i Attraction and Retention of Rural Primary Health Care Workers in Asia Pacific Region by Anna Z

175 Pages·2017·1.13 MB·English

Attraction  and  Retention  of  Rural  Primary  Health  Care  Workers  in  Asia  Pacific  Region  
by  
Anna  Zhu  
Duke  Global  Health  Institute  
Duke  University  

Date:_______________________  
Approved:  

___________________________  
Shenglan  Tang,  Supervisor  

___________________________  
Xiaoyun  Liu  

___________________________  
Chee-­‐‑Ruey  Hsieh  

___________________________  
Jeffrey  Moe  

Thesis  submitted  in  partial  fulfillment  of  
the  requirements  for  the  degree  of    
Master  of  Science  in  the  Global  Health  Program    
Duke  Kunshan  University  and  Duke  University  

2017  

i
v
ABSTRACT  
Attraction  and  Retention  of  Rural  Primary  Health  Care  Workers  in  Asia  Pacific  Region  
by  
Anna  Zhu  
Duke  Global  Health  Institute  
Duke  University  

Date:_______________________  
Approved:  

___________________________  
Shenglan  Tang,  Supervisor  

___________________________  
Xiaoyun  Liu  

___________________________  
Chee-­‐‑Ruey  Hsieh  

___________________________  
Jeffrey  Moe  

An  abstract  of  a  thesis  submitted  in  partial  
fulfillment  of  the  requirements  for  the  degree  
of  Master  of  Science  in  the  Global  Health  Program    
Duke  Kunshan  University  and  Duke  University  

2017
Copyright  by  
Anna  Zhu  
2017
Abstract
Background    
Human  resources  for  health  are  crucial  for  health  system  strengthening  and  
achieving  sustainable  development  goals  and  universal  health  coverage,  but  the  
shortage  and  maldistribution  of  health  workers  have  been  critical  concerns  in  the  Asia  
Pacific  region.  This  study  aimed  to  identify  the  key  interventions  on  attracting  and  
retaining  rural  health  workers,  understand  their  management  structure,  examine  the  
effectiveness  and  analyze  the  contexts  in  the  Asia  Pacific  region.  
Methods        
This  mixed-­‐‑method  study  used  systematic  review  and  country  case  studies  to  
synthesize  and  analyze  the  available  data.  A  systematic  review  on  attraction  and  
retention  of  rural  health  workers  in  the  Asia  Pacific  region  was  conducted.  Thirty-­‐‑five,  
fourteen  and  nineteen  studies  were  included  for  the  interventions  and  their  
management  structure,  effectiveness  and  contexts,  respectively.  In-­‐‑depth  interviews  of  
twenty-­‐‑two  key  informants  and  gray  literature  recommended  from  the  key  informants  
in  China,  Vietnam  and  Cambodia  were  used  to  gather  information  for  the  country  case  
studies.  Narrative  synthesis  was  applied  to  review  and  synthesize  the  extracted  data  
from  the  systematic  review  and  qualitative  analysis  using  Nvivo  11  was  conducted  for  
the  interviews.  
Results      
iv
Five  categories  of  interventions,  involving  education,  regulation,  financial  
incentives,  personal  and  professional  support  and  bundled  interventions  were  
implemented  to  attract  and  retain  rural  health  workers  in  the  Asia  Pacific  region.  
Regulatory  interventions,  such  as  MRBS,  task  shifting  and  compulsory  rural  services,  
were  the  key  interventions  reported  in  the  systematic  review.  Although  financial  
incentives  were  scarce  in  the  systematic  review,  they  were  the  key  strategies  in  the  
country  case  studies  of  China,  Vietnam  and  Cambodia.  Asian  Pacific  countries  also  had  
their  distinctive  interventions,  such  as  a  system  of  compulsory  rural  services  in  
Thailand,  training  on  community  health  workers  in  Afghanistan,  and  a  government  
midwifery  incentive  scheme  in  Cambodia.  Geographically,  the  Pacific  island  countries  
were  neglected.    
Six  categories  of  management  structure  of  implementation  were  summarized.  
Decentralization  from  the  central  to  the  regional  government  was  the  dominant  
management  structure.  The  regional  government  was  responsible  for  program  
implementation  in  the  decentralized  programs,  program  development  and  
implementation  in  the  regional  initiatives,  which  were  more  likely  to  be  discovered  in  
the  countries  and  regions  with  strong  economies.  International  donors  were  significant  
stakeholders  for  the  low-­‐‑income  and  post-­‐‑conflict  countries  through  providing  financial  
and  technical  assistance.  Several  challenges  emerged  during  implementation,  including  
v
lack  of  rural  eligible  candidates,  low  and  unsustainable  financial  incentives,  complicated  
recruitment,  poor  management  and  deployment  of  HRH.  
Although  the  majority  of  interventions  lacked  rigorous  effectiveness  evaluation  
or  were  without  evaluation,  most  evaluated  interventions  demonstrated  effectiveness  in  
attracting  and  retaining  rural  health  professionals.  Some  of  the  interventions  also  
reported  effectiveness  in  expanding  health  service  coverage  and  improving  health  
status.  The  regulatory  interventions  seemed  to  be  more  effective  in  attracting  and  
retaining  rural  health  workers  through  administrative  and  legislative  enforcement.  
Bundled  interventions  were  expected  to  be  more  effective  and  be  more  often  
recommended  by  the  researchers  and  interviewees.    
Various  contexts,  including  political,  economic  and  social  factors  and  health  
system  related  issues,  directly  and  indirectly  impacted  the  attraction  and  retention  of  
rural  health  workers.  The  political  issues,  economic  development  and  social  culture  
influenced  rural  HRH  strengthening  at  the  macro  level  while  the  health  system  reform  
pulled  or  pushed  rural  health  workers.  The  promotion  of  rural  health  workers  to  be  civil  
servants  in  Vietnam  and  Cambodia  was  a  good  motivation  for  rural  health  workers.  The  
post  mechanism  in  China,  abolition  of  the  referral  system  and  increasing  financial  
autonomy  in  the  hospitals  in  Vietnam,  the  popular  private  sector,  limited  physical  and  
human  resources  all  served  to  push  the  health  workers  out  of  rural  positions.  
Conclusion      
vi
Due  to  great  variation  in  economic  development,  Asian  Pacific  countries  
implemented  three  different  patterns  of  interventions:  1)  comprehensive  packages  in  the  
high-­‐‑income  countries;  2)  one  or  two  categories  of  interventions  in  the  low-­‐‑  and  middle-­‐‑
income  countries;  and  3)  training  of  community  health  workers  in  the  post-­‐‑conflict  
countries.  Economic  variation  was  also  reflected  in  the  differences  of  the  management  
structure  of  implementation.  The  upper-­‐‑middle-­‐‑  and  high-­‐‑income  countries  were  likely  
to  initiate  regional  interventions  while  the  low-­‐‑income  countries  partly  relied  on  
donations  for  HRH  development  and  implementation,  especially  for  the  post-­‐‑conflict  
countries.  Although  decentralization  was  widely  applied  to  implementation,  its  
implications  were  neglected  and  unclear.  Based  on  the  exclusive  mechanism,  
effectiveness  of  each  category  of  interventions  varied.  However,  the  regulatory  
interventions  seemed  be  better.  The  socio-­‐‑economic  development  significantly  
influenced  interventions  on  attracting  and  retaining  rural  health  workers.  Rural  HRH  
strengthening  required  strong  economic  support.  Health  financing  reform  for  universal  
health  coverage  did  impact  the  capacity  building  of  rural  health  workforce.  Further  
research  was  needed.    

