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Human Resources for Health

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Appropriate training and retention of community doctors in rural areas: a case study from Mali
Monique Van Dormael*1, Sylvie Dugas1,2, Yacouba Kone3,
Seydou Coulibaly3, Mansour Sy3, Bruno Marchal1 and Dominique Desplats4 Address: 1Institute of Tropical Medicine, Public Health Department, 155 Nationalestraat, 2000 Antwerp, Belgium, 2Direction Départementale des Affaires Sanitaires et Sociales, 2 boulevard Murat, BP 3840, 53030 Laval cédex 9, France, 3Santé Sud, BPE686, Bamako, Mali and 4Santé Sud, 200 Boulevard National, Le Gyptis, Batiment N, 13003 Marseille, France Email: Monique Van Dormael* - [email protected]; Sylvie Dugas - [email protected]; Yacouba Kone - [email protected]; Seydou Coulibaly - [email protected]; Mansour Sy - [email protected]; Bruno Marchal - [email protected]; Dominique Desplats - [email protected]

* Corresponding author

Published: 18 November 2008
Human Resources for Health 2008, 6:25

doi:10.1186/1478-4491-6-25

Received: 22 January 2008
Accepted: 18 November 2008

This article is available from: http://www.human-resources-health.com/content/6/1/25 © 2008 Van Dormael et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: While attraction of doctors to rural settings is increasing in Mali, there is concern for their retention. An orientation course for young practicing rural doctors was set up in 2003 by a professional association and a NGO. The underlying assumption was that rurally relevant training would strengthen doctors' competences and self-confidence, improve job satisfaction, and consequently contribute to retention.

Methods: Programme evaluation distinguished trainees' opinions, competences and behaviour. Data were collected through participant observation, group discussions, satisfaction questionnaires, a monitoring tool of learning progress, and follow up visits. Retention was assessed for all 65 trainees between 2003 and 2007.

Results and discussion: The programme consisted of four classroom modules – clinical skills, community health, practice management and communication skills – and a practicum supervised by an experienced rural doctor. Out of the 65 trained doctors between 2003 and 2007, 55 were still engaged in rural practice end of 2007, suggesting high retention for the Malian context. Participants viewed the training as crucial to face technical and social problems related to rural practice. Discussing professional experience with senior rural doctors contributed to socialisation to novel professional roles. Mechanisms underlying training effects on retention include increased self confidence, self esteem as rural doctor, and sense of belonging to a professional group sharing a common professional identity. Retention can however not be attributed solely to the training intervention, as rural doctors benefit from other incentives and support mechanisms (follow up visits, continuing training, mentoring...) affecting job satisfaction. Conclusion: Training increasing self confidence and self esteem of rural practitioners may contribute to retention of skilled professionals in rural areas. While reorientations of curricula in training institutions are necessary, other types of professional support are needed. This experience suggests that professional associations dedicated to strengthening quality of care can contribute significantly to rural practitioners' morale.

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Human Resources for Health 2008, 6:25

Background
Staffing of health centres in rural and remote areas is a
problem all over the world, affecting particularly subSaharan African countries [1-3]. In Mali, a country with critical shortage of health professionals [4], overall availability of skilled health workers is improving, but urban/ rural disparities remain strong [5], and staff turnover is

high [6,7]. Most health centres in Mali are headed by a
nurse, though medical doctors increasingly engage in first
line practice, including in rural and remote areas [8-10].
While attraction of rural doctors is steadily rising, there is concern about their long-term retention. In response, an
orientation course for recently established rural doctors
was set up in 2003, based on a training needs assessment.
This paper draws lessons from this experience, focusing
on processes and mechanisms operating in the relation
between training and retention in rural practice.
Determinants of staff turnover in rural and remote areas
It is widely recognised that qualified staff turnover tends
to be more acute in rural and remote areas than in urban
settings [11-13]. This may affect quality of service provision, as new comers need time to establish a relationship with the community. High turnover also affects health
service efficiency and team productivity during the initiation period of the newcomer [11]. Turnover may also result in prolonged periods of understaffing of health
facilities.

While there is considerable overlap between factors affecting attraction and retention in rural areas, attraction is based on expectations while retention is based on actual
working and living experience [14]. Turnover is partially a
result of job dissatisfaction, which induces not only demotivation and absenteeism, but also intentions to quit [11,15].
Job satisfaction, and consequently willingness to remain
in a rural post, is influenced by a complex interplay
between individual factors, living environment and working conditions [2,16]. Individual professionals have different backgrounds and expectations, but also vary in terms of self-confidence, which impinge on job satisfaction: people with higher self confidence are more likely to persist longer at the task in the face of obstacles than people with lower self-confidence [16]. Living environment has strong influence on job satisfaction in rural areas: inadequate housing, lack of schools and lack of recreational facilities are push factors inducing staff to leave [2,17]. The quality of relations with patients and recognition by local community are all the more

essential in rural practice since opportunities to develop
alternative social networks are limited [18].

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Last but not least, working conditions are major determinants of job satisfaction, According to Herzberg's motivational theory [19], factors that make people dissatisfied at work are different from those motivating them to do a

good job. Dissatisfiers relate to working conditions rather
than the task itself: low salary, poor career perspectives
and training opportunities, unsatisfactory access to supplies and support mechanisms, and disappointing human interactions with colleagues and managers all contribute
to a sense of dissatisfaction. In contrast to these extrinsic motivational factors, intrinsic motivation relates to the
actual content of work, feelings of achievement, self
esteem and self confidence; they contribute to job satisfaction and stimulate performance. According to Herzberg, limiting dissatisfiers motivates a worker to stay, but not to perform better. In line with this theory, some authors

argue that avoiding dissatisfiers is more important to promote retention than building particularly high levels of job satisfaction [20]. Others however challenge this view,
especially for professionals, and suggest that turnover
results as much from low intrinsic job satisfaction than
from experiencing difficult working environments [21].
The Malian Rural Doctors Movement
In 2007, 99 rural doctors were serving in over 13% of
Mali's rural community health centres [8]. Explanations
of th...

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