Rapid review
Of the 51 papers, 16 focus on the WHO African region [
19,
22‐
36], 11 on the Americas [
37‐
47], 10 on the Western Pacific [
48‐
57] region, 5 on the Eastern Mediterranean region [
58‐
62], 4 each on the European [
63‐
66] and South-East Asia [
67‐
70] regions and 1 on countries from different regions [
71]. The studies were conducted in high-income countries (
n = 19), low-income countries (
n = 12), low-middle income countries (
n = 9) and upper-middle countries (
n = 7). In four studies, more than one country or region was included; therefore, these studies were not categorized by income group.
The objectives of the studies ranged from forecasting future needs of the health workforce to examining the current status of the workforce (availability), external and internal migration of the workforce, attrition within specific training or health programmes and retention of health workers (factors and levels).
Most studies took place at the national level (
n = 29), using national data (from census, council registers or ministries of health). Sub-national studies (
n = 21) focused on states, provinces, districts, rural and remote areas, health facilities and education institutions. This classification was not applied to one study as it involved a scoping review of the literature [
71].
Only half of the studies provided a full definition of attrition. A small number of studies conducted a literature review of the definitions of attrition and/or used an international definition. The word ‘attrition’ was frequently used interchangeably with the terms ‘drop-outs’, ‘turnover’, ‘brain-drain’, ‘losses’, ‘premature departure’ and ‘separation’. Reasons for leaving the workforce were also used to define attrition, particularly migration. Others included retirement, resignation, dismissal or death.
Doctors, nurses (registered and enrolled nurses, licensed practical nurses, nurse assistants), midwives and community health workers (CHWs) were the cadres most often featured in the studies. Others included clinical officers, specialists, pharmaceutical staff, lab technicians, healthcare aides and allied health professionals.
Key reasons for attrition identified in the literature include low salaries, lack of access to professional development and further education, lack of effective supervision, weak regulatory environments, isolation (for health workers in rural or remote areas), poor working conditions (including facility conditions, lack of medical equipment and technology), stress or large caseloads and lack of motivation/low job satisfaction. In some countries, perceived lack of security is also a key factor in intentions to leave the health workforce.
The distinction between voluntary and total attrition was not clearly stated in most studies. Of the 51 papers, 29 provided information on total attrition, 18 on voluntary attrition and 4 on both.
Attrition rate estimates were provided for different periods of time, ranging from 3 months to 12 years. However, the annual attrition rate was the most common (
n = 27) and the only comparable measure. Only one study [
40] estimated attrition using full-time equivalents rather than headcounts.
Additional file
1 in the annex details all papers included in the review including the objectives, countries and settings, the definition of attrition provided and the total and voluntary attrition rate estimates by cadre.
Overall, the total annual attrition rate varied between 3 and 44% while the voluntary annual attrition rate varied between 0.3 and 28%. Table
1 shows how annual attrition varied by professional cadre, for doctors, nurses and midwives. Looking first at total attrition, out of the seven studies which included doctors, estimates of the total annual attrition rate varied from 1.7% in USA to 15% in Afghanistan. Out of the nine studies which included nurses, estimates of the total annual attrition rate varied from 4.9% (the average from several African countries) to 44.3% in New Zealand. Out of the four studies which included midwives, estimates of the total annual attrition rate varied from 4.5% in Zambia to 16% in Afghanistan. The two studies which included CHWs put forward estimates of the total annual attrition rate of 5% (in Afghanistan) and 22% (in Bangladesh). Estimates of voluntary attrition rates are considerably lower than estimates of total attrition rates. Within cadres, its variability is similar to total attrition. For doctors, the annual voluntary attrition rate ranged from 1% in Thailand to 10% in Romania and for nurses, between 1.4% in Zambia and 9.3% (an overall estimate for several European countries).
Table 1
Minimum and maximum estimates of total and voluntary annual attrition rates
N studies w/ total attritiona
| 7 | 9 | 4 |
Total attrition rate | 1.7% | 15% | 4.9% | 44.3% | 4.5% | 16% |
N studies w/ vol. attritiona
| 5 | 4 | 1 |
Voluntary attrition rate | 1% | 10% | 1.4% | 9.3% | 1.4% | – |
Table
2 shows the annual attrition rates by income group (for the year of publication). For doctors, there is some indication that total annual attrition rates are higher in low-income countries than in high-income countries. Small sample sizes mean that it is more difficult to distinguish a pattern for other cadres and for voluntary attrition.
Table 2
Minimum and maximum estimates of total and voluntary annual attrition rates by country income group
High | 1.7% | 4.5–17.3% | – | – | 6–9.3% | – |
Middle | 9.8% | 5.3–44.3% | 4.5% | 1–10% | 1.7% | 1.4% |
Low | 15% | 14% | 9–16% | 3.7% | 7.6% | – |
At the sub-national level, the availability of annual rates is low, which limits comparability.
Two studies analysed differences between sub-national regions: one provided separate attrition rates for all [
61] and the other provided estimates from regional (non-urbanized areas), rural and remote levels [
54]. The data show higher attrition rates in remote areas compared with rural areas (30.2 and 18.7% respectively).
A few studies considered how attrition rates vary by type of health facility as well as professional cadre. These seem to indicate variability within the same cadre according to the type of health facility to which the health workers are deployed, but there are insufficient data to draw general conclusions about how the rate of attrition varies by type of health facility, except to note that total attrition seems to vary more by facility type than voluntary attrition.
Attrition due to migration was addressed exclusively in 11 studies (2 included both internal and external migration and 9 external migration only) [
31,
32]. Nearly half involved physicians, and only two provided annual rates: 3.7% [
31] and 10% [
65].
SoWMy 2014 dataset
Of the 79 countries in the combined dataset, 49 provided some data on voluntary attrition rates of their SRMNH cadres, i.e. 30 countries could not provide even an estimate (see Additional file
2 for SoWMy Dataset on attrition). Data on attrition were provided for 166 unique SRMNH worker cadres, which represents a response rate of 40.5% from the all cadres in the dataset. These cadres were mapped against the corresponding ISCO-08 classification, yielding the results presented in Table
3 below.
Table 3
Average voluntary attrition rates by type of health worker (headcounts), SoWMy 2014 survey
Generalist medical practitioners | 33 | 8.8 | 11.7 | 4.0 | 0 | 45 |
Specialist medical practitioners (ob/gyns) | 36 | 4.5 | 7.8 | 1.0 | 0 | 30 |
Nursing professionals | 10 | 7.2 | 6.5 | 10.0 | 0 | 20 |
Midwifery professionals | 53 | 8.2 | 10.5 | 2.5 | 0 | 45 |
Associate nursing professionals | 5 | 4.6 | 7.8 | 0 | 0 | 20 |
Associate midwifery professionals | 24 | 5.9 | 6.5 | 3.0 | 0 | 23 |
Paramedical practitioners and medical assistants | 5 | 0.4 | 0.8 | 0 | 0 | 1.9 |
Total | 166 | 6.8 | 9.5 | 2 | 0 | 45 |
In SoWMy, the highest attrition rates were recorded for generalist physicians and midwives. Conversely, specialist medical practitioners (in the survey, these were obstetrician/gynaecologists) had the lowest rates of attrition (excluding paramedical practitioners and medical assistants, which had a very small sample size). It should be noted, however, that attrition rates were very widely spread, with wide ranges and large standard deviations. When comparing with the result ranges obtained in the rapid review, the SoWMy results show wider variation overall.