Increasing access to health workers in remote and rural areas through improved retention ·...

WHO/HRH/HMR/2009.04

Increasing access to health workers in remote and rural areas through improved retention Report on the second core expert group meeting

20–21 October 2009

WHO, Geneva, Switzerland


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Table of contents

Introduction ................................................................................................................................... 4 The bigger picture ......................................................................................................................... 4 Recommendations and the Guideline Review Committee............................................................ 5 Realist review of retention strategies ............................................................................................ 6 General comments on how to improve the draft document .......................................................... 6 Suggested additions to the document ............................................................................................ 7 General comments on the four categories of interventions ........................................................... 8 Education interventions................................................................................................................. 8 Regulatory interventions ............................................................................................................... 9 Financial incentives....................................................................................................................... 9 Management and social support interventions ............................................................................ 10 Costing tools................................................................................................................................ 12 Measuring results ........................................................................................................................ 13 Proposal to start with the problem analysis................................................................................. 14 Next steps .................................................................................................................................... 15 Annex 1: Provisional agenda...................................................................................................... 16 Annex 2: List of presentations ................................................................................................... 18 Annex 3: List of participants...................................................................................................... 19


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Introduction

On 2 February 2009, WHO launched a new programme to increase access to health workers in remote and rural areas through improved retention. The programme is an integral part of WHO’s renewed efforts to strengthen health systems through a primary health care approach.

The recommendations are being developed by a group of more than 30 international experts on health workforce rural retention and will be launched in May/June 2010. Since February 2009 the full Expert Group and the core expert group have both met on two occasions. Reports from these four meetings are available at: http://www.who.int/hrh/migration/expert_meeting/en/index.html.

This report presents highlights of the discussions from the second core expert group meeting which took place at WHO headquarters in Geneva 20–21 October 2009. Manual Dayrit chaired the first day and Charles Norman chaired the second day. The agenda, list of presentations, and list of participants can be found in Annexes 1, 2 and 3, respectively.

The main goals of this meeting were to:

• refine the draft recommendations

• begin discussions on tools for implementation

• build a plan of action for the finalization of recommendations

• prepare the next steps, especially for the Hanoi conference in November.

The bigger picture

In his opening remarks to the core expert group Manuel Dayrit said it was important to place the development of the retention guidelines in context and to keep in mind the bigger picture of human resources for health (HRH) and health systems strengthening (HSS). Major milestones in 2008-2009 include the Global Health Workforce Alliance conference in Kampala, the publication of the task shifting guidelines, WHO’s collaboration with PEPFAR, and the HRH department’s new strategy to reflect the four reform areas of primary health care.

Dayrit drew the group’s attention to the 10 critical success factors at country level described in the report from the Taskforce for Scaling Up Education and Training of Health Workers, the international focus on scaling up of midwives and interprofessional education, and the observatories being set up in countries and regions. The ultimate goal of all of these activities is to make progress towards achieving the health Millennium Development Goals (MDGs).

As far as the evolving code of practice for the international recruitment of health personnel is concerned, throughout 2009 there have been widespread national and regional consultations on the draft and a resolution is expected during the World Health Assembly in May 2010. This would be the ideal time to launch the rural retention guidelines, as the two issues are so closely linked.

Beyond 2010 the HRH department will look to support Member States in three ways. The first is to provide strategic information, which includes norms, guidelines, strategies, trends, statistics etc. The second is strategic investment – although WHO is not a funder it can work with PEPFAR and other partners to try to convince them to move investment to where it’s needed in a particular country and to provide funds for monitoring and evaluation (M&E) and other neglected areas. The third way the department can support countries is by promoting innovative approaches to meeting health workforce needs (interprofessional education, social accountability, etc.).


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Recommendations and the Guideline Review Committee

Laragh Gollogy reviewed the Guideline Review Committee (GRC) process and its requirements for grading evidence. The GRC reports to the Director-General any activity that results in a recommendation in order to ensure standards and processes are followed for the reporting and use of evidence. It does not matter what the final outcome is called—recommendations can go by many different names.

In the draft that was circulated for the meeting, she said that only C3 was a recommendation; the other 14, as presented, are statements that summarize the evidence. The downside of not turning the statements into recommendations is that it leaves nothing to evaluate and no ongoing programme of work. She asked if this was what the group wanted to do: having done all the work, did the expert group want to stop short of making recommendations?

Making recommendations would require looking at the evidence statements and asking:

• What policy decision are you addressing?

• What are the possible courses of action?

• What does the evidence show?

• What is the course of action you want people to take?

