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Objective: To evaluate the importance of rural internships to observed medical workforce distribution outcomes up to 8 years post-medical school., Design and Setting: Cohort study of medical graduates of The University of Queensland (UQ), Australia., Participants: UQ graduates who were medical interns in Queensland's public health system between 2014 and 2021 and observed working in Australia in 2022. Internship location was defined as being metropolitan or rural, along with other key rural exposures of whether they are of rural origin (childhood) and whether at least 1 year of clinical training at medical school was in a rural location., Primary Outcome Measure: Current work location was collected from the Australian Health Practitioner Regulation Agency (AHPRA) in 2022, classified as either rural or metropolitan and measured in association with their internship location., Results: From 1930 eligible graduates, 21.5% took up a rural internship, which was associated with rural origin (OR 1.5, 95% CI 1.2 to 2.0) and medical school rural immersions of either 1 year (OR 2.8, 95% CI 2.1 to 3.7) or 2 years (OR 5.8, 95% CI 4.4 to 7.7). Completing a rural internship was associated with currently working rural (47% vs 14%, OR 4.6, 95% CI 3.5 to 5.9), which weakened the observed (adjusted) effect of rural origin (OR 1.5, 95% CI 1.2 to 2.0) or medical school rural immersions (1 year: OR 1.4, 95% CI 1.0 to 1.9; 2 years: OR 1.7, 95% CI 1.2 to 2.3). All combinations of the key rural exposures that included rural internship had the highest proportions currently working rurally (range 32-69%) compared with the combinations with a metropolitan internship (range 12-22%)., Conclusions: Internship location appears to be a critical factor in shaping medical workforce distribution decisions. This evidence supports the need for strengthened and expanded rural training pathways after medical school. In particular, clearer pathways into specialty programmes via rural internships are likely to support increased numbers choosing (with confidence) to preference rural internship first and subsequently more working in rural areas long term., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the association between place of origin and principal place of practice (PPP) of domestic Tasmanian health graduates who received end-to-end training with the University of Tasmania (UTAS)., Methods: The 2022 PPP for all UTAS domestic Tasmanian graduates from medicine, nursing, pharmacy, psychology, medical radiation science and paramedicine between 2011 and 2020 was identified using the online Australian Health Practitioner Regulation Agency (Ahpra) registration database. The graduate's place of origin (home address at the time of course application), together with their 2022 PPP, was described using the Modified Monash Model (MM) classification system of remoteness. Data were analysed using STATA., Results: Over the 10-year period, 4079 domestic Tasmanians graduated from health courses at UTAS, of which 3850 (94.4%) were matched to an Australian PPP. In all, 78.3% of graduates were working in Tasmania, while the remainder (21.7%) were employed interstate. Of those with a Tasmanian PPP, 81.4% were working in a regional setting (MM2), while 77.6% of interstate employed graduates recorded a metropolitan (MM1) PPP. Rural place of origin (MM3-7) was associated with rural employment (MM3-7) in both Tasmania (OR, 37.08; 95% CI 29.01-47.39, p < 0.001), and on the Australian mainland (OR, 21.4; 95% CI 17.4-26.3, p < 0.001)., Conclusions: Most domestic Tasmanian origin UTAS health graduates contribute to the state's health workforce after qualifying. Further research is needed to explore PPP over time and to understand why some graduates are motivated to seek employment on the Australian mainland and in particular, metropolitan cities., (© 2024 The Author(s). Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Introduction: The distribution of health care workers differs greatly across Australia, which is likely to impact health delivery., Objective: To examine demographic and workplace setting factors of doctors, nurses and midwives, and allied health professionals across Modified Monash Model (MMM) regions and identify factors associated with shortfalls in the health care workforce., Design: Descriptive cross-sectional analysis. The study included all health professionals who were registered with the Australian Health Practitioner Regulation Agency in 2021, and who were working in Australia in their registered profession. The study examined number of registrations and full-timed equivalent (FTE) registrations per MMM region classification, adjusted for population. Associated variables included age, gender, origin of qualification, Indigenous status and participation in the private or public (including government, non-government organisation and not-for-profit organisations) sectors., Findings: Data were available for 31 221 general practitioners, 77 277 other doctors, 366 696 nurses and midwives, and 195 218 allied health professionals. The lowest FTE per 1000 people was seen in MM5 regions for general practitioners, other doctors, nurses and midwives, and allied health professionals. Demographic factors were mostly consistent across MM regions, although MM5 regions had a higher percentage of nurses and midwives and allied health professionals aged 55 and over. In the private sector, FTE per 1000 people was lowest in MM5-7 regions. In the public sector, FTE per 1000 people was lowest in MM5 regions., Discussion: A disproportionate shortfall of health workers was seen in MM5 regions. This shortfall appears to be primarily due to low FTE per capita of private sector workers compared with MM1-4 regions and a low FTE per capita of public sector workers compared with MM6-7 regions., Conclusion: In Australia, small rural towns have the lowest number of health care workers per capita which is likely to lead to poor health outcomes for those regions., (© 2024 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Background: Strong growth in graduate supply from health, welfare and care courses across Australia may bode well for easing rural workforce shortages. However, little is known about the employment opportunities available for recent graduates in non-metropolitan areas. This study aimed to quantify and describe advertised job vacancies for health, welfare and care professions in Tasmania, a largely rural and geographically isolated island state of Australia. Further, it aimed to examine those job vacancies specifying that recent graduates were suitable to apply., Methods: Job advertisements for health, welfare and care professionals were collected weekly throughout 2018 from six online job vacancy websites. Data were extracted on 25 variables pertaining to type of profession, number of positions, location, and graduate suitability. Location of positions were recoded into a Modified Monash Model (MM) category, the Australian geographic standard used to classify rurality. Positions advertised in MM2 areas were considered regional and MM3-7 areas rural to very remote. Data were analysed using descriptive and inferential statistics., Results: Over the twelve-month period, 3967 advertisements were identified, recruiting for more than 4700 positions across 49 different health, welfare and care professions in Tasmania. Most vacancies were in the non-government sector (58.5%) and located in regional areas (71.7%) of the state. Professions most frequently advertised were registered nurse (24.4%) and welfare worker (11.4%). Eleven professions, including physiotherapist and occupational therapist, recorded a disproportionate number of advertisements relative to workforce size, suggesting discipline specific workforce shortages. Only 4.6% of collected advertisements specified that a recent graduate would be suitable to apply. Of these, most were for the non-government sector (70.1%) and located in regional areas (73.4%). The professions of physiotherapist (26.6%) and occupational therapist (11.4%) were most frequently represented in advertised graduate suitable positions., Conclusions: Despite a range of advertised employment opportunities for health, welfare and care professionals across Tasmania, few specified vacancies as suitable for recent graduates and most were located in regional areas of the state. Health, welfare and care services in non-metropolitan locations may need to develop more employment opportunities for recent graduates and explicitly advertise these to job-seeking graduates to help grow and sustain the rural and remote health workforce into the future., (© 2024. The Author(s).)

