Table 1 Studies by intervention type

Availability (production + training)

1. Planning workforce and training needs

30

A variety of operational models developed and applied; complex data needs; limited evaluation of models identified.

2. Training school capacity building

13

Important requirement; some documented examples, including for online learning.

3. Attracting candidates

17

Wide variety of strategies, including outreach programs, selection policies, mentoring, and funding. For neglected specialties, more positive exposure during training may also be effective.

4. Funding/financial access

10

Financing students can be effective, including for targeting underrepresented populations and directing them to less popular specialties and areas.

5. Public/private and international partnerships for training

3

Detailed operational guidance has been developed as to how to implement international partnerships (mostly between low- and high-resource countries); no formal evaluations were identified however.

Availability (recruitment + retention)

1. Financing HRH

7

Limited evaluation studies but suggest that financing long-term positions can improve recruitment and retention.

2. Targeted recruitment

14

To widen the pool, greater access to training, additional tax relief for continued work, phased retirement, flexible work schedules, and language support (for immigrant groups) can be effective.

3. Improving HRIS

3

Important to support all HR functions; limited evaluations; implementation challenges noted.

4. Policies to reduce outmigration

7

Provision of good working conditions, training opportunities, supervision, and manageable workloads are among the factors highlighted in some contexts.

5. Increase in-migration of HRH

8

Bilateral partnerships and targeted visa programs are among the approaches shown to be effective, if this is the policy objective.

6. Reduced in-migration to build domestic workforce

29

Increased training capacity and task shifting internally, and restrictive immigration and licensing rules for expatriates can be effective. To mitigate brain drain from low-income source countries, ethical codes have had at least some short-term effects.

7. Increased retention

9

Preferences will be varied across cadres, age, location, and profile, so specific research is needed. For underserved specialties like primary care, it is important to provide good work/life balance and remuneration and build social status of role. Working hours and conditions, supervision, and access to training are typically important too. A balanced package should be provided. In some cases, task shifting to provide more support to clinical staff and delegate more routine tasks can support retention.

8. Incentives to postpone retirement

5

Countries with aging populations and shortages have had some successes with incentives for health staff to postpone retirement, full-time or part-time, general or targeted to underserved areas.

Distribution

1. Educational interventions

38

There is a substantial evidence base that recruiting students from rural areas and exposing them to rural areas (positively) during training can increase later rural post-uptake and retention. More recently, “social accountability” medical schools have focused on reinforcing rural service ethic.

2. Financial incentives

15

Financial support for those setting up and/or remaining in underserved areas may be effective, though evidence suggests that they need to be combined with support for living (e.g., housing) and working conditions.

3. Non-financial incentives

15

A variety of strategies have yielded results in different contexts, including supporting CPD (including using remote learning for staff in remote posts), assisting spouses to find work, providing networks and personal support to reduce isolation, and mentoring.

4. Bonding and contractual approaches

25

These appear to have had mixed success and/or are less studied. They include limited permits to serve by area to direct staff to shortage areas, bonding for a period as a condition for study grants, and contracts which allow for time away from the post (to rejoin families, where work stations are unattractive for them). Some countries also offer immigration opportunities for those willing to work in rural areas, though the longer-term effects on the local health labor market may be negative.

5. Adjusting service provision model

10

Telemedicine and task shifting have been adopted in some locations to service rural, hard-to-staff areas. The former has not yet been extensively evaluated.

Performance

1. Training-related approaches

31

Pre-service training of course has a substantial impact on HR performance. A rich body of knowledge exists on good training practices, including the emphasis on problem-based learning, problem-solving, and interpersonal skills. CPD is receiving more focus for all health professionals and is often linked to relicensing or reaccreditation.

2. Incentives and provider payment systems

10

Financial incentives are powerful, but complex. Most countries set wages centrally but recruit locally. Provider payment reforms are well documented—generally, mixed methods are recommended, with different approaches for primary and secondary care. Performance-based financing has been used in many countries, with some success and also challenges relating to cost-effectiveness and sustainability.

3. Task shifting

9

Reasonably strong evidence that task shifting to nurses in advanced roles can provide good quality of care and outcomes, as well as playing a role in retention of physicians through reducing workload, though cost savings have typically been modest or non-existent. Resistance is high in some settings to changing professional roles.

4. HR management

16

Decentralized HR management at the local level, along with effective deployment of HR management tools, is thought to improve performance, though evaluation evidence was lacking.

5. Regulation of dual practice and absenteeism

8

Dual practice is common and can support public service (where pay is low and dual practice well-regulated) or disrupt it, also demotivation those who do not engage in it. Some of the common successful approaches include addressing the problem openly, revising incentives, improving working conditions, having professional value systems, and regulating work in the private sector. Failed interventions included prohibition and simply closing the salary gap.

Absenteeism is seen as a warning sign to employers, who will need to understand the drivers. Changing organizational policies and culture, improving the workplace environment, and restricting private practice may be appropriate.