How to convince nurses to work in rural areas

Tanzanian nurses are reluctant to work in rural areas. - Offering further education and free housing may convince many more to move to remote areas, says CMI director Ottar Mæstad.

Tanzania has an acute deficit of health workers. An average of 1,4 health workers per 1000 persons and 0,02 physicians per 1000 persons makes the country one of the worst off  in the world. In addition, there are huge variations in the distribution of health workers across different regions. Many health facilities in rural areas have a huge deficit of nurses.

How can more nurses be convinced to work in rural areas?

Education and housing more cost-effective than a pay raise
Studies from a number of countries suggest that incentives like pay raise or free housing can be effective in motivating health workers to work in remote areas. Researchers Michael A. Munga from the National Institute of Medical Research, and Ottar Mæstad and Gaute Torsvik from CMI have studied the potential effects of incentive-based policy interventions in Tanzania. The findings have been published in the article “Using incentives to attract nurses to remote areas of Tanzania: a contingent valuation study” in the journal Health Policy and Planning.

To get a better idea of which interventions that would convince nurses to take a job in rural areas, the researchers conducted a survey among 362 nursing students from nine nursing schools. The students were asked to choose between urban and remote jobs in different scenarios involving different levels of incentives for a rural job.

Without any added incentives, only 19 percent of the students said that they would be willing to work in rural areas. By offering improved opportunities for further education to those who chose a rural job, the share increased to 47 percent. Free housing had a smaller effect than improved education opportunities, and increased the share to 34 percent.

-Further education and free housing both have significant effects, and are more cost-effective than raising salaries, says Mæstad. Free housing is probably the easiest policy to implement in practice.

Huge pay raises would be needed to get a similar effect on nurses’ job choices. A doubling of the salary was needed to increase the share of nursing students that said they would work in remote areas from 19 to 40 percent.

This alternative is neither cost-effective nor politically feasible, says Mæstad.

Rural background increases the odds
The study also found that nursing students who come from rural areas are more willing to work in the countryside. This gives a reason to build nursing schools in rural areas and otherwise promote the requirement of students from these areas, says Mæstad.

Mæstad stresses that the recommendations are based on students answering hypothetical questions.

-To provide more robust policy recommendations, we need to know more about how they would respond in a real world situation. More knowledge on how to strengthen health worker motivation is paramount for improving health services for the poor, says Mæstad.