Transition and change: opportunities and challenges of CHW programme reform for community health systems and vertical disease programmes in Liberia.

BACKGROUND: Globally, community health worker (CHW) programmes are critical to addressing health worker shortages and have been recognised as critical pillars within the drive towards universal health coverage (UHC). In 2016, the Liberian Ministry of Health launched the National Community Health Services Policy 2016-2021, which included significant CHW programme reform to address ongoing health workforce capacity gaps in the country. However, little consideration was given to the impact of such reforms on ongoing health interventions that rely heavily on the use of CHW cadres. Our study explores how CHW programme reform in Liberia influenced performance of CHWs involved in the delivery of Neglected Tropical Disease (NTD) programmes to elucidate how health systems reform can impact the delivery of routine health interventions and vice versa. METHODS: We used a qualitative case study approach conducted between March 2017 and August 2018. Our instrumental case study approach uses qualitative methods, including document review of five CHW and NTD program-related policy documents; 25 key informant interviews with facility, county, and national level decision-makers; and 42 life and job histories with CHWs in Liberia. Data were analysed using a thematic framework approach, guided by Kok et al. framework of CHW performance. Data were coded in QRS NVIVO 11 Pro. RESULTS: Our findings show that CHW programme reform provides opportunities and challenges for supporting enhanced CHW performance. In relation to health system hardware, we found that CHW programme reform provides better opportunities for: formal recognition of CHWs; strengthening capacity for effective healthcare delivery at the community level through improved and formalised training; a more formal supervision structure; and provision of monthly incentives of 70 US dollars. Efficiency gaps in routine intervention delivery can be mitigated through the strengthening of these hardware components. Conversely, supervision deficits in routine CHW functioning can be supported through health interventions. In relation to systems software, we emphasise the ongoing importance of community engagement in CHW selection that is responsive to gendered power hierarchies and accompanied by gendered transformative approaches to improving literacy. CONCLUSIONS: This study shows how CHW programme reform provides opportunities and challenges for health system strengthening that can both positively and negatively impact the functioning of routine health interventions. By working together, CHW programmes and routine health interventions have the opportunity to leverage mutually beneficial support for CHWs, which can enhance overall systems functioning by enhancing CHW performance.

Assessing the impact of COVID-19 management on the workload of human resources working in India's National Tuberculosis Elimination Program.

BACKGROUND: In 1993, WHO declared tuberculosis (TB) as a global health emergency considering 10 million people are battling TB, of which 30% are undiagnosed annually. In 2020 the COVID-19 pandemic took an unprecedented toll on health systems in every country. Public health staff already engaged in TB control and numerous other departments were additionally tasked with managing COVID-19, stretching human resource (HR) capacity beyond its limits. As part of an assessment of HR involved in TB control in India, The World Bank Group and partners conducted an analysis of the impact of COVID-19 on TB human resources for health (HRH) workloads, with the objective of describing the extent to which TB-related activities could be fulfilled and hypothesizing on future HR requirements to meet those needs. METHODS: The study team conducted a Workload Indicators and Staffing Needs (WISN) analysis according to standard WHO methodology to classify the workloads of priority cadres directly or indirectly involved in TB control activities as over-, adequately or under-worked, in 18 districts across seven states in India. Data collection was done via telephone interviews, and questions were added regarding the proportion of time dedicated to COVID-19 related tasks. We carried out quantitative analysis to describe the time allocated to COVID-19 which otherwise would have been spent on TB activities. We also conducted key informant interviews (KII) with key TB program staff about HRH planning and task-shifting from TB to COVID-19. RESULTS: Workload data were collected from 377 respondents working in or together with India's Central TB Division (CTD). 73% of all respondents (n = 270) reported carrying out COVID-19 tasks. The average time spent on COVID-19 tasks was 4 h / day (n = 72 respondents). Multiple cadres highly instrumental in TB screening and diagnosis, in particular community outreach (ASHA) workers and CBNAAT/TrueNAAT laboratory technicians working at peripheral, block and district levels, were overworked, and spending more than 50% of their time on COVID-19 tasks, reducing time for TB case-finding. Qualitative interviews with laboratory technicians revealed that PCR machines previously used for TB testing were repurposed for COVID-19 testing. CONCLUSIONS: The devastating impact of COVID-19 on HR capacity to conduct TB case-finding in India, as in other settings, cannot be overstated. Our findings provide clear evidence that NTEP human resources did not have time or essential material resources to carry out TB tasks during the COVID pandemic without doing substantial overtime and/or compromising on TB service delivery. To minimize disruptions to routine health services such as TB amidst future emerging infectious diseases, we would do well, during periods of relative calm and stability, to strategically map out how HRH lab staff, public health resources, such as India's Health and Wellness Centers and public health cadre, and public-private sector collaboration can most optimally absorb shocks to the health system.

