Understanding the preferences of patients and health professionals is useful for health policy and planning. Discrete choice experiments (DCEs) are a quantitative technique for eliciting preferences that can be used in the absence of revealed preference data. The method involves asking individuals to state their preference over hypothetical alternative scenarios, goods or services. Each alternative is described by several attributes and the responses are used to determine whether preferences are significantly influenced by the attributes and also their relative importance. DCEs are widely used in high-income contexts and are increasingly being applied in low- and middle-income countries to consider a range of policy concerns. This paper aims to provide an introduction to DCEs for policy-makers and researchers with little knowledge of the technique. We outline the stages involved in undertaking a DCE, with an emphasis on the design considerations applicable in a low-income setting.
INTRODUCTION: There is major maldistribution of physicians in the Democratic Republic of the Congo (DRC). While 70% of Congolese live in rural areas, relatively few doctors practice there. Of the 25 medical schools in the DRC (14 public and 11 private) only one private medical school is located in a rural area. The purpose of this article was to analyse and compare the graduates of an urban- and a rural-located university in DRC.
METHODS: The 6 first classes of the Catholic University of Graben (UCG) Medical School at Butembo (rural) and Université Evangélique en Afrique (UEA) at Bukavu (urban) (43 and 120 graduates, respectively) were compared according to their rural or urban employment, among other variables.
RESULTS: In total, 97.7% of graduates from the rural-located medical school were employed in the province where they trained, the majority (81.4%) in rural areas. In contrast, 40.0% of graduates from the urban-located school were employed in the province where they trained, with 23.7% working in a rural area. Over 55% of all graduates worked 78 km of their training medical school. Only 2.5% of the rural-school graduates entered residency programs, compared with 15.2% for urban-school graduates.
CONCLUSIONS: The results support the policy of establishing medical schools in rural areas, and also provide indications of approaches likely to increase the number and expertise of rural-located physicians.
BACKGROUND: There is growing evidence that informal payments for health care are fairly common in many low- and middle-income countries. Informal payments are reported to have a negative consequence on equity and quality of care; it has been suggested, however, that they may contribute to health worker motivation and retention. Given the significance of motivation and retention issues in human resources for health, a better understanding of the relationships between the two phenomena is needed. This study attempts to assess whether and in what ways informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention.
METHODS: Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and where possible, focus groups were divided by cadre. All data were processed and analysed by means of the NVivo software package.
RESULTS: The use of informal payments in the study area was confirmed by this study. Furthermore, a negative relationship between informal payments and job satisfaction and better motivation is suggested. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem. Furthermore, fear of detection was a main demotivating factor. These factors seem to counterbalance the positive effect of financial incentives. Moreover, informal payments were not found to be related to retention of health workers in the public health system. Other factors such as job security seemed to be more relevant for retention.
CONCLUSION: This study suggests that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed that not only provides better financial incentives for individuals but also tackles an environment in which corruption is endemic.
The importance of health workers to the effective functioning of healthcare systems is widely recognized (Ndetei et al, 2007). Shortages of health workers constitute a significant barrier to achieving health-related Millennium Development Goals (MDGs) and expanding health interventions in developing countries. In Kenya, internal migration of workers, from rural/poor areas to urban/rich areas, is just as serious a problem as international migration. Shortages in the health workforce are aggravated by the unequal distribution of health workers as a result of economical, social, professional and security factors that all sustain a steady internal migration of health personnel from rural to urban areas, from the public to the private sector, and out of the health profession itself. The crisis calls for investment in incentives to recruit and retain personnel in poorer, rural areas to service communities that need them
most.
This study was undertaken within the Regional Network for Equity in Health in east and southern Africa (EQUINET), in co-operation with the Regional Health Secretariat for East, Central and Southern Africa (ECSA). It was co-ordinated by the University of Namibia, with support from the Training and Research Support Centre, University of Limpopo and the ECSA Regional Health Secretariat.
The study aimed to conduct a literature review and field research to obtain data on strategies for the retention of health workers in various institutions in Kenya. Specifically, we aimed to:
• establish the context for, and trends in, the recruitment and retention of health workers;
• identify existing policies, strategies and interventions to retain health workers;
• identify how these strategies are being introduced and resourced and assess their sustainability;
• analyze management, monitoring and evaluation systems to measure the impact of the health worker retention incentive regimes; and
• identify lessons learned and appropriate guidelines for non-financial incentive packages to promote the retention of health workers.