A systematic approach to grading the evidence is required, and the final document needs to state how this was done. In addition, the document must be explicit on benefits, harms, values, and judgments associated with each recommendation. Consideration should also be given to local circumstances, resources, and barriers to implementation.

She stressed that WHO expert groups can make strong recommendations based on weak evidence in the same way that they can make weak recommendations in the face of high-quality evidence. A recommendation can be upgraded based on the confidence of the expert group that it will have an important and positive outcome.

In short, WHO recommendations assist providers and recipients of health care and other stakeholders to make informed decisions, and importantly for this group, they are actions that can be monitored.

This topic generated a great deal of discussion over the two days. By the end of the meeting it was agreed there is an acute need to take action and do something that can be measured and evaluated. So regardless of what they are called, the document will go beyond evidence summaries and make recommendations. Even though the evidence is sketchy, the group can still make strong recommendations that have an impact. The approach is to use what limited evidence there is and back it up with the expertise and knowledge of the group.

Of course not all recommendations will be relevant for all countries and in all contexts and like all WHO guidance it will be up to countries to choose the course of action.

These guidelines should be seen as an instrument for change and should be addressed primarily to policy-makers who are going to make the change. The document therefore needs to be written in action-oriented language. Furthermore, an important part of the recommendations shall be the encouragement of further research in this area in the coming years.

The final document will be reviewed by the GRC before being submitted to the Assistant Director-General for Health Systems and Services for final approval.


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Realist review of retention strategies

Marjolein Dieleman presented a summary of a review of retention interventions focusing on the role of context. The realist enquiry approach was applied to 30 papers with the aim of identifying the key elements that might explain why interventions were effective in one setting or failing in another.

The evidence from the papers shows that bundled approaches are more successful than solitary interventions. Bundles should include interventions to prepare health workers for rural practice, address the social and professional isolation associated with rural practice, and raise profile of rural practice. Other examples of influential contextual factors include: the health labour; gender, age, and place of birth of the health worker; management capacity and bureaucratic procedures; and the involvement of groups of local stakeholders.

In summary she said the limited evidence available supports the need for better understanding and analysis of contextual factors and the mechanisms that can be triggered through different interventions in similar settings. The question should not be: does the intervention work? It should be: In which circumstances does an intervention succeed or fail and why? Or: what mechanisms were triggered in that specific context that made the intervention work or fail? The answers to these questions will inform the formulating, validating, and refining of policies and programmes.

General comments on how to improve the draft document

• The preamble or guiding principles should discuss the need to take a multisectoral and multistakeholder approach at the country level from the beginning of the process of defining the problem, setting priorities, and identifying the solution through to implementation, and M&E. Policy discussions should involve ministries of health, education, and finance as well as professional associations, community representatives, researchers and funders.

• Engaging with researchers from the beginning of the process is essential to ensure the effect of any intervention that is implemented is studied. Rigorous research methodologies are needed to generate a higher standard of evidence and the knowledge that is gained about what works and what doesn’t and why needs to be shared.

• At the moment the recommendations have been dissected into different types of interventions but they need to be put back together to show policy-makers how they are going to work.

• The idea is to think holistically about the recommendations and not pick one or two. The message has to come across that implementation is a “bundled” approach and that these bundles should be designed and coordinated, not coincidental. This should be stressed both in the guiding principles as well as throughout the recommendations.

• The problem statement needs to be made upfront and clearer. An in-depth understanding of the problems and contextual factors will lead to the “right” bundle of interventions.

• Because of tendency to go too quickly to the solution, perhaps the process – starting with the situational and problem analysis – should come before the recommendations. How to do priority setting should be in the introduction. Consider including core HR messages before the problem analysis. First describe the core issues, and then the process, and finally the solutions.


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• Section 5 on how to implement could apply to any intervention or any programme and is too generic. Is implementation about the decision-making process or how to make it happen once the decision has been made?

• Ensure the language of the document reflects a broad definition of health workers: managers, faculty, and other essential cadres need to be retained as well as front-line health workers.

• For this programme on rural retention, governance has two meanings: one is governance of the process of implementing the guidelines and the other is the governance of health systems including HR. Issues of transparency, fairness, and accountability will affect all of the recommendations: hiring, recruitment, and the deployment of paid health workers depends on the principles of good governance.

• There are differing views about attraction/deployment vs. retention: some see them as two functions and others see the distinction as somewhat artificial. But the key question for this document is: What were the intended effects when the intervention was set up—was the intention for health workers to stay for one year or three years or to improve performance?

