Retention and Productivity

  Retention and Productivity

CapacityPlus built the capacity of national human resources for health (HRH) leaders and managers in Uganda, Laos, and Malawi to use the project’s retention and productivity tools to generate evidence and inform decisions to influence policy-making and improve the availability of services through increased staffing and distribution.


The 13 million global health workforce deficit (Campbell et al. 2013), coupled with the difficult living and working conditions encountered in rural areas, result in serious geographical maldistribution of health workers: 56% of the global rural population—and 83% of Africa’s rural population—are without health coverage (International Labour Organization 2015). Without aggressive efforts to increase access to health workers in rural areas, countries will be unable to meet their goals of increasing use of modern contraception, ending preventable child and maternal deaths, and achieving an AIDS-free generation. While rural attraction and retention strategies are implemented over the medium and long term, health system performance can be maximized in the meantime through improved productivity of currently available health staff. Moreover, if productivity issues are not adequately resolved, newly deployed health workers will enter into weak systems and perpetuate low productivity and inefficient service delivery leading to poor-quality services.

Strategies and Approaches  

To attract and retain health workers to provide needed services in rural and other underserved areas, countries must develop recruitment and retention strategies that address the motivational factors that influence health worker behavior and guide their employment decisions. However, how do stakeholders know which are the right incentives and interventions and in what combination? How much will they cost and are they financially sustainable? Further, how will stakeholders identify and address productivity bottlenecks hindering the provision of quality health care? To aid countries in answering these essential questions, CapacityPlus developed three tools designed to build national HRH stakeholders’ capacity to generate evidence for decision-making.

Rapid Retention Survey Toolkit: One powerful solution to the question of how to select the right incentive combination is the discrete choice experiment (DCE). The DCE is a rigorous quantitative research method that can be used to assess health workers’ motivational preferences and design appropriate financial and non-financial incentive packages to increase rural job uptake and retention. To put the power of this complex econometric approach in the hands of HRH managers and other lay stakeholders, CapacityPlus developed the Rapid Retention Survey Toolkit, a step by step approach that, with the aid of specific software programs, guides HRH managers to rapidly assess motivational preferences to take up posts and remain in underserved facilities. The results of the rapid DCE survey are then used to create evidence-based incentive packages and to advocate with policy-makers regarding the most favorable recruitment and retention strategies for implementation.

iHRIS Retain: To directly engage HRH managers and other stakeholders in the costing aspects of the recruitment and retention strategy design process, CapacityPlus and the World Health Organization (WHO) developed iHRIS Retain, an open source software tool to cost health worker retention strategies. The tool guides users through the costing process step-by-step to capture all relevant financial, operational, and workforce data and calculate individual and aggregate costs of each incentive or intervention strategy and compare them to available funds.

Productivity Tools: The Health Workforce Productivity Analysis and Improvement Toolkit provides a stepwise process that empowers managers and supervisors to measure the productivity of facility-based health workers, understand the underlying causes of problems, and identify potential interventions to address them. In the tool’s quantitative, formulaic approach, productivity is calculated by taking the ratio of the aggregate service delivery outputs (e.g., number of family planning consultations, number of institutional deliveries) produced over the human resources inputs (salaries) used. Qualitative research methods are then used to identify the issues affecting productivity levels, such as health facility inefficiencies, health worker absenteeism, or low patient demand. Through participatory engagement approaches, stakeholders develop action plans to implement and monitor improvement interventions.