their home community on completion of their studies. The managers reported the success of the programme in increasing the number of healthcare personnel at the hospitals, and the increased range of available medical services. Since the graduates are familiar with the language and culture of their patients the managers considered that they are better able to assist them. Conclusions The system was well thought-out and achieved its goal of improving health services in an underdeveloped rural area of South Africa. More could be achieved if other government services in the area were simultaneously improved and if the system were replicated elsewhere. The students and graduates from rural areas are involved on sustaining health services in rural areas while rural managers support the programme and make suggestions for improvement and to promote the program in other regions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06178-w.
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O'Sullivan B, Chater B, Bingham A, Wynn-Jones J, Couper I, Hegazy NN, Kumar R, Lawson H, Martinez-Bianchi V, Randenikumara S, Rourke J, Strasser S, Worley P. A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries. Front Med (Lausanne) 2020; 7:594728. [PMID: 33330559 PMCID: PMC7729061 DOI: 10.3389/fmed.2020.594728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.
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Affiliation(s)
- Belinda O'Sullivan
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - Bruce Chater
- Faculty of Medicine, Rural Clinical School, University of Queensland, Theodore, QLD, Australia
| | - Amie Bingham
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - John Wynn-Jones
- Keele Medical School, Keele University, Keele, United Kingdom
| | - Ian Couper
- Ukwanda Center for Rural Health, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Nagwa Nashat Hegazy
- Medical Education and Human Resources Center, Faculty of Medicine, Menoufia University, Shibin el Kom, Egypt
| | - Raman Kumar
- Family Medicine Practitioner, DOC24 Family Practice Clinic, Ghaziabad, India
| | - Henry Lawson
- Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | | | - James Rourke
- Center for Rural Health Studies, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Sarah Strasser
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - Paul Worley
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Motala M, Van Wyk J. Where are they working? A case study of twenty Cuban-trained South African doctors. Afr J Prim Health Care Fam Med 2019; 11:e1-e9. [PMID: 31478745 PMCID: PMC6739522 DOI: 10.4102/phcfm.v11i1.1977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/09/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The year 2017 marked the 21st anniversary of the South African Cuban Medical Collaboration (SACMC) programme that offers disadvantaged South African (SA) students an opportunity for medical training in Cuba. Graduates are expected to return to practice at a primary care level in rural communities; however, little is known about the professional trajectories and career choices of graduates from the programme. AIM This study explored the reasons why students enrolled in the programme, their professional and career choices as graduates and their career intentions. SETTING The study setting was the whole of SA although participants were primarily drawn from KwaZulu-Natal. METHODS An exploratory, qualitative case study used a purposive sampling strategy to gather data through semi-structured interviews from participants. RESULTS Graduates (N = 20) of the SACMC programme were all practicing in local SA settings. Participants preferred the SACMC programme as it offered them a full scholarship for medical training. Nineteen doctors had fulfilled their obligation to work in rural areas. Thirteen doctors are engaged in primary healthcare practice, either as private practice generalists or as public service medical officers. Three doctors had completed specialty training: one doctor was training towards specialisation, one doctor was employed at national government and two doctors were employed as medical managers. At the time of the study, 11 doctors were practicing in rural locations and 19 had indicated a long-term intention to work and live within South Africa. CONCLUSION The participants of this study who graduated from the SACMC programme are fulfilling their obligations in rural communities. They all intend to contribute to the SA medical workforce in the long-term.
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Affiliation(s)
- Munirah Motala
- School of Medicine, University of KwaZulu-Natal, Durban.
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Liu J, Zhu B, Mao Y. Association between rural clinical clerkship and medical students' intentions to choose rural medical work after graduation: A cross-sectional study in western China. PLoS One 2018; 13:e0195266. [PMID: 29608624 PMCID: PMC5880380 DOI: 10.1371/journal.pone.0195266] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 02/23/2018] [Indexed: 11/18/2022] Open
Abstract
Background A large number of programs have been implemented in many countries to increase the healthcare workforce recruitment in rural and remote areas. Rural early exposure programs for medical students have been shown to be effective strategies. However, no related studies have been reported before in China. This study was carried out to determine the association between medical students’ participation in rural clinical clerkships and their intentions to choose rural medical work after graduation from western medical schools in China. Methods Based on a two-stage random sampling method, the cross-sectional survey was carried out in ten western provinces in China. A brief questionnaire filled in by medical students was used for data collection. A total of 4278 medical students participated in the study. The response rate was approximately 90.34%. Pearson’s chi-squared tests and binary logistic regression analyses were performed for data analyses. Results Approximately 52.0% of medical students disclosed intentions to work in rural medical institutions after graduation. Only one in five participants had experience with a rural clinical clerkship. Rural clinical clerkships were significantly associated with medical students’ intentions to work in rural medical institutions (OR: 1.24, 95%CI: 1.05–1.46); further analyses indicated that such clerkships only had a significant impact among the medical students with an urban background (OR: 2.10, 95%CI: 1.48–2.97). In terms of the sociodemographic characteristics, younger age, low level of parental education, majoring in general practice, and studying in low-level medical schools increased the odds of having intentions to engage in rural medical work among medical students; however, rural origins was the only positive univariate predictor. In addition, the predictors of intentions to choose rural medical work were different between medical students with a rural background and those with an urban background. Conclusions Rural clinical clerkship is likely to increase the odds of having intentions to work in rural medical institutions after graduation among medical students in western China, especially for those with an urban background. Related policy makers could consider developing compulsory rural clerkship programs and implement them among medical students to increase early rural exposure.
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Affiliation(s)
- Jinlin Liu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Bin Zhu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Department of Public Policy, City University of Hong Kong, Hong Kong, China
| | - Ying Mao
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- * E-mail:
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Budhathoki SS, Zwanikken PAC, Pokharel PK, Scherpbier AJ. Factors influencing medical students' motivation to practise in rural areas in low-income and middle-income countries: a systematic review. BMJ Open 2017; 7:e013501. [PMID: 28232465 PMCID: PMC5337703 DOI: 10.1136/bmjopen-2016-013501] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES There is a shortage of doctors working in rural areas all over the world, especially in low-income and middle-income countries. The choice to practise medicine in a rural area is influenced by many factors. Motivation developed as a medical student is one key determinant of this choice. This study explores influences on medical students' motivation to practise in rural areas of low-income and middle-income countries following graduation. DESIGN A systematic review was conducted to identify influences on medical students' motivation to work in rural areas in low-income and middle-income countries. Papers reporting influences on motivation were included, and content analysis was conducted to select the articles. Articles not published in English were excluded from this review. RESULTS A rural background (ie, being brought up in a rural area), training in rural areas with a community-based curriculum, early exposure to the community during medical training and rural location of medical school motivate medical students to work in rural areas. Perceived lack of infrastructure, high workload, poor hospital management and isolation are among the health facility factors that demotivate medical students for medical practice in rural areas. CONCLUSIONS Medical school selection criteria focusing on a rural background factor and medical education curriculum focusing on rural area are more relevant factors in low-income and middle-income countries. The factors identified in this review may assist the planners, medical educators and policymakers in low-income and middle-income countries in designing relevant interventions to positively influence rural choices where the shortage of rural physicians is an ongoing and increasing concern.
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Affiliation(s)
- Shyam Sundar Budhathoki
- School of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Paras K Pokharel
- School of Public Health & Community Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Albert J Scherpbier
- Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
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