• One important contextual factor is the broader policy agenda, for example, the decentralization agenda and the civil service reform agenda will influence the most appropriate interventions.

Suggested additions to the document

• Somewhere it should be said that rural retention requires a constant effort to find new ways to meet new challenges – no one solution can solve the problem and all solutions will have to be adapted over time.

• More information on what studies are under way and some way to track the evidence that is being collected from these studies.

• The critical success factors.

• There is some evidence about interventions that have failed and it would be good to give countries some information about what doesn’t work.

• Include examples of country experiences throughout the report as policy-makers like to read what other countries that have done, what it has cost, and what was the impact.

• A discussion of the effect global health initiatives are having at country level (e.g. PEPFAR’s effort to strengthen health service delivery).

• References to WHO’s five year plan, equity, and the Commission on the Social Determinants of Health.

• Make the point that individual interventions are unlikely to work unless action is taken in a series of other domains and that a good policy badly managed or badly implemented is not good policy.

• Ensure that bundled interventions are encouraged and referred to throughout the recommendations.

• Consider splitting the final document into a part A containing all the recommendations and grading of evidence, followed by part B with the "how to" guide and tools.


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General comments on the four categories of interventions

It may be good to have some more overarching recommendations or statements that are important but not specific to rural retention. Two examples: countries should aim to be self sufficient in their health workforce, and health workers should be paid on time.

Word the recommendations in sections A, B, C and D in a way to ensure they can be evaluated.

Many interventions are missing the context that makes a recommendation relevant from the point of view of the country/state/district/community.

Need to add evidence summaries like in section A explaining what the evidence is to support the recommendation and include a brief statement about the quality of the evidence. The evidence summaries need to include the outcome or impact, the interlinkages, and a mention of the benefits, risks, harms, costs and cost effectiveness.

Each recommendation should say something about implementation barriers at different levels and to what extent those barriers can be addressed.

Have to be careful that the discussion on salaries, performance, etc., is specifically about rural retention.

Education interventions

Introduced by Estelle Quain - There are five recommendations altogether, which need to be bundled and mapped because there is overlap between them and one can’t be done without doing at least a couple of the others. The most interesting studies are the ones that brought out the qualifying issues. Most of the recommendations have more to do with recruitment than with retention: they are concerned with attraction, except for the last recommendation.

Selected comments and suggested changes

Make stronger recommendations for preparing students for practicing in rural areas and for ensuring health workers in rural areas have opportunities for continuing professional development.

The word medical is used a lot but this is not only about physicians in medical schools – it is about all health workers and so the language needs to be more equitable.

This section could be a bit more visionary and include, for example, information technology, adult learning, distance learning, and in-service vocational training. Evidence exists on how vocational training can be done in rural areas without compromising the quality of the training. At present the recommendation carries the notion that training has to be done before sending health workers out to remote and rural areas and this should change to encourage continuing training opportunities throughout the careers of health workers.

Include some examples of risks and the need to build in safe guards.

Bundle A1 and A4 in some way as there is a relationship. Aside from fully fledged professional schools, there are more innovative ways to have learning centres, which should cover different cadres, not only physicians and nurses.

There were different views, but it was decided to keep A5 in this section and as a separate recommendation because it is important to make point that health workers can have a complete professional career in rural areas. A link could be made to section E because a complete career path could also involve rural and urban practice.


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Regulatory interventions

Introduced by Seble Frehywot – The first two recommendations are concerned with compulsory service, the third relates to career development, and the fourth to scope of practice (from the task shifting guidelines). Is there any evidence that compulsory service is working? Many countries use compulsory service, but no country has done full M&E of the impact before and after implementation. This is an example of why M&E needs to be built in from the beginning of the process.


Some of the other recommendations (e.g. flexible contracting) may require some sort of regulatory support. Perhaps this point should be covered in the preamble.

Consider adding a recommendation: Regulating the labour market can have an impact on rural retention of health workers and access to health services. For example, restricting the number of pharmacies in urban areas in Finland and Norway pushed pharmacies out to rural areas.

Some dimensions have been left out of B1 and B2. For example, compulsory service before post-graduate training (as opposed to compulsory service after graduation) is another way of regulation.

Success depends on how much the state is able to enforce the compulsory service regulation—the level of governance is the key contextual factor for regulatory interventions.

What about private sector? So far it is not mentioned in this section.

Regulations can be used to steer people to the hardest to serve areas. In Australia new graduates spend six years in a rural area (one year for every year of education) but this can be reduced to two years if they go to a very remote area.

Have to be careful not to drive people out of a profession. This is a risk when rural service is mandatory for general practice but not for specialists.

