Compulsory service programmes for recruiting health workers in remote and rural areas: do they work?

364 Special theme – Health workforce retention in remote and rural areas Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605 Introduction Compulsory service programmes have existed since the early 20th century. Different names have been given to such pro- grammes, including “obligatory”, “mandatory”, “requisite” and “coercive” programmes. In this paper, we will use the term “compulsory service” to describe such programmes. Literature shows evidence of programmes in the Soviet Union in 1920,1–3 in Mexico in 1936,1 and in Norway in 1954. In the 1970s, there was an acceleration of new programmes worldwide. No one reason is evident for this rapid growth, though this decade witnessed an overall increase in attention paid to inequities in health provi- sion (as evidenced by the 1978 adoption of the Declaration of Alma-Ata), as well as increased worldwide interest in socialist ideologies, especially the belief in national service and pride. Over the years different countries created and implemented compulsory service programmes, one of the most recent ones was started in Ghana in 2009. Fig. 1 shows more than 70 countries with current and past compulsory service programmes. The map shows countries where this study found corroborative evidence of compulsory service programmes as well as countries where it found some indications, but no corroborative evidence. Methods Robust information on the specifics of compulsory service pro- grammes is not readily available. We did a country-by-country inventory of all Member States of the World Health Organiza- tion (WHO). We did a literature search, formal interviews, as well as informal questioning of relevant informants to identify countries with compulsory service programmes and their details in each of the WHO regions. A literature review was conducted of internet databases (Box 1) using the following terms: bond doctor, bond scheme, bonding, bonding medical, compulsory medical, compulsory medical service, conditional medical, conditional scholarship, mandate doctor, mandate medical, mandate nurse, mandate rural, medicatura rural, obligatory medical, obligatory service, coercive service, rural health service, rurales, social doctor, social medical, social nurse, [COUNTRY NAME] health human resources, [COUNTRY NAME] health human resources rural. A “snowballing” technique was employed, whereby references were culled from each document for review. All searches were conducted in English, though laws published in French, Portu- guese or Spanish were reviewed after translation using Google Translator. Documents found included peer-reviewed articles and grey literature, historical and journalistic accounts, policies and laws. Documents were excluded from review if they did not specifically mention one or more compulsory service scheme. To better determine the different requirements, inter- views with key government officials from nine countries were conducted. A questionnaire was developed after a preliminary review of literature on compulsory service. This questionnaire was pretested in consultations with health workforce experts from five countries that provided feedback. The questionnaire was modified accordingly. Officials completing the instrument either via e-mail or telephone represented Australia, Ghana, Haiti, India (Tamil Nadu, Meghalaya), Mozambique, Nigeria, Norway, Peru and South Africa. Interview topics included: (i) history, (ii) description, (iii) administration and finance, (iv) outcomes, (v) problems/challenges, and (vi) advice to oth- ers regarding compulsory service programme implementation. Classification of programmes Based on the literature review and key informant interviews, a tripartite classification system for compulsory service programmes was developed (Fig. 2). The types are: (i) condition of service/state Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا Abstract Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include ”obligatory”, ”mandatory”, ”required” and ”requisite.” All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Seble Frehywot,a Fitzhugh Mullan,a Perry W Paynea & Heather Rossa a Department of Health Policy, George Washington University, 2121 K Street NW, Washington, DC, 20006, United States of America. Correspondence to Seble Frehywot (e-mail: seblelf@gwu.edu). (Submitted: 1 October 2009 – Revised version received: 15 December 2009 – Accepted: 8 January 2010 ) Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605 365 Seble Frehywot et al. Compulsory service programmes Special theme – Health workforce retention in remote and rural areas employment programme, (ii) compulsory service with incentives, and (iii) compul- sory