Health Workers' Preferences and POLICY Interventions to Improve Retention in Rural Areas in Thailand

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Health workers’ preferences and policy interventions to improve retention in rural areas in Thailand POLICY BRIEF JUNE 2011

INTRODUCTION

The research presented in this policy The human resources crisis in low-income countries has become increasingly brief was conducted by Nonglak apparent since the adoption of the Millennium Development Goals in 2000. Pagaiya, Viroj Tangchareonsathien, The maldistribution of health workers within countries is a crucial problem felt Thinakorn Noree, Sanya Sriratana, most acutely in rural areas. Several international initiatives have stressed the Duane Blaauw and Mylene Lagarde. important role played by human resources for health but despite this health The authors are part of the Consortium worker shortages remains a key policy concern. for Research on Equitable Health The shortage of doctors and nurses in rural areas of Thailand is a recurring Systems (CREHS) and funded by problem. Over the past 20 years the Thai government has introduced a range the Department for International of strategies aimed at recruiting and retaining more in rural areas. There is Development, UK. a dearth of empirical data on health worker flows and behaviours and their This policy brief is based on a research implications on policy. A range of financial and non-financial factors have been report, “Policy Interventions to described as playing a role in health workers’ decisions and motivations, yet improve health worker retention in their relative importance when considering a rural posting remains unclear. rural areas”. The report is available on Effective retention strategies need evidence-based information to support their the CREHS website design and implementation. http://www.crehs.lshtm.ac.uk This research set out to examine the job preferences of newly graduated doctors For more information about and nurses to identify effective policy interventions that could improve their this publication please contact: recruitment and retention in rural areas. Similar studies were carried out in Nonglak Pagaiya South Africa and Kenya. Email: [email protected] This policy brief provides findings from the baseline for this research as well as from a cohort of 198 doctors and 342 nurses. It is hoped that this will help the Thai government to better understand the impact current and future policy interventions might have on employment preferences and their influence on recruitment and retention of doctors and nurses in rural areas of Thailand.

METHODS USED

Study participants were recently of 4 colleges were invited to enrol in • Pre-baseline, key informant qualified doctors and nursing students the study (342 enrolled). interviews were held with higher selected using a stratified sampling level Ministry officials and other Multiple methods were used to evaluate technique. relevant stakeholders to identify individuals’ attitudes, preferences and strategies that have been or could choices in relation to the likelihood of • Doctors were selected from provinces be developed to improve recruitment selecting a rural job posting. stratified into 3 categories: poor and retention of nurses and doctors (25 provinces), medium (25 provinces) • A self-administered questionnaire in rural areas, noting successes and/ and rich (25 provinces). Three provided information on basic or failures in policies. provinces were randomly selected individual characteristics (age, sex, from each category. All doctors who • Focus group discussions were used parents’ education, religion, etc.). to help inform the design of the had been working for less than three Questions related to educational years after medical graduation in discrete choice experiment. Focus background, attitudes towards living groups were also used to gather district and provincial hospitals were and working in rural areas, and invited to participate in the study. information on job preferences and reasons for their choice of nursing/ factors that may influence choice of In total 211 doctors were enrolled medical career were also asked. in the study. nursing and medical jobs sought by The self-administered questionnaire nursing and medical graduates. was given to all study participants • There are 25 Ministry of Public at baseline and again during a At follow-up, the self-administered Health controlled nursing colleges in follow-up survey. questionnaire was designed to capture four regions of Thailand; North- the actual choices and decisions Eastern, Central, Southern and • A discrete choice experiment aimed made by nurses and doctors and to Northern. One college from each at investigating participants’ job corroborate information collected region was selected based on its size preferences relating to possible policy over the 1-year follow-up period. It and location within the region. All interventions that could be used to included a description of current job final year nursing students from each attract them to rural job postings. characteristics and job satisfaction. Table 1: KEY FINDINGS Prediction of doctors’ job preferences under different policy simulations

