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existing workforce, creating new care professions/cadres is another option, although it often takes longer to show an impact. These new cadres can be created to fill new roles, as in the case of care coordinators, self-management counselors, and case managers (De Carvalho et al. 2017; Jakab et al. 2018). Alternatively, new cadres can take over some current activities from existing personnel, as with physician assistants and medical officers (Halter et al. 2013). In some cases, professional managers can be introduced to manage integrated multidisciplinary teams and coordinate services across the spectrum of prevention, promotion, care, and rehabilitation. Of course, creative workforce policies must still be compatible with the regulatory framework, for example, in terms of professional classification and licensing standards.

Proactive polices for workforce development, deployment, and regulation can help address the maldistribution of health workers across countries and within national borders, creating conditions for more equitable service delivery to those most in need. Engaging health professionals in rural service

Encouraging rural service requires changing the balance of incentives that pushes health workers toward urban centers in virtually all countries. One common approach is to offer financial or in-kind benefits to counterbalance health workers’ quality-of-life concerns. Rural health workers receive housing benefits and electricity in Moldova, allowances in South Africa, and paid tuition fees for their children along with housing renovations in Zambia. Few studies have assessed interventions in LMICs empirically and individually (that is, not as part of a package of services). A Cochrane review found that the provision of bursaries or scholarships had variable success across countries, while increased financial compensation generated more consistently positive results, although with undetermined cost-effectiveness (Grobler et al. 2015). A review of systematic reviews similarly found that such policies were effective in attracting practitioners, but that few physicians stayed in rural areas long term (Chopra et al. 2008).

Rural service requirements may also help fill vacant postings, and several countries have made service in resource-constrained areas a prerequisite to graduation or certification. Japan and Lesotho exchange pregraduation financial aid for postgraduation rural service (Frehywot et al. 2010); other countries, such as Mongolia and Vietnam, have made rural service a prerequisite to

certain career changes (for example, entering a postgraduate or specialization program) (Frehywot et al. 2010). Most of the existing research on compulsory service programs is descriptive and uses stakeholder interviews to document program effects. Anecdotal evidence suggests that participants in compulsory service programs often leave soon after the mandatory period ends. Such programs can also be difficult to enforce, particularly for wealthier individuals who can use their financial resources to bypass service requirements. Thailand imposes financial penalties on public medical school graduates who violate their rural service requirements—but many graduates choose to work in the private sector, quickly earning enough to offset the penalty (Wiwanitkit 2011).

Studies from high-income countries (HICs) and LMICs identify rural residence or upbringing as a consistent predictor of an applicant’s eventual willingness to accept a postgraduation rural posting (Simoens 2004). Where sensible, medical schools can adjust admissions criteria to prioritize rural applicants, increasing the number of graduates who would be willing to accept rural positions. In addition, opening medical schools or other training facilities in rural areas could reduce the workforce gap via two channels. First, rural medical schools can offer continuing medical education and professional opportunities in rural areas, making rural service more attractive. Second, rural medical schools can attract more students from rural areas, who would be more inclined to remain in rural postings. In Japan, for example, almost 70 percent of graduates from a rurally located medical school remained in their home prefectures for at least six years after the end of their mandatory service periods (Dolea, Stormont, and Braichet 2010). In the Democratic Republic of the Congo, graduates from a rural medical school were almost four times as likely to practice in rural areas, compared to a cohort from an urban medical school (Longombe 2009); in China, a single rural medical school produced more rural doctors than 12 metropolitan schools combined (Wang 2002).

A specific medical education model to encourage rural community service is Community Engaged Medical Education (CEME), in which medical schools form an “interdependent and reciprocally beneficial partnership” with the communities they serve (Strasser et al. 2015), thereby creating opportunities for clinical learning in PHC services and other community clinical settings. CEME programs often recruit primarily local students through selection and admissions processes that value not only academic ability but also other characteristics important to local comprehensive PHC. Students support local PHC team members, who, in turn, serve as clinical teachers and role models. Trainees come to understand their rural/underserved setting as home base, preparing them to practice in the surrounding areas—with city rotations as

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a requirement to complete postgraduate training. Trainees undertake additional specific skills training relevant to their future practice, such as general surgery, anesthesia, procedural obstetrics, endoscopies, indigenous health, and geriatrics.

Examples of CEME programs illustrate the potential benefits. In the Philippines, a group of doctors in a highly rural and underserved region founded the Ateneo de Zamboanga University (ADZU) medical school in 1994. The school operates on an almost exclusively volunteer basis; most of its students are drawn from the local community, and the curriculum focuses on case-based learning, problem solving, and community health, in addition to clinical competency. As of 2011, 80 percent of its graduates were still practicing in the Zamboanga region, and 50 percent were practicing in rural areas (Cristobal and Worley 2012). Similarly, the Northern Ontario School of Medicine (NOSM) targets health improvement in northern Ontario, a vast and underserved region of Canada. NOSM’s admissions process selects a student body that reflects the population distribution of northern Ontario; community members help with student selection, education, and support during community placements; 92 percent of NOSM-trained family physicians are practicing in northern Ontario; and many graduates now serve on faculty (Tesson et al. 2009; Strasser 2016a; Strasser et al. 2018).