service without incentives. Condition of service These programmes require health profes- sionals to work for the government. There is little or no opportunity for private or nongovernmental practice. Government employment contracts give the employer (federal and state ministries of health) the authority to assign health employees in any part of the country, based on need for a specified number of years. The Islamic Republic of Iran’s behvarz, a type of com- munity health worker, work within that country’s health system at rural health clinics as assigned by the government for four years after the completion of their training.4 Cuba’s doctors serve the government both within Cuba and internationally.5 In Myanmar, personnel may choose to spend an entire career in a condition of service system.6 In Australia, all international medical graduates must spend ten years working in a “district of workforce shortage” as assigned by the Rural Workforce Agencies. Compulsory service with incentives Compulsory service with incentives does not rely on governmental mandate but, rather, is associated with incentives to serve in designated areas for specified time periods. Governmental regulations govern the implementation and enforce- ment of these programmes. Four catego- ries of compulsory service with incentives were identified; examples are presented in Table 1. Educational Three types of education-incentive-linked compulsory service programmes have been identified: In the first type, students are required to complete a rural place- ment during the course of their training to complete their education. If com- pulsory service requirement is not met, the diploma/degree will not be given. Pharmacy students in New Zealand are required to perform a rural “externship” during training.7 In the second type, the graduate is required to serve in an underserved re- gion of the country as a prerequisite for entering a postgraduate/specialization programme. Countries requiring this type of service include Mongolia8 and Viet Nam.9 In the third type, there is a return of service programme where rural placement is required after graduation, often for one year for each year that educational financial support was provided. These systems are found in Australia (K Web- ber, personal communication), Lesotho7 and Japan.10 Employment Two employment-linked models exist; the first, as a requirement for attaining a licence to practise (publicly or privately) and the second, as a prerequisite for career Fig. 1. Countries with past and current compulsory service programmes Corroborative evidence of programmes Some indications of programmes Compulsory service Box 1. Databases used PubMed, Academic Search Premier, Scopus, SPORTDiscus, PsycINFO, CINAHL, Global Health, LexisNexis, Google, Google Scholar, Yahoo, NCBI Bookshelf, REHABDATA, AMED, ALADIN, MDConsult, LEXIS-NEXIS Academic Universe, Proquest Research Library Plus, Access Surgery, POPLINE, MEDLINE, images MD, Lexi-Comp, R2 Library, ebrary, First Consult, Cochrane Library, National Guideline Clearinghouse, Psychiatry Online, TOXNET, ABI/Inform Complete Plus, GPO Access, Natural Medicines, Web of Science, CINAHL, PAIS, BMJ Clinical Evidence, Global Health, Himmelfarb (GWU) library’s card catalogue, Wiley Encyclopedia of Clinical Trials, Books @ Ovid, Access Medicine, eMedicine Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605366 Seble Frehywot et al.Compulsory service programmes Special theme – Health workforce retention in remote and rural areas advancement. For example, Ecuador,1 Myanmar11 and South Africa12 allow med- ical personnel to practise privately only after they complete a period of compul- sory service. Peru has employment-linked compulsory service programmes which are associated with career advancement. Living provisions-linked Some countries provide incentives that are family- and resource-linked, such as housing in Kenya13 and Mozambique ( J Ferro, Dean Catholic University, Beira, personal communication), and lower car loan rates and children’s scholarships in Zambia,14,15 to encourage the graduates to stay in a remote area after the compulsory service period ends. Bundled A few countries like Ecuador and Thai- land have programmes that combine incentives for education, employment and living provisions. Ecuador’s Medicatura Rural system requires one year of service before doctors, nurses and dentists gain their licence to practise.1 Rurales are paid variable salaries based upon remoteness of assignments and they receive housing in posted locations. In Thailand, public medical school graduates must perform compulsory service for three years. They may supplement their public salaries by concurrently practising privately, or they can receive US$ 250 per month