Introduction: There is a long standing and worsening shortage of psychiatrists in Australia particularly in rural areas. The majority of psychiatrists work in major cities., Objective: To identify recent trends in the Australian rural psychiatrist workforce compared with the metropolitan workforce., Design: We descriptively analysed population-level data from the National Health Workforce Data Set (NHWDS), the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS). A descriptive analysis of the numbers (count) and gender of psychiatrists from 1995 to 2022 working in Australia was conducted. For the period 2013 to 2022, we analysed for rurality, gender, years' experience, hours worked, Medicare-subsidised services provided and proportions of Specialist International Medical Graduates (SIMG) by sex, with a focus on the rural workforce. For international comparison, psychiatrist numbers were obtained for other OECD countries. The number of psychiatrists working in Australia, as per NHWDS and AIHW, was quantified. We analysed trends in demographics, hours worked and rurality of psychiatrists working in Australia in a serial cross-sectional design., Findings: Most psychiatrists are maldistributed to major cities, while outer regional and remote areas have few resident psychiatrists. Outer regional New South Wales (NSW) and South Australia (SA) have the lowest numbers of psychiatrists per capita. The full-time equivalent (FTE) of psychiatrists per 100 000 has increased from 12.6 in 2000 to 15.2 in 2022. However, the average hours worked by psychiatrists has declined. In total, available psychiatrist hours worked per 100 000 population has increased by 6.1% since the beginning of the millennium., Discussion: Rural areas in NSW and SA have the greatest shortage of psychiatrists. Specialist International Medical Graduates and females (43% of the overall workforce) are the predominant workforce in rural areas. Although Medicare-subsidised services per 1000 people have increased in rural areas, they remain lower than for those living in major cities., Conclusion: There remains an acute shortage of psychiatrists in many regional and remote areas of Australia, with an increasing proportion of SIMGs and females working in these areas, in the context of future increased demand., (© 2024 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Background: There is a growing deficit of rural surgeons, and preparation to meet this need is inadequate. More research into stratifying factors that specifically influence choice in rural versus urban practice is needed., Methods: An institutional review board-approved survey related to factors influencing rural practice selection and increasing rural recruitment was distributed through the American College of Surgeons. The results were analyzed descriptively and thematically., Results: Of 416 respondents (74% male), 287 (69%) had previous rural experience. Of those, 71 (25%) did not choose rural practice; lack of professional or hospital support (30%) and lifestyle (26%) were the primary reasons. A broad scope of practice was most important among surgeons (52%), who chose rural practice without any previous rural experience. Over 60% of urban practitioners agreed that improved lifestyle and financial advantages would attract them to rural practice. The thematic analysis suggested institutional support, affiliation with academic institutions, and less focus on subspecialty fellowship could help increase the number of rural surgeons., Conclusions: Many factors influence surgeons' decisions on practice location. Providing appropriate hospital support in rural areas and promoting specific aspects of rural practice, including broad scope of practice to those in training could help grow interest in rural surgery. Strong collaboration with academic institutions for teaching, learning, and mentoring opportunities for rural surgeons could also lead to higher satisfaction, security, and potentially higher retention rate. These results provide a foundation to help focus specific efforts and resources in the recruitment and retention of rural surgeons., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Independent freestanding emergency departments (IFEDs) have proliferated over the last decade, largely in Texas. We examined the IFED physician workforce composition and changes in emergency physician workforce supply across states and in rural Texas over the period of IFED proliferation following a 2009 legislation allowing the licensing of these sites., Data Sources: IFED websites, Texas Medical Board lookup tool, National Plan & Provider Enumeration System (NPPES), Provider Enrollment and Chain/Ownership System (PECOS), Medicare Physician Shared Patient Patterns, CareSet DocGraph Hop Teaming, Healthcare Provider Database., Study Design: Descriptive analysis of the IFED physician workforce; quasi-experimental difference-in-difference analysis of Texas emergency physician movement into and out of the state; and difference-in-difference-in-difference analysis of the change in emergency physician supply between rural and urban areas in Texas compared with other states., Data Extraction Methods: Using the NPIs obtained through Texas IFED websites and Texas Medical Board data, we examined NPPES/PECOS files, Medicare Physician Shared Patient Patterns, and CareSet DocGraph Hop Teaming for IFED physician practice locations from 2009 to 2017. We extracted all active emergency physicians from a Healthcare Provider Database, derived from a 5% Medicare claims (1999-2017)., Principal Findings: In 2019, 545 physicians practiced in Texas IFEDs, of which 515 (94.5%) were emergency physicians. We located 533 in previous practice, of whom 522 (97.9%) previously practiced in Disproportionate Share Hospitals and 100 (18.8%) in rural areas. Following legislation to begin licensing IFEDs in 2009, there were on average 42.1 (P < .01) moving into Texas and 17.0 (P < .01) fewer moving out compared with all other states. Our results also indicated that the difference in emergency physician supply between rural and urban Texas was 1,002 (P < .01) fewer than for other states., Conclusions: New models of health care organizations such as IFEDs have workforce implications that may further exacerbate rural and underserved workforce and access challenges., (© Health Research and Educational Trust.)

Objective: This study investigates whether the regional pharmacy school at James Cook University in North Queensland is providing graduates geared to address the pharmaceutical needs of the state's regional, rural and remote communities., Design: A cross-sectional study of practice locations of James Cook University pharmacy graduates in 2019 compared to those from other Australian pharmacy schools., Participants: Pharmacists from the James Cook University pharmacy program and those from other Australian pharmacy schools working in Queensland., Main Outcome Measures: Comparison of the proportion of James Cook University pharmacy graduates practising in the seven Modified Monash Model rurality classifications in Queensland to graduates from other pharmacy schools. Comparison of Index of Relative Social Advantage and Disadvantage for local government areas in these practice locations. Association between Modified Monash Model for hometown and Australian practice locations for domestic James Cook University pharmacy graduates., Results: Of 973 James Cook University pharmacy graduates, 640 (65.8%) practised within Queensland in 2019. Compared to other Australian pharmacy graduates practising in Queensland at this time, James Cook University graduates had significantly higher odds of practising in local government areas with greater social disadvantage (lower Index of Relative Social Advantage and Disadvantage indices [<975]) and in rural and remote locations. Of 822 domestic James Cook University graduates, 84.5% were from a regional, rural or remote area, and compared to their hometown Modified Monash Model classification, two-thirds of these graduates practised in settings with the same or more rural Modified Monash Model classification., Conclusions: This study indicates that regional pharmacy schools have potential to attract and retain graduates in regional, rural and remote areas, including disadvantaged and/or rural towns., (© 2020 National Rural Health Alliance Ltd.)

