Imbalances in rural primary careBrief based on a scoping literature review with an emphasis on the WHO European Region

BRIEF

Imbalances in rural primary careBrief based on a scoping literature review with an emphasis on the WHO European Region

BRIEF

Acknowledgements

This document was produced as part of the technical series on primary health care on the occasion of the Global Conference on Primary Health Care under the overall direction of the Global Conference Coordination Team led by Ed Kelley (WHO headquarters) Hans Kluge (WHO Regional Office for Europe) and Vidhya Ganesh (UNICEF) Overall technical management for the series was provided by Shannon Barkley (Department of Service Delivery and Safety WHO headquarters) in collaboration with Pavlos Theodorakis (Department of Health Systems and Public Health WHO Regional Office for Europe) This document was produced under the overall direction of Pavlos Theodorakis (WHO Regional Office for Europe)

The principal writing team consisted of Mark WG Bosmans Wienke GW Boerma and Peter P Groenewegen of the Netherlands Institute for Health Services Research (Nivel) Utrecht Netherlands

We also acknowledge a number of international experts including Christos Lionis (University of Crete) for his valuable contribution by providing the text for the description of primary care in the Greek islands as well as other colleagues from Nivel for helpful suggestions and feedback

Other valuable comments and suggestions were made by WHO staff in particular Gabrielle Jacob (WHO Regional Office for Europe) Rania Kawar (WHO headquarters) Briana Rivas Morello (WHO headquarters) and Cris Scotter (WHO Regional Office for Europe)

The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here or their affiliated institutions

WHOHISSDS201860

copy World Health Organization 2018 Some rights reserved This This work is available under the CC BY-NC-SA 30 IGO licence

Imbalances in rural primary careBrief based on a scoping literature review with an emphasis on the WHO European Region

BRIEF

Acknowledgements

This document was produced as part of the technical series on primary health care on the occasion of the Global Conference on Primary Health Care under the overall direction of the Global Conference Coordination Team led by Ed Kelley (WHO headquarters) Hans Kluge (WHO Regional Office for Europe) and Vidhya Ganesh (UNICEF) Overall technical management for the series was provided by Shannon Barkley (Department of Service Delivery and Safety WHO headquarters) in collaboration with Pavlos Theodorakis (Department of Health Systems and Public Health WHO Regional Office for Europe) This document was produced under the overall direction of Pavlos Theodorakis (WHO Regional Office for Europe)

The principal writing team consisted of Mark WG Bosmans Wienke GW Boerma and Peter P Groenewegen of the Netherlands Institute for Health Services Research (Nivel) Utrecht Netherlands

We also acknowledge a number of international experts including Christos Lionis (University of Crete) for his valuable contribution by providing the text for the description of primary care in the Greek islands as well as other colleagues from Nivel for helpful suggestions and feedback

Other valuable comments and suggestions were made by WHO staff in particular Gabrielle Jacob (WHO Regional Office for Europe) Rania Kawar (WHO headquarters) Briana Rivas Morello (WHO headquarters) and Cris Scotter (WHO Regional Office for Europe)

The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here or their affiliated institutions

WHOHISSDS201860

copy World Health Organization 2018 Some rights reserved This This work is available under the CC BY-NC-SA 30 IGO licence

Acknowledgements

This document was produced as part of the technical series on primary health care on the occasion of the Global Conference on Primary Health Care under the overall direction of the Global Conference Coordination Team led by Ed Kelley (WHO headquarters) Hans Kluge (WHO Regional Office for Europe) and Vidhya Ganesh (UNICEF) Overall technical management for the series was provided by Shannon Barkley (Department of Service Delivery and Safety WHO headquarters) in collaboration with Pavlos Theodorakis (Department of Health Systems and Public Health WHO Regional Office for Europe) This document was produced under the overall direction of Pavlos Theodorakis (WHO Regional Office for Europe)