if they agree only to work in the public system.16 Additional incentives for rural practice include: higher pay for more rural place- ments, greater access to postgraduate training, logistic and housing support, career enhancement and improved health infrastructure. Compulsory service without incentives The third type of compulsory service pro- gramme found is one that does not offer any incentives nor relate to condition of service. These programmes require the graduate to work in an underserved set- ting with no attached incentive, usually for one year. Some examples are found in India in Kerala4 and Assam (T Sundara- raman, personal communication), Iraq,17 Malaysia,18 Mexico,1 the former Soviet Union (historic)1 and Venezuela.5 Results While we found more than 70 countries (and parts of Canada,14 India19 and Japan)10 with some type of compulsory service programme, exact dates of initia- tion for some programmes were unclear. These programmes were started for sev- eral reasons. Most programmes where the designing entity is known were designed by the ministry of health or a legislative body with the involvement of local gov- ernment agencies (ministry of health: 14; federal body: 6; state bodies: 2; private entity: 2; unknown: 48). Where a method is known, the most common means (64%) of enforcing the requirement is by withholding the certification needed to practise. Some countries enforce graduates to pay back the government money spent on education. For example, in Meghalaya and Tamil Nadu States in India, graduates who do not complete their compulsory service must pay a fine of 1 million Rupees (about US$ 21 000). The cost of the compulsory programme varies due to the size of the service areas, population of the countries and economic status of the country. Costs range from US$ 100 000 in Haiti to US$ 10 million per year in Australia. National taxes are the most common means of financing the programmes. Outcomes Numerous programmes indicated that they had not measured outcomes or that they were just starting to measure outcomes and the results were not yet available. The number of health profes- sionals who stay in the rural areas after their compulsory service is over was not clear for most countries (6 of 9). Norway’s administrators measure a variety of factors related to the types of individuals who stay in rural areas after the requirement is complete. These factors included: rural/urban upbringing, age, family composition and gender. Norway estimated that 20% stay in rural areas, and was in the process of analysing these data at the time of writing this paper. Nigeria anecdotally stated that people do not stay in the rural areas after completing the requirement. In Peru, the health profes- sionals are not allowed to stay in the rural area after the programme has ended. If they do remain, they are often paid less than they received while fulfilling their compulsory service requirement. Impact In Puerto Rico before compulsory service, 16 of 78 municipalities had no physician. After implementation, all 78 had at least one doctor.20 Incentive-linked compul- sory service in Indonesia increased new doctors’ willingness to work in remote areas.21 Turkey’s programme was effective at mitigating staffing discordance.22 In South Africa, better staffing levels in rural hospitals, shorter patient wait times and more frequent visits to outlying clinics by Fig. 2. Classification of compulsory service programmes Compulsory service 1. Condition of service/state employment programme Federal or state (employment contract) 2. Compulsory service with incentives Attached with financial and non-financial incentives 3. Compulsory service without incentives With no attached financial or non-financial incentives and not due to condition of service a. Educationally linked Country natives programme International medical graduate programme Before graduation programme as part of training requirement (rural placement to complete education) After graduation programme (to be able to specialize) Return of service (mandatory rural placement after graduation for provided educational financial support) b. Employment linked Licence to practise (public/private) Career advancement c. Living-provisions linked Housing allowance, car Ioan, children’s school, etc. d. Bundled programmes Combination of a, b or c Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605 367 Seble Frehywot et al. Compulsory service programmes Special theme – Health workforce retention in remote and rural areas health workers are reported.23 In Thailand it helped to narrow the disparities in ur- ban/rural health worker density.24 Challenges from professional groups Many health professionals object to compulsory service programmes.1,6,9,25–27 Reasons given