How effective are interventions aimed at developing the health workforce in countries with severe shortage: Intrinsic motivation might be key
Creators: name: Ijeoma Omenugha
Publisher: name: F1000 Research Limited
Year: 2024

description: <b>Background</b><b>:</b><br>
The migration of human resources for health from low-income countries to high-income countries is worsening the global health inequality gap and posing a serious threat to Universal Health Coverage, especially in low-income countries.(1) The WHO estimates that there will be a global shortage of 10 million health workers by 2030 and that low-income countries that lose their health workforce will be more affected.(2) A number of policy interventions have been implemented at both national and international levels to either regulate this disproportionate health workforce migration or to motivate and retain skilled health workers in low/middle income countries. However, it is unclear how effective these interventions have been.<br>
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<b>Aims and objectives:</b> To assess the effectiveness of interventions aimed at reducing the out-migration of skilled health workers from low/middle income countries to high-income countries, and use this to inform policy for human resources for health management.<br>
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<b>Summary of Methodology:</b> A systematic review was conducted following the PRISMA for systematic review Protocol. Eight electronic databases were searched up to June 2023 including PUBMED, Web of Science, National Library of Medical Sciences, EMBASE, the Advanced version of Google Scholar, the EPPI Center for Policy and Practice, the Campbell Collaboration Data, and the WHO databases. Studies that evaluated interventions to reduce health workers' outmigration from low/middle-income countries to high-income countries were selected and a narrative approach was used to synthesize the evidence based on how they address factors in Young's migration framework.<br>
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<b>PICOS Framework</b>

 <b>Population:</b> Health workers from low/middle income countries
 <b>Intervention:</b> Policies addressing out-migration and motivation
 <b>Comparator:</b> None
 <b>Outcome:</b> Impact on migration. Assessed using the interventions' ability to address the push and pull factors of migration. (Young's Framework)
 <b>Study design:</b> All study designs evaluating the effectiveness of interventions to address health workers' outmigration from LMICs to HICs.

<b>Summary of findings:</b> A total of 9 studies met the inclusion criteria (3 Interrupted time series analyses, 1 Before and After interventional study, and 5 Quantitative and Qualitative surveys).(3-11) Using Young’s framework, two levels of intervention were identified in the review. The macro-level interventions which addressed the macro factors of migration (e.g. WHO Code and UK policy on international recruitment of health workers) and Meso-level/national government interventions (e.g. Occupational Dispensation Scheme (OSD), Dual Practice Scheme, African Health Placement Program, and Zambian Health Worker Retention Scheme). The WHO Code and UK policy on international recruitment of health workers did not significantly affect the international recruitment of health workers among member states. In 2013 and 2003, three years following the proposal of the WHO recruitment Code and the adoption of UK policy respectively, there was still a 75% P (&lt;0.05) and 15% P(&lt;0.05) rise in the number of health workers recruited from African countries to the US and UK respectively. With the introduction of bilateral agreements, international recruitment of healthcare workers from South Africa to the UK declined from 3206 in 2003 to 4 in 2004. In South Africa, the Occupational Specific Dispensation improved health workers' retention while the Dual Practice scheme did not. Foreign aid in the form of technical and financial assistance reduced physician emigration from developing countries. Additionally, it was noted that Performance Based Financing (PBF) increased health workers' job satisfaction, reduced attrition, but had little effect on motivation.<br>
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<b>Discussion and conclusions:</b> Over the years, the effectiveness of policies aimed at reducing the migration of skilled health workers from LMICs to HICs has received inadequate attention. The WHO Code for ethical recruitment has so far failed to meet its objective due to the complexity of its adoption and implementation by both donor and recipient countries. Similarly, national-level interventions in low-income countries have also faced challenges related to complex and unfavourable political and economic conditions. Strengthening low-income countries' health systems, and managing their health workforce capacity should not be left to their governments alone. Global health agencies and the international community should support these countries through foreign aid, technical assistance, and funding of medical education to drive self-sufficiency. LMICs should consider a multifaceted approach where they simultaneously strengthen their health systems and other sectors of their economies such as security, education, and their governance structure. This will enable them to motivate and retain their skilled health workers.<br>
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<b>Take home message:</b> Conventional policy analysts have focused on the limitations of migration policies as the major problem in addressing the health workers' migration crisis. This perspective ignores the plight of health workers and the role of the state in ensuring conducive working environments for health workers. It also ignores the impact of trade relations and economic differences between rich and poor countries which pull health workers towards rich countries. This study therefore suggests that modifying migration policies may not completely change the trend of skilled health workers’ migration. However, adopting a multifaceted approach to strike the balance between push and pull factors would be more effective.