What Health Workers Are Saying about Their Rural Service in Lao PDR

As a young woman in the Lao People’s Democratic Republic, Souta Phanouvong was interested in learning about medicines so she could help people feel better. It didn’t hurt that her parents were also urging her to study pharmacy.

Last January, soon after completing her pharmacy degree, Souta—along with 399 other newly graduated doctors, pharmacists, and dentists—was assigned to serve three years in one of the country’s rural districts.

Like many other countries around the world, attracting health workers to take up rural posts is a big challenge. Most health workers choose to work in urban areas where they have better access to educational and economic opportunities, as well as more social options.

A new rural recruitment and retention policy
Souta’s deployment was part of the first phase of rolling out the Ministry of Health’s new national rural recruitment and retention policy. The Ministry developed the policy to respond to the country’s urgent need for more health workers—there are fewer than 6 doctors for every 10,000 people—especially in the rural and remote areas where two-thirds of Laotians live

Prior to becoming a health worker, Souta says she was young, carefree, and lacking responsibility. But with her new degree and new post at a district hospital in Bolikhamxay Province, she is changed. “Now as a health worker,” she says, “I have to be more responsible, help other people, be harmonious.”

While Souta gained relevant experience interning at the Food and Drug Testing Center and a pharmaceutical factory, this is her first time working in a hospital setting. She remembers one of her first patients who was in an accident and had serious wounds all over his body. Even though she was trained as a pharmacist, she pitched in to provide the care he needed: “I was called to assist a doctor. When I first saw the patient’s wounds I was shaking and afraid. A few minutes later I stopped myself from shaking, and I concentrated on cleaning and stitching his wounds.”

What are the other health workers saying about their rural experience so far? How is the policy working overall?

An early programmatic review

To figure out the most effective way to increase access to care in rural areas, the Ministry teamed up with CapacityPlus and the World Health Organization and applied the Rapid Retention Survey Toolkit and iHRIS Retain. The toolkit is based on the discrete choice experiment, a powerful research method that identifies what would most motivate health workers to accept a post a rural health facility. iHRIS Retain is an open source software tool to cost retention interventions and incentive packages. The Ministry used the results to create the new policy.

Announced in October 2012, the policy stipulates that all graduates—in medicine, nursing, midwifery, pharmacy, and dentistry, as well as postgraduates in family medicine—must complete three years of rural service in order to receive their licenses to practice. The policy also provides incentives to motivate these health workers to deliver high quality services and to remain in their posts after their compulsory service has ended. Incentives include a permanent civil service position after the three years, transportation, additional salary, and eligibility for continued education. 

CapacityPlus assisted the Ministry to conduct an early programmatic review, which involved interviewing a sampling of health workers and their managers in four districts in Bolikhamxay Province. While the primary goal was to identify implementation issues, which the Ministry has already moved to resolve, the findings point to strong positive effects after a short time.

Increased quality and availability of health services

Both health workers and facility managers reported that the rural deployment of health workers increased the quality and availability of services for villages. Thirty-five of the 68 vacant posts at the rural health facilities surveyed are now filled. Having more staff members reduced other health workers’ workloads, allowing them to perform their assigned tasks. Some respondents observed that more staff contributed to reduced patient wait time. And many of the newly deployed health workers were motivated to take on night shifts, further increasing the availability of health services.

The health workers surveyed felt they were able to effectively apply the skills they learned during their studies. Doctors, for instance, provided a wide range of services, including immunizations, antenatal care, assisted deliveries, family planning consultations, postpartum and infant care, and health education on malaria and parasitic diseases. Pharmacists like Souta are ensuring that patients take medicines properly, including contraception. Previously, prescriptions were not written out for villagers, but according to a number of respondents, the newly deployed pharmacists now provide written instructions for all medicines. They are also improving drug management to prevent stockouts and ensure that quality drugs are administered.

One doctor deployed to the Vienthong District Hospital said that according to a daily service report, the number of patients increased by 50%. Likewise, a dentist at the Vienthong District Health Office noted an increase in the number of dental consultations, adding, “Before I came here there were not any dentists.”

Many of the health workers remarked, again like Souta, that they had gained a greater understanding for rural health care needs. One worker appreciated other aspects of working in a rural location: “Working in a rural area is better than in an urban area. Villagers and health workers are so friendly, and health worker teams are so harmonious. It is a good experience.”

Looking ahead
Most of the recently deployed health workers said that they would be willing to continue working in rural areas. Some added that this would be the case even after marriage or continued education.

Overall, the vast majority of health workers interviewed said they were motivated by their job package, particularly by the opportunity to obtain a position in the civil service.

CapacityPlus will continue to work alongside the Ministry of Health to assess the policy’s impact over time on increasing access to skilled health professionals in rural areas.

Learning from Lao PDR

Other countries can adapt the same rural retention tools that Lao PDR has successfully used. At the Third Global Forum on HRH this Saturday, CapacityPlus’s Wanda Jaskiewicz will share Lao PDR’s experience using the tools and initiating the national recruitment strategy during a side session, “Achieving human resources for health commitments: Lessons learned and resources from CapacityPlus.”

On Sunday, Jaskiewicz will present factors affecting health workforce employment decisions for rural areas at a side session cosponsored by the World Bank, the WHO, and CapacityPlus, “How to recruit and retain health workers in rural and remote areas in developing countries—using discrete choice experiment to inform policy design and implementation.” During the same session, IntraHealth International’s Vincent Oketcho will present a case study on Uganda’s experience in developing and taking action on health worker retention strategies.

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