The principal writing team consisted of Mark WG Bosmans Wienke GW Boerma and Peter P Groenewegen of the Netherlands Institute for Health Services Research (Nivel) Utrecht Netherlands

We also acknowledge a number of international experts including Christos Lionis (University of Crete) for his valuable contribution by providing the text for the description of primary care in the Greek islands as well as other colleagues from Nivel for helpful suggestions and feedback

Other valuable comments and suggestions were made by WHO staff in particular Gabrielle Jacob (WHO Regional Office for Europe) Rania Kawar (WHO headquarters) Briana Rivas Morello (WHO headquarters) and Cris Scotter (WHO Regional Office for Europe)

The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here or their affiliated institutions

WHOHISSDS201860

copy World Health Organization 2018 Some rights reserved This This work is available under the CC BY-NC-SA 30 IGO licence

1

Shortages in rural primary careDespite a trend of urbanization almost half (45) of the worldrsquos population currently lives in rural areas (1) The infrastructure and services are usually less developed in rural and remote areas These areas tend to suffer from population decline as young people move towards urban centres for education and employment This results in ageing rural populations with increasing health needs and a shrinking carrying capacity for community functions

In terms of health care rural populations are disadvantaged in many cases health care systems fail to reach rural populations at the same levels as for urban populations (2) Worldwide access to health care services is lower for people living in rural areas as shown in Figure 1 In urban areas 22 of the population has no health care coverage compared to 56 in rural areas

Figure 1 Global population not covered by legal health coverage urbanndashrural comparison

World

World

100 20 30 40 50 60

Urban

Urban

Rural

Rural

Source International Labour Organization estimates 2015

In addition to lower access evidence points to lower quality of health care services in rural areas in particular in low- and middle-income countries The worldwide shortage of health care staff labelled as the ldquoglobal health workforce crisisrdquo by the World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD) appears to be much more severe in rural than in urban areas On several occasions the WHO Regional Office for Europe has addressed the current challenges in human resources for health including geographical maldistribution and Member States have been urged to invest in the health workforce (3ndash5) Estimates published in 2015 by the International Labour Organization (ILO) show that two thirds of the deficit of 103 million health care workers in the world is in rural and remote areas (Figure 2) and this deficit is much higher in low-income countries than elsewhere More recent estimates are even considerably higher (6 7)

Figure 2 Global estimates of skilled health worker deficits in rural and urban areas 2015

Global health worker deficit

103 million

Rural deficit

About 7 million

Urban deficit

More than 3 million

Source ILO estimates 2015

Health care needs in rural areas are largely provided for by generalists working in the community such as general practitioners nurses midwives therapists and allied health professionals Together they provide primary care health services that are first contact accessible continuous and comprehensive and that coordinate care for individuals families and communities This is a key process in the health system and a subset of primary health care This brief focuses on primary care and service delivery as part of the wider context of primary health care

A primary care shortage in rural areas caused by the combination of increasing demand for care and undersupply of health care services creates a specific challenge to the attainment of the Sustainable Development Goals (SDGs) and universal health coverage Ensuring that health care policies ldquoleave no one behindrdquo means that the almost half of the world population currently living in rural areas (1) should obtain essential health services This requires a focus on increasing availability of and geographical and financial access to health services in rural areas

The focus of this brief is on rural and remote areas although it is important to recognize that imbalances also exist in health and health care in urban areas particularly in low- and middle-income countries where deprived populations have no access to highly specialized and often private health care facilities due to high user access fees The scoping review of the literature which forms the basis for this brief focused on the WHO European Region but also took into account review studies from other regions of the world (see box on method and scope at the end of this brief)

3

4

Causes of imbalances in rural primary careUnderstanding the root causes and consequences of unequal distribution of primary care is essential for policy-makers seeking to tackle the primary care shortage in rural areas Given that so many countries with both low and high population densities recognize the challenge of providing accessible and good-quality primary care in rural and remote areas successful approaches can provide valuable opportunities for shared learning between countries

