A qualitative inquiry of rural-urban inequalities in the distribution and retention of healthcare workers in southern Nigeria

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Abstract

Introduction

Globally, the population in rural communities are disproportionately cared for by only 25% and 38% of the total physicians and nursing staff, respectively; hence, the poor health outcomes in these communities. This condition is worse in Nigeria by the critical shortage of skilled healthcare workforce. This study aimed to explore factors responsible for the uneven distribution of healthcare workers (physicians and nurses) to rural areas of Ebonyi State, Nigeria.

Methods

Qualitative data were obtained using semi-structured in-depth interviews and focus group discussions from purposively selected physicians, nurses, and policymakers in the state. Data was analysed for themes related to factors influencing the mal-distribution of healthcare workers (physicians and nurses) to rural areas. The qualitative analysis involved the use of both inductive and deductive reasoning in an iterative manner.

Results

This study showed that there were diverse reasons for the uneven distribution of skilled healthcare workers in Ebonyi State. This was broadly classified into three themes; socio-cultural, healthcare system, and personal healthcare workers’ intrinsic factors. The socio-cultural factors include symbolic capital and stigma while healthcare system and governance issues include poor human resources for health policy and planning, work resources and environment, decentralization, salary differences, skewed distribution of tertiary health facilities to urban area and political interference. The intrinsic healthcare workers’ factors include career progression and prospect, negative effect on family life, personal characteristics and background, isolation, personal perceptions and beliefs.

Conclusions

There may be a need to implement both non-financial and financial actions to encourage more urban to rural migration of healthcare workers (physicians and nurses) and to provide incentives for the retention of rural-based health workers.

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Most cited references 30

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Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

Uta Lehmann, Marjolein Dieleman, Tim Martineau (2008)

Background Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making. Methods This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review. Results The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies. Conclusion There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.

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Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Gilles Dussault, Maria Franceschini (2006)

Access to good-quality health services is crucial for the improvement of many health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. The health-related MDGs cannot be achieved if vulnerable populations do not have access to skilled personnel and to other necessary inputs. This paper focuses on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel. The objective of this paper is to offer a better understanding of the determinants of geographical imbalances in the distribution of health personnel, and to identify and assess the strategies developed to correct them. It reviews the recent literature on determinants, barriers and the effects of strategies that attempted to correct geographical imbalances, with a focus on empirical studies from developing and developed countries. An analysis of determinants of success and failures of strategies implemented, and a summary of lessons learnt, is included.

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Retention of health workers in rural Sierra Leone: findings from life histories

Haja Wurie, Mohamed Samai, Sophie Witter (2016)

Background Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts. Methods This article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts. Results Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Conclusions This study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.

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Author and article information

Contributors

Ogonna N. O. Nwankwo:

ORCID: https://orcid.org/0000-0001-9683-4920

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Chukwuebuka I. Ugwu: Role: Data curationRole: Formal analysisRole: MethodologyRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – review & editing

Grace I. Nwankwo: Role: Formal analysisRole: Funding acquisitionRole: InvestigationRole: Project administrationRole: ResourcesRole: ValidationRole: Writing – review & editing

Michael A. Akpoke: Role: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: Project administrationRole: ResourcesRole: SoftwareRole: ValidationRole: Writing – review & editing

Collins Anyigor: Role: Data curationRole: InvestigationRole: Project administrationRole: ResourcesRole: ValidationRole: Writing – review & editing

Uzoma Obi-Nwankwo: Role: Data curationRole: Formal analysisRole: ValidationRole: VisualizationRole: Writing – review & editing

Sunday Andrew Jr.: Role: Data curationRole: Formal analysisRole: ValidationRole: VisualizationRole: Writing – review & editing

Kelechukwu Nwogu: Role: Formal analysisRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – review & editing

Neil Spicer: Role: ConceptualizationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing

Santosh Kumar: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS One

Journal ID (publisher-id): plos

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 29 March 2022

Publication date Collection: 2022

Volume: 17

Issue: 3

Electronic Location Identifier: e0266159

Affiliations

[1 ] London School of Hygiene and Tropical Medicine, London, United Kingdom

[2 ] World Health Organization Field Office, Awka, Nigeria

[3 ] Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria

[4 ] Ola During Childrens Hospital, Freetown, Sierra Leone

[5 ] Department of Family Medicine, Federal Medical Center, Abuja, Nigeria

[6 ] Detar/A&M University FM Residency Program, Victoria, Texas, United States of America

[7 ] Christian Medical and Dental Association, National Office, Abuja, Nigeria

[8 ] Unicef Country Office, Abuja, Nigeria

[9 ] Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom

University of Tennessee Health Science Center College of Pharmacy Memphis, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

[¤]

Current address: Department of Community Medicine, University of Calabar, Calabar, Nigeria

* E-mail: drogonnanwankwo@ 123456gmail.com

Author information

Ogonna N. O. Nwankwo https://orcid.org/0000-0001-9683-4920

Article

Publisher ID: PONE-D-21-07517

DOI: 10.1371/journal.pone.0266159

PMC ID: 8963562

PubMed ID: 35349602

SO-VID: 4abc8aa0-5378-4728-a466-d0c5d66fce99

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 7 March 2021

Date accepted : 15 March 2022

Page count

Figures: 1, Tables: 1, Pages: 17

Funding

The author(s) received no specific funding for this work.

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Data Availability Data cannot be shared publicly as the informed consent we obtained from our participants limits our ability to share the raw data collected. Uploading the interview transcripts into an online public repository would breach the terms and conditions agreed to with the research participants. There are some sensitive information contained within some of the transcripts which potentially can be identifying. The Research Ethics Committee of Ebonyi State University, Abakaliki, Nigeria imposes ethical restriction in sharing such data. However, Data request may be sent to the University Research Ethics Committee, Directorate of Research, Innovation and Commercialization, Ebonyi State University, PMB 053, Abakaliki, Nigeria, ebsu_drec@ 123456yahoo.com for researchers who meet the criteria for access to confidential data.

A qualitative inquiry of rural-urban inequalities in the distribution and retention of healthcare workers in southern Nigeria

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Abstract

Introduction

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Conclusions

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Most cited references 30

Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Retention of health workers in rural Sierra Leone: findings from life histories

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