include: cost, utility and sustainability of programmes;25 poor rural facilities;25 lack of transportation; and inadequate clean water, electricity, equipment and medications, making per- formance of some skills learnt in medical schools impossible.1 In Kerala, India, a strike protesting against a three-year com- pulsory service requirement influenced the government to reduce the service period to one year.3 Professionals’ oppo- sition can be minimized if programmes are planned in consultation with health professionals.26 Management Success or failure of these programmes largely depends on supportiveness in the broader health system.23 Governments must clearly state what they expect from compulsory service personnel. While the Ecuadoran government considers par- ticipants to be qualified doctors, doctors view compulsory service as part of their education, which results in disillusion- ment when they perform their service without supervision.1 In South Africa, vague guidelines for compulsory service doctors resulted in uneven utilization by clinics and hospitals.13 Several authors advise that compulsory service should be supplemented by a support system and incentives.2,15,25,27 Programmes that pro- vide reasonable benefits and support may be more costly than compulsory service without incentives, but the likelihood of effective service will be maximized. For instance, in Zambia, before its incentive-based health workforce reten- tion scheme was implemented, many doctors assigned to rural areas resigned from government service to avoid serving in rural posts (T Sundararaman, personal communication). Turnover of health workers Doctors’ unwillingness to continue in their assigned posts negatively impacts continuity of care2 and may mean that many workers in underserved areas are inexperienced. Managers in South Africa believe the inexperience of doctors sent to a Ghana’s system of withholding pay cheques from non-compliant personnel means that the equivalent to a “buy out” would be that the health worker accepts no salary. b Enforced through fine of 1 million rupees (approx. US$ 21 000) which is only affordable to some. c Health workers may opt to spend their entire career outside Peru’s public sector, such as by emigrating after graduation. Table 1. Examples of countries that have compulsory service programmes with incentives Country Cadre Years of service “Buy out” Incentives to encourage rural posting or retention Australia Doctor 6 No Scholarship (undergrad), licence to practise (Medicare provider number) Bolivia (Pluri- national State of) Doctor 1 Yes Graded salary, licence to practise Ecuador Doctor, dentist, nurse 1 Graded salary, licence to practise, preference for PG specialization, career advancement Ethiopia Doctor 2–4 Yes Graded salary, preference for PG specialization, degree, textbooks, computer, variable length of service Ghana Doctor 1–3 Yes a Preference for PG specialization, PG scholarship Nurse 3 Preference for PG placement Technician 3 Preference for PG placement India (Meghalaya) Doctor 3 No Sponsorship to undergraduate training, some undergraduate scholarships, housing India (Orissa) Doctor 1 No Preference for PG specialization India (Tamil Nadu) Doctor 3 Yesb Preference for PG specialization, increased preference for every 2 years served in tribal areas. Specialist 5 Yesb Return of service for PG specialization Indonesia Doctor < 1–5 Graded salary, preference for PG specialization, career advancement Kenya Doctor, nurse 3 Licence to practise, preference for PG specialization, PG scholarship, career advancement, various according to locality Lesotho Doctor 1/year trained No Return of service for training provided overseas, graded salary, housing Malawi Nurse tutor 2 Scholarship (undergraduate/PG), housing, medical assistance Mozambique All 2 Housing, career advancement Mongolia Doctor 2 Degree Myanmar Doctor, nurse 3 No Graded salary, licence to practise, housing, preference for PG specialization Namibia Doctor 2 Graded salary, preference for PG scholarships Nepal Doctor Licence to practise Nigeria All 1 No Licence to practise, preference for PG specialization, career advancement Norway Many 1.5 No Licence to practise Pakistan Doctor 1 Preference for PG training after 3 years in rural area Peru Doctor 1 Yesc Licence to practise in public sector, preference for PG specialization, PG scholarship, career advancement South Africa Doctor, dentist, pharmacist 1 Yes Graded salary, licence to practise in private sector Thailand Doctor 3 Yes Graded salary, preference for PG specialization, housing, career advancement Turkey 2–4 Graded salary, variable length of service Viet Nam Doctor 5 Degree Zambia Doctor 3 Graded salary, housing, child education, loans, preference for PG specialization, PG