Underlying causes of the primary care shortage are diverse First living and working conditions are often more adverse in rural than in urban areas for both the general population and for health workers Housing and equipment of care facilities may suffer from lower funding career options and access to continuous professional development for health care workers may be more limited the workload may be higher and income lower and job opportunities for spouses and educational opportunities for children are restricted Training programmes for health professions often lack ldquorural immersionrdquo opportunities Students in the health professions often have no options to complete significant elements of training in the rural setting This can make health care workers less inclined to work in rural than in urban settings Higher workloads due to staff shortages may serve as another disincentive OECD countries show a consistently higher physicianndashpopulation ratio in urban areas than in rural areas (8) In low- and middle-income countries the contrasts between rural and urban provision are sharper than in high-income countries and in these countries rural areas more often suffer from inadequate care services and poor funding than do cities Migration of young people including those who could add to the health workforce also negatively affects the social structure of communities

7

Consequences of imbalances in rural primary careInadequate health worker coverage coinciding with the general shortage of primary care may lead to an erosion of availability accessibility and quality of primary care in rural areas Faced with the growing health needs of an ageing and often poorer population health care services are disadvantaged by outdated facilities and equipment Additionally hospitals and other specialized services may be hard to access or not easily available for follow-up care in rural settings Therefore the gap in quality of care between rural and urban populations tends to grow as a result of the primary care shortage This may contribute to the difference in life expectancy between urban and rural populations for instance related to differences in maternal mortality

Solutions to imbalances in primary care in rural and remote areasThe following four groups of strategies have been identified and can be used to address the primary care shortage as part of a wider human resources for health strategy

bull Recruitment retention and training strategies (including clear requirement for rural placement and values-based recruitment)

bull Task shifting within primary care teams

bull Promoting the mobility of health care workers and patients (as a short-term solution) and

bull Implementing technological innovations in information and communication

Some attempts to develop evidence-based policies to tackle the primary care shortage suffer from lack of methodologically sound research to support reliable conclusions about their effectiveness as shown in the scoping review upon which this brief is based and evidence is largely limited to programmes targeting physicians Although more systematic research is needed the literature does offer indications of promising policy options and information for their implementation As the evidence base is generally weak it should be stressed that while there are indications of their effectiveness solid evidence is lacking

8

Policy optionsPolicy efforts to ensure equitable access to health workers stress the context of overall strengthening of health systems and promote multifaceted and tailor-made approaches (6 9) Available evidence recommends the following options to decision-makers to turn the tide of declining health care services in rural areas

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

Figure 2 Global estimates of skilled health worker deficits in rural and urban areas 2015

Global health worker deficit

103 million

Rural deficit

About 7 million

Urban deficit

More than 3 million

Source ILO estimates 2015

Health care needs in rural areas are largely provided for by generalists working in the community such as general practitioners nurses midwives therapists and allied health professionals Together they provide primary care health services that are first contact accessible continuous and comprehensive and that coordinate care for individuals families and communities This is a key process in the health system and a subset of primary health care This brief focuses on primary care and service delivery as part of the wider context of primary health care

A primary care shortage in rural areas caused by the combination of increasing demand for care and undersupply of health care services creates a specific challenge to the attainment of the Sustainable Development Goals (SDGs) and universal health coverage Ensuring that health care policies ldquoleave no one behindrdquo means that the almost half of the world population currently living in rural areas (1) should obtain essential health services This requires a focus on increasing availability of and geographical and financial access to health services in rural areas

The focus of this brief is on rural and remote areas although it is important to recognize that imbalances also exist in health and health care in urban areas particularly in low- and middle-income countries where deprived populations have no access to highly specialized and often private health care facilities due to high user access fees The scoping review of the literature which forms the basis for this brief focused on the WHO European Region but also took into account review studies from other regions of the world (see box on method and scope at the end of this brief)

