A major challenge to the achievement of Millennium Development Goals is the shortage of health workers in the remote areas, especially in the developing countries where preventable disease burden is high. The aim of the study was to determine perceived factors contributing to non-stay of professional health workers in rural areas of Enugu state and strategies to retain them. The study was a descriptive, cross-sectional, questionnaire-based study carried out in randomly selected health districts of Enugu state. A total of 236 consenting professional health staff with at least two years working experience were randomly selected. A validated researcher developed questionnaire was used to obtain information from the respondents. Data were analysed using descriptive statistics and facilitated by the Statistical Package for the Social Sciences (SPSS version 17.0). Findings revealed that there were 70.8% females and 29.2% males in the study. Age distribution showed a mean age of 33.8 with a standard deviation of 8.23. Family tie was the most significant personal factor identified as contributing to non-stay of health workers (P<0.0005). Among the institutional factors affecting non-stay of health workers in rural areas, poor organizational policy and inadequate reward/ recognition were considered very strong reasons for non-stay (P<0.005). None of the community factors had a significant relationship with the staff decision to stay or not stay in the rural areas. Suggested strategies identified by respondents to retain health workers in rural areas included paying more to professionals working in rural areas (92.79%), provision of adequate security in the health centres (88.56%) and provision of rural allowance (92.79%). It is therefore recommended that the observed factors should assist stakeholders and government of Enugu State in formulating effective strategies that would improve retention of health workers in the rural areas. Postings to the rural areas should be rotational and preferably staff family locations should be considered. In addition, adequate remuneration and motivation for staff working in the rural areas should be considered as ways of improving shortage of professional health workers in the remote areas.
Background to the study.
The shortage of healthcare professionals in rural communities remains an intractable problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthier areas (Wilson, Couper & De Vries, 2009). Rural communities are on the average poorer, less educated and have higher disease burden; they also have worse access to health care than people in urban areas (Wilson, Reid, Fish, & Marais, 2009). This discrepancy between health care needs and service provision has been captured by Hart’s ‘inverse care law’, which states that those with the greatest health needs usually have the worst access to healthcare services (Flament, 2012). Rapid urbanization is a global phenomenon but it also poses particular health problems in developing countries with poor infrastructural development (Wilson, Reid, Fish & Marais, 2009). Improved access to healthcare should therefore be seen as an indicator of the level of development of any nation.
International attention has recently been drawn to the problems of attracting, retaining and motivating health workers in developing countries particularly in remote areas, which has created human resource for health (HRH) crisis (Williams, 2007). Health workers form the foundation of health service delivery and therefore the staff strength, skill and level of commitment are critical for the delivery of good, quality and effective health care (Serneels, Montalvo & Lievens, 2010). Renewed attention is being given to the role of geographical imbalances in the health workforce, a feature of nearly all health systems. This raises concerns about the equity in access to health care as well as the efficiency of allocation of human resources bearing in mind the impact on health outcomes (Petterson, Serneels, Aklilu & Butera, 2010). The issue is particularly relevant for developing countries with limited resources and poor health outcomes. Ultimately, the difficulties to attract and retain staff in rural facilities may also stem from the preferences and choice made by the health workers. Furthermore, a growing body of evidence shows that apart from wages, other job attributes like training opportunities, career development prospects, living and working conditions may also play a role (Hays, Veitch, Cheers & Crossland, 2007).
The challenges in maintaining an adequate workforce that meets the needs of a population with social, demographic, epidemiological and political transitions require a sustained effort in addressing workforce planning, development and financing. Skilled health workers are increasingly taking up job opportunities in the global labour market as the demand for their expertise rises in high income areas. It has been suggested that the rural to urban and international migration of health workers in African countries inevitably leaves poor, rural and remote areas underserviced and disadvantaged (Bach, 2003). Developing countries often experience ‘urban-bias’ where the political and economic forces support the provision of services and investment in urban areas to the detriment of rural areas. This increases the disparities in health worker distribution, access to services and health outcome (Zurn, Dal Poz, Barbara & Orvill, 2004).
A regression of data for 117 countries found a significant relationship between health worker density and maternal mortality rates (Gerein, 2006). Nigeria has high numbers of healthcare providers, who together make up the largest human resource for health in Africa. There are 52,408 doctors, 219,399 nurses and midwives, and 19,268 community health workers practicing in the public sector (Professional Regulatory Agencies, 2008). However, these values translate to only 23 doctors, 112 nurses, and 64 community health workers per 100,000 people. To put these figures into context, European health worker density values are 332 doctors and 780 nurses per 100,000 people (World Health Organisation [WHO], 2008). Poor, rural communities experience the lowest health worker densities, with three times as many doctors and two times as many nurses practicing in urban areas as opposed to rural. These figures imply that the number of women in rural areas giving birth unaccompanied by skilled birth attendants is directly impacted by the understaffed rural health facilities.
Maternal mortality continues to be the leading cause of death of women of reproductive age in developing countries. Maternal death is primarily a result of the health care system’s inability to deal effectively with complications during and shortly after childbirth (World Health Report, 2005). Recruitment and retention of skilled workers, particularly midwives, nurses, doctors, and obstetricians, are essential to the provision of quality antenatal, delivery, emergency obstetric and postnatal services. It is necessary to realize both the United Nations millennium development goals (MDG) 4 (Reduce under 5 mortality) and MDG 5 (reduction of maternal mortality) (MDG Report, 2006). Nigerian policy-makers are looking for solutions. Researchers and development agencies agree that the disproportionate rates in the developing world, particularly Sub-Saharan Africa, are as a result of high rate of births unaccompanied by a skilled birth attendant (WHO, 2005).
To achieve the MDGs for health by 2015, improving access to key interventions such as anti-retroviral therapy, immunizations, tuberculosis and malaria treatments are top priorities for most health system (Adano & Vicks, 2008). However, in addition to financial resources for commodities, improving access requires a well-functioning health system and adequate workforce capable of delivering interventions at a large scale (Drager, Gedik & DolPoz, 2006). The 2004 joint learning initiative report on human resource for health and others have concluded that shortage and skewed distribution of health personnel especially in the rural areas undermine the scaling up efforts, particularly in low income countries (Bloom & Barnighausen, 2009). It is against this background that this study sought to determine perceived factors that affect non stay of health workers in rural areas of Enugu State.