Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review

Introduction

Primary health care (PHC) includes provision of services for the prevention, treatment, management, rehabilitation, and palliation of disease, and is integral to achieving global health security, universal health coverage and the Sustainable Development Goals^1–7. A robust PHC system requires an adequate number of trained and motivated health care providers^6,8,9 Alarmingly, the World Health Organization (WHO) has estimated that the global shortage of providers will increase by 80% to 12.9 million over the next 20 years and has called for the development of an expanded, high-quality workforce¹⁰. Given the projected shortages and estimates that ministries of health may spend 50% to 80% of their budget on staff remuneration¹¹, there is great interest in strategies to retain existing providers and improve provider efficiency and productivity. The reasons for lower efficiency and productivity are unclear, and may be linked to extrinsic motivational factors including financial and non-financial, organizational, and environmental incentives¹² or to incompletely described intrinsic motivational factors such as achievement, recognition, responsibility, and growth¹³, which may be negatively impacted by provider burnout.

Burnout, as described by Freudenberg¹⁴ and expanded by Maslach, is comprised of three dimensions: emotional exhaustion (‘emotionally overextended and exhausted by […] work’), depersonalization (‘unfeeling and impersonal response towards recipients of one’s care or service’), and low personal achievement (‘feelings of competence and successful achievement […] with people’), and results in negative work experiences^15–17. There are a number of surveys used to assess burnout^18,19; however, the Maslach Burnout Inventory (MBI) has emerged as perhaps the most widely used survey to assess burnout across a wide variety of work and cultural settings²⁰. Studies using the MBI in the United States, Canada, and mostly high-income countries in Europe have found that up to half of outpatient providers report high levels of emotional exhaustion, depersonalization, and a sense of low personal achievement^21–23). These findings are supported by a systematic review which documented high levels of burnout in both outpatient and inpatient providers in high-income countries²⁴. In these studies, high burnout was associated with feeling undervalued and unsupported, having too much paperwork, and the existence of long waits for specialists and tests, among other factors^21–23.

Identifying and characterizing burnout is important as it can have a negative impact on providers and patient care. Studies from predominantly high-income countries have shown that provider burnout is associated with adverse events including medical errors, unexplained work absenteeism, reduction in quality of care,^25,26 higher number of negative rapport-building statements (physician or patient offers a statement ‘characterized as criticism or disagreement’),²⁷ job dissatisfaction²⁸, and poor patient satisfaction.^29,30 A large study of 11,530 health professionals in Spain and Latin America showed that higher emotional exhaustion was associated with higher absenteeism, intention to exit the profession, and low quality of personal and family life.³¹

Despite the growing recognition of the need to retain trained providers and improve the quality of care they provide, there is no comprehensive analysis of the burden of provider burnout in low and middle-income countries (LMICs). In addition to the paucity of studies, current data are cross-sectional without an evaluation of potential change over time and most studies have not characterized institutional (e.g., institutional management, quality, or supervision), individual, socioeconomic, or geopolitical factors that could potentially contribute to provider burnout. To address this gap, we conducted a systematic review to describe the prevalence of and factors associated with outpatient provider burnout in LMICs, to help managers and policymakers develop and implement effective interventions to prevent burnout and improve work productivity, efficiency, quality and retention.

Data sources and search strategy

We performed a systematic literature search to identify articles on burnout among outpatient health care providers in LMICs. We focused on outpatient care settings as this is where the majority of primary health care services are provided. Our initial search was based on articles published in EMBASE (from 1947), MEDLINE (from 1966), and Commonwealth Agricultural Bureau (CAB) Abstracts (from 1973) up to December 1, 2014. We developed a broad search strategy for each key term: ‘burnout’, ‘healthcare providers’, and ‘LMICs’, through a combination of text words, words in the abstract or title, and Medical Subject Headings (MeSH). For burnout, we included “motivation” and “achievement”. For healthcare providers, we included “physician”, “nurse”, and “community health worker”; and for LMICs, we included “developing countries”, “resource constrained”, and “resource poor”. We used the World Bank system to classify countries as low or middle-income based on gross national income per capita.³² The search terms were combined using ‘AND’ to identify articles that included all three concepts, as outlined in the S1 Supplementary Material. The search was updated using the same methodology to include articles from December 1, 2014 through January 23, 2016.

Study selection

The titles and abstracts for the initial search were reviewed independently by two authors (SD and HA) and also by two authors (SD and HR) for the updated search. Research articles written in English were included if the study was based in an LMIC and explicitly investigated burnout and not solely work-related depression, anxiety, or stress, in outpatient healthcare workers. Articles were excluded if they were conference abstracts, case reports, case series, simulations, review articles, editorials, commentaries, perspectives, or personal narratives; if the full-length article was not available; if the study had fewer than 50 subjects; or if the study focused on trainees (for example, students, residents, or fellows), inpatient providers, or on veterinary care providers. Discrepancies between the authors in abstracting data were resolved by discussion or through consultation with other authors (AB and LRH). The detailed selection strategy is outlined in Supplementary File 3.

Data extraction and analysis

We collected information on the study location and design, participant demographics, cadre, and duration in practice. For burnout, we collected information on the type of burnout inventory used, and estimates of overall burnout and its subcomponents (depersonalization, emotional exhaustion, and level of personal achievement).

