Abstract

Background: The shortage and inequitable distribution of the health workforce in low resource settings is a barrier to attaining Universal Health Coverage. Measures to improve health workforce retention will improve availability and distribution of the health workforce, especially if healthcare workers’ expectations are addressed. It is, therefore, imperative to determine patterns and factors affecting retention among healthcare workers, in relation to interventions such as in-service training, and explore perspectives of healthcare workers and policy makers to help inform policies and interventions.

Methods: A mixed-methods approach was used. A quantitative five-year longitudinal observational study of 127 healthcare workers, who had received a special in-service training course (ETATMBA), was undertaken, 46 from Malawi and 81 from Tanzania. Retrospective tracking was done for two years (2012-2014) and prospectively for three years (2015-2017) to determine retention rates. Interviews were conducted with healthcare workers and key informants from the Ministry of Health to explore their perceptions of mobility and retention. The Socio-Ecological Model was used as a framework for analysing the qualitative data. The retention pattern of healthcare workers from four facilities (case studies), two in each country was studied in-depth to provide an understanding of the study context.

Results: The retention of healthcare workers in target facilities at the end of follow-up was 46.5%(59/127). 13.4%(17/127) of participants had left the health system permanently due to death, retirement or being disqualified from practice. The remaining 51 participants left target facilities to various destinations; majority of them, (44/51) did so after graduating from the in-service training course. Three characteristics of participants were significantly associated with retention; participant’s age, the age group 31-40 showing a higher retention than the rest (p=0.003), growing-up in a rural rather than urban setting (p<0.001), and duration in the job of 11 to 15 years compared to less than 10 or more than 15 (p=0.03). Participants from rural areas were more likely to remain in post longer, regardless of whether they were posted to a rural or urban facility. Two other aspects of retention were measured; the retention in government employment and the retention in the provision of clinical care which was 76.1%(35/46) and 69.5%(32/46) in Malawi and 72.8%(59/81) and 76.5%(62/81) in Tanzania respectively. Perspectives on factors affecting healthcare worker retention focused mainly on three aspects: individual, family and surrounding community. Whereas, the focus by key informants was mainly on two factors: individual and the national policies on human resources for health.

Conclusion: There is no standard definition for retention nor its indicators, these are needed to improve the understanding of health workforce retention. Exposure of healthcare workers to a rural setting has a strong influence on retention. In-service training improves healthcare worker’s capabilities through improved competency and autonomy on the one hand, but on the other, it increases the likelihood of attrition through increased mobility as healthcare workers become eligible to more job opportunities. Although the resulting mobility can worsen workforce imbalance, it can improve it as well. An in-depth understanding of the forces at play and a clear response via policy is critical for addressing health workforce challenges in low- and-middle-income countries. There is recognition of individual factors affecting mobility and retention from the perspectives of the healthcare workers and policymakers. However, incorporating wider aspects such as family, community and societal factors at policy level may be necessary to bring about the desired changes in the human resources for health in line with the global agenda.