Rural/Urban Imbalance

This paper reviews the situation and trend in human resources for health and its priority problems in Thailand. It also highlights the issue of the inequitable distribution of doctors. Through several brainstorming sessions among stakeholders, it summarizes a package of recommendations for the future continuous and sustainable knowledge-based human resources for health development. [from abstract]

In rural areas across Australia the recruitment and retention of adequate numbers of medical specialists, including psychiatrists, has been a long outstanding problem. Latrobe Regional Hospital reached a major crisis in 1994, with only one psychiatrist and a large number of vacancies. This led to a focus on the recruitment and retention of psychiatrists in order to improve this essential element of the workforce. [from abstract]

Australia is experiencing workforce shortages across a number of health professions despite a significant and growing reliance on overseas trained health workers. The shortages are even more acute in rural and remote areas. It is critical to increase the efficiency and effectiveness of the available health workforce, and to improve its distribution. This report describes the Australian government’s objectives of developing a more sustainable and responsive health workforce while maintaining a commitment to high quality and safe health outcomes. A set of national workforce objectives are also proposed.

Understanding the supply and utilization of nurses is critical to maintaining an effective community health system. There has to be sufficient staff and a work environment that builds on the existing strengths of community health nursing to meet emerging needs. This report provides a demographic profile of community health nurses (CHNs) in Ontario and identifies enablers that support optimal practice of their competencies. [from executive summary]

The configuration of rural health services is influenced by geography. Rural health practitioners provide a broader range of services to smaller populations scattered over wider areas or more difficult terrain than their urban counterparts. This has implications for training and quality assurance of outcomes. This exploratory study describes the development of a “clinical peripherality” indicator that has potential application to remote and rural general practice communities for planning and research purposes. [from introduction]

The overall objective of community-based medical education (CBME) is to produce highly qualified doctors in sufficient numbers to meet the health needs of the nation at community and hospital levels. In the current program, medical students undertake an eight-week residential posting in their final year. The objective of this study was to assess the communities’ awareness, perception and participation in the CBME program. [adapted from introduction]

This paper analyzes the present situation of general practitioners in the Thai health care system and the conditions under which their contribution could be strengthened. [from abstract]

This article presents the result of a literature review examining possible ways to improve healthcare services in rural areas. [from abstract]

The township health system in Myanmar is regarded as means to achieve the end of an equitable, efficient and effective health system based on the principles of primary health care approach. A township hospital caters medical care at the second referral level. Under the leadership and management of a Township Medical Officer in each township, para-professionals deployed at Rural Health Centers (RHCs) and Sub-centers under each RHC’s jurisdiction play key roles for providing primary health care services for rural population. There had been an expansion of township hospital beds, RHCs and Sub-centers during the past 15 years.

Rural background and training have previously been found to increase the likelihood of rural practice. However, practitioners of many health professions remain in shortage in rural and remote Australia. This study builds on previous work in that it includes medical, nursing and allied health professions, considers the role of the health professional’s family in employment decisions, and includes a broader array of factors influencing employment preference and the preferred location of practice. The survey also examines when students might work in a rural area. [introduction]

This paper begins by clarifying the terms shortage and underserviced. Provincial and federal programs for underserviced areas in Ontario are then described and considered in terms of their relevance to nursing. A discussion of the issues associated with policies addressing shortage and underserviced areas follows. The paper concludes with recommendations for change. The importance of making funding decisions based on a clear understanding of relevant concepts and models is emphasized. [introduction]

This presentation was part of the ECSA Workforce Observatory Meeting in Arusha. It describes an incentive scheme to help retain certain critical staff in the rural areas and to attract health workers to areas with inadequate staff.


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This paper examines the design and limitations of incentives for health care providers to serve in rural areas in developing countries. [from summary]

This article reports a project that investigated the way government policies, health and community services, population characteristics and local peculiarities combined for residents in two small rural towns in New South Wales. Interviews and focus groups with policy makers, health and community service workers and community members identified the felt, expressed, normative and comparative needs of residents in the case-study towns. [from abstract]

There has been a lively debate in the media about working conditions in rural South African Hospitals, with a particular focus on staffing and quality of care. From a medical perspective, it has been stated that poorly equipped and managed hospitals, inappropriate training and an excessive workload are significant contributors to the problem. This study was conducted to investigate the experiences of medical practitioners in performing their professional duties in rural district hospitals in the Western Cape. [from abstract]

In 2003 the Network published a discussion paper reviewing available literature and identifying key issues in need of further work, which this paper summarizes. In Southern Africa there are inadequate ratios of personnel to population for key skilled health personnel. There are a variety of push and pull factors that impact on the movement of healthcare workers. A more rigorous policy analysis is needed to stimulate innovation and to avoid measures and incentives counteracting each other. It is important to provide clearer policy analysis on production of health workers, on availability and distribution, and on movement and migration.