Characteristics of the study population Policy % % intervention rural urban Of the 198 doctors still completing their compulsory service and who agreed Current working 20.00 80.00 to participate in the study, the majority were in their first year of practice conditions (60.1%). Female doctors (54.5%) made up slightly more of the sample than male Single incentives doctors (45.5%). Of all study participants, 83.3% spent their childhood in urban areas. The majority of study participants graduated from regional universities 30% rural incentive 24.09 75.91 (63.6%). The majority of doctors were recruited by entrance examinations 45% rural incentive 38.20 61.80 (89.4%) with only 10.6% being recruited through the local recruitment system Specialty training 42.65 57.35 where students are recruited from rural areas by local mechanisms. quota 342 student nurses agreed to participate in the study. The study sample was Workplace close to 45.88 54.12 relatively equally distributed between the four nursing colleges; although hometown there was a larger group from the nursing college located in the North- Only 7 on-call nights/ 35.40 64.60 Eastern region (34.2%). Female study participants represented 95.3% of the month total sample. Overall 83.6% were born in a rural area with the majority coming Faster promotion 24.84 75.16 from the North-Eastern region (68.4%) and relatively few from the Central Education incentives + region (1.2%). working environment Specialty training 49.58 50.42 Career choices quota + faster promotion + Rural vs. urban areas 15% salary increase Overall Thai nurses and doctors had relatively positive attitudes towards Specialty training 63.30 36.70 quota + only rural areas. on-call nights A high proportion of doctors felt that working in a rural setting is not Specialty training 76.93 23.07 as stressful when compared to living in a city. One of the doctors’ main quota + closer to hometown concerns about working in rural areas centred on their belief that bringing up children in rural settings is difficult. Specialty training 87.96 12.04 quota + only 7 on-call nights + close to Nurses were even more optimistic about working in rural settings with hometown almost all of them agreeing that working in rural settings is not stressful (97%). A very high proportion of nurses agreed that ‘quality of life in rural Financial and career incentives areas is good’, ‘living in a city is stressful’, and ‘social life in rural areas 30% salary increase + 29.55 70.45 is enjoyable’. Only 17% of nurses thought that ‘working in rural areas Faster promotion meant being without support from colleagues/supervisors’. However, in 45% salary increase + 44.95 55.05 agreement with their doctor colleagues they worried that ‘bringing up faster promotion children in rural areas is difficult’. 45% salary increase + 57.52 42.48 only 7 nights a months on call What incentives would encourage the doctors and nurses to 30% salary increase 47.90 52.10 work in rural areas? + faster promotion + specialty training Although the majority of doctors valued living and working in rural areas, quota their responses in the discrete choice experiment showed that only 20% 30% salary increase 51.84 48.16 would choose a rural post, see Table 1. The results show that a higher + workplace close to salary (45% increase for rural doctors), a workplace close to their hometown hometown, working in smaller hospitals, less overtime, and especially 30% salary increase 58.73 41.27 better opportunities for specialist training would be possible incentives to + workplace close to attract more doctors to rural posts. hometown + faster promotion In comparison, nurses were more attracted by rural posts in the current Financial and education incentives working conditions (45%), with nurses from rural areas and from the North- 30% salary increase 48.57 51.43 Eastern region more likely to choose rural posts, see Figure 1. Results reveal + specialty training that nurses were particularly sensitive to the type of facility they would quota be posted to in rural areas, with a very strong preference for hospitals 45% salary increase 64.77 35.23 over health centres. Results show there are several policy levers that could + specialty training be used by policy-makers to make rural posts more attractive to nurses. quota In particular, more nursing graduates would choose rural jobs if medical Note: The simulations are based on results obtained cover was extended to include their family members. from the Discrete Choice Experiment. Figure 1: Prediction of nurses’ job preferences under different policy simulations

% choosing rural posts % choosing urban posts 100 Single incentives Packages of incentives

0 e e g e t g n t

conditions rrent working Better housin Cu Faster promotion better housin 20% rural incentiv management styl faster promotio 20% salary increase20% + medical + benefi better managemen Medical benefit packag 20% + medical benefit + lational Re lational management style + Re

Note: The simulations are based on results obtained from the Discrete Choice Experiment.

