Table 3.
Rural Pathways Checklist including eight actionsa.
| Checklist action | Summary of evidence | Reflective questions |
|---|---|---|
| Community needs, rural policies, and partners | Working with rural communities to explore their needs for healthcare helps to work out priorities for action community. A scan of the national policies and plans for rural health provides insights into directions for governments and potential synergies between policies and the local priorities. Priorities may need to be sorted into an order, particularly in the face of competing demands for resources and in some cases, extensive unmet need. Government and other partners, along with decentralized finance and management is important for enabling solutions to be appropriately tailored and for ensuring appropriate technical and financial support is available. | What do our rural communities need? • Is the community involved in defining priorities and possible solutions? • What are key priorities now, which can be built on later? What rural health policies/plans exist to support action? • Are they implemented? • Do these cover health workforce, training, and rural health priority areas? • Is policy/planning decentralized? • Are new policies needed? What global, national, or local partnerships can we build to help? • Who can assist? • How can the partnership be sustained? (7, 8, 23, 25, 36–43) |
| Existing workers and their scope | The skill levels of rural workers may not be sufficient to meet rural and remote community needs. A scan of existing rural and remote health workers and their skills, practices, and motivations can inform rural pathways strategies. Rural and remote healthcare teams having a wider range of skills, supported by organizations to address community need, can improve comprehensive local care, and potentially help to improve health worker satisfaction and retention. Communities need to balance short-term recruitment needs with long-term workforce building processes. | What rural healthcare teams, working within what scope, are needed? Do workers already exist with skills for this scope of work, easily recruited/retained? • What are their qualifications and training relative to the skills demands of the role? • Are they motivated to work at the required scope? • Is their health service supporting their increased scope? • Are they being retained in rural and remote areas? • Are they attracted to work in rural and remote communities? • Are there short-term recruitment options whilst longer-term workforce is developed? (41, 44–54) |
| Selection of health workers | An extensive range of community selection options are demonstrated involving selecting people with a connection to “place,” commitment to serve others, motivated to learn, and invested in improving access to community health services. Universities and training courses with a social accountability for developing health workers with a desire to serve others, trained, and ready to work where they are most needed, tend to select students committed to helping underserved. Selection of rural background, people from disadvantaged communities of different race and language groups relative to the country and rural context is important, along with financial and social support for these groups to fully participate in city courses. Cost benefits of developing new workers are important considerations and should be evaluated. | How can we select workers for this role from the community? • Are there people in the rural community who could fill roles with some education and training? • What process and criteria will effectively select them from the community for the community? • What is the entry level standard appropriate for coping with the training? • What financial and social support do community members need to access training? • What are the cost-benefits of training a new worker and who will share the costs of training? (27, 28, 32, 55–70) |
| Education and training | Optimal education and training for rural practice occurs through exposure to rural and remote practice, teams, and health systems. Learning the range of skills needed is effective through distributed training systems using locally-available qualified teachers and supervisors, in the place where people are going to practice and involving of the people that the workers are going to help after they finish training. This often occurs within University and other training organizations with a social accountability for developing health workers with desire to serve others, trained, and ready to work where they are most needed. And also by providing options for existing rural workers to learn and get qualified, on the job, through supervision, and decentralized courses. For optimal effect, more practical training in the rural communities is best, along with bundled support to optimize the educational experience. Compulsory service strategies work best if they are combined with selection, education, and support strategies. Beyond any one course, there should be options for doing more advanced training, for career progression. Training covers the breadth of skills needed for the role. Sustainable funding and technical support for decentralized training is important. |
How can we effectively educate, train, and up-skill people in rural areas and for the breadth of skills needed by rural communities or support existing rural workers to learn on the job? • What bridging courses are required? • What rural curriculum is relevant? Who will develop and validate this? • How can theoretical and practical components be delivered in rural areas? • How much real-time supervision and virtual supervision will work to learn practical skills safely? • How can practical learning support the scope and complexity of skills required? • What further training can the qualification articulate with for career development (short course or university)? • How much would it cost to train/employ/support students and how can this be funded? • How can the local government, community, and champions support the training? (8, 24–28, 33, 34, 56, 62, 71–91) |
