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Researches Human resources for health
DETERMINANTS OF THE ABILITY TO ATTRACT AND RETAIN HEALTH WORKERS AT GRASSROOTS LEVEL IN SPECIFIC MOUNTAINOUS PROVINCES

Trần Thị Mai Oanh, Nguyễn Thị Thắng, Nguyễn Hoàng Giang,

Dương Huy Lương, Hoàng Thu Thủy
 
Place of publication: Ministry of Health
Year of publication: 2012
 
Introduction
 
Health workforce if one of the six most essential and vital components of health system, of which, human resources are invariable considered the core of the entire system. Challenges in health human resources development are the common challenges to the health system of all countries in the world, especially developing countries. The World Health Organization have summarized the key issues of health human resources development that the Western Pacific is facing: Imbalanced human resources allocation, imbalanced human resources allocation by qualifications and competence, lack of strict quality control, incomplete and irrational regulatory framework on human resources, lack of effective leadership and management.
In the context of socioeconomic development toward a market economy in Vietnam, the local health system is also encountering similar challenges, where guaranteeing and maintaining quality human resources in rural areas and for the primary health care network is a major challenge and one of the top priorities of the health system in Vietnam. Reports of the Ministry of Health and recent literature on health human resources have also reflected the health workforce deficiency in rural areas, in terms of number, structure and quality of health workers, in which, a common problem in rural areas is the inability to recruit new health workers to compensate for the retired, leaving or relocating staff. This review will concentrate on factors influencing recruitment, maintenance and development of human resources for the primary health care service network in rural mountainous areas, focusing on managers and hands-on curative and preventive health workers at the population level. 
 
Objectives
1. To describe current situation health workforce at grassroot level in specific mountainous provinces; 
2. To explore some determinants of the ability to attract and retain frontline health workers in mountainous areas;
3. Evaluate the outcomes of specific health policies related to attracting and retaining health workforce at grassroot level in specific mountainous provinces; 
4. To assess implementation of some health policies related to attraction and retention of health workforces. To identify policy gaps that need revising to increase attraction and retention of the current  health workforce at grassroot level in mountainous areas. 
 
Methods
The review is conducted in four mountainous provinces, including Dien Bien, Bac Giang, Binh Dinh and Lam Dong. In each of the provinces, field activities were undertaken in two mountainous districts, and 2 communes in each district. 
This review employs a cross-sectional approach, combining collection of retrospective data, qualitative and quantitative data collection.
Targeted sampling was used, with participating 635 health workers (from 8 commune health centers (CHCs)/district hospitals and 16 CHCs). 
Findings
Current status of the health workforce in the four selected provinces: In 5 years (2007-2011), the ratio of doctor for every ten thousand population increased from 4.9 in 2007 to 5.7 in 2011, but was still lower than the country average of 7.2 (as of 2010). An analysis of staff quality by levels of care indicate that if with nearly similar number of hospital beds, the percentage of medical workers being doctors and Bachelor's pharmacists working in the province level almost doubles the district level (Dien Bien, Bac Giang and Ha Nam). Staff moving in the district level is higher than in the commune, mostly among official trained  doctors and pharmacists. In 5 years, resigned/leaving workers in the district level were about half of the new recruits in both the curative and preventive systems, while satff moving in the commune level was less severe (resigned/leaving staff equaling one third of new recruits). 
Determinants of the ability to attract and retain frontline health workers in mountainous areas: Findings reveal 5 key factors influencing the ability to attract and retain health workers in mountainous areas, including:
- Income: 61% of district health workers and 50.5% of commune health workers rate the current remuneration scheme as undesirable. Doctors account for 72.6% (statistically significant figure), higher than other groups.
- Inadequate allowances and bonuses: 40.6% of district and commune health workers are not happy with their current jobs because they think that the existing allowance and bonus system is less than optimal.
- Difficult working conditions: 26% of the participating doctors are not happy with their current jobs because the equipment and working conditions are not as good as they expect. Doctors rating infrastructure and equipment not meeting the required standards account for 18.9%, while the same rate with other job titles is only 10.2% (p < 0.05).
- Work environment: Evidence shows that as much as 21% of the respondents are not happy with their current jobs because of unsafe work environment; 19.5% others because of work overload; and 16% because of stress and excessive pressure. Doctors who are not happy with the current jobs for these reasons take up a higher percentage than other groups by 33% and 12% respectively, with statistically significant difference (p < 0.01).
- Less training opportunities: 38% of the respondents report the lack of short- and long-term training. Doctors account for about 24% of them. 
Findings indicate that to retain the health workforce at the population level, both determinants of income and being a local native should be satisfied. Health workers willing to work permanently at the district/commune level if salary/allowances are good account for 78.7%. Among those willing to have long-term commitment with frontline health care, 63.7% are local natives, while the figure for non-natives is only 43.6% (p < 0.05).
Results of implementation of specific financial incentives to attract  and retain  health workers at grassroots level: The study reviews the implementing results  of specific policies associated with financial and training incentives for frontline health workers, including Decree 64/2009/NĐ-CP, Decision 75/2009/QĐ-TTg, Decree 56/2011/NĐ-CP and Decision 1544/QĐ-TTg. The implementing process of these legislative instruments shows that they have had some positive impact on health workers. A few obvious gaps remain throughout the implementing process, including the lack of allowances for village health workers in urban wards and towns, adversely affecting performance in urban wards and towns. In the four surveyed provinces, in Lam Dong, there were 128 out of 152 units, compared to only 2 out of 216 units in Dien Bien where active village health worker have absolutely no pays. Selection of employees eligible for career allowances (under Decree 56/2011/NĐ-CP) also faces difficulty with those working in joint department or working on a part-time basis in district level hospitals, among others.
 
Conclusions
All the 4 provinces face challenges in drawing quality staff for district and commune frontline health. The district health workforce has more turnover than the communes, mostly among doctors and Bachelor’s pharmacists. Resigned/leaving employees equal about 50% of new recruits. 
Other vital elements for health workers to offer long-term commitment with the population level are: Adequate remuneration, being local natives or having families living locally, good working conditions and training opportunities;
The introduction of a few financial incentives for health workers has in general had some positive impact on those working in remote and far-flung areas. Field outcomes of the policies in some places are still impressive, including setbacks in interagency coordination in policy implementation. Health authorities in some places have not been really proactive in counseling and advocating relevant line agencies in the policy making process. 
 
Recommendations
For provincial level
- Local health authorities need to take initiatives in counseling and leveraging the support of related  agencies in the province in policy making and enforcement. Intersectoral  collaboration in enforcement needs to be strengthened. 
- Plans to monitor and supervise policy implementation to detect any weaknesses in the process to recommend timely remedies to the relevant authorities.
For Ministry of Health
- Collaborate with local authorities in monitoring and supervising the implementation of existing policies on the ground to identify in time weakness  in the implementation process and recommend relevant solutions and policy adjustments.
- Strengthen collaboration with related  ministries and line agencies in monitoring and supervising policies related  to health human resources training for disadvantaged areas, including selected training model.  
- Revise Decision 75/2009/QĐ-TTg on increasing inclusiveness (for village health workers) in especially disadvantaged areas to attract and retain the health workforce at grassroot level.
 
 
 

03/12/2013
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