Equitable mobility and cross-jurisdictional solutions

International recruitment has been a popular strategy for wealthier countries facing acute PHC workforce shortages, including expanding cohorts like home health care workers. However, outmigration of health workers from LMICs to high-income countries with far higher compensation can exacerbate existing international inequities in health workforce density and contribute to deepening human resource gaps in the origin country, particularly when the training slots for medical education are highly constrained.

Smarter processes can increase the benefits of health worker migration for all parties. A Global Skills Partnership (GSP) (Clemens 2015) consists of a bilateral agreement in which migrant-destination countries and migrant-origin countries share the benefits and costs of skilled migration. Responding to a nursing shortage in Germany combined with a surplus of recent graduates in China, one pilot program aimed to train and place 150 Chinese nurses within German nursing homes up to five years. Before their migration, the nurses received an eight-month intensive training course and language training to ease their entry into the German health system and society (Oelmaier 2012).

Accreditation and licensing differences between states or jurisdictions can make it challenging for health workers to move to areas of greater need or opportunity, even within the same country. In Canada, individual provinces set their own standards for licensure of foreign medical graduates, with widely varying processes (Nasmith 2000). A backlog of applications and bureaucratic processes can also make the licensure process very lengthy, and qualifying exams and supplemental education can be expensive and time consuming. In the United States, state-level licensing procedures can often take three to six months, with application fees typically totaling several hundred US dollars (Medicus Healthcare Solutions 2017).

Regulatory reforms can help increase health worker mobility. In the United States, the Interstate Medical Licensure Compact offers a voluntary statebased approach to reduce licensing barriers by introducing a common licensure application across 29 participating states (although the individual states still issue the licenses)9 the Nurse Licensure Compact (NLC) likewise allows US nurses to obtain a single license for physical, telephone, and electronic practice across any of the participating states.10 Regional efforts also include mutual recognition agreements for three types of health workers under the Association of Southeast Asian Nations Framework Agreement on Services (Forcier, Simoens, and Giuffrida 2004; Kanchanachitra et al. 2011).

Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health care facilities (WHO 2018c). It includes virtual home health care, where patients can receive medical advice and guidance in their own homes, as well as virtual guidance for health workers in providing diagnosis, care, and referral of patients. Telehealth can connect health care providers with remote rural populations and mobility-constrained patients, and it offers more efficient routine care in nonemergency situations, for example, among patients with chronic conditions. Systematic reviews find that proactive telephone support or case management over the phone can improve clinical outcomes and reduce symptoms in people with heart disease, diabetes, or asthma (Barlow, Singh, and Bayer 2007), while regular phone calls from nurses can reduce hospital admissions and costs (Lake et al. 2017).A Cochrane review similarly concluded that 50 percent of calls taken by doctors or nurses could be handled over the phone without a subsequent hospital visit (Lake et al. 2017).

Regulatory reforms can also help enable telehealth’s potential to at least partially break down geographical barriers to care and potentially address workforce shortages in specific regions, particularly underserved or remote rural areas. (However, internet access remains highly correlated

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with health worker density, limiting the applicability of telehealth in some of the most underserved regions and/or countries [Suzuki et al. 2020].) In some cases, onerous regulatory barriers can stymie efforts to provide telecare when the provider and patient are based in different jurisdictions. For example, for different US states or Canadian provinces, providers often must receive licensure in the jurisdiction in which their patient is based, limiting the potential for cross-jurisdiction practice. A few states have either established registries of qualified out-of-state telehealth providers or offer telemedicine-only medical licenses (Thomas and Capistrant 2017). The European Union takes a more flexible approach by defining the relevant jurisdiction as the one in which the provider is based, allowing a single provider to practice telemedicine with patients across the bloc (Hashiguchi 2020). Likewise, financing reforms can enable reimbursement of a broader range of telehealth services through public or private insurance packages, facilitating more equitable uptake.

COVID-19 has accelerated the relaxation of many regulatory and financing barriers to telehealth and restrictions regarding practice jurisdiction, at least temporarily. In the United States, the Department of Health and Human Services temporarily waived certain privacy requirements related to the choice of telehealth platform for the duration of the COVID-19 crisis (Department of Health and Human Services 2020). Several US states and the Center for Medicaid and Medicare Services (CMS) waived state-specific licensing requirements (Goodman and Ferrante 2020), and both the United States and France have expanded the range of reimbursable telehealth services (OECD 2020b; Ohannessian, Duong, and Odone 2020). In South Africa, an extraordinary policy decision authorized the broad use of telemedicine during the COVID-19 pandemic subject to consent and privacy guidance (AHPCSA 2020).

Beyond physical mobility, international or private sector collaborations can help expand countries’ access to specific cadres of health care workers in high demand. Several public-private partnerships and regional coordination mechanisms already exist in East Africa. The East Africa Public Health Laboratory Networking Project (EAPHLNP) aims to establish a network of high-quality public-health laboratories in Burundi, Kenya, Rwanda, Tanzania, and Uganda; an evaluation of the network in Kenya documented improvements in client satisfaction, test accuracy, and scores on peer audits (Lehmann et al. 2018). Other initiatives include the Medical Education Training Partnership Initiative (MEPI), the Nursing Training Partnership Initiative (NEPI), and the Rwanda Human Resources for Health Program (HRH Program). Telemedicine approaches may also offer access to remote expertise for residents of rural villages. For example, in India’s Aravind system, community members send