3

4

Causes of imbalances in rural primary careUnderstanding the root causes and consequences of unequal distribution of primary care is essential for policy-makers seeking to tackle the primary care shortage in rural areas Given that so many countries with both low and high population densities recognize the challenge of providing accessible and good-quality primary care in rural and remote areas successful approaches can provide valuable opportunities for shared learning between countries

Underlying causes of the primary care shortage are diverse First living and working conditions are often more adverse in rural than in urban areas for both the general population and for health workers Housing and equipment of care facilities may suffer from lower funding career options and access to continuous professional development for health care workers may be more limited the workload may be higher and income lower and job opportunities for spouses and educational opportunities for children are restricted Training programmes for health professions often lack ldquorural immersionrdquo opportunities Students in the health professions often have no options to complete significant elements of training in the rural setting This can make health care workers less inclined to work in rural than in urban settings Higher workloads due to staff shortages may serve as another disincentive OECD countries show a consistently higher physicianndashpopulation ratio in urban areas than in rural areas (8) In low- and middle-income countries the contrasts between rural and urban provision are sharper than in high-income countries and in these countries rural areas more often suffer from inadequate care services and poor funding than do cities Migration of young people including those who could add to the health workforce also negatively affects the social structure of communities

7

Consequences of imbalances in rural primary careInadequate health worker coverage coinciding with the general shortage of primary care may lead to an erosion of availability accessibility and quality of primary care in rural areas Faced with the growing health needs of an ageing and often poorer population health care services are disadvantaged by outdated facilities and equipment Additionally hospitals and other specialized services may be hard to access or not easily available for follow-up care in rural settings Therefore the gap in quality of care between rural and urban populations tends to grow as a result of the primary care shortage This may contribute to the difference in life expectancy between urban and rural populations for instance related to differences in maternal mortality

Solutions to imbalances in primary care in rural and remote areasThe following four groups of strategies have been identified and can be used to address the primary care shortage as part of a wider human resources for health strategy

bull Recruitment retention and training strategies (including clear requirement for rural placement and values-based recruitment)

bull Task shifting within primary care teams

bull Promoting the mobility of health care workers and patients (as a short-term solution) and

bull Implementing technological innovations in information and communication

Some attempts to develop evidence-based policies to tackle the primary care shortage suffer from lack of methodologically sound research to support reliable conclusions about their effectiveness as shown in the scoping review upon which this brief is based and evidence is largely limited to programmes targeting physicians Although more systematic research is needed the literature does offer indications of promising policy options and information for their implementation As the evidence base is generally weak it should be stressed that while there are indications of their effectiveness solid evidence is lacking

8

Policy optionsPolicy efforts to ensure equitable access to health workers stress the context of overall strengthening of health systems and promote multifaceted and tailor-made approaches (6 9) Available evidence recommends the following options to decision-makers to turn the tide of declining health care services in rural areas

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

4

Causes of imbalances in rural primary careUnderstanding the root causes and consequences of unequal distribution of primary care is essential for policy-makers seeking to tackle the primary care shortage in rural areas Given that so many countries with both low and high population densities recognize the challenge of providing accessible and good-quality primary care in rural and remote areas successful approaches can provide valuable opportunities for shared learning between countries

Underlying causes of the primary care shortage are diverse First living and working conditions are often more adverse in rural than in urban areas for both the general population and for health workers Housing and equipment of care facilities may suffer from lower funding career options and access to continuous professional development for health care workers may be more limited the workload may be higher and income lower and job opportunities for spouses and educational opportunities for children are restricted Training programmes for health professions often lack ldquorural immersionrdquo opportunities Students in the health professions often have no options to complete significant elements of training in the rural setting This can make health care workers less inclined to work in rural than in urban settings Higher workloads due to staff shortages may serve as another disincentive OECD countries show a consistently higher physicianndashpopulation ratio in urban areas than in rural areas (8) In low- and middle-income countries the contrasts between rural and urban provision are sharper than in high-income countries and in these countries rural areas more often suffer from inadequate care services and poor funding than do cities Migration of young people including those who could add to the health workforce also negatively affects the social structure of communities

