Table 3.

Overview of Study Outcomes Relating to Retention Strategies of Doctors in LMICs

Authors (Year)	Category of strategies	Outcome measured	The main description of outcomes	Factors influencing the outcomes
Arora et al. (2017) [32]	Education Regulatory	Retention rate Number of doctors Provincial assignment compliance	• The overall and year-by-year retention of medical graduates under the special recruitment track (CPIRD) was higher than the normal track (overall retention of 78.2% and 52.5% respectively, p < 0.05) between 2001–2016 • Increased production of doctors for rural areas, with a significant rise in graduates from the special recruitment track from eight in 2001 to 883 in 2015 • Among 4,869 medical graduates under the special recruitment track remaining in the MOPH, 90.9% (n = 4425) worked in their primarily assigned provinces	Not mentioned
Boonluksiri et al. (2023) [33]	Education Regulatory	Retention rate CBL contact time	• 5,774 of 10,018 doctors (57.6%) were retained. CPIRD retained at a higher rate (1,514 of 2,098 doctors; 72.1%) than normal track (4,260 of 7,919 doctors; 53.8%; p < 0.001) • Graduate entry CPIRD were retained at a higher rate than normal track; 108 of 128 doctors (84.4%) and 1406 of 1971 doctors (71.3%), respectively (p = 0.001) • More CPIRD doctors worked in rural areas than normal track doctors (62.3% and 49.0%, p < 0.001) • Higher contact time of CBL in the retention group than in the resignation group (305.9 h (2.97%) versus 312.5 h (2.90%), respectively, P = 0.046)	CBL programmes differed based on the affiliated university, staff preparedness, learning quality, community appeal, engagement level, rural setting, and contact time of rural exposure
De Mesa et al. (2023) [39]	Financial incentives Professional and personal support	Intention to stay Job satisfaction	• Urban areas: No change in the intent to stay, with 74% of HCPs intending to stay both at baseline and the end of the study (p-value = 1.000) • Rural areas: Increased in the intent to stay from 75% at baseline to 89%, although this change was not statistically significant (p-value = 0.090) • Remote areas: Significant decrease in the intent to stay from 93% at baseline to 76% (p-value < 0.001) • Baseline: Urban HCPs showed lower work enjoyment (63%) and morale (72%) than those in rural and remote areas, with widespread feelings of under-compensation, especially in remote areas concerning equipment access • Final improvements: Increased satisfaction with compensation fairness at urban (p = 0.001) and rural sites (p = 0.016), and access to medicines in rural areas (p = 0.012), were significant, moving median satisfaction scores from neutral to satisfied • Differences in satisfaction: Urban and rural HCPs maintained satisfaction levels, while remote HCPs experienced significant drops in morale and overall satisfaction (p < 0.001)	Facilitators: Fair remuneration for HCPs in both urban and rural areas Performance-based incentives, electronic health records adoption, improving diagnostic capabilities and medicine access improved job satisfaction and retention Barriers: Late or irregular salary payments Poor working conditions such as infrastructures and workplace hygiene
Gow et al. (2013) [38]	Financial incentives Professional and personal support	Recruitment rate Job satisfaction and intentions to quit	• The ZHWRS did not meet its targets for health worker recruitment • In 2009, the MOH workforce consisted of 627 health workers, representing 3% of the total health workforce, a 24% decrease from 2006, indicating declining attraction and retention capabilities • 40% of health workers have very low or low job satisfaction, contributing to high attrition rates. 48% of the workers showed a desire to quit their current locations, with intentions to join the private sector, migrate outside Zambia, or move to local NGO health facilities​​	The "one-size-fits-all" approach overlooked the unique characteristics and requirements of various health cadres Absence of a comprehensive multi-sectoral rural implementation plan Weak human resource management system with health worker distribution biased toward urban areas Lack of non-financial incentives
