Striking the right balance: health workforce retention in remote and rural areas.

Ensuring universal access to skilled, motivated and supported health workers, especially in remote and rural communities , is a necessary condition for realizing the human right to health, a matter of social justice. It is also at the core of each and every global health goal – the United Nations' Millennium Development Goals, primary health care, immunization, and control of HIV/AIDS, malaria and tuberculosis. For none of these goals is attainable if significant population groups are denied access to health workers. Despite recent increased rhetoric, human resources remain a sorely neglected and grossly under-financed engine for health improvement. That is why 1500 global health leaders issued the Kampala Declaration in 2008: " to assure adequate incentives and an enabling and safe environment for effective retention and equitable distribution of the health workforce ". 1 Maldistribution is arguably the most critical workforce challenge, not only for achieving universal coverage but also for addressing inextricably linked workforce problems such as shortages and skill imbalances. In many countries, overall shortages are exacerbated, indeed even caused, by severe maldistribution. This is both a symptom as well as a driver of skill–mix imbalances. Often the problem may not be the absolute number of workers but the type of workers trained and their job location. National shortages often may be juxtaposed with rural vacancies and urban unemployment. Moreover, severe maldistribution in some circumstances may harm not only the disadvantaged , but also high-income populations. On the other side of the coin, excessive concentration of overly specialized professionals can cause unnecessary tests and procedures, over-prescription of drugs, iatrogenic diseases and wasted higher costs – plaguing the poor and rich alike. Maldistribution is a commonly shared problem in all countries, as all market-based economies have labour markets where professionals exercise occupational mobility. Only one or two authoritarian regimes currently dictate exactly where each worker must live and work. And most professionals, it must be acknowledged, seek urban-based, middle-class professional work and personal lives. There is nothing wrong with this. It is the biased institutions , inequitable policies and perverse public subsidies that need fixing because they produce a workforce misaligned with equitable national health development. Some problems of maldistribution are rooted in deep historical processes, like left-over colonial structures. In many countries, ethnic and cultural minorities have been forced into remote mountains, arid lands and recently into urban slums – that are further handicapped by weak economies and …