| Working conditions for recruitment and retention | Education and training is only likely to be effective in recruiting and retaining health workers if the practice conditions are right, there is a supportive learning culture and strong management in the health service and there are supplies, clinical infrastructure, safe housing, good remuneration, and sustainable workload. Health worker motivation and engagement is better if employers regularly check in with them about their goals and any factors impacting their performance. Structured orientation and community-based projects for new staff can improve transition to rural work as a new worker and interest in continuing in the role. | What are the practice conditions in the community which could affect satisfaction, recruitment and retention? • Are we recruiting people who completed training in the community to work in the community? • Do the rosters make the workload sustainable? • Are we creating jobs with satisfactory employment terms and variety, volume, and scope of work? • Is remuneration appropriately rewarding employees? • Is there an orientation to the workplace? • Is there orientation to the community? • Are senior workers and supervisors available onsite/virtual? • Is there training for health service managers? • What support is there for housing and meals? • Do health workers have transport for their work? • Are there baseline stocks of medical supplies, equipment, and drugs? • Are the health service buildings and clinical infrastructure of reasonable standard? • Is there security for workers? • Are workers given enough time off? • Are there subsidies for work away from home? • Do workers have access to technology support and internet? • Is there rural health team cohesion? (62, 92–103) |
| Accreditation and recognition | Accreditation and formal professional recognition of the worker is important for recognizing the worker's training and scope of work. It helps reinforce their investment in doing more training and supports their retention in the role and use of all their skills. Clear accreditation and recognition also helps the community to identify qualified health workers. Recognition of supervisors is equally important. | How can people who are trained for rural work be accredited and recognized for transferability of the qualification? • What qualification can they be given? • How can the community value graduates of the training? • Is there a professional title for graduates? • Are the graduates recognized at country level for what they do? • Can the graduates be paid appropriately for using the skills they have developed? • Do they have options for progressing their career path? (62, 81, 92, 96, 104, 105) |
| Professional support and up-skilling | It is important to provide professional supervision and networking opportunities to reduce health worker isolation and reinforce skills development. Online communities of practice and peer exchange systems can be useful but they need to be tailored to the health workers' needs, organized, and evaluated. If senior staff are not onsite, then at least monthly virtual or face-to-face meetings and case reviews by senior staff should be facilitated. Structured orientation and community-based projects for new staff can improve transition to new workers to rural work and support their interest in continuing the role. |
How can rural workers be professionally supported? • What senior clinician support and supervision is available? • Are the information systems available to the health workers optimal for the job? • What systems (outreach, telehealth and onsite) are there for getting feedback on challenging cases? • What refresher courses and simulations could be available for low volume but important skills? • How can the health workers access peer support - professional meetings and practice discussions? • What professional networking is possible? • Are there opportunities to participate in local research projects? (21, 97, 106–128) |
| Monitoring and evaluation | Monitoring and evaluation of rural pathways plays a central role in informing any adjustment to the pathways as well as providing evidence about the effect on rural workforce, their supply, qualifications and retention, accessible health services and demonstrating community health, social, and economic outcomes. This requires consideration of routine data collection for pre and post testing or using control groups of rural communities without pathways. | Are the activities and outputs of the program being implemented as planned?What are the intended outcomes of pathways and how can we collect data to measure this effect? • Do we have workforce registries and health data or how can these be built and managed? • Are partnerships set up for strong evaluation? • What do we want to measure? - Is community need being monitored? - Is selection and training effective for pathways goals? - Are there more rural students / local workers and supervisors? - Is professional development effective? |
| - Is there more infrastructure? - Is workforce retention better? - Is access to health services better? (earlier intervention, continuity and prevention measures) - Have there been changes in service volume and complexity? - What are the social, economic and health outcomes in the community? (7, 21, 39, 129, 130) |
a
Please see the graphically-designed Checklist in Data Sheet 1.