Empowering and Building the Capabilities of Mid-Level Health Service Managers to Lead and Support the Health Workforce-A Study Protocol.

(1) Background: Mid-level managers in healthcare are central to improving safety and quality of care. Their ability in demonstrating leadership and management competency in their roles and supporting frontline managers and frontline staff has a direct effect on staff retention and turn-over. Yet, investment in their professional development and support for mid-level managers is often neither adequate nor effective, and high rates of staff turnover are evident. This study, set in northern Queensland, Australia, takes a strength-based approach to explore the role and strengths of mid-level managers and organisations' existing mechanisms in supporting managers. With broad involvement and contribution from managers at different management level and frontline staff, the project will identify strategies to address the challenges mid-level managers face while building on their capabilities. (2) Methods: Using co-design principles, a situation analysis approach will guide a mixed-methods, multiphase design. Qualitative data will be collected using transcripts of focus groups and quantitative data will be collected by surveys that include validated scales. (3) Results: Thematic analysis of the transcripts will be guided by the framework of Braun and Clarke. Quantitative data will employ descriptive and inferential analysis, including chi-squared, t-tests, and univariate analyses of variance. (4) Conclusions: This study will generate evidence to guide two partner organisations, and other similar organisations, to develop strategies to improve support for mid-level managers and build their capabilities to support and lead frontline managers and staff. Competent mid-level managers are critical to high-quality patient care and improve the outcomes of the population they serve.

Describing a medical school's rural activity footprint: setting selection and workforce distribution priorities.

CONTEXT: There is growing evidence supporting a shift towards 'grow your own' approaches to recruiting, training and retaining health professionals from and for rural communities. To achieve this, there is a need for sound methodologies by which universities can describe their area of geographic focus in a precise way that can be utilised to recruit students from their region and evaluate workforce outcomes for partner communities. In Australia, Deakin University operates a Rural Health Multidisciplinary Training (RHMT) program funded Rural Clinical School and University Department of Rural Health, with the purpose of producing a graduate health workforce through the provision of rural clinical placements in western and south-western Victoria. The desire to establish a dedicated Rural Training Stream within Deakin's Doctor of Medicine course acted as a catalyst for us to describe our 'rural footprint' in a way that could be used to prioritise local student recruitment as well as evaluate graduate workforce outcomes specifically for this region. ISSUE: In Australia, selection of rural students has relied on the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) or Modified Monash Model (MMM) to assign rural background status to medical course applicants, based on a standard definition provided by the RHMT program. Applicants meeting rural background criteria may be preferentially admitted to any medical school according to admission quotas or dedicated rural streams across the country. Until recently, evaluations of graduate workforce outcomes have also used these rurality classifications, but often without reference to particular geographic areas. Growing international evidence supports the importance of place-based connection and training, with medical graduates more likely to work in a region that they are from or in which they have trained. For universities to align rural student recruitment more strategically with training in specific geographic areas, there is a need to develop precise geographical definitions of areas of rural focus that can be applied during admissions processes. LESSONS LEARNED: As we strived to describe our rural activity area precisely, we modelled the application of several geographical and other frameworks, including the MMM, ASGS-RA, Primary Healthcare Networks (PHN), Local Government Areas (LGAs), postcodes and Statistical Areas. It became evident that there was no single geographical or rural framework that (1) accurately described our area of activity, (2) accurately described our desired workforce focus, (3) was practical to apply during the admissions process. We ultimately settled on a bespoke approach using a combination of the PHN and MMM to achieve the specificity required. This report provides an example of how a rural activity footprint can be accurately described and successfully employed to prioritise students from a geographical area for course admission. Lessons learned about the strengths and limitations of available geographical measures are shared. Applications of a precise footprint definition are described including student recruitment, evaluation of workforce outcomes for a geographic region, benefits to stakeholder relationships and an opportunity for more nuanced RHMT reporting.

