WHO recommendation on recruitment and retention of staff in rural and remote areas

WHO recommendation on recruitment and retention of staff in rural and remote areas



Policy-makers should consider educational, regulatory, financial, and personal and professional support interventions to recruit and retain qualified health workers in rural and remote areas.

(Context-specific recommendation)


Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016



  • Recommendation adapted and integrated for the ANC guideline from the 2010 WHO publication Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations (1).
  • Strong recommendations (abridged) on recruitment and staff retention from the above guideline include the following.

– Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines and/or establish a health-care professional school outside of major cities.

– Revise undergraduate and postgraduate curricula to include rural health topics and clinical rotations in rural areas so as to enhance the competencies of health-care professionals working in rural areas.

– Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools, etc.).

– Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring.

– Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better-served areas and those in underserved areas, and, where feasible, use tele-health to provide additional support.

– Develop and support career development programmes and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education and training, without necessarily leaving rural areas.

– Support the development of professional networks, rural health-care professional associations, rural health journals, etc., to improve the morale and status of rural providers and reduce feelings of professional isolation.

– Adopt public recognition measures such as rural health days, awards and titles at local, national and international levels to lift the profile of working in rural areas.

  • Conditional educational, regulatory and financial recommendations from this guideline can be found in the WHO global policy recommendations document (1), available at: http://www.who.int/hrh/ retention/guidelines/en/



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • Should education, regulatory, financial and supportive interventions be used to improve recruitment and retention of health workers in remote and rural areas?


Evidence base

Further information and considerations related to these recommendations can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement- eng.pdf?ua=1


Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG did not identify any priority question related to this recommendation.


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health




  1. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010 (http://www.who. int/hrh/retention/guidelines/en/, accessed 28 September 2016)
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).