B3 may attract the wrong type of worker, so add a reference to quality of care.

B4 is perhaps too broad and too generic. It is making at least three different points:

• the training of nurses assistants, medical officers and other cadres with sets of skills that are less in demand in the private sector in urban areas is promising to explore;

• service providers may trade off less desirable postings for the opportunity to learn a wider range of skills;

• when certain services cannot be provided with the existing workforce, then training other cadres can be a way to make those services available.

Financial incentives

Introduced by Christrophe Lemière - The first recommendation states the obvious: If the financial incentive is big enough, then it works. C1 includes non-financial incentives such as housing and opportunity costs, etc. Incentives alone are not enough to retain people in rural areas but they need to be part of the package. Technical tools that have already been developed should be used to measure the opportunity costs that could trigger decisions to move to rural areas. The other two recommendations are more specific cases. C2 states that one way to provide financial incentives is to subsidize capital and recurrent costs of private rural practice. Important contextual factors are: a surplus of doctors in urban areas, a densely populated rural area, and decentralization. C3 is about pay for performance (P4P) and is based on evidence from Rwanda’s experience using P4P for rural retention, among other things.


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This section is clearly set out—a few people made this comment.

Include other examples of the impact of increased salaries (e.g. Thailand) in C1, define non-monetary in the text (it is costing someone something—how much?), and consider building time into the incentive (e.g. in Quebec incentives increase over time).

Set out what should be included in the financial incentive package in a separate recommendation.

Transparency and consistency in the process of setting up and providing incentives, as well as communication and documentation are all important to ensure all health workers are aware that certain incentives are available and/or that incentives have changed over time.

Define what “low level of governance” means. One suggestion was to use the World Bank’s indicators as a reference, and ensure politically sensitive terminology is used when writing this recommendation.

Any set of financial incentives has to be variable over time because people learn how to cheat the system and what is right now won’t be right in two years.

Contextualize the evidence from country case studies because it is bundled interventions that work, the financial incentive alone is not enough. Cambodia and Afghanistan are special cases. Madagascar is an example of a bundled approach that addressed professional and social isolation and involved the local community.

How does C2 fit into the wider overall health policy and HRH plan? What about countries with high unemployment of doctors? Does it apply to other categories of health workers in addition to doctors?

Given very tight resources where does the money come from? Where efficiency is very low, motivation and productivity are key. Deploying large numbers of health workers on low salaries is self defeating.

Timely payment and continuity in delivery of the monetary payment is very important, otherwise there is a risk of the programme losing credibility.

The points in C3 are not recommendations; they are about context, about how to do all of these things well.

Service-contingent loans and scholarships could be included as a separate recommendation in section C, acknowledging the overlaps with regulation.

Take out the reference to P4P as the evidence is mixed in both the North and South.

“Performance” sounds bad and may scare people away from health service rather than attract them. Can compliance be used instead of performance?

P4P may be better as a factor and not a separate recommendation, but it should be in the document. If removed, low-income countries may lose an opportunity because many donors have agreed to increase funding for health workers in rural areas, but only under a P4P scheme. A box specifically referring to the Rwandan case could be included.

Management and social support interventions

Introduced by Jim McCaffery and Jim Buchan – The aim is to select bundles of interventions based on local conditions. Overall there are good examples but also significant research gaps and not enough studies from developing countries. M & E needs to be a part of all of these recommendations in order to build up a database over time. D1 and D2 are very context


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specific. D1 is about making professional service more compelling and attractive. Choosing the bundle from the menu of options implies certain competencies at provincial and district levels to gather and analyse data and to make decisions.

D2 relates to housing, water, cell phone support, schooling, etc, and involves risks in terms of the financial implications. There is much to learn from faith-based organizations working in sub-Saharan Africa about interventions that don’t cost a lot. Simple surveys are needed to determine what would make the most sense to try to improve.

D3 is a cross-cutting recommendation: a strengthened human resource management system (HRMS) will likely increase the effectiveness of all interventions. There is a need to scale up from pilots, and there is a risk of not acting. One positive development compared with three to four years ago is that the global health initiatives are more open to health system strengthening.

In was agreed that this is most difficult section and that it needed the most work.


This is the only section that has merged a few themes and as a result the specificity has been lost. Each theme (e.g. how to make rural practice a more professional experience) is important and should be unbundled and given more emphasis and attention because there is evidence to make more specific recommendations.

D1 mixes up too many heterogeneous things—work environment, school fee support, remuneration package, professional development, etc. The dot points in D1 should be the recommendations themselves: the first and fourth are so important that they could be recommendations on their own and the second dot point could fit into D3.

