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.