scholarship Zimbabwe Doctor 3 Licence to practise, preference for PG specialization PG, postgraduate Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605368 Seble Frehywot et al.Compulsory service programmes Special theme – Health workforce retention in remote and rural areas rural areas resulted in slower, poorer care for some patients.2 Thirty-four per cent of compulsory service doctors intended to leave South Africa after completing their obligation, and an additional 13% planned to go into private practice.13 Indonesia offers specialist training as an incentive to serve in remote areas, but this incentive may speed turnover as personnel uninterested in general practice perform their service in rural regions where they are unlikely to return as specialists.28 Community support Studies regarding community support or disapproval regarding compulsory service programmes are very scant. Community support is a key factor both for making personnel feel welcome in their posts and allowing them to practise their profes- sions. In some parts of Ecuador, compul- sory service doctors were interviewed on this subject. One stated: “There were no problems (of adjustment to the post site), because the leaders of the community were organized and helped.”1 In South Africa, “communities valued the services of the compulsory service doctors, as they ‘make a difference’.”29 Human rights An inherent conundrum of a compulsory service system is the “need to respect the human rights of the professionals [to migrate], at the same time recognizing that the poor countries also have a right to lay claims to the investment they made in training them.”30 It is also argued that freedom of movement, in this case of health workers, is a human right.31 Discussion The full extent of compulsory service programmes’ prevalence, requirements, effectiveness and long-term impact has never been studied. Two important areas warrant further discussion – policy con- cepts and policy implementation. Policy concepts Compulsory service programmes are an instrument of social justice, an exercise in health equity, in that they enable governments to direct or augment health services to geographical areas that are not well served and in communities that are not favoured by market forces and health worker preferences. The premise that underlies most compulsory service programmes (except condition of service programmes) is that government-spon- sored education of a health professional provides that individual with a critical skillset valuable to all members of society. Since it has been given to the individual at little or no cost, the individual therefore has incurred a debt to the country and a period of clinical pay-back is warranted. Most often, this translates into a require- ment for service provision in an area of national need, usually defined as “the periphery”, “rural areas” or “underserved populations.” There are multiple challenges in designing and managing an effective compulsory service programme and high turnover is singled out as a common “weakness.” This criticism bears further examination. The areas to which doc- tors and other health professionals are sent are typically rural, underdeveloped and deficient in both personal/family amenities and clinical support. These are settings that do not attract doctors or other health professionals under current circumstances. Turnover is very much a given. In the view of many policy-makers and compulsory service programme strat- egists, service with predictable turnover is far preferable to no service at all. This is hardly a shortcoming of the programmes; rather, it represents a practical adaptation for the provision of health services in the challenging circumstances in rural areas of many countries. Finding proof of efficacy in clinical outcomes in these programmes is not eas- ily done but, in fairness, evidence of direct physician impact on population health outcomes is not easily proven in health services research in general. The impact of compulsory service is much more easily identified by process measures that track the presence or augmentation of health services. For instance, Mozambique is able to declare this year for the first time that, due to its national service programme, all 148 districts in the country now have at least one physician.20 This is a public health achievement for the country as a whole and for the compulsory service programme in particular. Some commentators express con- cerns about compulsory service pro- grammes based on the compulsory nature of the programmes themselves and argue that it is contrary to the rights of the in- dividual health worker. These concerns, however, conflate human rights and the personal preferences of health workers who have received