[Recruitment, selection and retention staffing policies in health services directly managed. SESPAS Report 2024]. / Reclutamiento, selección y retención de profesionales en servicios de salud de gestión directa. Informe SESPAS 2024.

In an organization with highly specialized and changing services over the course of a working life, such as health services managed directly by public administrations (DM-NHS) are, the issues related to the recruitment, selection and retention of professionals should receive special attention. much larger than what is provided. For too long, the DM-NHS has mainly been working to resolve the problems that affect the organization, with enormous disregard for those suffer by the recipients of its services, the real population to which it provides assistance. In the DM-NHS, its administration (rather than management) of human resources is circumscribed by the contours of the Framework Statute and its implementing regulations and rulings. This is an inadequate instrument, both empirically in view of the results obtained (50% temporary employment among professionals working in the NHS), and conceptually, since it fails to comply with the reasons that normatively justify its existence: "that its legal regime is adapts to the specific characteristics of the practice of health professions, as well as the organizational peculiarities of the National Health System". The text describes the characteristics of statutory regulation and reviews how regulatory restrictions affect recruitment, selection and retention policies. Finally, possible alternatives are proposed to have coherent and rational permanent staffing policies that cover the real needs of the health services.

Rural healthcare workforce preparation, response, and work during the COVID-19 pandemic in Australia: Lessons learned from in-depth interviews with rural health service leaders.

BACKGROUND: Low population density, geographic spread, limited infrastructure and higher costs are unique challenges in the delivery of healthcare in rural areas. During the COVID-19 pandemic, emergency powers adopted globally to slow the spread of transmission of the virus included population-wide lockdowns and restrictions upon movement, testing, contact tracing and vaccination programs. The aim of this research was to document the experiences of rural health service leaders as they prepared for the emergency pandemic response, and to derive from this the lessons learned for workforce preparedness to inform recommendations for future policy and emergency planning. METHODOLOGY AND METHODS: Interviews were conducted with leaders from two rural public health services in Australia, one small (500 staff) and one large (3000 staff). Data were inductively coded and analysed thematically. PARTICIPANTS: Thirty-three participants included health service leaders in executive, clinical, and administrative roles. FINDINGS: Six major themes were identified: Working towards a common goal, Delivery of care, Education and training, Organizational governance and leadership, Personal and psychological impacts, and Working with the Local Community. Findings informed the development of a applied framework. CONCLUSION: The study findings emphasise the critical importance of leadership, teamwork and community engagement in preparing the emergency pandemic response in rural areas. Informed by this research, recommendations were made to guide future rural pandemic emergency responses or health crises around the world.

Meeting Gaps in the Public Health Workforce During Emergencies: How a Nongovernmental Organization Supported Critical Staffing Needs in the COVID-19 Response.

The public health workforce continues to experience staff shortages, which hampered the ability of US state, tribal, local, and territorial health departments to respond to the COVID-19 pandemic. In April 2020, the US Centers for Disease Control and Prevention (CDC) awarded $45 million to the CDC Foundation to provide field assignees to support these health departments. To expand these efforts, the CDC provided an additional $20 million in May 2021 for vaccination efforts and $200 million in June 2021 to support COVID-19 response and general infrastructure support. The CDC Foundation worked with jurisdictions across the United States to develop job descriptions based on need and recruit nationally for positions. This expanded project, called the Workforce/Vaccine Initiative, hired 3,014 staff in 91 jurisdictions, with 2,310 (77%) hired by January 2022. Most assignments were fully remote (55%) or hybrid (28%). The largest number of staff (n=720) supported COVID-19 response work in schools. Other common functions included contact tracing/case investigation (n=456), program coordination (n=330), epidemiology (n=297), data and surveillance (n=283), and administrative support (n=220). To advance health equity and improve response efforts, 79 health equity staff were assigned to 30 jurisdictions. To support the needs of tribes, 76 field staff supported 22 tribal entities. This project demonstrated the important role of a flexible, centralized approach to rapid placement of staff in public health departments during an emergency response. While the goal of the Workforce/Vaccine Initiative was to meet short-term staffing needs, lessons learned could provide insights for building a sustainable and scalable public health workforce.