Take costing into account, include a discussion on financially feasibility, and address both professional and social isolation.

D3 needs more specific recommendations related to rural retention.

The decentralization of HR management should be added to D3. There is some evidence from Tanzania that it has an impact on rural retention and motivation. The presence of adequately trained, motivated, and resourced managers at district and local levels underpins all the other recommendations.

Define HRMS more clearly—if they are to use the term, policy-makers need to understand what it means.

The discussion on workforce management should include what doesn’t work and why.

There is evidence to translate governance principles into more concrete recommendations in section D.

Gender and age are missing in the four areas.

Leadership skills should be included, as well as management.

Eric de Roodenbeke gave a short presentation on outreach activities and possibilities for remote areas and requested it be included in the recommendations. The main point is that health workers do not necessarily have to be based in rural areas for people living in rural areas to have access to health services. Although outreach activities are well-established in many countries they have rarely been systematically studied and so there is a need to do case studies to build the evidence based. Questions were raised over the appropriateness of different service delivery models as a recommendation due to their relevancy to retention of health workers.


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Costing tools

Pascal Zurn presented an overview of the main points in a paper that was submitted to the WHO Bulletin for publication in the May 2010 special theme issue: “Health workforce retention in remote and rural areas: towards universal access”.

Costing is a neglected policy area and at present there is almost no evidence of the cost of policy interventions related to rural retention. A literature search led to only four relevant papers.

Although there is no intention to make a recommendation on costing, the expert group has to provide some guidance because there is a cost associated with whatever options are chosen.

How will countries with limited financial resources implement rural retention policies? They will have to make choices. In addition, financial language is essential in a document whose target audience is policy-makers.

Key questions are: How much does the policy intervention cost, who is financing it and how, and is the policy intervention financially sustainable?

Jim Campbell elaborated on some of the issues. The variety of stakeholders involved and the complexity in funding streams and mechanisms makes it difficult to track HRH costs, including for retention. What is known is that resources from both domestic sources and ODA are considerable. The Global Fund has invested US$ 660 million towards HSS since 2007 and PEPFAR is supporting salaries for 130 000 health-care workers.

An independent evaluation is currently under way in Malawi that should provide some evidence. Retention is one of the four key areas being evaluated in terms of costs, delivery, impact, and sustainability.

Countries and donors need to build the evidence base related to costs and to share this information for the benefit of all.

Costing is set to become a policy priority area. The Global Fund, the GAVI Alliance, and the World Bank have announced their intention to launch a single global funding platform for HSS. Funds will roll out to countries on the basis of costed health sector and HRH plans, including the costs associated with rural retention.


Will the document include cost estimates for each of the recommendations and/or the implementation tool?

This section should consider the cost of NOT doing the intervention at all; there is a cost and it can be evaluated. In addition to the cost, include the expected benefits of the interventions in human and economic terms.

Cross reference work that has been done on cost and cost effectiveness, skill mix, skill substitution, turnover, etc. Can expand upon already developed broader HR costing tools, yet make them specifically focused on costs related to retention strategies and efforts.

The Commission on the Social Determinants of Health made specific recommendation on rural retention that should be included in the introduction of this section, which also needs to link to the broader WHO programme on financing health systems led by David Evans.

In summary, costing needs to be on the agenda going forward. Cost information is needed for different purposes: for evaluation looking forward, for evaluation looking backward, for planning and budgeting, and for interactions with development partners and funders. The document must understand and respond to these needs. It is important to have a tool developed as there is no satisfying tool to date, but this is separate from the working group’s recommendations. However, the document could perhaps include a checklist.


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Measuring results

Luis Huicho outlined a conceptual framework for measuring results of HRH interventions to increase access to health workers in underserved areas (see figure below). Policy- and decision-makers need to know whether interventions work or not, why they work and in which context. But at present the evidence on successes or failures is scant and weak. The few evaluations that have been done rarely facilitate the transfer of knowledge or a comparison of lessons. Going forward, the conceptual framework will be extensively piloted and refined based on inputs from different sources to ensure that it is an effective user-friendly evaluation tool.