Background: The care of rural trauma patients in northern Alberta can be extremely challenging because of the vast geographic area, the limited access to health care facilities and the lack of adequate resources to manage severe injuries. Identifying gaps in equipment and personnel in rural centres can provide opportunities for improving the care of injured patients in these environments. We conducted a survey based on Canadian Accreditation Council quality indicators to evaluate trauma infrastructure and human resources in rural centres across northern Alberta., Methods: A standardized survey was developed to assess the availability of trauma-specific equipment and personnel across the prehospital and emergency department (ED) settings. The survey was distributed to 50 peripheral hospitals biannually from January 2017 to September 2018. Two-tailed paired t tests were used to evaluate changes in survey responses; a p value of less than 0.05 was considered statistically significant., Results: The survey response rate was 100%. By the end of the study period, there were significant improvements in the number of providers (p = 0.04), nurses (p = 0.01) and dedicated trauma resuscitation bays (p = 0.04) in the ED for managing injured patients. There were also significant increases in the availability of equipment, including advanced airway management tools (p = 0.02), rapid infusion devices (p = 0.02) and warmers (p = 0.04). Access to x-ray equipment (p = 0.03) and computed tomography (CT) scanners (p = 0.04) as well as equipment to support telehealth and teleconferencing (p = 0.04) increased during the study period. Access to, and supply of, blood products also increased significantly (p = 0.02) during the study period., Conclusion: Our study demonstrates that the trauma resources of rural health care centres may be evaluated in a standardized fashion centres, and the results point to opportunities to remedy gaps in equipment and personnel. Our methods may be applied to any trauma network that serves geographically large areas with a sparse distribution of health care facilities, to provide critical information for the optimization of resources in rural trauma., Competing Interests: None declared., (© 2020 Joule Inc. or its licensors.)

Chronic health workforce shortages significantly contribute to unmet health care needs in rural and remote communities. Of particular and growing concern are shortages of allied health professionals (AHPs). This study explored the contextual factors impacting the recruitment and retention of AHPs in rural Australia. A qualitative approach using a constructivist-interpretivist methodology was taken. Semi-structured interviews (n = 74) with executive staff, allied health (AH) managers and newly recruited AHPs working in two rural public health services in Victoria, Australia were conducted. Data was coded and categorised inductively and analysed thematically. The findings suggest that to support a stable and sustainable AH workforce, rural public sector health services need to be more efficient, strategic and visionary. This means ensuring that policies and procedures are equitable and accessible, processes are effective, and action is taken to develop local programs, opportunities and supports that allow AH staff to thrive and grow in place at all grade levels and life stages. This study reinforces the need for a whole-of-community approach to effectively support individual AH workers and their family members in adjusting to a new place and developing a sense of belonging in place. The recommendations arising from this study are likely to have utility for other high-income countries, particularly in guiding AH recruitment and retention strategies in rural public sector health services. Recommendations relating to community/place will likely benefit broader rural health workforce initiatives.

Introduction: Shortage of health workers is a worldwide problem but is particularly critical in sub-Saharan Africa. In Mali, the number of health workers is insufficient and their retention is low, particularly in rural and remote areas. Rural postings are unattractive to health workers. Very few studies have examined the factors contributing to the shortage and poor retention of health workers in Mali. The objective of this study is to identify and understand these factors with regards to skilled health workers in two rural health districts (Y&eacute;liman&eacute; and Bafoulab&eacute;) in the region of Kayes, Mali., Methods: This qualitative study is based on the conceptual framework of Lehman, Dieleman and Martineau. Data were collected through 46 in-depth interviews with health workers and decision-makers. A thematic content analysis was conducted with the support of QDA Miner software., Results: The study identified factors contributing to the insufficient allocation and poor retention of rural health workers in these districts. They are individual-level factors (gender, family situation, age), unattractive living and working conditions, community recognition and participation, quality of leadership, an unfavourable recruitment/assignment process and insufficient financial incentives. It shows that female staff have specific constraints that prevent them from deploying to or staying in rural areas for long periods. In addition, the number of staff recruited at the national level is unpredictable and insufficient, while their recruitment and assignment process is perceived to be inequitable and not very transparent, disadvantaging rural health structures. Some strategies were identified to improve the availability and retention of health workers in these areas. They take into account certain social norms, notably gender roles, and include the improvement of living and working conditions, as well as the strengthening of health workforce management., Conclusion: This study's findings highlight the multifaceted nature of factors contributing to the availability and retention of health workers in rural and remote areas of sub-Saharan Africa and the challenges associated with them. This study identifies some strategies that can be combined to facilitate the retention and availability of health workers in these areas. Some strategies involve actors outside the health sector, requiring joint efforts for their implementation. This research provides decision-makers with evidence to support informed decision making with regards to the retention of health workers in rural areas.

Background: Accessibility of healthcare in rural areas is globally impeded by physical, material, human, financial and managerial resources and societal barriers in the healthcare system. Developing countries like Zimbabwe are significantly affected., Aim: The aim of this article was to share the perspectives of nurses and healthcare users (HCUs) in the rural areas of Zimbabwe with regard to the accessibility of healthcare., Setting: The study was conducted at 45 rural health facilities in Chegutu district, Mashonaland West province and Masvingo district in Masvingo province, Zimbabwe., Methods: A self-administered questionnaire (for professional nurses) and a structured interview questionnaire (for HCUs) were utilised to gather data in a cross-sectional survey. Two districts were randomly sampled from 59 districts. All nurses working in 45 public health facilities in the selected two districts, who were willing and available to participate, were included. Ninety nurses participated in the study. The HCUs were selected through a multistage sampling technique. The sample size for HCUs was calculated by using Dobson's formula, and 445 HCUs were included via convenience sampling., Results: Nurses reported challenges such as work overload because of staffing shortages (55%) and the supply of necessary medical drugs that lacked consistency in both the quantity and type ordered(46.7%). The challenges faced by HCUs included long distances from villages to health facilities (86%), unaffordability of transport costs and lack of access to medical drugs (59.95%), causing them to seek assistance from traditional healers (43%)., Conclusion: Both the nurses and HCUs perceived grave challenges regarding access to health facilities, health workers and medical drugs, all of which are bound to have an impact on the health of communities in rural Zimbabwe.