We reviewed existing strategies for recruiting and retaining health workers over time in Kenya. We looked at the Ministry of Health (national public health sector), national referral and teaching hospitals, Nairobi Hospital (private medical institution), Kenya Medical Training College (KMTC), the University of Nairobi (College of Health Sciences) and an NGO, the Adventist Development and Relief Agency (ADRA). Focus group discussions and interviews were held. The existing health worker retention incentive schemes, government policy and strategies on retention of health workers were analyzed in the form of policy documents, terms and conditions of service for each institution and questionnaires that were filled in at selected institutions. Challenges facing the recruitment and retention of health workers in Kenya were also analyzed to understand how these policies were implemented.
Facilities offered a number of financial incentives to their staff, such as paid leave and overtime pay, access to house or car loans at lower negotiated market rates (for highly skilled public sector workers) and numerous allowances, such as transport, entertainment, hardship, responsibility, special duty and uniform allowances. Some staff worked in bonding agreements, whereby the institution paid for their studies but they had to work for a specific numbers of years in return. Non-financial incentives for health workers included housing (or a housing allowance), post-graduate training and continuing medical education, life insurance, personal loan facilities, shorter working hours, membership to the National Social Security Fund (NSSF), medical cover (includes nuclear family) and the introduction of HIV and AIDS treatment in some workplaces.
Terms and conditions of service in private and teaching facilities were reviewed regularly and health workers were informed on any changes of services through improved human resource management. Private medical institutions, national hospitals and training institutions had implemented non-financial incentives by improving working conditions through renovations, upgrading the facilities (re-equipping the medical facilities with new technology) and making medical supplies accessible to the communities.
However, in public facilities, there were many unfilled positions despite high unemployment rates for health workers in the country. Primary health care facilities were severely understaffed, with relative over staffing of hospitals (district, provincial and national hospitals).
This imbalance causes health workers in public institutions to migrate from primary health care (PHC) facilities to district hospitals, provincial and then national hospitals.
The data presented shows a need to address the maldistribution between urban and rural areas, and between levels of care, as well as to stem the internal migration from poorer to richer areas. Poorer areas generally have worse living and working conditions, and better non-financial incentives propel the health workers to migrate to bigger health facilities (provincial and national hospitals) situated in towns and cities across the country. In these urban areas, they work fewer hours (due to higher staffing levels) and can also engage in private practice for more money. The incentives introduced to retain health workers often depend for their effective implementation on the facility, with better organized facilities, often in higher-income areas, more successful in providing incentives. Yet, ironically, it is at the lower levels of the health system (in rural and poorer areas) where incentives are more urgently needed to counteract the strong push factors that force workers out of these areas.
We recommend that government put in place national-level policies to retain health workers in rural areas, in lower-income districts and at lower levels of the health system to ensure that all areas reach minimum standards with regard to numbers of personnel per population (such as the WHO recommended minimum standard of 20 doctors per 100,000 patients).
We stress that such incentives are not only financial. According to the feedback we received from health workers, a number of non-financial incentives are highly valued:
• improved working conditions;
• training and supervision; and
• good living conditions, communications, health care and educational opportunities for themselves and their families.
The government needs to invest not only in its health workers but in its facilities, by ensuring regular medical supplies, upgrading facilities and improving working conditions in rural and poorer areas. Continuous medical education in specific areas is required, depending on service needs, in response to areas of increasing public health burden, such as antiretroviral therapy (ART), voluntary counseling and testing (VCT), and services for tuberculosis, epilepsy, mental health, diabetes and hypertension.
Management practices also appear to be important. However, the strategic information needed for effective management was often missing in the facilities that needed it most. We set out to assess the impact of incentives, but were not able to access the sort of routine information needed to make this assessment. This information gap puts human resource managers at a disadvantage for their own strategic planning, and makes it harder for them to argue for further resources needed for retention incentives. The reasons why health workers resign or leave facilities should be routinely documented to assist policy makers to address the causes of internal and external migration. Health information management systems should be used to track the flows of health workers and inform the planning and distribution of health workers. Particularly in the public sector, health worker records are necessary to be able to monitor implementation and assess the impact of incentives.
CONTEXT: Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed.
PURPOSE: To examine RPAP outcomes in recruiting and retaining rural primary care physicians.
METHODS: The RPAP database, including moves and current practice settings, was examined using descriptive statistics. Findings: On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice.
CONCLUSION: RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.
OBJECTIVE: To provide data on the career trajectories of medical students from rural and remote workforce programs at Flinders University (the Parallel Rural Community Curriculum [PRCC] and the Northern Territory Clinical School [NTCS]), comparing them with students at the urban Flinders Medical Centre (FMC).