[The challenges of human resources governance in public healthcare. SESPAS Report 2024]. / Los retos de la gobernanza de los recursos humanos de la sanidad pública. Informe SESPAS 2024.

Recurrent imbalances between supply, demand and personnel needs are one of the main challenges facing the National Health System (NHS). This situation has its origin both in supply factors and in the conditioning factors of the demand for human resources in the public health sector. The demographic structure of the NHS health professionals is generating an increasing number of outflows of doctors and nurses. On the other hand, the complex institutional architecture of the public health system produces dysfunctions in the structure of demand and in the form of recruitment. This paper argues for the need to articulate a strategic response that addresses the improvement of the governance of the human resources of the NHS and the reform of the instruments of coordination and harmonization of actions at the three levels of government of public healthcare.

Development of a University-Government Partnership for Public Health Response and Workforce Development in the State of Oregon.

The COVID-19 pandemic exposed and exacerbated a public health workforce shortage and national strategies have called for the development of clear occupational pathways for students to enter the public health workforce and meaningful public health careers. In response to the immediate need for public health workers during the pandemic, several universities and academic hospitals rapidly mobilized students and employees and partnered with local or state health departments. However, many of those partnerships were based on short-term volunteer effort to support critical COVID-19 public health efforts. In this article, we document the development of Oregon's Public Health Practice Team, a student, staff, and faculty workforce developed at the Oregon Health & Science University-Portland State University (OHSU-PSU) School of Public Health in close collaboration with the Oregon Health Authority (OHA). This project contributed significant effort to several phases of Oregon's statewide public health response to COVID-19, and over time developed into a lasting, multi-purpose, inter-agency collaborative public health practice program. Health equity has been centered at every stage of this work. We describe the phases of the partnership development, the current team structure and operations, and highlight key challenges and lessons learned. This provides a case-study of how an innovative and flexible university-government partnership can contribute to immediate pandemic response needs, and also support ongoing public health responses to emerging needs, while contributing to the development of a skilled and diverse public health workforce.

How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review.

Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.

Developing the future research agenda for the health and social care workforce in the United Kingdom: Findings from a national forum for policymakers and researchers.

There is a gap between healthcare workforce research and decision-making in policy and practice. This matters more than ever given the urgent staffing crisis. As a national research network, we held the first ever United Kingdom (UK) forum on healthcare workforce evidence in March 2023. This paper summarises outputs of the event including an emerging UK healthcare workforce agenda and actions to build research capacity and bridge the gap between academics and decisionmakers. The forum brought together over 80 clinical and system leaders, policymakers and regulators with workforce researchers. Fifteen sessions convened by leading experts combined knowledge exchange with deliberative dialogue over 2 days. Topics ranged from workforce analytics, forecasting, international migration to interprofessional working. In the small groups that were convened, important gaps were identified in both the existing research body and uptake of evidence already available. There had not been enough high quality evaluations of recent workforce initiatives implemented at pace, from virtual wards to e-rostering. The pandemic had accelerated many changes in skillmix and professional roles with little learning from other countries and systems. Existing research was often small-scale or focused on individual, rather than organisational solutions in areas such as staff wellbeing. In terms of existing research, managers were often unaware of accepted high quality evidence in areas like the relationship between registered nurse staffing levels and patient outcomes. More work is needed to engage new disciplines from labour economics and occupational health to academic human resources and to strengthen the emerging diverse community of healthcare workforce researchers.

Emergency responses for a health workforce under pressure: Lessons learned from system responses to the first wave of the pandemic in Canada.