Gyedu et al. (2019) [29]	Education	Retention rate Health service provision	• A high retention rate of 87–97% among GCPS-trained surgeons with 44% in the rural and higher-need areas • Surgeons performed 13 weekly operations, with 35% of elective and 77% of emergency operations classified as essential, highlighting the scheme's effectiveness in addressing critical surgical needs • Surgeons in Ghana contributed to medical education and evidence base through their involvement in training (79%) and research (46%) • Surgeons reported improvements in their hospitals, such as expanded surgical services, reduced referrals, enhanced quality of care, and increased patient satisfaction	Regular engagement in community service, health education, training of other HWCs, advocacy, and collaboration with international organisations
Hutch et al. (2017) [27]	Education	Retention rate	• High retention rates of surgical graduates within their countries of training, 85.1% (883/1038), the ECSA region, 88.3% (917/1038), and Africa, 93.4% (970/1038) • Retention rate by country of graduation within Africa varied from Malawi (100%, 11/11) to Zimbabwe (65.5%, 38/58) • Zambia retained 97.9% (46/47) of graduates in the country, while Ethiopia and Uganda showed lower rates with 77.8% (277/356) and 77.3% (75/97)	Provision of surgical training via 24 university-affiliated teaching hospitals
Lisam et al. (2023) [37]	Financial incentives	Vacancy rate Financial incentives utilisation	• In 2010–11, 1,319 health workers joined CRMC, and the vacancy rate reduced from 90 to 45% across facilities, with a further increase to 1,658 in 2011–12 with a 20% increase in the proportion of staff joining CRMC areas • Increase in the budget utilisation for CRMC, from 27% in 2009–10 to 98% in 2011–12 • Doctors expressed that they continued to work in CRMC areas due to financial incentives and extra marks for post-graduate admissions	Increased budget provisions by the government Delayed and irregular payment of incentives Limited access to training, inadequate supervision, and poor monitoring Inadequate healthcare infrastructures and personal support such as residential accommodation, educational facilities, transportation allowances, and life insurance in CRMC
Pagaiya, Kongkam and Sriratana (2015) [30]	Education Regulatory	Retention rate Resignation rate Risk of leaving service	• CPIRD doctors had a higher retention rate in rural areas (29%) compared to non-CPIRD doctors (18%) • Overall median survival time was 4.2 years for CPIRD doctors and 3.4 years for normal track doctors • The survival time decreased for later cohorts, with CPIRD doctors' median survival dropping from 8.0 years (2002 cohort) to 3.9 years (2007 cohort), and normal track doctors from 8.4 years (2000 cohort) to 3.1 years (2007 cohort) • Even though almost half of the doctors (45.9%) left the MOH service during the study period, the rate of leaving was lower among CPRID doctors (33%) than those in the normal track (48%) • The incidence rate of doctors who left the rural areas was lower for CPIRD than for normal track at 14.9% and 18.2% of doctor-years • The rate increased over time, from 2.2% for CPIRD (2001 cohort) to 17.0% (2007 cohort), and from 8.1% for the normal track (2000 cohort) to 28.3% (2007 cohort) • Normal track doctors had a 1.3 times higher risk of leaving rural areas than CPIRD doctors	Selective admission of students with rural background students Collaborative training with medical schools and the MoH Preferential job placement in their home provinces after graduation
Prashad et al. (2017) [34]	Education	Retention rate Career promotion	• 11 out of 14 (78.6%) resident graduates practised in Guyana • Mixed experiences from participants about the rural practice environment, with some expressing satisfaction while others expressed frustrations due to overwork and understaffing • Rural training programme improved understanding of challenges in under-resourced areas and made the graduates more inclined to practise there • Participation in the programme led to promotion and senior positions	Alignment of training with actual country medical practice and training skills relevant to the local community International partnerships with the Canadian Association of General Surgeon Diploma programme were still insufficient for some, resulting in them leaving to pursue higher-level training abroad Inequalities arising from diploma qualification compared to other postgraduate programme Lack of support from important stakeholders
