Publication: Getting Health Workers to Rural Areas: Innovative Analytic Work to Inform Policy Making
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2010-12
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2017-08-15
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Decision makers face serious challenges in attracting health workers to rural areas, in both the developed and developing world, but while they have access to a wide range of policy options, the effectiveness of interventions is highly contingent on context. To make them more effective, decision makers need to have an in-depth understanding of, especially, the factors that influence individual workers decisions on choice of practice, particularly regarding relocation to rural areas. The current paper presents results of an empirical study conducted in Liberia and Vietnam using a discrete choice experiment (DCE). The study's aim was to predict the likelihood of health workers taking up a rural area job under alternative incentive schemes. This study is the first DCE analysis to then go the extra step of costing out the alternative packages. The analysis revealed quite different results for the two countries. The most powerful single incentive in motivating workers to practice in rural areas was increased pay in Liberia, and long-term education in Vietnam. The cost-effectiveness of incentives also varies by country. In Liberia, monetary incentives were by the most cost effective while in Vietnam it was opportunities for skills development. While the study methodology needs further enhancement, especially costing of incentive packages, the work shows that a DCE analysis can be a powerful tool in informing the design of rural area incentive schemes in developing countries.
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“Vujicic, Marko; Alfano, Marco; Shengelia, Bukhuti. 2010. Getting Health Workers to Rural Areas: Innovative Analytic Work to Inform Policy Making. Health, Nutrition and Population Discussion Paper;. © World Bank. http://hdl.handle.net/10986/27845 License: CC BY 3.0 IGO.”
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Publication Policy Options to Attract Nurses to Rural Liberia : Evidence from a Discrete Choice Experiment(World Bank, Washington, DC, 2010-11)There is major geographic variation in nurse staffing levels in Liberia with the largest shortages in rural areas. A discrete choice experiment (DCE) was used to test how nurses and certified midwives in Liberia would respond to alternative policies being considered by the ministry of health and social welfare (MOHSW). The DCE methodology provides a quantitative estimate of how individuals value different aspects of their job. In Liberia we focused on six key job attributes: location, total pay, conditions of equipment, availability of transportation, availability of housing, and workload. Results were used to predict the share of nurses and certified midwives who would accept a job in a rural area under different schemes. Based on the DCE analysis there are four main actionable recommendations that emerge for improving recruitment and retention of nurses and certified midwives in rural areas of Liberia. First, the MOHSW should consider actively recruiting students from rural areas and exposing them to rural work conditions during their training. Second, the MOHSW should strongly consider increasing pay levels in rural areas as this is likely to be cost effective. Third, if for some reason financial bonuses are not feasible, the MOHSW should consider providing transportation to nurses and certified midwives in rural areas. Fourth, the MOHSW should reconsider its housing strategy. Providing newly constructed housing is not a cost effective policy according to the DCE study.Publication How to Attract Health Workers to Rural Areas? Findings from a Discrete Choice Experiment from India(World Bank, Washington, DC, 2012-08)India faces significant challenges in attracting qualified health workers to rural areas. In 2010 the authors conducted a Discrete Choice Experiment (DCE) in the Indian states of Uttarakhand and Andhra Pradesh to understand what health departments in India could do to make rural service more attractive for doctors and nurses. Specifically, we wanted to do the following: (a) examine the effect of monetary and nonmonetary job attributes on health worker job choices; and (b) develop incentive 'packages' with a focus on jobs in rural areas. The study sample included medical students, nursing students, in-service doctors and nurses at primary health centers. An initial qualitative study identified eight job attributes health center type, area, health facility infrastructure, staff and workload, salary, guaranteed transfer to city or town after some years of service, professional development, and job in native area. Respondents were required to choose between a series of hypothetical job pairs that were characterized by different attribute-level combinations. Bivariate probit and mixed logit regression was used for the statistical analysis of the choice responses. The findings suggest that the supply of medical graduates for rural jobs remained inelastic in the presence of individual monetary and nonmonetary incentives. In contrast, the supply of nursing students for rural jobs was elastic. Further, medical and nursing students from rural areas had a greater inclination to take up rural jobs. The supply of in-service doctors and nurses for rural posts was elastic. Higher salary and easier enrolment in higher education programs in lieu of some years of rural service emerged as the most powerful