The global health workforce crisis, simmering for decades, was brought to a rolling boil by the COVID-19 pandemic in 2020. With scarce literature, evidence, or best practices to draw from, countries around the world moved to flex their workforces to meet acute challenges of the pandemic, facing demands related to patient volume, patient acuity, and worker vulnerability and absenteeism. One early hypothesis suggested that the acute, short-term pandemic phase would be followed by several waves of resource demands extending over the longer term. However, as the acute phase of the pandemic abated, temporary workforce policies expired and others were repealed with a view of returning to 'normal'. The workforce needs of subsequent phases of pandemic effects were largely ignored despite our new equilibrium resting nowhere near our pre-COVID baseline. In this paper, we describe Canada's early pandemic workforce response. We report the results of an environmental scan of the early workforce strategies adopted in Canada during the first wave of the COVID-19 pandemic. Within an expanded three-part conceptual framework for supporting a sustainable health workforce, we describe 470 strategies and policies that aimed to increase the numbers and flexibility of health workers in Canada, and to maximise their continued availability to work. These strategies targeted all types of health workers and roles, enabling changes to the places health work is done, the way in which care is delivered, and the mechanisms by which it is regulated. Telehealth strategies and virtual care were the most prevalent, followed by role expansion, licensure flexibility, mental health supports for workers, and return to practice of retirees. We explore the degree to which these short-term, acute response strategies might be adapted or extended to support the evolving workforce's long-term needs.

Global health workforce strategies to address the COVID-19 pandemic: Learning lessons for the future.

COVID-19 put unprecedented strain on the health and care workforce (HCWF). Yet, it also brought the HCWF to the forefront of the policy agenda and revealed many innovative solutions that can be built upon to overcome persistent workforce challenges. In this perspective, which draws on a Policy Brief prepared for the WHO Fifth Global Forum on Human Resources for Health, we present findings from a scoping review of global emergency workforce strategies implemented during the pandemic and consider what we can learn from them for the long-term sustainability of the HCWF. Our review shows that strategies to strengthen HCWF capacity during COVID-19 fell into three categories: (1) surging supply of health and care workers (HCWs); (2) optimizing the use of the workforce in terms of setting, skills and roles; and (3) providing HCWs with support and protection. While some initiatives were only short-term strategies, others have potential to be continued. COVID-19 demonstrated that changes to scope-of-practice and the introduction of team-based roles are possible and central to an effective, sustainable workforce. Additionally, the use of technology and digital tools increased rapidly during COVID-19 and can be built on to enhance access and efficiency. The pandemic also highlighted the importance of prioritizing the security, safety, and physical and mental health of workers, implementing measures that are gender and equity-focused, and ensuring the centrality of the worker perspective in efforts to improve HCWF retention. Flexibility of regulatory, financial, technical measures and quality assurance was critical in facilitating the implementation of HCWF strategies and needs to be continued. The lessons learned from COVID-19 can help countries strengthen the HCWF, health systems, and the health and well-being of all, now and in the future.

Health workforce in the Eastern Mediterranean Region: From COVID-19 lessons to actions.

The COVID-19 pandemic has had a devastating and unprecedented impact on health and health systems globally leaving an indelible mark on health system infrastructures. The pandemic also clearly demonstrated the critical role of health workers for well-performing health systems, in particular during emergencies and have prompted the need to undergo a critical re-evaluation of health systems and health workforce design and implementation. As the year 2023 marks the halfway point of the 2030 Agenda for Sustainable development, the time is pertinent for action by governments and partners to scale up the health workforce to advance towards sustainable developement goal (SDG) 3 on health and well-being and other health-related SDGs, building on the lessons from COVID-19. Therefore, at the 70th session of World Health Organization Regional Committee for Eastern Mediterranean, Member States unanimously adopted a resolution to call for accelerated actions to address health workforce challenges through solidarity, alignment, and synergy of efforts in order to rebuild resilient health systems after the COVID-19 pandemic.

How can countries respond to the health and care workforce crisis? Insights from international evidence.