Introduction: Very little is known about the long term workforce outcomes, or factors relating to these outcomes, for nursing and allied health rural placement programs. The positive evidence that does exist is based on short term (1-3 year) evaluations, which suggest that undergraduate rural placements are associated with substantial immediate rural practice of 25-30% graduates practising rurally. These positive data suggest the value of examining long term practice outcomes, since such data are necessary to providing an evidence base for future workforce strategies. The objective was to measure long term (15-17 year) rural practice outcomes for nursing and allied health graduates who had completed an undergraduate rural placement of 2-18 weeks through a university department of rural health (UDRH)., Methods: This was a longitudinal cohort study, with measures taken at the end of the placement, at one year and at 15-17 years post-graduation. Participants were all nursing and allied health students who had taken part in a UDRH rural placement, who consented to be followed up, and whose practice location was able to be identified. The main outcome measure was factors associated with location of practice as being either urban (RA 1) or rural (RA 2-5)., Results: Of 776 graduates initially surveyed, 474 (61%) were able to be contacted in the year after their graduation, and 244 (31%) were identified through the Australian Health Practitioner Regulation Agency, 15-17 years later. In univariate analysis at the first graduate year, previously lived rural, weeks in placement, discipline and considering future rural practice all had significant relationships with initial rural practice. In multivariate analysis, only rural background retained significance (odds ratio (OR) 3.19, confidence interval (CI) 1.71-5.60). In univariate analysis 15-17 years later, previously lived rural and first job being rural were significantly related to current rural practice. In multivariate analysis, only first job being rural retained significance (OR 11.57, CI 2.77-48.97)., Conclusion: The most significant long term practice factor identified in this study was initial rural practice. This suggests that funding to facilitate a rural pathway to not just train but also support careers in rural nursing and allied health rural training, similar to that already established for pharmacy and medicine, is likely to have beneficial long term workforce outcomes. This result adds to the evidence base of strategies that could be implemented for the successful development of a long term rural health workforce.

Background: One of the key barriers to health in rural areas is health workforce. Poor understanding and communication about health workforce across all stakeholder groups (including the broad community) is very common and can negatively affect the health workforce, recruitment, experiences and outcomes., Hypothesis: In this paper, we propose the concept of literacy about health workforce. We propose this as a specific, actionable extension of the existing and well accepted health literacy concept. We hypothesise that improving literacy about health workforce will improve, in particular, rural health workforce recruitment, retention and capability., Implications of the Hypothesis: We propose that literacy about health workforce is important for all members of the health and broader system (e.g. local GP, mayor, workforce agency, health manager, Aboriginal health worker, carers, community health facilitators, patients, schools, local businesses, cultural and recreation groups) because we hypothesise their literacy about health workforce affects their capacity to make informed decisions and take action to manage their health workforce needs in direct synchrony with the community's health needs. We hypothesise that improving literacy about health workforce will improve the effectiveness and efficiency of attracting, recruiting, training, and retaining a high quality, capable, health workforce, and further, will support the development and acceptance of innovative solutions to health workforce crises such as new models of care. This hypothesis is action orientated, is testable and includes the consideration of methods to engage and improve literacy of those within and external to the health workforce.

Background: Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention., Main Text: Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'., Conclusion: Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.

Background: Maternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers., Methods: Four rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework., Results: Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman's final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure., Conclusions: MWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs., Trial Registration: Clinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436.

Background: A competent, responsive, and productive health workforce is central to a well-performing health system capable of providing universal access to high-quality care. Ensuring health workers' psychological wellbeing is critical to sustaining their availability and productivity. This is particularly true in heavily constrained health systems in low- and lower-middle-income countries. Research on the issue, however, is scarce. This study aimed to contribute to filling the gap in knowledge by investigating levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi., Methods: The study relied on a cross-sectional sample of 174 health workers from 33 primary- and secondary-level health facilities in four districts of Malawi. Psychological wellbeing was measured using the WHO-5 Wellbeing Index. Data were analyzed using linear and logistic regression models., Results: Twenty-five percent of respondents had WHO-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived coworker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents' satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. Results were inconclusive in regard to personal relationship status, seniority and responsibility at the health facility, clinical knowledge, perceived competence, perceived supervisor support, satisfaction with job demands, health facility level, data collection year, and exposure to performance-based financing., Conclusions: The high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, our results underline the importance of considering this as a key concern for human resources for health.

Introduction: Physician shortages in rural regions of OECD countries has led to the development of regulatory, financial, educational and tailored interventions designed to reduce physician shortages. Studies evaluating these interventions report weak or inconclusive results. The objective of this research is to examine the strategic relevance of the interventions by identifying and prioritizing the determinants of physician shortages and analyzing the interventions based on their ability to target the determinants., Methods: First, the determinants of physician shortages were identified and categorized using Mays et al's 2005 method for reviewing qualitative literature. Second, the determinants were prioritized based on importance, severity and solvability, using Lehmann et al's multilevel categorization of factors affecting attraction and retention. Third, the interventions were analyzed based on their ability to target the determinants through a document analysis as descriptive commentary from a policy analysis perspective., Results: Three individual and 10 contextual (work, rural or international context) determinants of physician shortages were identified. Non-rural background, inadequate training and inadequate incentive structure were prioritized as level 1. Lack of professional support, poor work infrastructure and personal interests were prioritized as level 2. Poor rural infrastructure, inadequate supply planning and cultural difference were prioritized as level 3. Non-minority background, geography and climate, global migration and aging population were prioritized as level 4. Establishing rural medical schools targets the greatest number of priority determinants, followed by financial interventions targeting practicing physicians and non-traditional health services delivery strategies. Curriculum changes, professional support strategies, selective admission to medical schools, financially targeting student physicians and coercive regulatory measures follow. Community support strategies target the fewest number of determinants and trickle-down economic regulation targets none., Conclusion: Strategic analysis demonstrates that most interventions designed to reduce physician shortages in rural regions are strategically relevant because they address the priority determinants of physician shortages. A link is established between the determinants of physician shortages and the interventions, thereby addressing an important concern expressed in the literature. An original contribution is made to health human resources literature by relying on established theoretical frameworks to achieve a strategic analysis of the interventions.