7

Consequences of imbalances in rural primary careInadequate health worker coverage coinciding with the general shortage of primary care may lead to an erosion of availability accessibility and quality of primary care in rural areas Faced with the growing health needs of an ageing and often poorer population health care services are disadvantaged by outdated facilities and equipment Additionally hospitals and other specialized services may be hard to access or not easily available for follow-up care in rural settings Therefore the gap in quality of care between rural and urban populations tends to grow as a result of the primary care shortage This may contribute to the difference in life expectancy between urban and rural populations for instance related to differences in maternal mortality

Solutions to imbalances in primary care in rural and remote areasThe following four groups of strategies have been identified and can be used to address the primary care shortage as part of a wider human resources for health strategy

bull Recruitment retention and training strategies (including clear requirement for rural placement and values-based recruitment)

bull Task shifting within primary care teams

bull Promoting the mobility of health care workers and patients (as a short-term solution) and

bull Implementing technological innovations in information and communication

Some attempts to develop evidence-based policies to tackle the primary care shortage suffer from lack of methodologically sound research to support reliable conclusions about their effectiveness as shown in the scoping review upon which this brief is based and evidence is largely limited to programmes targeting physicians Although more systematic research is needed the literature does offer indications of promising policy options and information for their implementation As the evidence base is generally weak it should be stressed that while there are indications of their effectiveness solid evidence is lacking

8

Policy optionsPolicy efforts to ensure equitable access to health workers stress the context of overall strengthening of health systems and promote multifaceted and tailor-made approaches (6 9) Available evidence recommends the following options to decision-makers to turn the tide of declining health care services in rural areas

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

7

Consequences of imbalances in rural primary careInadequate health worker coverage coinciding with the general shortage of primary care may lead to an erosion of availability accessibility and quality of primary care in rural areas Faced with the growing health needs of an ageing and often poorer population health care services are disadvantaged by outdated facilities and equipment Additionally hospitals and other specialized services may be hard to access or not easily available for follow-up care in rural settings Therefore the gap in quality of care between rural and urban populations tends to grow as a result of the primary care shortage This may contribute to the difference in life expectancy between urban and rural populations for instance related to differences in maternal mortality

Solutions to imbalances in primary care in rural and remote areasThe following four groups of strategies have been identified and can be used to address the primary care shortage as part of a wider human resources for health strategy

bull Recruitment retention and training strategies (including clear requirement for rural placement and values-based recruitment)

bull Task shifting within primary care teams

bull Promoting the mobility of health care workers and patients (as a short-term solution) and

bull Implementing technological innovations in information and communication

Some attempts to develop evidence-based policies to tackle the primary care shortage suffer from lack of methodologically sound research to support reliable conclusions about their effectiveness as shown in the scoping review upon which this brief is based and evidence is largely limited to programmes targeting physicians Although more systematic research is needed the literature does offer indications of promising policy options and information for their implementation As the evidence base is generally weak it should be stressed that while there are indications of their effectiveness solid evidence is lacking

8

Policy optionsPolicy efforts to ensure equitable access to health workers stress the context of overall strengthening of health systems and promote multifaceted and tailor-made approaches (6 9) Available evidence recommends the following options to decision-makers to turn the tide of declining health care services in rural areas

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

8

Policy optionsPolicy efforts to ensure equitable access to health workers stress the context of overall strengthening of health systems and promote multifaceted and tailor-made approaches (6 9) Available evidence recommends the following options to decision-makers to turn the tide of declining health care services in rural areas

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

9

Evidence-based recommendations to improve the human resources for health situation in remote and rural areas

Role substitution Task shifting between cadres of health workers often between physicians and nurses can be an effective approach to spreading work sensibly as long as the following conditions are met (10ndash12)

bull The quality of care should be equivalent to that before delegation

bull The task shifting initiative must fit within legal and regulatory constraints

bull Task shifting must be accepted by both the delegating health worker and the patient

bull Task shifting must take into account the optimal skill mix within multidisciplinary primary care teams

bull Successful implementation requires sufficient funding and resources (including for continuous professional development)