Plans are under way to apply the tool in a number of countries that are designing and implementing attraction and retention strategies in underserved areas. Figure: Increasing access to health workers in underserved areas: measuring results

Carmen Dolea presented the results of a literature review of impact evaluations. Impact evaluations can provide insights about the effectiveness of interventions to increase access to health workers in underserved areas. Of 14,746 titles that were searched, only 31 studies were found to be suitable for the review. In the paper that has been submitted to the WHO Bulletin’s special theme issue indicators, methods, and results are presented against the dimensions of attractiveness, deployment/recruitment, retention, and performance. Among other observations, the literature review revealed:

• skewed geographical distribution;

• an absence of evaluations from low- and middle-income countries (with the exception of Mali and Niger);

• very few evaluations of financial incentives and management interventions;

• the majority of studies focused on doctors;

• rarely is there alignment of proposed interventions with a factor analysis.


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Be clear on why there haven’t been many replicated studies and why there are no standards. Among the reasons: these are difficult to do, the data are not there; managers and policy-makers have other things to do. This is an opportunity to develop a common approach to look at different interventions, build the evidence base, and improve the transferability of knowledge. If the approach is to be widely used it cannot be too complicated and so there needs to be a balance between comprehensiveness and utility.

This section should also discuss the instruments used to measure the indicators. With good survey methodology it is possible, for example, to show that job satisfaction and intention to leave are highly correlated.

The push and pull factors are two sides of the same coin—motivational factors would be more useful.

Given that low-income countries do not have resources to do M&E should one recommendation be that governments and/or donors set aside adequate funds over a five-year period to carry out this work?

M&E needs to be considered from the start of the intervention – what is the intervention trying to achieve and can it be measured? If this is the group’s position then consideration should be given to moving M&E towards the front of the document rather than leaving it at the end.

The section would benefit from clear messages about the different purposes of evaluation and the need for comparable data. This will show that the framework has the characteristics to meet these needs (including aligning inputs and outputs so that comparable data can be collected). At a minimum are there two or three key indicators?

The next step in this evolving process is to test out the framework in pilot countries with different structures and contexts and several countries have already expressed their interest in this.

Proposal to start with the problem analysis

It is essential that countries do an in-depth problem analysis and have a thorough understanding of what is or is not currently being done before looking at the strategies. All too often, deployment policies are developed and implemented without due attention to this first step. This tendency to jump too quickly to the solution should be resisted.

The document should start by helping policy-makers to analyse the problem, perhaps by providing some sort of checklist to work through the process. Then it can move on to how to solve the problems and how to go through the selection process (each of the four sets of recommendations requires some sort of selection criteria).

Tim Martineau presented a draft mapping tool that could be used to help in choosing the most appropriate bundle. It does not add anything to what is already in the material but rather is a way to present what is in the recommendations. It is designed to assist the decision-making process, to decide on the criteria and to find a way to apply them. Examples would be helpful to show how the bundles can be combined. The important thing is to get people to keep referring to the problem analysis and to what is already going on. It could be developed into a CD-ROM or interactive tool to go along with the recommendations.

It was agreed that this would be worthwhile to develop further as a way of thinking of the complementary of different recommendations and the most appropriate combinations.

Choosing the most appropriate bundle of interventions needs to be linked to the costing tool and also needs take into account what is technically, politically, and economically feasible. These are the three elements of a comprehensive decision-making tool.


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Next steps

The aim is to launch the recommendations during the World Health Assembly in May 2010 along with a bigger event in June 2010 in a place that has yet to be decided, perhaps in an African country. If this is to happen the following timeline has to be followed:

The three day workshop in Hanoi will be a good opportunity to share the draft recommendations (which will have been revised after the second core group meeting) and invite reactions and comments on how to improve it. Some 150 people will attend the event, including representative from 15 ASEAN countries and seven African countries. The third full expert group meeting in Hanoi on 25–26 November will be an opportunity to share impressions and feedback from the workshop.

In December the draft guidelines will be revised again before being circulated for peer review in January. The third and last core expert meeting to finalize the document will take place at the end of January or early February. The workshop in Dakar in March 2010 has been cancelled as it is too late in the process to integrate any changes.

Implementation begins in earnest in June 2010. One important way forward in implementing the programme is to identify and work with pilot countries. Jean-Marc Braichet presented the Mali case study and asked the group to start to think about six to seven additional pilot countries.