Background: St. Boniface Hospital (SBH) plays a critical role in providing safe, accessible surgery in rural southern Haiti. We examine the impact of SBH increasing surgical capacity on case volume, patient complexity, and inpatient mortality across three phases., Materials and Methods: A retrospective review and geospatial analysis of all surgical cases performed at SBH between 2015 and 2017 were performed. Inpatient mortality was defined by in-hospital deaths divided by the number of procedures performed., Results: Between February 2015 and August 2017, over 2000 procedures were performed. The average number of surgeries per week was 3.1 with visiting surgical teams in phase 1 (P1), 10.4 with a single general surgeon in phase 2 (P2), and 20.1 with two surgeons and a resident in phase 3 (P3). There was a six-fold increase in surgical volume between P1 and P3 and a significant increase in case complexity. The distribution of American Society of Anesthesiologists scores of 1, 2, 3, and 4 during P2 was 81.05%, 14.74%, 3.42%, and 0.79%, respectively, whereas in P3, the distribution was 68.91%, 22.55%, 7.70%, and 0.84%. Surgical mortality was 0%, 1.2%, and 1.67% across phases., Conclusions: Increasing resources and surgical staff at SBH allowed for greater delivery of safe surgical care. This study highlights that investing in surgery has a significant impact in regions of great surgical need., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The impact of new medical graduates on the social dimensions of the rural medical workforce is yet to be examined. Social Network Analysis (SNA) is able to visualize and measure these dimensions. We apply this method to examine the workforce characteristics of graduates from a representative Australian Rural Clinical School., Methods: Participants were medical graduates of the Rural Clinical School of Western Australia (RCSWA) from the 2001-2014 cohorts, identified as being in rural work in 2017 by the Australian Health Practitioner Regulation Agency. SNA was used to examine the relationships between site of origin and of work destination. Data were entered into UCInet 6 as tied pairs, and visualized using Netdraw. UCINet statistics relating to node centrality were obtained from the node editor., Results: SNA measures showed that the 124 of 709 graduates in rural practice were distributed around Australia, and that their practice was strongly focused on the North, with a clear centre in the remote Western Australian town of Broome. Women were strongly recruited, and were widely distributed., Conclusions: RCSWA appears to be a "weak tie" according to SNA theory: the School attracts graduates to rural nodes where they had only passing prior contact. The multiple activities that comprise the social capital of the most attractive, remote, node demonstrate the clear workforce effects of being a "bridge, broker and boundary spanner" in SNA terms, and add new understanding about recruiting to the rural workforce.

Introduction: Previous studies show that supply of behavioral health professionals in rural areas is inadequate to meet the need. Measuring shortage using licensure data on psychiatrists is a common approach. Although inexpensive, the licensure data have many limitations. An alternative is to implement an active surveillance system, which uses licensure data in addition to active data collection to obtain timely and detailed information., Methods: Nebraska Health Professions Tracking Service (HPTS) data were used to examine differences in workforce supply estimates between the passive (licensure data only) and active (HPTS data) surveillance systems. The impact of these differences on the designation of psychiatric professional shortage areas has been described. Information regarding the number of psychiatrists, advanced practice registered nurses and physician assistants specializing in psychiatry was not available from the licensure database, unlike HPTS., Results: Using licensure data versus HPTS data to estimate workforce, the counts of professionals actively practicing in psychiatry and behavioral health were overestimated by 24.1-57.1%. Ignoring work status, the workforce was overestimated by 10.0-17.4%. Providers spent 54-78% of time seeing patients. Based on primary practice location, 87% of counties did not have a psychiatrist and 9.6% were at or above the Health Professional Shortage Area designation ratio of psychiatrists to population., Conclusion: Enumeration methods such as ongoing surveillance, in addition to licensure data, curtails the issues and improves identification of shortage areas and future behavioral workforce related planning and implementation strategies.

Mental illness is a leading cause of disability with many public health implications. Previous studies have demonstrated a national shortage of psychiatrists, particularly in rural areas. An analysis of how this workforce distribution relates to population demographics and public/behavioral health is lacking in the literature. This study encompassed a statewide assessment of the Indiana psychiatric workforce as it relates to population characteristics and public/behavioral health. This study's findings demonstrate a profoundly low psychiatry workforce in rural counties of Indiana. The low psychiatry workforce capacity in rural counties is so disparate that the demographic and public/behavioral health characteristics differ from the State averages in the same manner as counties without a psychiatrist at all. The psychiatric workforce distribution did not differ significantly on the basis of poverty prevalence. The potential utility of indicators of population health was also evaluated and revealed that social factors such as poverty and Medicaid prevalence may be superior to more traditional measures.

Government doctor absenteeism from their public posts is a sizable problem across developing economies. The consumer demand estimation for outpatient fever treatment presented in this paper investigates the interrelationship between government doctor absenteeism and the large informal healthcare sector. Using a counterfactual framework, this paper estimates treatment effect of eliminating government doctor absenteeism. The effects are measured by changes to the market share of government Bachelor of Medicine and Bachelor of Surgery (MBBS) providers and resulting own-price elasticities of demand for government MBBS providers and unqualified providers. Modelling incorporates patients expected health outcomes by provider via the use of a qualitative measure of word-of-mouth recommendations. Results indicate that eliminating government MBBS provider absenteeism in North India would increase utilisation of government outpatient fever treatments from 18% to 50%., (© 2019 John Wiley & Sons, Ltd.)

The vast distances across Australia and the uneven population distribution form a challenging environment in providing the population with health and dental care. The Australian dental workforce distribution was analysed by using statistics from the open Census source available on the Australian Bureau of Statistics (ABS) website. This study aimed to construct a detailed analysis of the large differences in the practice-to-population (PtP) ratios across Australia, as well as the effect of maldistribution for rural and remote areas, where economics plays an important role. The national Census data at the level of Statistical Area Level 2 (SA2) (approximating suburbs) from 2011 was integrated with the location of all private dental practices in Australia (collected in late 2015) using modern geographic tools. All private dental practice (n=7597) location coordinates were mapped nationwide, across 2157 statistical areas. The population in Australia without a dental practice in their area was 31.6%. The PtP ratio differed from one practice per 40 people to one practice per 27773 people. The nationwide calculation of the PtP ratio shines light on issues about the dental workforce. The study results confirmed the uneven distribution of dental practices in rural and remote areas and socioeconomically disadvantaged areas.