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

10

Recruitment and training of staffThe education sector has the potential to produce primary care staff that are able and willing to work in rural areas (13ndash15)

bull Efforts should be made to recruit the ldquorightrdquo students (students with rural background or an interest in working in rural areas) (6910)

bull Medical students could be trained closer to rural communities medical schools could be located within rural areas

bull Curriculum development should take full account of rural health needs (16ndash20)

bull Continuous professional development should be facilitated

bull Students can be exposed to rural primary care in an early stage of their education

Supportive interventionsSupportive strategies that directly address factors shown to be negatively related to recruitment and retention of health care workers should be included in policies aimed at deploying more staff to rural areas (21 22)

bull Rural care networks should be created to support access to referral care and advice

bull Interaction between urban and rural health workers should be fostered

bull Career perspectives should be designed for rural health workers

bull Knowledge exchange should be facilitated

Mobility supportMobility programmes can either bring health care workers to patients or patients to the health care facility

bull Mobile health service delivery may offer a short-term solution to lack of access in some rural areas

bull However as outreach services have negative consequences in the longer run for example in terms of poor continuity of care they are only recommended as a temporary remedy where populations in remote areas have poor access to primary care services

bull Mobility programmes should be accompanied by measures to strengthen primary care locally

bull Alternatively transportation of patients from remote locations to primary care providers should take into account patient preferences as well as legal and logistical constraints (23ndash25)

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

12

Technological supportNewly developed information and communications technology can support primary care workers in rural and remote areas Twinning with hospitals for distance telemedical support may be an option

bull Remote diagnosis treatment and monitoring particularly for chronic conditions can help to combat the primary care shortage in rural areas

bull Implementation of technology should be preceded by research and development regarding diagnostic accuracy

bull Concerning the implementation of telehealth support the following recommendations should be followed

Ensure the adequate infrastructure and training of staff

Clearly define professional roles and protocols and

Involve end users in the development and implementation and

Ensure that technologies fit within primary care workflow and

Safeguard the quality of clinical care (26ndash28)

Financial incentives Financial incentives may induce some primary care workers to come to or stay in rural areas however they should be used as additional to more intrinsic incentives

bull Financial incentives are not recommended as a high-priority single policy option

bullTo have any real impact they must be implemented in combination with other measures and may supplement other policy responses

Obligatory serviceIn some countries recently graduated physicians must work for a certain period in remote or rural areas before they can apply for work in the public sector

bull Obligatory service is not suitable as a strategy for long-term recruitment It is a viable short-term policy option for acute shortages

bull If it is used transparency should be ensured and sufficient support should be made available

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

General observations and conditions

General health system developmentGeneral measures to structure the health care system and adopt a comprehensive approach to the health labour market have a positive effect on the delivery of health care services in rural areas For example policies to regulate the private sector (6) may enhance the ndash usually public ndash delivery of primary care in rural areas However specific evidence in this area is lacking

Strong primary care is characterized by good access (with extended access and night cover) provision of a comprehensive package of services to the community throughout the life cycle and coordination with other levels of care public health and social services

Effective policies to strengthen primary care overall are particularly beneficial for people living in rural areas These policies may more easily be implemented in rural areas than in cities because of a less complex health care supply situation and clearer catchment population for the primary care service

Health care systems that neglect holistic primary care in favour of subspecialist approaches and vertical ldquosilordquo programmes are less sustainable and may therefore be less suited to meet the needs of local communities

Effective governanceSolutions for the primary care shortage in rural and remote areas must be supported by political commitment and effective leadership and governance at national subnational and local levels The WHO Global Strategy on Human Resources for Health Workforce 2030 has provided numerous options for Member States (6)

