Attraction and Retention of Rural Primary Health Care Workers in Asia Pacific Regio

Background: Human resources for health are crucial for health system strengthening and achieving sustainable development goals and universal health coverage, but the shortage and maldistribution of health workers have been critical concerns in the Asia Pacific region. This study aimed to identify the key interventions on attracting and retaining rural health workers, understand their management structure, examine the effectiveness and analyze the contexts in the Asia Pacific region.;Methods: This mixed-method study used systematic review and country case studies to synthesize and analyze the available data. A systematic review on attraction and retention of rural health workers in the Asia Pacific region was conducted. Thirty-five, fourteen and nineteen studies were included for the interventions and their management structure, effectiveness and contexts, respectively. In-depth interviews of twenty-two key informants and gray literature recommended from the key informants in China, Vietnam and Cambodia were used to gather information for the country case studies. Narrative synthesis was applied to review and synthesize the extracted data from the systematic review and qualitative analysis using Nvivo 11 was conducted for the interviews.;Results: Five categories of interventions, involving education, regulation, financial incentives, personal and professional support and bundled interventions were implemented to attract and retain rural health workers in the Asia Pacific region. Regulatory interventions, such as MRBS, task shifting and compulsory rural services, were the key interventions reported in the systematic review. Although financial incentives were scarce in the systematic review, they were the key strategies in the country case studies of China, Vietnam and Cambodia. Asian Pacific countries also had their distinctive interventions, such as a system of compulsory rural services in Thailand, training on community health workers in Afghanistan, and a government midwifery incentive scheme in Cambodia. Geographically, the Pacific island countries were neglected.;Six categories of management structure of implementation were summarized. Decentralization from the central to the regional government was the dominant management structure. The regional government was responsible for program implementation in the decentralized programs, program development and implementation in the regional initiatives, which were more likely to be discovered in the countries and regions with strong economies. International donors were significant stakeholders for the low-income and post-conflict countries through providing financial and technical assistance. Several challenges emerged during implementation, including lack of rural eligible candidates, low and unsustainable financial incentives, complicated recruitment, poor management and deployment of HRH.;Although the majority of interventions lacked rigorous effectiveness evaluation or were without evaluation, most evaluated interventions demonstrated effectiveness in attracting and retaining rural health professionals. Some of the interventions also reported effectiveness in expanding health service coverage and improving health status. The regulatory interventions seemed to be more effective in attracting and retaining rural health workers through administrative and legislative enforcement. Bundled interventions were expected to be more effective and be more often recommended by the researchers and interviewees.;Various contexts, including political, economic and social factors and health system related issues, directly and indirectly impacted the attraction and retention of rural health workers. The political issues, economic development and social culture influenced rural HRH strengthening at the macro level while the health system reform pulled or pushed rural health workers. The promotion of rural health workers to be civil servants in Vietnam and Cambodia was a good motivation for rural health workers. The post mechanism in China, abolition of the referral system and increasing financial autonomy in the hospitals in Vietnam, the popular private sector, limited physical and human resources all served to push the health workers out of rural positions.;Conclusion: Due to great variation in economic development, Asian Pacific countries implemented three different patterns of interventions: 1) comprehensive packages in the high-income countries; 2) one or two categories of interventions in the low- and middle-income countries; and 3) training of community health workers in the post-conflict countries. Economic variation was also reflected in the differences of the management structure of implementation. The upper-middle- and high-income countries were likely to initiate regional interventions while the low-income countries partly relied on donations for HRH development and implementation, especially for the post-conflict countries. Although decentralization was widely applied to implementation, its implications were neglected and unclear. Based on the exclusive mechanism, effectiveness of each category of interventions varied. However, the regulatory interventions seemed be better. The socio-economic development significantly influenced interventions on attracting and retaining rural health workers. Rural HRH strengthening required strong economic support. Health financing reform for universal health coverage did impact the capacity building of rural health workforce. Further research was needed.