DESIGN: Retrospective postal survey of all 150 graduates who undertook their Year 3 study in the period 1998-2000.
OUTCOME MEASURE: Associations with career preference, assessed using univariate analyses and multivariate regression.
RESULTS: PRCC and NTCS graduates were more likely to choose rural career paths than graduates from FMC. The odds ratios were 19.1 (95% CI, 3.4-106.3; P < 0.001) and 4.3 (95% CI, 1.2-14.8; P = 0.026), respectively, after adjusting for age and rural background. There was no difference in the specialty choices of graduates of the three programs.
CONCLUSION: This study provides evidence that clinical attachments designed to increase the rural and remote medical workforce do fulfil this objective.
OBJECTIVE: To explore student perceptions of rural pharmacy practice, factors affecting interest in rural work and effects of an educational intervention designed to raise awareness of rural practice.
DESIGN: Qualitative and quantitative survey questionnaire administered before and after a week-long rural externship.
SETTING: Undergraduate - rural pharmacy externship.
PARTICIPANTS: Third-year Bachelor of Pharmacy undergraduate cohort (n = 123).
INTERVENTION: Week-long exposure to rural pharmacy practice
MAIN OUTCOME MEASURES: Rural/urban origin of students, interest in working in rural practice, views held of rural practice and towards externship.
RESULTS: Rural-origin students were significantly more likely to report they would consider working in rural practice prior to the intervention than urban-origin students (77% rural origin versus 40% urban origin). The intervention significantly increased the overall proportion (48% pre-versus 73% post-externship), proportion of female students (48% pre versus 79% post-externship) and proportion of urban-origin students (38% pre-versus 67% post-externship) prepared to consider rural practice. Despite apprehension towards the externship, students reported overwhelmingly positive experiences of it. Negative aspects related mainly to travel and accommodation costs incurred.
CONCLUSIONS: This targeted, experiential intervention affected perceptions of rural practice in a positive direction among urban-origin students by raising awareness and challenging their preconceptions of rural pharmacy practice. Further research is required to see whether this will affect recruitment and to investigate what appears to be a particular effect on female students.
INTRODUCTION: Jichi Medical University (JMU) is an experimental medical school established in 1972 by the Japanese Ministry of Home Affairs and all 47 prefectures in Japan (equivalent to the states of Australia) with a special mission to produce rural doctors and distribute them nationwide. The JMU has adopted a contract-based 'home prefecture recruiting scheme' in which students recruited evenly from all the 47 prefectures of Japan are required to work in their home prefectures for 9 years (including 6 years of rural service) after graduation in exchange for having their 6 years of undergraduate medical education tuition fees waived. Although the JMU system is now being partially adopted by an increasing number of other medical schools in Japan, the effectiveness of this equal distribution scheme is largely unknown. METHODS: A retrospective cohort study of 1255 graduates who had completed their contract by 2000 was conducted. Baseline data were collected at matriculation and graduation between 1972 and 1991. Workplace addresses were followed up in 2000, 2004, and 2006. Follow-up rates were 98.7% in 2000, 98.2% in 2004, and 98.0% in 2006. Data excerpted from the 2004 National Population Census including various demographic indicators (eg population, population density, and physicians/population ratio) for each of the 47 prefectures were merged, through prefectural identification codes, with the baseline and follow-up addresses of the subjects. RESULTS: Of all JMU graduates after contract, 69.8% settled in their home prefectures. The rates varied from 45.5% to 93.3% among the prefectures (p<0.001). The settlement rate tended to be higher in prefectures with a lower population density or physician : population ratio. Among prefectural demographics, the physician : population ratio and medical institution : population ratio were negatively correlated with settlement rate in the prefecture (correlation coefficient -0.34 [p=0.020]; and -0.35 [p=0.017], respectively). In short, prefectures with a relative shortage of physicians had higher settlement rates. In multivariable analysis of personal factors, female sex and physician : population ratio of home prefecture were negatively associated with settlement (OR 0.25 [95%CI 0.10-0.58] and OR for 1 SD increase 0.82 [0.71-0.94], respectively). Primary care specialty was positively associated with settlement (1.80 [1.35-2.39]). Mother's higher academic background was negatively associated with settlement (OR for university vs junior high school graduate 0.54 [95%CI 0.34-0.88]). CONCLUSIONS: The home prefecture recruiting scheme has attained its goal, particularly in medically underserved prefectures. The high retention rates indicate that the scheme would be beneficial for other medical schools in Japan, which are now beginning to implement programs similar to JMU, and also medical educators and policy makers in countries searching for effective political interventions to maldistribution of physicians.