Qureshi et al. (2013) [28]	Education	Staff number Operative case Accreditation and training expansion Integration of surgery residents	• Increase in physician staff, indicating a bolstered surgical capacity • A marked increase in major operative cases performed from 1,070 in 2007 to 1,573 in 2010, indicating the department's growing capacity and skill level • Accredited programme by COSECSA in 2009 to provide 5 years of basic surgical training to local surgeons, with six more residents joining in 2011 • Surgery residents have replaced the responsibilities traditionally held by Clinical Officers, indicating successful integration and potential for long-term retention​​	Integration of local surgical training programme into existing educational and healthcare infrastructure with international collaboration Governmental support from the MOH Career advancement through research, educational resources opportunities and improved hospital facilities Efforts to address and secure funding and resources despite economic challenges
Sirili et al. (2018) [36]	Financial incentives Professional and personal support	Financial incentive system Working conditions Career development Living environment and social services Implementation challenges Vacancy rate	• The participants expressed that the non-uniform application of financial incentives across districts may lead to an internal brain drain of doctors seeking better incentives • They highlighted that despite efforts to improve working conditions, under-equipped facilities, and general feeling of being undervalued by the community suggest a need for further improvements to enhance their satisfaction and work environment • The participants mentioned that implemented career development strategies like postgraduate scholarships, but lack of a clear career path in districts discouraged doctors, highlighting the need for a structured approach • The living environment and social services, including housing, education, and recreational facilities, significantly influenced doctors' decisions to stay or leave rural districts, emphasising the need for improved quality of life • Health managers reported that they implemented strategies to retain doctors, including career development plans, financial incentives, and private practices, but faced challenges due to limited resources and rural doctor retention complexity • None of the three districts achieved the recommended minimum number of doctors recommended for their staffing level • District A had a 26.3% shortage (59 out of 80 required doctors). Districts B and C had only 3 out of 8 required doctors, equivalent to a 62.5% shortage	Unfavourable working conditions, unclear career paths, and a non-uniform financial incentive system across districts Unsupportive community environments like difficulty finding housing, limited income opportunities, lack of community appreciation, and inadequate social services Minimum financial incentives due to financial constraints and competing priorities Weak management capacity across all levels in the country
Techakehakij and Arora (2017) [31]	Education Regulatory	Retention rate Probability of leaving Resignation rate	• Rural service retention of normal track doctors was significantly lower than their CPIRD counterparts (p < 0.001) • CPIRD medical graduates were 2.44 times more likely to complete a 3-year rural service compared with their normal track graduates • The 3-year rural retention rate was 286.7% higher in Grad CS doctors compared to Regular CPIRD physicians, while Grad medical graduates showed a 52.9% lower retention rate • CPIRD physicians have a 54.4% lower annual probability of leaving the MoPH hospitals than normal track peers • ODOD and Grad CS physicians were respectively 37.0% and 74.8% less likely to leave rural services each year compared to Regular CPIRD counterparts • Grad doctors had a 63.0% higher annual resignation rate than Regular CPIRD physicians	Female doctors were more likely to resign from MoPH hospitals Higher resignation rates among physicians from certain regions Compulsory service lengths and penalties for non-compliance differ for different tracks
Zimmerman et al. (2016) [35]	Professional and personal support Education Regulatory Financial incentives	Recruitment Hospital service delivery	• Continuous posting of family practice doctors in each of the seven hospitals • Mean annual admissions and outpatient visits per hospital almost doubled, from 832 to 1,592 and 10,585 to 21,341, respectively • Mean deliveries per hospital per year tripled from 152 to 462 • The mean caesarean sections per hospital per year increased from 1.4 to 24.8	Compulsory-service scholarships ensure a binding commitment to serve in a rural hospital Performance-based incentives with higher salaries Central personnel management to streamline the recruitment and deployment of hospital staff Personal, professional, and management support to all hospital staff which includes improved living quarters, new hospital equipment, and internet access