Kenya, South Africa and Thailand

a study to improve human resource policies

A study across three countries to identify policies which would help recruit and retain health workers in rural areas revealed that there is a danger in “one size fits all” recommendations when it comes to designing human resource policies. Results also show that there is room for both financial and non-financial incentives in human resource interventions in developing countries.

Nursing students completing survey forms during data collection process

Nursing students completing survey forms during data collection process

Mylene Lagarde and Duane Baauw describe the research process and findings in more detail.

Since the adoption in 2000 of the ambitious Millennium Development Goals to improve health outcomes, several initiatives and reports have focused on the critical role played by human resources for health in improving health system performance in developing countries. The vast majority of poor and disadvantaged patients live in rural areas where health services are least developed. A major constraint to improving the availability and quality of health care services in rural areas is that it has proved difficult to attract and retain skilled health workers in rural health facilities. Significant attention is being focused on human resource strategies to address this mal-distribution but it is not clear which policy interventions would be most effective.

This research project was undertaken to address this gap and try to identify more effective policy interventions that could improve the recruitment and retention of health workers in rural areas. The study investigates the job preferences and early career choices of a cohort of nursing graduates in Kenya, South Africa and Thailand. The multi-country aspect of the study allows an assessment of how the attitudes towards rural areas and potential policy options differ between countries.

Most of the studies looking at career choices of health workers usually interview them at one point in time and ask them to provide a detailed account of their employment history and the reasons which made them change jobs. Such studies might suffer from “recall bias”, whereby the actual choices and justifications are distorted by time and memories. To avoid such a problem, this project will follow the same group of nurses over several years, to collect information about their professional life as it happens. This will allow us to collect a unique set of good quality data about the job choices nurses make and the reasons that drive these choices.

In each country, nursing students who were about to graduate from different training institutions were invited to join the study. A baseline survey was administered to 377 nursing students in South Africa, 345 in Kenya and 342 in Thailand. Table 1 provides some descriptive information about the cohort study members and highlights the differences across countries. For example, the Thai cohort consists of a very homogenous and young group of nurses. In contrast, the profile of the two African cohorts is more diverse.

Table 1: Description of study participants

Variables South Africa (N=377) Thailand (N=342) Kenya (N=345)
Sex % Male 14.3% 4.7% 31.9%
% Female 85.7% 95.3% 68.1%
Age Mean 31.5 yrs 22.6 yrs 31.0 yrs
Marital status Single 65.9% 100.0% 54.8%
Married 30.4% 0.0% 41.7%
Divorced / Widowed 3.7% 0.0% 3.5%
Any children % Yes 61.0% 0.0% 51.3%

To investigate the relative importance of different policy interventions that may be used to attract and retain health workers in rural areas, we used an innovative quantitative tool called Discrete Choice Experiment (DCE). DCE is a methodology for understanding the relative importance of different factors in the decisions that people make. In essence, participants were asked to choose repeatedly between two hypothetical job descriptions, one in a rural and another in an urban area. Each job description was made up of different combinations of job characteristics. The job characteristics had been chosen based on a literature review and interviews with key stakeholders, and provided some potential interventions to increase the attraction of rural areas to nurses.

This technique allows the simulation of different policy scenarios, some of which are summarised in Table 2. The findings show that Thailand faces fewer challenges to staff in its rural positions than Kenya and South Africa. This is probably linked to successful education policies which have favoured rural recruits and located training centres in rural areas. Moreover, the analysis reveals possibly that different interventions across the three countries have different effects. For example, better training opportunities (the possibility to obtain study leave to specialise) offered in rural posts are highly valued by South African nurses, and less so by Kenyan nurses. The results also suggest that financial incentives are not necessarily the best way forward, as alternative options might be equally or more effective, and possibly less costly. For instance, better housing opportunities attract nearly as many nurses as a 10per cent rural allowance in African countries, and many more nurses in Thailand.

Table 2: Proportion of nurses who would choose a rural post, under different policy intervention

South Africa Thailand Kenya
Current conditions* 33.8% 78.7% 42.0%
10% rural allowance 46.4% 81.2% 54.6%
30% rural allowance 71.4% 85.4% 76.8%
Better rural housing 42.3% 89.8% 51.2%
Preferential training opportunities 64.2% 77.3% 58.7%
10% rural allowance + training opportunities 75.3% 79.9% 70.3%

* No rural allowance, no training opportunity, modest housing offered in rural posts.

These results underline the danger of “one size fits all” recommendations when it comes to designing human resource (HR) policies. The results also underline that there is room for both financial and non-financial incentives in HR interventions in developing countries. Of course, these results are limited by the hypothetical nature of the tools used. Yet, the results provide some concrete indications for policy makers who want to increase the recruitment of nursing graduates in rural areas.

The data collection continues in all three countries. Regular contacts are made with cohort members and information is collected on their actual career choices and job satisfaction. We hope to share more results soon. In the meantime, those interested in the project are welcome to visit the website of the cohort at

Mylene Lagarde, Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine

Duane Blaauw, Centre for Health Policy, University of Witwatersrand

Acknowledgement: this project is funded by the Consortium for Research in Equitable Systems, a DFID-funded research consortium.

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One Response

  1. hi we need to improve the quality of nursing in rural areas through provision of healthcare to all, stocking our health facilities with enough drugs,employment of more staffs(staffing).

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