Results

Discussion

In this systematic literature review, we observed that burnout is prevalent across a range of frontline PHC service delivery providers including physicians, nurses, pharmacists, and community health workers in various outpatient health care settings including HIV care clinics in a number of LMICs. To our knowledge, this is the first systematic review to describe provider burnout in LMICs, and provides insight into factors that could influence worker productivity, efficiency, quality, and retention through their influence on burnout. The level of burnout across each MBI dimension is comparable to rates observed among outpatient general internists in the US, family doctors in Canada, and family doctors across 12 countries in Europe^21–23. These studies, which include several high-income countries, found rates of high emotional exhaustion (range 43.0% to 48.1%), high depersonalization (32.7% to 46.3%), and low personal achievement (20.3% to 47.9%).

We were able to identify several consistent factors associated with different dimensions of burnout. Modifiable factors included levels of organizational support, time pressure and workload, as well as the availability of accessible opportunities for professional growth. These results are generally supported by the other studies that showed positive association with longer work hours and inverse association with job satisfaction.^35,36,49,50 Absence of supportive supervision (managers helping health workers to do their job better) appears to also be related to the presence of burnout. Supportive supervision can provide health care workers with opportunities for new skills development as well as improving effectiveness and efficiency of their care delivery. While higher disease burden of patients is less amenable to simple solutions, service delivery changes such as multidisciplinary teams may provide approaches to reducing provider burnout. These reported findings were generally similar to findings seen in high-income countries.^21,23

Additionally, there were also factors which were not modifiable through workplace interventions including age, gender, and level of education, which is also similar to results seen in high-income countries.^21,23 Further research is required to understand why burnout is higher among these groups in order to ensure that effective support and coping strategies are provided for health care workers.

Improving PHC will be critical for achieving universal health coverage and the Sustainable Development Goals by 2030. In LMICs, this will require an available, accessible, and acceptable workforce that can deliver efficient, high-quality patient care.⁵³ While increasing the number of providers in some regions is clearly necessary, health systems will also have to focus on ways to retain existing staff by reducing burnout, providing a supportive environment, creating opportunities for personal achievement and growth, reducing stress and maintaining motivation. Interventions focused on improving interpersonal relationships, supportive work environments, supportive supervision including mentorship, coaching incentives and training on self-awareness and mindfulness, may help to reduce burnout, however evidence from LMICs is often lacking and the generalizability of many of these interventions done in high income settings is not certain^54–60. For example a pre-post study of 84 mental health professionals in the United States found that a one-day retreat and training focused on increasing knowledge of and strategies to prevent burnout was associated at six weeks with significant decreases in emotional exhaustion and depersonalization.⁵⁶ While larger studies on effectiveness of interventions are generally lacking, a few ongoing studies in high-income countries on interventions to reduce burnout and improve patient outcomes may shed light on promising approaches, although these are generally limited to specific cadres or settings.^56,61

Our paper has a number of important limitations. We included articles from three widely used electronic databases, and different cadres of health care providers across LMICs from many regions. However, we did not include articles that were not in English or articles that were published outside of the three search engines, including in non-peer reviewed literature. Only 15 of the 20 included studies used the MBI, and among them, differences in study population and design precluded analyses across different cadres of health providers.

We included a wide variety of primary care providers ranging in training from physicians to community health workers and volunteer caregivers. Because of high prevalence of HIV in some of the countries, we included providers of HIV services as they are a significant source of critical first contact care for people living with HIV/AIDS. The comparability of findings across these widely different health workers who operate within the primary health care sector in LMICs may not be complete. However, despite these limitations, we were able to observe consistent trends in burnout across these different health providers and in different countries.

Our understanding of factors related to high rates of burnout and low provider motivation in LMICs is still in its infancy. This review is based on 20 cross-sectional studies of diverse health providers in different countries. To better describe burnout and reduce its impact on provider retention and quality, further research should focus on more comprehensive investigation of the i) burden of provider burnout from diverse health care providers at different levels in the health care system, ii) demographic, socioeconomic, institutional, and geopolitical factors that influence or mitigate provider burnout, iii) longitudinal changes in burnout in response to extrinsic (i.e. monetary or training) and intrinsic motivational factors, and iv) interventions likely to reduce the burden of burnout. These studies can guide health and policy makers on strategies to improve provider efficiency, productivity, quality, and possibly retention in the workforce.

Conclusions

The delivery of high quality care in low and middle-income countries requires a workforce that is competent, effective, and motivated. Our results show that provider burnout is prevalent across different cadres of providers in various countries with different health care systems. As we move beyond the Health Workforce Decade (2006–2015)⁶², towards achieving universal health coverage and the Sustainable Development Goals, populations and countries will require a robust primary health care system to deliver efficient care. Furthermore, the Global Health Workforce Alliance, which was passed at World Health Assembly 2016, specifically highlights a vision in which: “all people everywhere will have access to a skilled, motivated and supported health worker, within a robust health system”⁶³. However, projections show that the global health workforce shortage is only expected to increase over the coming years. In this context, our results suggesting high rates of provider burnout in a number of low and middle income countries underscore the urgent need for health and policy makers to characterize specific risk factors and develop evidence-based interventions to reduce provider burnout, slow down the ongoing attrition of providers from the global workforce, and ensure all patients everywhere receive quality care from motivated and hopeful frontline providers.