driver of job choice. Overall, better salary, good facility infrastructure, and easier enrolment in higher education programs appear to be the most effective drivers of uptake of rural posts for students and in-service workers. Combining these incentives can substantially increase rural recruitment. Incentivizing medical graduates to take up rural service appears to be challenging in India's context. This can be improved to some extent by offering easier admission to specialist training and recruiting students from rural backgrounds. In contrast, nursing students and in-services nurses are much more receptive to incentives for uptake of rural service. This suggests that cadres such as nurse practitioners can play an important role in delivering primary care services in rural India.Publication Health Worker Attitudes toward Rural Service in Liberia : Results from Qualitative Research(World Bank, Washington, DC, 2010-11)In Liberia, the maldistribution of health workers is particularly pronounced as 14 years of civil war exacerbated the concentration of experienced health workers in urban areas. The government has identified this challenge as a priority area for policy intervention. The objective of this study was to explore the drivers of health workforce choice including job location. It presents the results from preparatory qualitative research that fed into the design of a discrete choice experiment (DCE). The qualitative study interviewed 26 registered nurses, midwives, and physician assistants about their current working conditions, their job location preference, and priority areas for change in working conditions. Content analysis was used to analyze the data. The study shed light on health worker job preferences and their working conditions, and identified six job attributes that health workers consider to be important when choosing a job. These were pay, transport, availability of medical materials and infrastructure, housing, workload, and further training opportunities. These attributes were chosen because they reflect the frequency to which they were cited during the interviews and the extent to which they were amenable to policy intervention. Associated attribute levels were chosen for each attribute to reflect current work conditions and the levels of change that will be necessary to trigger changes in job choice. The relative weight of each of these attributes in location choice has been quantitatively determined through the follow-up DCE. 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The study was carried out in two geographically diverse Indian states, Uttarakhand and Andhra Pradesh. A total of 80 in-depth interviews were conducted with a variety of participants: medical students (undergraduate, postgraduate, and Indian system of medicine), nursing students, and doctors and nurses in primary health centers. The information collected was clustered by constructing several hierarchical displays, and collated into job-attribute matrixes. The findings indicate that, while financial and educational incentives attract doctors and nurses to rural postings, they do not make effective retention strategies. Frustration among rural health workers often stems from the lack of infrastructure, support staff, and drugs, a feeling exasperated by local political interference and lack of security.Publication How to Recruit and Retain Health Workers in Rural and Remote Areas in Developing Countries : A Guidance Note(World Bank, Washington, DC, 2013-06)Worldwide the geographical distribution of health workers is skewed towards urban and wealthier areas. This pattern is found in nearly every country in the world, regardless of the level of economic development and health system organization, but the problem is especially acute in developing countries. The geographical imbalances in the health workforce further exacerbate inequities in the health sector, as the services are not available where needs are higher and impact greater. A variety of interventions have been applied in different contexts and for different types of health workers to address this problem. There is an emerging consensus that policies for recruitment and retention in rural and remote areas need to address two critical issues: i) to be effective, interventions need to be implemented in bundles, combining different packages of interventions according to the variety of factors influencing the health worker's decision to work in rural or remote areas; and ii) to match the interventions with health worker's preferences and expectations, since the health worker's employment decisions are a function of these preferences. In order to respond to these requirements, this paper proposes the application of Discrete Choice Experiments (DCEs) to allow for measurement of health workers' preferences and quantitatively predicts the job uptake given a set of job characteristics. This paper has a two-fold objective: a) to give the reader an overview of the magnitude of unequal health workforce distribution in the developing countries, provide a summary of the evidence to date on the factors that contribute to these imbalances, and present a systematic set of policy interventions that are being implemented around the world to address the problem of recruitment and retention of health workers in rural and remote regions of the developing countries; and b) to introduce the reader to the potential application of the DCE to elicit health workers' preferences and determine the factors likely to increase their probability of taking up a rural or remote job.
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