Strategies to effectively and equitably retain, recruit, and station providers – commonly called Posting and Transfer (P&T) - include: expanding medical education and in-service training targeted at specific cadres or regions; strengthening primary and rural care programs in existing institutions; providing incentives and support for providers to work in rural areas, public facilities, or primary care settings; instituting mandatory civil service in these same areas; training facility-based providers from underserved areas who are more likely to return or remain in these areas; and developing methods for improving provider motivation and satisfaction such as supportive supervision, career development, adequate workload and facility infrastructure, and continuing education, so as to promote provider retention.11 12 13 14 More information on provider motivation is included in the provider motivation module.
Despite P&T being an important consideration for operations of a health system, delegation of roles and responsibilities and methods for provider deployment is vastly understudied in the LMIC literature. Formal responsibility for P&T is often included in policies in public administration structures or various levels of the Ministry of Health within a given country. However, there are often informal norms or practices that also govern the placement and distribution of providers such as preferential treatment for specific cadres, bribery, nepotism, or gendered delegation of responsibilities.9 When instituting systems and policies for P&T, it is important that stakeholders explore some of these informal practices that influence provider distribution through qualitative or participatory evaluation and research to inform policies and interventions.
It is also important for stakeholders to consider incentives or specific training that can help providers more successfully carry out their responsibilities in underserved areas. For instance, if countries are struggling with posting and/or retention in rural areas, they could increase salaries or institute loan repayment for providers who serve in these areas. Non-financial support that is important to consider may include cultural or language training and systems for providing in-service training and professional growth.15
Community health workers (CHWs) can be a valuable resource for increasing geographic access to health services. CHWs require less training than doctors or nurses and thus can be deployed quickly and are quite cost effective. Additionally, they have been shown to effectively provide high quality preventative and some curative care in remote areas where access to facilities is challenging (see proactive population outreach within "service delivery acticites" and in the Population Health Management module). While CHW-based care is not a substitute for comprehensive primary care, and CHWs should have a clear and limited set of responsibilities, CHWs can play an important role in the health system. In addition to improving health outcomes, bolstering the CHW workforce can have an intersectoral impact, creating job opportunities and ultimately reducing unemployment and strengthening economies. While CHWs may be cost-effective in terms of salary and training, it is important to note that they often require additional resources such as transportation or communication technology in order to be effective, and these inputs should be considered during program planning and budgeting.
A successful CHW program must include a comprehensive plan considered from a whole health system perspective. UNAIDS has developed a report calling for increased CHW training and deployment across Africa. Within the report, they highlight key barriers that may arise when scaling-up CHW programs. These include inadequate political commitment, insufficient funding, policy and regulatory gaps, and lack of partnership with other health professionals.8 Although they are framed as challenges, they can also be considered opportunities for collaboration during initial planning and implementation.
In addition to many individual countries’ programs, there are several large CHW-initiatives such as the African Union’s 2 million CHW Initiative, which has committed to bolstering the health workforce throughout African settings by training two million new CHWs.8 The new CHW Academy will also focus on training and development of global best practice standards for CHWs. Additional information on the potential of CHW programs – including a report synthesizing implementation considerations from six high-performing CHW programs - can be found at CHW Impact.
In addition to improving geographic access to services through community-based care, health system stakeholders may also choose to engage in partnerships to provide greater access to and quality of primary health care services. In certain areas, public/private partnerships (PPPs) may increase geographic accessibility if private organizations already have adequate physical infrastructure and are set up in such a way to promote partnership.16 PPPs are sometimes pursued solely for the building of infrastructure; these partnerships often result in faster and more efficient development of facilities. However, PPPs are also pursued in instances where public entities work with private ones to use existing physical facilities and/or service delivery structures. This more comprehensive PPP model is often called an “integrated partnership”.17 In an integrated partnership, governments will contract private organizations for use of existing infrastructure and service delivery in places that lack access to public facilities. This requires a shift in the role of the government from providers of care to managers, regulators, and purchasers. Additionally, these partnerships must entail a formal agreement between the private organization and the government with defined projects and payment contingent upon fulfillment. Thus, there must be effective performance measurement and management systems in place to ensure that goals are achieved. These partnerships should also not increase costs at the point of care, and under the best circumstances, they should improve quality while reducing out of pocket payments.
It is important to note that one method for addressing inadequate facility distribution – particularly in conflict zones where facilities have been destroyed or are inaccessible – is mobile clinics. While there are certainly benefits associated with mobile clinics such as quick access and flexible infrastructure, mobile clinics are not a solution for strengthening a primary care system in the long term. By nature of mobility, patients are unable to form continuous relationships with providers and clinics are not accessible at all times, compromising first contact accessibility.