However as part of policy development and prior to any implementation the need for change in the health care system needs to be assessed and change should be designed in a way that it will be supported as much as possible including by patients For a more balanced distribution of health services and workers instruments for health workforce planning and related strategies are needed Also following the framework of the European Observatory on Health Systems and Policies effective governance and policies should be transparent and accountable include participation of stakeholders and maintain organizational integrity (29)

15

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

16

Comprehensive approachesPolicies must address the full range of factors known to be associated with rural and remote primary care worker education training recruitment retention and system governance Interventions should be measured designed and implemented in areas and professions where workforce supply and retention is the most problematic If possible effective strategies should be combined and multifaceted while unintended consequences should be anticipated and addressed Selection of the interventions should be based on analyses of local situations and interventions should be flexible enough to be adapted to changes in local environments

Local involvement and supportStakeholders It is essential to develop policies together with health care workers and the population Successful implementation of policies is less likely when support among stakeholders is low This is usually the case with restrictive and coercive policies these may lead to unmotivated health care workers and may harm the quality of care Support in the population is important because acceptance of and trust in new care arrangements influence their use

People-centred approach People-centred approaches focus on person-centred care and a population approach taking the health and well-being of a community as the starting point Solutions to the primary care shortage should involve the communities concerned and explore the potential of communities to take action Primary care policies should be coordinated with policies to strengthen the social structure of local communities

Monitoring and evaluation All strategies should be accompanied by continuing and systematic monitoring of implementation roll-out and outcomes both in terms of the health workforce in primary care (including information on entry retention and attrition of primary care professionals and team skill mix) and in terms of the people served (including information on access utilization quality and (patient-reported) outcomes) Monitoring helps to prevent strategic or policy drift and flags when programmes need adjustment Scientific research aims to improve the evidence base for the effectiveness of programmes and contributes to the potential for learning between countries

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

18

Conclusions Shortages in rural primary care are a significant problem that has received much attention by decision-makers nationally and internationally However findings are limited by the overall evidence base which lacks sufficient methodologically sound research to support definitive conclusions about the effectiveness of measures (21) Nevertheless the scoping review of the literature on which this brief is based did offer indications of the most promising interventions which can be recommended for implementation

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

19

Method and scope of this brief

This brief and its background report are based on a scoping literature review aiming to rapidly provide a summary of best practices and approaches to solve imbalances in rural primary care The review covered research dealing with primary care in rural and remote areas that has been published between 2008 ndash the year that the landmark World health report ndash Primary care now more than ever was launched ndash and the summer of 2018 Where available in review studies we took into account the methodological quality of studies However a methodological assessment of individual studies has not been undertaken This review also offers a situation description regarding the problems of access to primary care in rural areas and describes what is known about its root causes and consequences The main focus of this brief and its background report is on the WHO European Region but a substantial portion of the included studies comes from several large countries outside the WHO European Region such as Australia Canada and the United States that have been coping with this problem for a long time Because of the global nature of available evidence findings and reported policy options are globally applicable

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

20

References1 World Bank indicators rural population ( of total population) Washington (DC) World Bank (httpsdata

worldbankorgindicatorSPRURTOTLZSview=chart accessed 30 September 2019)

2 Monitoring health for the SDGs In World health statistics 2016 Chapter 5 Geneva World Health Organization 2016

3 Towards a sustainable health workforce in the WHO European Region framework for action World Health Organization Regional Committee for Europe 67th session Budapest Hungary 11ndash14 September 2017 WHO Regional Office for Europe 2017

4 Health systems for prosperity and solidarity leaving no one behind High-level meeting Tallinn Estonia 13ndash14 June 2018 Geneva World Health Organization 2018

5 Reaffirming commitment to health systems strengthening for universal health coverage better outcomes and reduced health inequalities World Health Organization Regional Committee for Europe 68th session Rome 17ndash20 September 2018 WHO Regional Committee for Europe 2018