Follow-up cohort Of 198 doctors at baseline, only 117 (59%) could Thai Government) only 15% of them intended to stay at be followed up. At follow-up the majority (91%) the same hospital, with 74% of them wishing to move remained working in rural hospitals. Only 4.5% and to obtain specialist training. Following completion of 4% had moved to urban hospitals and had enrolled compulsory public service, 3% indicated they would move for specialist training, respectively (1 doctor resigned to urban areas, while 8% said they would resign from the from their public hospital post). However, as many government sector altogether. Although there was some of the cohort members were compelled to provide indication that financial incentives could encourage them public services for 3 years, real choices to move post to stay longer in a rural posting, the majority confirmed were limited. their intention to seek specialist training, with only 17% indicating their intention to stay at a rural hospital over From the follow-up survey with doctors, 73 self- the next 2 years. administered questionnaires were completed for analysis. The analysis revealed that the majority of doctors One year following their graduation, 235 nurses could worked at smaller hospitals (79%), with approximately be followed-up and were asked about their actual half of them working in their home provinces. Almost workplace. 49% worked in rural settings and 51% worked 90% of doctors reported their overtime duty to be more in urban settings. Among the 51% who worked in urban than 8 days per month, with 82% stating that there was settings, 38% worked in public hospitals, 9% worked in no opportunity for specialist training. The majority of private hospitals, and 4% were not in direct nursing respondents (59%) stated that a case consultant was services. Analysis showed that there was a significant not present at their hospitals. When asked about association between intention to work in a rural area and their intention to stay in their rural posting (prior to a actual job of choice. Nurses who graduated from regional financial incentive package introduced in 2008 by the colleges were more likely than those who graduated from the capital, Bangkok, to choose a rural posting nurses to choose an urban area (25%). Other findings (58.1% compared to 20.7%). Nurses who had a rural revealed that college locations and positive attitude upbringing were more likely to choose a rural posting towards working in a rural area were significantly compared with nurses who had an urban upbringing associated with rural workplace choice. Those who (52.7% compared to 22.0%). Having a workplace close obtained scholarships tended to choose rural areas, to their hometown was a strong determining factor for although this was not statistically significantly.

CONCLUSION AND POLICY RECOMMENDATIONS

• This research provides evidence from Thailand about the challenges of recruiting and retaining doctors and nurses in rural posts, and the potential of a range of strategies to address this. Quantitative and qualitative data indicates that a number of strategies could work to improve rural recruitment and retention, with a particular emphasis on salary enhancements for doctors and increased family medical cover for nurses. • For doctors, the study showed that a 45% salary increase could be one of the most important factors to increase the uptake of rural posts. This finding has been corroborated by results from the follow-up cohort where the majority of doctors have remained in rural postings following a similar salary increase implemented by the government in 2008. However, other incentives could be used to secure long-term retention of doctors in rural areas. These include allowing doctors to be posted in hospitals that are located close to their hometowns and better opportunities for specialist training if they accept a rural post. In addition, smaller hospitals, fast-tracked promotion, case consultant provision and less overtime are also levers that policy-makers should consider. • Most nurses in this study came from rural areas and had a positive attitude towards working and living in rural setting. Despite this, significant numbers of nurses do not choose a rural job posting. Rural recruitment and retention of nurses could be increased if medical insurance coverage was extended to include their family members. This policy measure alone, our research shows, would be more efficacious than fast-tracked promotion, salary increases (of up to 20%) or more training opportunities; although these remain important incentives as part of an overall package. • The recruitment of student nurses from rural areas, who can access local training and be offered hometown job placements, in combination with financial and non-financial incentives, offers a good policy option for successful rural recruitment and retention.

RELATED PUBLICATIONS Blaauw D, Erasmus E, Pagaiya N, Tangcharoensathein V, Mullei K, Mudhune S, Goodman C, English M, Lagarde M. Policy interventions that attract nurses to rural areas: a multicounty discrete choice experiment. Bull World Health Organ. 2010 May;88(5):350-6. Mullei K, Mudhune S, Wafula J, Masamo E, English M, Goodman C, Lagarde M, Blaauw D. Attracting and retaining health workers in rural areas: investigating nurses’ views on rural posts and policy interventions. BMC Health Serv Res. 2010 Jul2;10 Suppl 1:S1.

This document is an output from a project funded by the UK Department for International Development (DFID) for the benefit of developing countries. The views expressed are not necessarily those of DFID.