Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment

Abstract

Background Workforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia. Methods The study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job “choice sets,” was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked. Results Although health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11–1.75), employment incentives influenced health workers’ decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12–6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake. Conclusions Non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas. Electronic supplementary material The online version of this article (10.1186/s12960-019-0359-3) contains supplementary material, which is available to authorized users.

Job preferences of medical and nursing students seeking employment in rural China: a discrete choice experiment

“…From a policy makers’ perspective, future programs should focus on not only non–financial strategies like educational opportunities or adequate equipment but also financial incentives. In contrast to several studies that determined that financial incentives were not the most powerful policy levers to attract medical students to rural locations [ 12 , 25 , 27 , 30 , 32 , 35 , 37 , 46 ], our findings, along with other studies [ 9 , 36 , 47 ],suggesting that monthly income had a significant impact on job choices.…”

A Discrete Choice Experiment on Factors Influencing Attrition and Motivation of Frontline Health Workers in Remote and Rural Areas in Nigeria

“…Even though that the geography and settings may differ, this supports the notion that improving the quality of the facility and providing incentives like housing are likely to improve client satisfaction in these settings. Our ndings were corroborated by DCE studies conducted amongst health care workers which identi ed the provision of basic government housing as having the greatest impact on the probability of choosing a job [19,31]. Also, a study amongst healthcare students identi ed improved facility infrastructure as important attributes to health worker retention [21,26].…”

“…Our study had some limitations. DCEs are known to suffer from limitations of offering hypothetical preferences that may not be correlated with real-life options [20,31]. In generating the job attributes and its dimensions, we ensured that it was informed by the qualitative perspectives of the study participants and a literature review.…”

Job preferences for medical and nursing students to work in rural Guizhou Province, China: a discrete choice experiment

“…Unlike several studies showing that financial incentives were not found to be most powerful policy levers [13,26,28,31,33,36,38,44]. However, our findings conformed that monthly income had a significant impact on the job choices of undergraduate health students, similar with other studies [10,37,45].…”