6 Global Strategy on Human Resources for Health Workforce 2030 Geneva World Health Organization 2016

7 Working for health and growth investing in the health workforce Geneva World Health Organization 2016

8 Health at a glance 2017 OECD indicators Paris Organisation for Economic Cooperation and Development 2017 (httpwwwoecdorghealthhealth-systemshealth-at-a-glance-19991312htm accessed 30 September 2019)

9 Five-year action plan for health employment and inclusive economic growth (2017ndash2021) Geneva World Health Organization 2018

10 Banner D Macleod MLP Johnston S Role transition in rural and remote primary health care nursing a scoping literature review Canadian Journal of Nursing Research 201042(4)40ndash57

11 Bosley S Dale J Healthcare assistants in general practice practical and conceptual issues of skill-mix change British Journal of General Practice 200858(547)118ndash24

12 Hoeft TJ Fortney JC Patel V Unuumltzer J Task-sharing approaches to improve mental health care in rural and other low-resource settings a systematic review Journal of Rural Health 201834(1)48ndash62

13 Parlier AB Galvin SL Thach S Kruidenier D Fagan EB The road to rural primary care a narrative review of factors that help develop recruit and retain rural primary care physicians Academic Medicine 201893(1)130ndash40

14 Lee DM Nichols T Physician recruitment and retention in rural and underserved areas International Journal of Health Care Quality Assurance 201427(7)642ndash52

15 Verma P Ford JA Stuart A Howe A Everington S Steel N A systematic review of strategies to recruit and retain primary care doctors BMC Health Services Research 201616(1)

16 Crampton PES McLachlan JC Illing JC A systematic literature review of undergraduate clinical placements in underserved areas Medical Education 201347(10)969ndash78

17 Viscomi M Larkins SL Recruitment and retention of general practitioners in rural Canada and Australia a review of the literature Canadian Journal of Rural Medicine 201318(1)13ndash23

18 Barrett FA Lipsky MS Nawal Lutfiyya M The impact of rural training experiences on medical students a critical review Academic Medicine 201186(2)259ndash63

19 Guilbault R Vinson J Clinical medical education in rural and underserved areas and eventual practice outcomes a systematic review and meta-analysis Education for Health (Abingdon) 201730(2)146ndash55

20 Strasser R Couper I Wynn-Jones J Rourke J Bruce Chater A Reid S Education for rural practice in rural practice Education for Primary Care 201627(1)10ndash4

21 Roberts R Integrating rural health care Australian Journal of Rural Health 201725(1)4

22 McLean R Continuing professional development for rural physicians an oxymoron or just non-existent Internal Medicine Journal 200636(10)661ndash4

23 Carey TA Sirett D Wakerman J Russell D Humphreys JS What principles should guide visiting primary health care services in rural and remote communities Lessons from a systematic review Australian Journal of Rural Health 2018146ndash56

24 Haumlmel K Kutzner J Vorderwuumllbecke J Mobile Versorgungseinrichtungen zur Staumlrkung der Versorgungssicherheit im laumlndlichen Raum [Mobile utilities to strengthen security of supply in rural areas] Gesundheitswesen 201779(12)1012ndash8 (in German)

25 Hussain R Maple M Hunter SV Mapedzahama V Reddy P The fly-in fly-out and drive-in drive-out model of health care service provision for rural and remote Australia benefits and disadvantages Rural and Remote Health 201515(3)1ndash7

26 Davis MM Freeman M Kaye J Vuckovic N Buckley DI A systematic review of clinician and staff views on the acceptability of incorporating remote monitoring technology into primary care Telemedicine Journal and e-Health 201420(5)428ndash38

27 Warshaw EM Hillman YJ Greer NL Hagel EM MacDonald R Rutks IR et al Teledermatology for diagnosis and management of skin conditions a systematic review Journal of the American Academy of Dermatology 201164(4)759ndash72

28 Marsh-Feiley G Eadie L Wilson P Telesonography in emergency medicine a systematic review PLoS One 201813(5)e0194840

29 Greer SL Wismar M Figueras J editors Strengthening health system governance better policies stronger performance European Observatory on Health Systems and Policies 2016

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