Introduction: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background., Methods: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated., Results: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system &#40;ASGC, MMM&#41; used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally., Conclusion: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Background: Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment., Methods: An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access -spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning., Results: 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion., Conclusions: Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

Background: Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers' views on privacy and satisfaction with quality of care were also assessed., Methods: The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes., Results: The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women's satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges., Conclusion: Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage.

Despite its increasing urbanization, North Carolina still has a large rural population that lacks optimal health care. While multiple programs have been successful in recruiting clinicians to rural communities, improving the retention of those clinicians will require the development and implementation of novel strategies along with the evaluation of their effectiveness., (©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

For most health professions, rural North Carolina has lower relative supply than urban parts of the state. Although there are plenty of innovative models addressing this disparity, a holistic approach is necessary if we want to effect real change., (©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities - in terms of context, contents, actors, and processes., Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping., Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector)., Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: We study healthcare employees' turnover intentions in the Afar National Regional State of Ethiopia. This rural region is experiencing the globally felt crisis in human resources, which is inhibiting its ability to meet health-related sustainable development goals., Methods: Realist case study which combines literature study and qualitative analysis of interview and focus group discussion data, following a realist case study protocol., Results: A large majority of employees has turnover intentions. Building on Herzberg's two-factor theory, person-environment fit theory, as well as recent sub-Saharan evidence, analysis of the collected data yields four turnover mechanisms: (1) lack of social and personal opportunities in the region, (2) dissonance between management logic and professional logic, (3) standards of service operations are hard to accept, and (4) lack of financial improvement opportunities., Conclusions: While the first and fourth mechanisms may be out of reach for local (human resource) management interventions, the second and third mechanisms proposed to explain health workforce turnover appear to be amenable to local (human resource) management interventions to strengthen healthcare. These mechanisms are likely to play a role in other remote sub-Saharan regions as well.

Background: Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived., Methods: We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status., Results: Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01)., Conclusions: Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care.

Background: Tasmania established its medical programme in 1965 to produce graduates to address medical workforce recruitment challenges. Many Tasmanian graduates work in Tasmania, but workforce problems continue. This paper reports the workforce outcomes of the first 42 graduating cohorts., Methods: A database for all University of Tasmania medical graduates from the years 1970 to 2011 was developed by combining information from university, registration and local workforce survey databases., Results: A total of 2012 doctors graduated from 1971 to 2011 and 1707 (85%) were registered, most commonly in general practice (45.8%), medicine (13%), anaesthetics (7.9%), surgery (7.5%), psychiatry (4.3%), emergency medicine (35, 3.5%), paediatrics (3.4%) and pathology (3.3%). While 41.9% worked in Tasmania, they comprised 35.6% of the local workforce and were clustered around the two larger cities. The proportion entering general practice has fallen since 1980s., Discussion: The contribution of the Tasmanian medical programme is substantial but appears less than other regional medical schools. Relatively few work in smaller communities, particularly in specialties other than general practice. Lifestyle choices and the availability of training opportunities and career positions might be contributing factors. The medical school has established clinical schools in rural communities, promoted admission of rural applicants and increased rural clinical placement opportunities, with some early signs of success., Conclusion: The Tasmanian medical programme is important in this regional, island economy, but the rural and remote communities have not benefited as much as the two larger cities. Sustaining a regional workforce mission over time might require frequent adjustments to admissions and curriculum processes., (© 2017 National Rural Health Alliance Inc.)

Objectives Regional centres and their rural hinterlands support significant populations of non-metropolitan Australians. Despite their importance in the settlement hierarchy and the key medical services provided from these centres, little research has focused on their issues of workforce supply and long-term service requirements. In addition, they are a critical component of the recent growth of 'regional' hub-and-spoke specialist models of service delivery. Methods The present study interviewed 62 resident specialists in four regional centres, seeking to explore recruitment and retention factors important to their location decision making. The findings were used to develop a framework of possible evidence-informed policies. Results This article identifies key professional, social and locational factors, several of which are modifiable and amenable to policy redesign, including work variety, workplace culture, sense of community and spousal employment; these factors that can be targeted through initiatives in selection, training and incentives. Conclusions Commonwealth, state and local governments in collaboration with communities and specialist colleges can work synergistically, with a multiplicity of interdigitating strategies, to ensure a positive approach to the maintenance of a critical mass of long-term rural specialists. What is known about the topic? Rural origin increases likelihood of long-term retention to rural locations, with rural clinical school training associated with increased rural intent. Recruitment and retention policy has been directed at general practitioners in rural communities, with little focus on regional centres or medical specialists. What does this study add? Rural origin is associated with regional centre recruitment. Professional, social and locational factors are all moderately important in both recruitment and retention. Specialist medical training for regional centres ideally requires both generalist and subspecialist skills sets. Workforce policy needs to address modifiable factors with four groups, namely commonwealth and state governments, specialist medical colleges and local communities, all needing to align their activities for achievement of long-term medical workforce outcomes. What are the implications for practitioners? Modifiable factors affecting recruitment and retention must be addressed to support specialist models of care in regional centres. Modifiable factors relate to maintenance of a critical mass of practitioners, training a fit-for-purpose workforce and coordinated effort between stakeholders. Although remuneration is important, the decision to stay relates primarily to non-financial factors.

Purpose: The shortage of trained health care personnel has been increasing worldwide. With the physician assistant (PA) profession, created in the United States in the 1960s, expanding globally, this study sought to ascertain whether PAs can be an innovative solution to this crisis., Methods: We conducted a convenience sample survey to assess the need for and acceptability of future PA professionals in Guatemala. Eighty-nine doctors, nurses, and community members from rural and urban areas of Guatemala participated in the survey., Results: More urban (70%) than rural (58%) respondents found it difficult to access a doctor, with cost being the major reason (34%). Access in rural areas was reportedly limited by lack of doctors and inaccessible office hours., Conclusions: Most survey respondents considered PAs to be suitable and potentially helpful providers for Guatemala, with a preference for competencies in the diagnosis of serious illnesses, drug prescription, labor and delivery attendance, and care for injuries and fractures, especially in rural locations. Belonging to the community was deemed very important for a PA who would practice in the country.