This presentation was part of the International Conference on Global Health session, “Expanding Emergency Obstetric Care: Overcoming Challenges in Training and Service Delivery.” It discusses the first planned effort by the the largest association of ob/gyns and its academic wing to help build human resource capacity in India to develop EmOC in rural areas. It also presents the specifics of the training EmOC certification course they have developed to address the issue.

The availability of medical human resource supply is a growing concern for rural and remote communities in many countries. In the last decade, various telehealth experiences in Canada have highlighted the potential impact of this technology on professional practice. The purpose of this study was to explore physicians’ and managers’ perceptions regarding the potential of telehealth to support recruitment and retention of physicians in remote and rural regions. [abstract]

This pilot study focused on self-identified factors of nursing students who expressed an interest in rural practice post-graduation. The sample included students from the USA and Canada, who were enrolled in graduate and undergraduate programs of nursing, and were attending an international rural nursing conference. [From abstract]

Geographical imbalances in the health workforce have been a consistent feature of nearly all health systems, especially in developing countries. The authors investigate the willingness to work in a rural area among final year nursing and medical students in Ethiopia. Analyzing data obtained from contingent valuation questions, they find that household consumption and the student’s motivation to help the poor, which is their proxy for intrinsic motivation, are the main determinants of willingness to work in a rural area. The authors investigate who are willing to help the poor and find that women are significantly more likely to help than men.

This document report on the trends of HRH during past fifty years including the issues of unqualified doctors in rural areas, geographical differences in HRH, and the increase in medical school graduates. It also forecasts HRH needs for fifteen years from 2000 to 2015.

Most human resources for health in developing countries are produced by highly subsidized public institutes. Due to inequity in basic education most health science students are from wealthier urban families. They tend to remain in urban areas after graduation, creating inequitable distribution of health personnel. At the same time the public education institutes are subject to strong bureaucratic inefficiency and usually no systematic quality control system. This paper analyses this situation in Thailand. [adapted from abstract]

Against the backdrop of growing concern about shortages of health personnel, the report focuses on one of the most critical components of the workforce – nurses. Nurses are the “front line” staff in most health systems, and their contribution is recognised as essential to meeting these development goals and delivering safe and effective care. In presenting a global overview, the paper reports on key trends, main challenges and potential solutions. The emphasis is on breadth of coverage, but specific nursing workforce issues in different countries are highlighted to illustrate the main challenges facing those responsible for developing and implementing policies on the nursing workforce. The report presents a snapshot of a dynamic and challenging situation worldwide. [from executive summary]

Chapter 2, section A discusses the distribution of HRH in Thailand as well as providing recommendations to address the unequal distribution of health personnel between Bangkok and other regions with respect to providing equal access to health services. [adapted from author]

The report provides evidence of inadequate ratios of personnel to population for key skilled health personnel, and a maldistribution of personnel along three different axes, between: public and private heath sectors, urban and rural areas and tertiary and primary levels of the health system. It describes the exodus of healthcare workers from areas of poverty and low socio-economic development, to more highly developed areas. [from executive summary]

The human resource (HR) problem in the health sector in sub-Saharan Africa has worsened to an extent that it has reached crisis proportions in some countries. Although the gravity of the problem varies across the continent, the situation in some of the countries is so grave that urgent action is needed. A complex set of factors has contributed to this problem, some exogenous, such as the austere fiscal measures introduced by structural adjustment, often resulting in cutbacks in the number of health workers. But endogenous factors are also to blame, including misdirected human resource and training policies, weak institutions, and possibly even inappropriate structures. Section I of the paper lays out the key features of the HR crisis as gathered from a review of available data and reports and interviews with health program managers, health officers and project task managers in east and southern Africa. Section II of the paper gathers a few good practices and mechanisms that have been tried to ease the HR problems in the region. It highlights some opportunities for reform and cites the continuing challenges and risks. [adapted from author]

Ghana, a low income developing country, is undergoing health sector reforms aimed at achieving greater equity of access to services, improved efficiencies in resource utilization, development of wider linkages with communities and other partners, as well as improved quality of health services. These reforms have strong influences on, and are influenced by, issues of human resources development, deployment and motivation. Some of the human resources issues debated under the reforms include issues of distribution of personnel, reprofiling of staff types and skill mixes including delegation of some essential skills.

The main purpose of the report was to review the current situation on human resource for health and the mobilization of medical doctors to work at commune level in Vietnam…Although Vietnam has established an extensive network and plentiful supply of health personnel, the distribution of health workers is significantly imbalanced, especially at the commune level. In order to improve accessibility and quality of health care for population especially for the poor, the appropriate policies are needed to motivate health worker, especially medical doctors to work at commune level. [abstract]

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. [from abstract]

The objective of this paper is to contribute to a better understanding of the issues related to imbalance through a critical review of its definition, nature and measurement techniques, as well as the development of an analytical framework. [author’s description]