Equip and Send: Fueling the Rural Healthcare Workforce

By Tsion Fikre, Key Correspondent for the Irish Forum for Global Health

The resolution to ensure healthy lives and promote wellbeing for all, encapsulating the desire to radically transform the current healthcare system by 2030 envelops the need to employ more health care workers in the field– and particularly fields where not enough attention is paid to rural communities. The Fourth Global Forum on Human Resources for Health launched two days ago in Dublin and the buzz has been about the need for more. The need to hire. The need to train. The need to recruit. And the hardest of the four – the need to retain health care workers in rural and under-served areas.

70% of the 42 million-strong population in Uganda is rural. In an effort to come up with a few solutions, an affirmative action was implemented to attract staff to go into the rural areas. The Ugandan Ministry of Health recruited 7,500 health care workers and increased staffing by 68%. After two years, many of those workers had left. A hardship allowance for people living in the rural areas was allocated, and people from urban areas started moving because their base salary was not sufficient to sustain a living. This also did not last long. There were no schools for their kids, they struggled with the poor infrastructure, and ultimately, they left.

Incentivizing health professionals by getting rid of some of their loans in exchange for serving in rural areas is an approach Dr. George Sigounas discussed at the plenary on Wednesday morning. Dr. Martinho Dgedge, General Inspector of Health in the Ministry of Health of Mozambique, outlined another basic problem:

You educate people, but you don’t employ them. The public sector does not have enough resources.

While training and incentivizing community health workers may work for one country, this approach may not be the right move for another. Money is also the issue here. The demand exists, and the supply (of health care workers) is needed. They are trained but if there are not enough resources, there will be many who have to wait around to be employed.

The conversation continued in a session later that afternoon: The need for community engagement is highlighted as a crucial factor – when individuals are recruited, their family members are also indirectly being recruited. Shelley Nowlan, Chief Nursing and Midwifery Officer in the Department of Health of Queensland, Australia, proposed the utilization of knowledge transfer tools to allow the learning to continue and training the healthcare workforce based on demand. If a tropical disease is the most prominent, make sure the workforce has the skillset for that. Rural Seeds proposed planting a seed: Expose young doctors in training to working in rural areas, and if they like it, they will hopefully stay and spread the word to others.

I turned to my neighbor briefly and asked, “what do you think is the issue here?” He had served as a community health worker in Nepal for the past eight years, and his response reflected that depth of experience:

The term ‘rural’ needs to be redefined. Do we mean rural in terms of accessibility or rural because of cultural norms, or what else?

And then suddenly it was not so clear any more. Implementing social accountability of medical schools and residency programs by sending students for a section of their educational life is a very temporary solution. It is also a solution that may work in the rural parts of Canada, but not those of Nepal. He also highlighted that personal career goals are left on the back burner – as his were for the past eight years.

The conversation around health workforce shortages has been eminent as long as the issue itself. Akiko Maeda from OECD mentioned that there is a political shift now – that is what is different. That’s why our conversation now will be different than the ones we had previously. It has been echoed from the plenary that the need for reforming the system via governments would be a great place to start. The economists declare that, “it is not enough to be told this is the fact. The politics is just as important as the evidence”.

If we boil health care down to the person – the one caring and being cared for, and the unwritten agreement that health care professionals make when they’re sworn into the job – then why do we still struggle to find enough community health workers to fill the gap in rural and under-served communities? For one, these people who are health care workers are also someone’s somebody. They have financial responsibilities, they have social ties and burdens as does the next person. So, let’s start by addressing their needs. In practice, the effort should begin by establishing policy. The SDGs also apply to the rural areas. And that’s where it is the hardest to achieve them.

Regardless of where they are in the world, rural areas have similar needs – but they do not have the same solutions. And so, the dialogue must continue.

November 16^th, 2017

Tsion Fikre is a senior at Boston University, majoring in Health Science, and is currently studying at Dublin City University for the semester. She is a research intern at Concern Worldwide in the Strategic Advocacy & Learning – Health & HIV Unit.