Objective: To understand factors affecting specialty heterogeneity in physician migration., Data Sources/study Setting: Physicians in the 2009 American Medical Association Masterfile data were matched to those in the 2013 file. Office locations were geocoded in both years to one of 293 areas of the country. Estimated utilization, calculated for each specialty, was used as the primary predictor of migration. Physician characteristics (e.g., specialty, age, sex) were obtained from the 2009 file. Area characteristics and other factors influencing physician migration (e.g., rurality, presence of teaching hospital) were obtained from various sources., Study Design: We modeled physician location decisions as a two-part process: First, the physician decides whether to move. Second, conditional on moving, a conditional logit model estimates the probability a physician moved to a particular area. Separate models were estimated by specialty and whether the physician was a resident., Principal Findings: Results differed between specialties and according to whether the physician was a resident in 2009, indicating heterogeneity in responsiveness to policies. Physician migration was higher between geographically proximate states with higher utilization for that specialty., Conclusions: Models can be used to estimate specialty-specific migration patterns for more accurate workforce modeling, including simulations to model the effect of policy changes., (© Health Research and Educational Trust.)

Objective: To describe the distribution of Veterans in areas of the United States where there are potentially inadequate supplies of health professionals, and to explore opportunities suggested by this distribution for fostering health workforce flexibility., Data Sources: County-level data from the 2015-2016 Health Resources and Services Administration's (HRSA's) Area Health Resources Files (AHRF) were used to estimate Veteran populations in HRSA-designated health professional shortage areas (HPSAs). This information was then linked to 2015 VA health facility information from the Department of Veterans Affairs., Study Design: Potential Veteran populations living in Shortage Area Counties with no VHA facilities were estimated, and the composition of these populations was explored by Census division and state., Principal Findings: Nationwide, approximately 24 percent of all Veterans and 23 percent of Veterans enrolled in VHA health care live in Shortage Area Counties. These estimates mask considerable variation across states., Conclusions: An examination of Veterans residing in Shortage Area Counties suggests extensive maldistribution of health services across the United States and the continued need to find ways to improve health care access for all Veterans. Effective avenues for doing so may include increasing health workforce flexibility through expansion of nurse practitioner scopes of practice., (© Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Information and communication technologies have become a vital infrastructural asset for use in the retention of rural health workers. However, little is known about the potential influence of ICT use, perceptions of health workers on ICT in healthcare delivery, and contribution of ICT to health care providers' retention in rural and remote areas in rural post-war and conflict situations of northern Uganda., Methods: Data from interviews were transcribed, coded and thematically analysed., Results: Participants generally exhibited low confidence, knowledge and low ICT skills. Majority of participants, however, perceived ICT as beneficial in relation to job performance and health care provider retention in rural areas. Common barriers for the implementation and use of ICT in health centres were inadequate ICT knowledge and skills, poor Internet networks, inadequate computers, inadequate power supply, lack of Internet Modems and expensive access to outside computer centres., Conclusions: This qualitative study showed low confidence, poor knowledge and skills in ICT usage but positive perceptions about the benefits and contributions of ICT. These findings suggest the need for specific investment in ICT infrastructural development for health care providers in remote rural areas of northern Uganda.

Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status. Nowhere is the worldwide shortage of health professionals more pronounced than in rural areas of developing countries. Sub-Saharan Africa (SSA) includes a disproportionately large number of developing countries; therefore, this article explores SSA in depth as an example. Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from underserviced areas to deliver quality health care in rural community settings.

Creating a stable and sustainable health workforce in regional, rural and remote Australia has long been a challenge to health workforce planners, policy makers and researchers alike. Traditional health workforce planning is often reactive and assumes continuation of current patterns of healthcare utilisation. This demonstration project in Far North Queensland exemplifies how participatory regional health workforce planning processes can accurately model current and projected local workforce requirements. The recent establishment of Primary Health Networks (PHNs) with the intent to commission health services tailored to individual healthcare needs underlines the relevance of such an approach. This study used action research methodology informed by World Health Organization (WHO) systems thinking. Four cyclical stages of health workforce planning were followed: needs assessment; health service model redesign; skills-set assessment and workforce redesign; and development of a workforce and training plan. This study demonstrated that needs-based loco-regional health workforce planning can be achieved successfully through participatory processes with stakeholders. Stronger health systems and workforce training solutions were delivered by facilitating linkages and planning processes based on community need involving healthcare professionals across all disciplines and sectors. By focusing upon extending competencies and skills sets, local health professionals form a stable and sustainable local workforce. Concrete examples of initiatives generated from this process include developing a chronic disease inter-professional teaching clinic in a rural town and renal dialysis being delivered locally to an Aboriginal community. The growing trend of policy makers decentralising health funding, planning and accountability and rising health system costs increase the future utility of this approach. This type of planning can also assist the new PHNs to commission health services that meet the needs of the population and contribute to service and system improvement and innovation.

Context: Maintaining an adequate health workforce in rural and remote Australia is challenging. The Australian Government has addressed this challenge by encouraging the admission of rural background students and supporting the growth of regionally based academic health faculties and clinical schools., Issue: It is imperative to assess the relevance and effectiveness of regionally based academic health faculties and clinical schools so standards can be maintained and health workforce supply and distribution can be maximised to benefit local populations., Approach: The James Cook University (JCU) College of Medicine and Dentistry, the first regional Australian medical school, has developed a longitudinal tracking system for its medical graduates. Processes include administering an exit survey to each cohort immediately prior to graduation (which also collects each graduate's details and consent to be contacted for follow-up studies and practice/career choice data), a FacebookTM page to search for hard-to-trace graduates, and accessing the Australian Health Practitioner Regulation Authority (AHPRA) website., Conclusions: The comprehensive personal contact tracking system backed by the AHPRA website has resulted in a 98% complete longitudinal tracking database, and thus a comprehensive picture of the practice location of JCU medical graduates from 2006 to 2013, enabling exploration of the patterns of practice to be conducted with considerable confidence. It is intended that the tracking database will be maintained for many years to allow regular follow-up of graduates well into their established careers. However, as graduate numbers increase at the JCU medical school, personal contact will be made with the majority of graduates on a less frequent basis.