Future global health security requires a health and care workforce (HCWF) that can respond effectively to health crises as well as to changing health needs with ageing populations, a rise in chronic conditions and growing inequality. COVID-19 has drawn attention to an impending HCWF crisis with a large projected shortfall in numbers against need. Addressing this requires countries to move beyond a focus on numbers of doctors, nurses and midwives to consider what kinds of healthcare workers can deliver the services needed; are more likely to stay in country, in rural and remote areas, and in health sector jobs; and what support they need to deliver high-quality services. In this paper, which draws on a Policy Brief prepared for the World Health Organization (WHO) Fifth Global Forum on Human Resources for Health, we review the global evidence on best practices in organising, training, deploying, and managing the HCWF to highlight areas for strategic investments. These include (1). Increasing HCWF diversity to improve the skill-mix and provide culturally competent care; (2). Introducing multidisciplinary teams in primary care; (3). Transforming health professional education with greater interprofessional education; (4). Re-thinking employment and deployment systems to address HCWF shortages; (5). Improving HCWF retention by supporting healthcare workers and addressing migration through destination country policies that limit draining resources from countries with greatest need. These approaches are departures from current norms and hold substantial potential for building a sustainable and responsive HCWF.

How new clinical roles in primary care impact on equitable distribution of workforce: a retrospective study.

BACKGROUND: There are inequalities in the geographical distribution of the primary care workforce in England. Primary care networks (PCNs), and the associated Additional Roles Reimbursement Scheme (ARRS) funding, have stimulated employment of new healthcare roles. However, it is not clear whether this will impact inequalities. AIM: To examine whether the ARRS impacted inequality in the distribution of the primary care workforce. DESIGN AND SETTING: A retrospective before-and-after study of English PCNs in 2019 and 2022. METHOD: The study combined workforce, population, and deprivation data at network level for March 2019 and March 2022. The change was estimated between 2019 and 2022 in the slope index of inequality (SII) across deprivation of full-time equivalent (FTE) GPs (total doctors, qualified GPs, and doctors-in-training), nurses, direct patient care, administrative, ARRS and non- ARRS, and total staff per 10 000 patients. RESULTS: A total of 1255 networks were included. Nurses and qualified GPs decreased in number while all other staff roles increased, with ARRS staff having the greatest increase. There was a pro- rich change in the SII for administrative staff (-0.482, 95% confidence interval [CI] = -0.841 to -0.122, P<0.01) and a pro- poor change for doctors-in-training (0.161, 95% CI = 0.049 to 0.274, P<0.01). Changes in distribution of all other staff types were not statistically significant. CONCLUSION: Between 2019 and 2022 the distribution of administrative staff became less pro-poor, and doctors-in-training became pro-poor. The changes in inequality in all other staff groups were mixed. The introduction of PCNs has not substantially changed the longstanding inequalities in the geographical distribution of the primary care workforce.

Using the socio-ecological model to appraise perspectives on health workforce retention and intention to leave in Malawi and Tanzania: a qualitative longitudinal study.

INTRODUCTION: The chronic health workforce shortage poses a significant setback to achieving universal health coverage. Health authorities continually develop and implement human resources for health policies and interventions to alleviate the crisis, including retention policies. However, the success of such policies and interventions is tangential to the alignment with health workers' expectations. The aim of this study was to explore perspectives on health workforce retention and intention to leave among health workers and policy-makers from rural and remote areas of Malawi and Tanzania. METHODS: Semi-structured interviews were conducted with 120 participants - 111 rural and remote mid-level health workers, and nine policy-makers in Malawi and Tanzania - for a period of 3 years, 2014-2017. The semi-structured interviews were conducted face to face, and follow-up interviews were conducted through emails or social media. By using the socio-ecological model as a framework for analysis, the emerging themes were mapped out and linked. RESULTS: Health workers related their perspectives on retention and intention to leave to the individual (intrapersonal), family (interpersonal/microsystem), and community (institutional/mesosystem) factors, whereas policy-makers focused their views mainly on the individual (intrapersonal) factors and retention policies at the national level (macrosystem). CONCLUSION: Policy-makers and health workers in rural and remote settings in Malawi and Tanzania recognise the factors influencing health workforce retention, and intention to leave at the individual level. However, while policy-makers focus mainly on national-level retention policies, health workers focus on retention aspects related to the family and the surrounding community - a clear misalignment. Therefore, health authorities need to align health policies to health workers' expectations to bridge this gap, improve access to the health workforce in rural and remote populations, and improve health outcomes.