Rural health workforce reform: lessons informing implementation, monitoring and evaluation

Introduction

The complexity of recruiting and retaining health workers in rural areas is evident. There is variation in uptake, applicability, and effectiveness of retention schemes. This is complicated by the fact that rural health systems range substantially in the design and composition of staff roles, resources and local needs. In 2021, the World Health Organization released Guidelines including a suite of recommendations around education, regulation, incentives, and personal and professional support. Understanding how these guidelines are implemented is urgent.

Methods

In 2025, we searched the peer-reviewed literature for articles on the implementation of rural and remote health workforce retention, attraction, development and recruitment strategies, focusing implementation. A total of 1,992 articles were identified,1,009 articles were screened, and 77 considered eligible. We conducted purposive key informant discussions to obtain information about specific country cases, where the literature review did not reveal sufficient information.

Results

Using country examples, we present the extent to which countries are implementing the WHO-recommended strategies and to which key implementation factors, such as availability, affordability, acceptability, relevance, feasibility are used to decide what to implement. We highlight what we know about what works in the 4 domains of the WHO guidelines: Education, Regulation, Incentives, and Support using country examples.

Conclusions

The most effective interventions are tailored to the local context and implemented as bundled strategies. Feasibility, acceptability, and affordability are not holistically assessed prior to implementation. Rigorous and holistic evaluation, including systematic monitoring are needed. Unintended consequences and continuous learning are under explored (e.g. spillover effects, community resistance). The findings informed the development of implementation, monitoring and evaluation guidance.

Key messages

• Successful implementation of strategies for recruiting and retaining health workers in rural areas requires bundled, interventions, tailored in partnership with communities and health care workers.

• The guidance prepared supports local actors to carry out holistic evaluations that assess feasibility, acceptability, and affordability of reforms and ongoing monitoring for learning and adaptation.