Introduction: The regionally based James Cook University (JCU) College of Medicine and Dentistry aims to meet its mission to address the health needs of the region by using a selection policy favouring rural origin applicants and providing students with early and repeated exposure to rural experiences during training. This study seeks to determine if the JCU medical school's policy of preferentially selecting rural and remote background students is associated with differing patterns of undergraduate performance or graduate practice location., Methods: Data at application to medical school and during the undergraduate years was retrieved from administrative databases held by the university and the medical school. Postgraduate location data were obtained either from personal contact via email, telephone or Facebook or electronically from the Australian Health Practitioner Regulation Authority website. Practice location was described across Australian Standard Geographical Classification Remoteness Area (ASGC-RA) categories, with 1 being a major city and 5 being a very remote location., Results: The 856 Australian-based students accepted into the JCU medical program between 2000 and 2008 came from all geographical regions across Australia: 20% metropolitan (ASGC-RA 1), 20% inner regional (ASGC-RA 2), 56% outer regional (ASGC-RA 3), and 5% from remote or very remote locations (ASGC-RA 4 and 5). Having a rural or remote hometown at application (ASGC-RA 3-5) was significantly associated with a lower tertiary entrance score (p<0.001), a lower interview score in the medical school selection process (p<0.001), being less likely to be admitted into the Honours program (p=0.001), being an advanced standing student (p=0.025), being awarded a Medical Rural Bonded Scholarship (p=0.005), taking longer to complete the 6-year course (p=<0.009) and having a lower academic achievement across years 1 to 3 (p=0.002, p=0.005 and p=0.025, respectively). Graduates having either a rural or a remote home town at application were more likely to practise in rural (RA 3-5) towns than graduates from metropolitan/inner regional centre across all postgraduate years. For example, the prevalence odds ratios (POR) for graduates practising in a rural town at postgraduate year 1 (PGY 1) having either a rural or remote hometown were 2.6 and 1.8, respectively, times that of graduates having a metropolitan/inner regional hometown, while at PGY 9 the PORs had increased to 4.2 and 9.5, respectively. Bonded medical place students showed many similar trends to rural students in both their pre-medical school and undergraduate performance indicators but lower engagement in rural practice in the 5 years of data available., Conclusions: Some significant differences were noted between rural and remote origin students and metropolitan or inner regional origin students in terms of academic achievement in the first 3 years of the course and length of time taken to complete the course. However, this group of rural and remote-origin students seems to do just as well in the exams in the clinical years (years 4-6) and are much more likely to practise in rural and remote areas. These data suggest that JCU's selection process favouring rural origin applicants does not compromise academic standards, but does produce graduates whose patterns of practice accord with the mission of the school.

Introduction: The aim of this study was to identify the preference of Indonesian medical students to work in rural areas, to enroll in the (PTT; which means 'temporary employment') program, and to identify factors that influence their choice of a preferred future practice area. Under the PTT program, doctors are obliged to work as temporary staff on a contract basis for a certain period in a rural area of Indonesia., Methods: The study design was cross-sectional and a total sampling method was used. The subjects were year 4 and 5 medical students from the Faculty of Medicine at Universitas Indonesia and had already been exposed to clinical practice rotations within their education program. Students rated the importance of 21 factors influencing their future workplace preference using a questionnaire with a five-point Likert scale., Results: A total of 310 students (83.3%) responded to the questionnaire. The authors found that 27 out of 310 (8.71%) subjects wanted to work in rural areas, while 128 out of 264 (48.5%) students who chose other than rural areas wanted to enroll in the PTT program. A previous experience of living in rural areas seemed to be the only factor favouring students' choice to have future practice in rural areas (adjusted odds ratio (OR) 3.20, 95% confidence interval (CI) 1.27-8.08, =0.01). Factors that influenced respondents to say they didn't intend to practice rurally were the influence of spouse (adjusted OR 0.38, 95%CI 0.16-0.89, =0.03), and the opportunities for career advancement (adjusted OR 0.28, 95%CI 0.11-0.73, =0.009). The choice of enrollment in the PTT program was positively associated with opportunity for an academic career (adjusted OR 2.39, 95%CI 1.27-4.50, =0.007) and negatively associated with proximity to family/friends (adjusted OR 0.38, 95%CI 0.22-0.65, 0.001)., Conclusions: Only 8.7% of the students were interested in rural areas for their future practice location. Multiple factors were associated with students' interest to choose a career in rural areas later, after graduation from medical school.

Township hospitals, the main provider of rural primary healthcare in China, are severely understaffed. International studies on factors influencing rural working are increasing; however, studies on factors affecting the recruitment and retention of health workers in Chinese township hospitals are limited. The current study aims to understand the motivation of health workers and arrive at a systematic framework of pluralistic factors that would help support health workers in terms of receiving posts and remaining in posts in township hospitals. A three-stage integrated quantitative and qualitative methodology was employed. First, a survey on 120 directors of township hospitals was conducted to learn the latest status of health workers in township hospitals and distinguish existing problems. Second, after sending these problems back to the directors, an open-ended pen-and-paper survey was conducted to ask the directors to identify the factors influencing the attraction and retention of health workers in township hospitals. Third, four focus groups were conducted to gauge the underlying reasons. Five problems from the questionnaire survey were recognized, and numbers of thematic factors were identified at the individual, professional, and treatment environment from the pen-and-paper survey and focus group. Similar to other studies, this framing of both non-financial and financial elements affected the attraction and retention of health workers in township hospitals, thereby filling the gap in a Chinese context. Although several factors had been recognized earlier, our findings further highlighted the importance of these factors. Meanwhile, the factors identified in this study were barely explored in literature. This paper identifies and develops multi-faceted factors to call for a bundled package of multidimensional incentives if decision-makers get interested. The evidence-based findings in our study can be used to provide China-specific policy recommendations on how to recruit and retain health workers in rural areas of China.

Background: Despite growing recognition of the massive surgical burden of disease, unmet need, and disparities in access to care in many African countries, little is known about their capacity to deliver surgical, obstetric, emergency, and anesthetic care, particularly in the rural areas where up to 50% of the population lives. This study aimed to quantify the surgical capacity of select healthcare facilities in rural southern Nigeria in five key areas: Workforce, Infrastructure, Skill, Equipment, and Supplies., Methods: We assessed the surgical capacity of 41 private, rural hospitals in southern Nigeria using the Personnel, Infrastructure, Procedures, Equipment, and Supplies survey tool developed by Surgeons OverSeas. The survey was administered to surgical practitioners during their annual conference in November 2011., Results: Among the 41 hospitals surveyed, general practitioners (52.1%) constituted most of the surgical workforce. Only one anesthesiologist was available in 16 secondary hospitals. Although most of the primary and secondary hospitals had running water (82.3%), a designated emergency room (80.5%), and medical records (95.9%), only 50.3% of all hospitals had electricity through the power grid. Also, only 37.5% of all facilities had a blood bank and 43.8% had an X-ray machine. Common surgical procedures were done by most of the facilities; however, cricothyroidotomy, clubfoot repair, and obstetric fistula repair were scarcely done. Less than half of the facilities provided general anesthesia, only 20% have an anesthesia machine, and 44.5% have a pulse oximeter., Conclusion: Severe shortages in key areas should motivate stakeholders to devote more effort and resources to strengthening surgical capacity in rural southern Nigeria.