the benefit of state- sponsored education. A compulsory service requirement which is clearly stated at the time of entry into health profes- sions training can hardly be considered an abridgement of human rights. When a country devotes national wealth to estab- lishing health science schools and enrols students in the expectation that they will use their education to better the nation’s health, there is a reasonable presumption that the students will fulfil their com- mitment by providing service to largely underserved people (which on its own is a strategy that is very much in keeping with basic principles of human rights). Policy implementation The spectrum of compulsory service programmes reviewed in this paper sug- gests several principles that are likely to increase the effectiveness and success of compulsory service programmes. Good planning Compulsory service programmes are complex in that they involve the place- ment of individuals in communities over a period of time. The management of potential problems associated with as- signment, placement and fulfilment all depend upon commitments and relation- ships that can fail. Therefore, prospective and proactive planning are essential predicates of subsequent success. The in- dividuals should be trained in procedures relevant to working in a rural area. Transparency and clarity Closely associated with planning is transparency – a clear understanding of the rationale and requirements for any compulsory service programme. Health professionals, who are asked to spend years of service in locations they might not otherwise have chosen, need to have a clear understanding of the rationale for their assignment and a clear set of expec- tations concerning the many issues that may arise during the compulsory service period. Clarity of intent and consistency of implementation of the assignment process will increase the likelihood of an effective programme. The nature of the as- signment process, including the rationale for the assignment, its duration, whether or not the individual has a voice in the assignment, and the role of the host com- munity in the selection process, is critical. Norway’s system is a good example of this clarity. Each graduate is assigned a random number. The numbers are called in order and the graduate has six hours Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605 369 Seble Frehywot et al. Compulsory service programmes Special theme – Health workforce retention in remote and rural areas صخلم ؟حجنت له :ةيئانلا قطانلماو ةيفيرلا قطانلما في ينيحصلا ينلماعلا ينيعتل ةيمازللإا ةمدخلا جمارب عيزوتل ةليسوك لماعلا عاقب ةفاك في ةيمازللإا ةمدخلا جمارب تمِدخُتسا هذه لىع ىرخأ ءماسأ تقلطأ دقو .نادلبلا لخاد ينيحصلا ينينهلما ءاقبتساو لكو .”ةيبوجولا“ ،”ةيمتحلا“ ،”ةبجاولا“ ،”ةيرابجلإا“ جمابرلا اهنم جمابرلا يتلا ةيرطقلا تاسايسلا وأ ينناوقلا لىإ دوعت جمابرلل ةفلتخلما ءماسلأا هذه نم ةمورحلما قطانلما في ينيحصلا ينلماعلا ءاقبتساو يمازللإا عيزوتلا مكحت ةساردلا هذه تددحو .ةددحم ةينمز ةترفل ةيفيرلا قطانلما وأ تامدخلا جمارب يهو .ًادلب 70 في ةيمازللإا ةمدخلا جمارب نم ةنيابتم طانمأ ةثلاث تاسايسلا لىإ ةينالمبرلا ينناوقلا نم دتيم ميظنتلا طانمأ ضعبب اهعيمج مَكحُت ،ينضرملماو ،ءابطلأا لىع ضيتقي ،دلبلا ماظنل اقفوو .ةحصلا ةرازوب ةصاخلا اذه في ةكراشلما ،نيدعاسلما ينينهلماو ينيحصلا ينلماعلا فلتخمو ،تلاباقلاو .جمانبرلا مدع جمانبرلا اذهل لاثتملاا ليعفتب ةصاخلا تاءارجلإا ضعب لمشتو زاجتحاو ،ةبجاولا تامازتللاا ءافيتسا لبق ليجستلا لماكتساب حماسلا هذه حشر لىإ ةقرولا هذه فدهتو .ةيربك تامارغ ضرف وأ بتارلاو ةجردلا لمعت لازت لا وأ اهمدختست تناك يتلا نادلبلا ديدحتو ،ثركأ حوضوب جمابرلا .اهذيفنتو تاسايسلا ميهافبم ةقلعتلما ةماهلا اياضقلا ءوض في كلذو اهب ينينهلما ميلعت رماثتسا ةفلكت في رابتعلاا ينعب رظنت تاموكحلا تناك المو صقن نم كلذ نع مجني امو ،ةرجهلا ببسب كلذ دعب مهدقف مث ،ينيحصلا تاموكحلا هذه نإف ،ةيفارغجلا قطانلما نم ديدعلا في ينيحصلا ينلماعلا في ىوقلا ءاقبتساو عيزوتل ةليسوك ةيمازللإا ةمدخلا تاطاترشا ضرف لىع لمعت .ةيحصلا ةلماعلا Résumé Programmes de service obligatoire pour recruter du personnel médical dans les zones rurales et reculées : quels résultats ? Les programmes de service obligatoire sont utilisés dans le monde entier comme moyen de déployer et de retenir une main d’œuvre médicale professionnelle dans les pays. On donne à ces programmes des noms divers, qui font référence à une loi ou à une politique du pays considéré qui régit le déploiement et le maintien obligatoires, sur une certaine durée, des agents de santé dans les zones mal desservies et/ou rurales de ce pays. La présente étude identifie trois types différents de programmes de service obligatoire parmi 70 pays. Ces programmes sont régis par certains types de règles, qui vont de la loi parlementaire à la politique ministérielle. Selon le pays, les médecins, le personnel infirmier, les sages- femmes ou tous