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Annex 1: Provisional agenda

20–21 October 20009, World Health Organization, Geneva

(Salle M 105)

Tuesday 20 October

Chair: Dr Manuel M. Dayrit

09:00 Session I – Evidence challenges

Welcome and opening remarks (Jean-Marc Braichet)

09:15 Challenges for grading and interpreting the evidence • GRC requirements for grading the evidence (Laragh Gollogly) • Realist review of retention strategies – role of context (Marjolein Dieleman)

10:00–10:30 Coffee break

10:30–12:30 Session II – Drafting the recommendations

Plenary discussion to refine recommendations and elaborate upon benefits, values and risks for each recommendation Presentation of proposed 3–5 recommendations, followed by discussion

• Education (Estelle Quain) • Regulatory interventions (I) (Seble Frehywot)

12:30–13:30 Lunch

13:30–15:15 Session II – Drafting the recommendations (cont'd)

Plenary discussion to refine recommendations and elaborate upon benefits, values and risks for each recommendation Presentation of proposed 3–5 recommendations, followed by discussion

• Regulatory interventions (II) (Seble Frehywot) • Financial incentives (Christophe Lemière)


15:45–17:15 Session II – Drafting the recommendations (cont'd)

Plenary discussion to refine recommendations and elaborate upon benefits, values and risks for each recommendation Mobilizing health workers to outreach rural population: a first overview of strategies and results (Eric de Roodenbeke) Presentation of proposed 3–5 recommendations, followed by discussion

• Management, environmental and social support (Jim Buchan/Jim McCaffery)

18:00 Reception at WHO main restaurant


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Wednesday 21 October

Chair: Dr Manuel M. Dayrit

09:00–10:00 Session III – Tools to develop alongside the recommendations

Plenary discussion to refine the following tools • Tools for costing (Pascal Zurn/Jim Campbell) • Tools for evaluation (Carmen Dolea/Luis Huicho)


10:30–12:30 Session IV – “How to” choose the appropriate interventions

Plenary discussion to refine sections on implementation • Mali case study-implementation and pilot countries issues

(Jean-Marc Braichet) • Diagram for choosing the most appropriate bundle (Tim Martineau) • Brainstorming plenary discussion on a stepwise approach to select,

design and implement the most relevant interventions (Carmen Dolea)

12:30–13:30 Lunch

13:30–14:30 Session IV – “How to” choose the appropriate interventions (cont'd)

Plenary discussion to refine sections on implementation (continued)

14:30–16:00 Session V – Next steps

Presentation from Jean-Marc Braichet, with moderated discussion • Revised draft recommendations (Carmen Dolea) • Next steps (Jean-Marc Braichet) • Preparations for the workshop in Viet Nam (Jean-Marc Braichet)

16:00 Closure of the meeting (Manuel Dayrit)


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Annex 2: List of presentations

GRC requirements for grading the evidence (Laragh Gollogly)

Realist review of retention strategies – role of context (Marjolein Dieleman)

Presentation of draft education recommendations (Estelle Quain)

Presentation of draft regulatory recommendations (Seble Frehywot)

Presentation of draft financial incentives recommendations (Christophe Lemière)

Presentation of draft management and social support recommendations (Jim McCaffery)

Mobilizing health workers to outreach rural population: a first overview of strategies and results (Eric de Roodenbeke)

Tools for costing (Pascal Zurn/Jim Campbell)

Tools for evaluation (Carmen Dolea/Luis Huicho

Mali case study-implementation & pilot countries issues (Jean-Marc Braichet)

Diagram for choosing the most appropriate bundle (Tim Martineau)

Revised draft recommendations (Carmen Dolea)

Next steps and preparations for the workshop in Viet Nam (Jean-Marc Braichet)


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Annex 3: List of participants

Technical advisers Buchan, James Queen Margaret University GB-Edinburgh United Kingdom

Tel: +44 131 47 40000 Email: [email protected]

Campbell, Jim Integrare S.L. Aribau, 69, 2°-1a E-08036 Barcelona Spain

Tel: +34 934 530 788 Fax: +44 (0) 870 763 0263 Email: [email protected]

Codjia, Laurence Technical Officer, GHWA World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland

Tel: +41 22 79 12360 Email: [email protected] Email: [email protected]

Dieleman, Marjolein Royal Tropical Institute PO Box 95001 Mauritskade 63 NL-1090 HA Amsterdam The Netherlands

Tel: +31 20 5688658 Tel: +31 71 5137095 Fax: +31 20 568 8677 Email: [email protected]

Ding, Yang Health Human Resources Development Centre The Ministry of Health 3 Huoqiying Road, Haidian District Beijing, 100097 China

Tel: +86 10 5993 5224 Fax: +86 10 5993 5217 Email: [email protected]

El-Jardali, Fadi Assistant Professor and Acting Chair Department of Health Management and Policy American University of Beirut Riad El Solh 1107 2020 Beirut Lebanon

Tel: +961 1 350000, Ext. 4692 Email: [email protected]