vii
Dedication
I  dedicate  this  work  to  my  father,  mother  and  younger  brother  for  their  love  and  
encouragement.    

viii
Contents
Abstract  ..........................................................................................................................................  iv

List  of  Tables  ...............................................................................................................................  xiii

List  of  Figures  .............................................................................................................................  xiv

Acknowledgements  ....................................................................................................................  xv

1.  Introduction  ...............................................................................................................................  1

1.1  Significance  of  human  resources  for  health  ..................................................................  1

1.2  HRH  in  the  Asia  Pacific  region  .......................................................................................  3

1.3  Context-­‐‑specific  interventions  to  attract  and  retain  rural  health  workers  ...............  7

1.4  Effectiveness  of  the  interventions  ................................................................................  10

2.  Methods  ....................................................................................................................................  15

2.1  Study  design  ....................................................................................................................  15

2.2  Study  setting  ....................................................................................................................  16

2.2.1  Asia  Pacific  Region  ....................................................................................................  16

2.2.2  China  ...........................................................................................................................  17

2.2.3  Vietnam  .......................................................................................................................  18

2.2.4  Cambodia  ....................................................................................................................  18

2.3  Data  collection  .................................................................................................................  19

2.3.1  Systematic  review  ......................................................................................................  19

2.3.2  Country  case  studies  .................................................................................................  25

2.4  Data  Analysis  ..................................................................................................................  28

2.4.1  Data  analysis  for  systematic  review  .......................................................................  28

ix
2.4.2  Data  analysis  for  country  case  studies  ...................................................................  30

2.5  Ethical  consideration  ......................................................................................................  32

3.  Key  interventions  on  attraction  and  retention  of  rural  health  professionals  in  the  Asia  
Pacific  region  ................................................................................................................................  33

3.1  Introduction  .....................................................................................................................  33

3.2  Key  interventions  in  the  Asia  Pacific  region  ..............................................................  34

3.2.1  Economic  and  health  status  .....................................................................................  34

3.2.2  Key  interventions  ......................................................................................................  36

3.3  Implementation  of  interventions  ..................................................................................  42

3.3.1  Management  structure  of  implementation  ............................................................  42

3.3.2  Effects  of  components  of  implementation  .............................................................  47

3.4  Effectiveness  ....................................................................................................................  48

3.4.1  Attraction  ....................................................................................................................  48

3.4.2  Retention  .....................................................................................................................  49

3.4.3  Improved  health  performance  .................................................................................  50

3.4.4  General  effectiveness  of  the  interventions  .............................................................  51

3.5  The  effects  of  contexts  on  HRH  ....................................................................................  55

3.5.1  Political,  economic  and  social  issues  ......................................................................  55

3.5.2  Health  system  .............................................................................................................  57

3.5.3  Other  contexts  ............................................................................................................  60

3.6  Summary  of  main  findings  ...........................................................................................  61

4.  Country  case  studies  on  attraction  and  retention  of  rural  health  professionals  in  China,  
Vietnam  and  Cambodia  .............................................................................................................  64

x