les types apparentés de professionnels de santé sont obligés de participer à ces programmes. Parmi les mesures pour les faire appliquer, figurent l’absence d’enregistrement complet tant que l’agent ne s’est pas acquitté de ses obligations, la suspension d’avancement ou de salaire ou l’application de lourdes amendes. L’objectif de l’article est de présenter plus clairement ces programmes, d’identifier les pays qui en disposent ou en disposaient, de développer une typologie qui recense leurs différentes formes et de les examiner à la lumière des problèmes importants de conception et de mise en œuvre des politiques. Au vu des investissements consentis dans la formation des professionnels de santé, des pertes de personnel de santé dues à l’émigration et du manque d’agents de santé dans de nombreuses zones géographiques, les gouvernements ont recours au service obligatoire comme moyen de déployer et de retenir la main-d’œuvre médicale. in which to choose a post location from those still available. Except under extreme circumstances (i.e. severe illness in the immediate family), no swapping of as- signed locations is permitted (K Straume, personal communication). This system allows each graduate to know his/her chance of gaining a choice post location. Support The nature of support provided to com- pulsory service personnel during assign- ment plays a major role in the success of the placement. An important aspect is the benefits provided to the health worker, including pay, housing, continuing educa- tion and clinical backup or supervision. Programmes that send doctors to remote areas with little support may be delivering on a political promise to place doctors in the periphery, but the absence of as- sistance is likely to result in a minimally effective programme where clinicians may abandon their site or function inef- fectively. Conclusion No rigorous study has systematically com- pared rural and remote workforce dispari- ties in countries with compulsory service to those in countries that don’t have such programmes. Compulsory service pro- grammes are a mechanism for staffing and reinforcing the health workforce espe- cially in areas where access to primary and essential heath-care services and systems is weak. Compulsory service may not be able to provide a permanent answer to capacity development, nor guarantee the development of a permanent workforce for underserved communities but, if well planned with incentives, can contribute to a nation’s plan for health workforce capac- ity development, distribution and reten- tion in rural and underserved areas. ■ Acknowledgements We thank Jean-Marc Braichet, Carmen Dolea and Manuel Dayrit from the World Health Organization; Okey Akpala, J Koku Awoonor-Williams, Luis Huicho, Percy Mahlati, Karin Straume, Thiaga- rajan Sundararaman, Kim Webber and Lambert Wesler. Funding: The Health Workforce Migra- tion and Retention, Human Resources for Health, Health Systems and Services at the World Health Organization provided financial support to conduct this study under the work done on “Policy recom- mendations and guidelines on increasing access to health workers in remote and rural areas through improved retention.” Competing interests: None declared. Bull World Health Organ 2010;88:364–370 | doi:10.2471/BLT.09.071605370 Seble Frehywot et al.Compulsory service programmes Special theme – Health workforce retention in remote and rural areas Los programas de servicio obligatorio son una medida utilizada en todo el mundo para distribuir y conservar a los profesionales sanitarios en los países. Bajo distintas denominaciones, todos esos programas hacen referencia a las leyes o políticas de un país que rigen el despliegue y permanencia obligatorios de trabajadores de la salud en zonas subatendidas y/o rurales de su territorio durante un determinado periodo. En este estudio se identificaron tres tipos de programas de servicio obligatorio en 70 países. Todos ellos están sujetos a alguna forma de regulación, desde una ley parlamentaria hasta una política del ministerio de salud. Dependiendo del país, médicos, enfermeras, parteras y todo tipo de auxiliares sanitarios profesionales están obligados a participar en el programa. Como medidas de imposición de esa obligatoriedad cabe citar la suspensión de la colegiación plena hasta haber cumplido el servicio, la retención del título y del sueldo, o el pago de elevadas multas. Este trabajo tiene por objeto explicar más claramente esos programas, determinar qué países los han aplicado o los están aplicando, elaborar una tipología de esos programas, y analizarlos a la luz de algunas cuestiones importantes relacionadas con aspectos normativos y con la aplicación de las políticas. 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