Understanding Health Workers’ Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment

Abstract

BackgroundTimor-Leste built its health workforce up from extremely low levels after its war of independence, with the assistance of Cuban training, but faces challenges as the first cohorts of doctors will shortly be freed from their contracts with government. Retaining doctors, nurses and midwives in remote areas requires a good understanding of health worker preferences.MethodsThe article reports on a discrete choice experiment (DCE) carried out amongst 441 health workers, including 173 doctors, 150 nurses and 118 midwives. Qualitative methods were conducted during the design phase. The attributes which emerged were wages, skills upgrading/specialisation, location, working conditions, transportation and housing.FindingsOne of the main findings of the study is the relative lack of importance of wages for doctors, which could be linked to high intrinsic motivation, perceptions of having an already highly paid job (relative to local conditions), and/or being in a relatively early stage of their career for most respondents. Professional development provides the highest satisfaction with jobs, followed by the working conditions. Doctors with less experience, males and the unmarried are more flexible about location. For nurses and midwives, skill upgrading emerged as the most cost effective method.ConclusionsThe study is the first of its kind conducted in Timor-Leste. It provides policy-relevant information to balance financial and non-financial incentives for different cadres and profiles of staff. It also augments a thin literature on the preferences of working doctors (as opposed to medical students) in low and middle income countries and provides insights into the ability to instil motivation to work in rural areas, which may be influenced by rural recruitment and Cuban-style training, with its emphasis on community service.

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].…”

“…This is particularly true for medical and nursing students, who are often disappointed by the gap between what they have been taught to do, often based in a tertiary hospital infrastructure, and the availability of equipment in rural health facilities where they are expected to work after the graduation. These results are consistent with those from other DCEs [13,35,37,38,41]. Also, a review paper on health worker's motivation and retention indicates that the improvement of hospital infrastructure and resource available could increase retention [42].…”

“…Incentives to attract health workers to locate in disadvantaged areas have been well described by World Health Organization (WHO) including education interventions, regulatory interventions, financial incentives, personal and professional support [12]. WHO also proposed that countries need to identify the appropriate interventions that are suitable for their local context, given diverse health labor market and local demand [13]. Thus, the development of such strategies really needs a precise insight into job preferences of health workers in various counties.…”

Job preferences for medical students in China

“…[ 38 ] Studies from other countries have reported that the more centrally located the job, the more it will be preferred by health workers. [ 39 , 40 ] The relationship between geographical origin of students and their future choice of work, that is, whether medical students from rural areas will more likely to return to rural areas to practice, has been reviewed and discussed in Lehmann et al [ 38 ] Our study reveals that compared to students from rural areas, those from urban areas shown a much stronger preference to work in city rather than in county, or rural areas. Therefore, attracting and retaining students with a rural background for rural areas would be a more feasible strategy.…”

Application Of The Ultra-Poverty Graduation Model In Understanding Community Health Volunteers’ Preferences For Socio-Economic Empowerment Strategies: A Qualitative Study In Kilifi, Kenya

“…Performance of CHV programmes is measured by the sustenance of a high performance standard by assigned healthcare providers as well as the cost-effectiveness, impact and uptake of these programmes (8). This is capital intensive and several governments of LMICs struggle with creating a balance in implementation and sustainability of CHV programs(3)(18)(14) (19). In Kenya, CHVs are not government employees.…”