Frehywot, Seble Lemma Assistant Research Professor Health Policy and Global Health The George Washington University-SPHHS The Dept of Health Policy and the Dept of Global Health 2021 K Street, NW, Suite 800 2175 K Street, NW, Suite 810 Washington, D.C. United States of America

Tel: +1 (202) 994-4311 Email: [email protected]


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Huicho, Luis Universidad Peruana Cayetano Heredia Batallon Libres de Trujillo 227 LI33 Lima Peru

Tel: +51 1 993481121 Fax: +51 1 4314013 Email: [email protected]

Lemière, Christophe Senior Health Specialist The World Bank Senegal Country Office Corniche Ouest x Leon Gontran Damas Dakar Senegal

Tel: +221 33 86 97 609 Email: [email protected]

Martineau, Tim Senior lecturer in Human Resource Management International Health Group Liverpool School of Tropical medicine Pembroke Place GB-Liverpool L3 5QA United Kingdom

Tel: +44 151 7053194 Email: [email protected]

McCaffery, Jim Capacity Project IntraHealth International, Inc. 6340 Quadrangle Drive Suite 200 Chapel Hill, NC 27517 United States of America

Email: [email protected]

McManus, Joanne Consultant 105 Howard Street GB-Oxford OX4 3AZ United Kingdom

Tel: +44 1865 722880 Tel: +44 7867 772105 Fax: +44 1865 727602 Email: [email protected]

Noree, Thinakorn Researcher International Health Policy Program Ministry of Public Health Tiwanon Road Nonthaburi 11000 Thailand

Tel: +66 2 590 2396 Fax: +66 2 590 2385 Email: [email protected]

Normand, Charles Edward Kennedy Professor of Health Policy and Management University of Dublin Trinity College 3-4 Foster Place Dublin 2 Ireland



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Quain, Estelle E. Senior Technical Advisor – Human Capacity Development Office of HIV/AIDS U.S. Agency for International Development RRB 5.10.74 1300 Pennsylvania Avenue, NW Washington, DC 20523 United States of America


de Roodenbeke, Eric Director-General International Hospital Federation Immeuble JB Say 13 Chemin du Levant F-01210 Ferney-Voltaire France

Tel: +33 4 50 42 60 00 Fax: +33 4 50 42 60 01 Email: [email protected]

Seyer Julia Medical Advisor The World Medical Association 13 Chemin du Levant, BP 63 F-01210 Ferney-Voltaire France

Tel: +33 4 50 42 6763 Tel: +33 4 50 42 60 00 Fax: +33 4 50 40 5937 Fax: +33 4 50 42 60 01 Email: [email protected]

Straume, Karin Chief County Medical Officer Department of Health and Social Affairs Vardoeveien 46 N-9800 Vadsoe Norway


Sundararaman, Thiagarajan Executive Director National Health Systems Resource Centre I/II Taj Apartments, Rao Tula Ram Marg, Moti Bagh, New Delhi 110022 India

Tel: +91 9 9583 1755 Tel: +91 9 9714 1558 Email: [email protected]

Vanichanon, Pawit Langu Hospital Director Langu district Satun province 91110 Thailand

Tel: +66 74 773563-6 Fax: +66 74 773562 Email: [email protected]

Webber, Kim CEO, Rural Health Workforce Australia Rural Health Workforce Australia Suite 1, Level 6 10 Queens Road Melbourne VIC 3004 Australia



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Zhang, Guangpeng Division Director Health Human Resources Development Centre The Ministry of Health 3 Huoqiying Road, Haidian District Beijing, 100097 China


WHO technical resources Bergstrom, Karin TB Strategy and Operations World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Braichet, Jean-Marc Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Celletti, Francesca Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Chaouachi, Amel Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Dal Poz, Mario R. Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Dayrit, Manuel M. Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland



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Dolea, Carmen Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Durairaj, Varatharajan Health Systems Financing World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Fouquet, Benjamin Communication Officer Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Gollogly, Laragh GRG Co-chair World Health Oganization 20 Avenue Appia 1211 Geneva Switzerland


Hartmann, Paolo Country Focus World Health Oganization 20 Avenue Appia CH-1211 Geneva Switzerland


Nkowane, Mwansa Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Novarina, Valérie Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland



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Pasztor, Christine Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Stormont, Laura Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Yan, Jean Human Resources for Health World Health Organization 20 Avenue Appia CH-1211 Geneva Switzerland


Zurn, Pascal Human Resources for Health World Health Oganization 20 Avenue Appia CH-1211 Geneva Switzerland


Observers Rajan, Hamsa 28, avenue du Mail CH-1205 Geneva Switzerland


Increasing access to health workers in remote and rural areas through improved retention ·...

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