Addressing Health Workforce Distribution Concerns: A Discrete Choice Experiment to Develop Rural Retention Strategies in Cameroon

Document Type : Original Article


1 The World Bank, Cameroon Country Office, Yaoundé, Cameroon

2 World Health Organization, Geneva, Switzerland

3 Ministry of Public Health, Yaoundé, Cameroon

4 Institute for Survey and Statistical Analysis, Yaoundé, Cameroon


Nearly every nation in the world faces shortages of health workers in remote areas. Cameroon is no exception to this. The Ministry of Public Health (MoPH) is currently considering several rural retention strategies to motivate qualified health personnel to practice in remote rural areas.
To better calibrate these mechanisms and to develop evidence-based retention strategies that are attractive and motivating to health workers, a Discrete Choice Experiment (DCE) was conducted to examine what job attributes are most attractive and important to health workers when considering postings in remote areas. The study was carried out between July and August 2012 among 351 medical students, nursing students and health workers in Cameroon. Mixed logit models were used to analyze the data.
Among medical and nursing students a rural retention bonus of 75% of base salary (aOR= 8.27, 95% CI: 5.28-12.96, P< 0.001) and improved health facility infrastructure (aOR= 3.54, 95% CI: 2.73-4.58) respectively were the attributes with the largest effect sizes. Among medical doctors and nurse aides, a rural retention bonus of 75% of base salary was the attribute with the largest effect size (medical doctors aOR= 5.60, 95% CI: 4.12-7.61, P< 0.001; nurse aides aOR= 4.29, 95% CI: 3.11-5.93, P< 0.001). On the other hand, improved health facility infrastructure (aOR= 3.56, 95% CI: 2.75-4.60, P< 0.001), was the attribute with the largest effect size among the state registered nurses surveyed. Willingness-to-Pay (WTP) estimates were generated for each health worker cadre for all the attributes. Preference impact measurements were also estimated to identify combination of incentives that health workers would find most attractive.
Based on these findings, the study recommends the introduction of a system of substantial monetary bonuses for rural service along with ensuring adequate and functional equipment and uninterrupted supplies. By focusing on the analysis of locally relevant, actionable incentives, generated through the involvement of policymakers at the design stage, this study provides an example of research directly linked to policy action to address a vitally important issue in global health.


Main Subjects

  1. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder A, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004; 364: 900-6.
  2. Miller C, Holly L. Health workers and universal health coverage. Lancet 2012; 380: 1643. doi: 10.1016/S0140-6736(12)61939-4
  3. Jimba M, Cometto G, Yamamoto T, Shiao L, Huicho L, Sheikh M. Health workforce: the critical pathway to universal health coverage. In: World Health Organization, editor. First Global Symposium on Health Systems Research. Montreux, Switzerland: WHO; 2010.
  4. Anand S, Bärnighausen T. Human resources and health outcomes: cross-country econometric study. Lancet 2004; 364: 1603-9.
  5. Anand S, Bärnighausen T. Health workers and vaccination coverage in developing countries: an econometric analysis. Lancet 2007; 369: 1277-85. doi: 10.1016/S0140-6736(07)60599-6
  6. Rao K, Shroff Z, Ramani S, Khandpur N, Murthy S, Hazarika I, et al. How to Attract Health Workers to Rural Areas? Findings from A Discrete Choice Experiment From India. Washington, DC: The World Bank; 2012.
  7. Vujicic M, Alfano M, Shengelia B, Witter S. Attracting Doctors and Medical Students to Rural Vietnam: Insights from a Discrete Choice Experiment. Washington, DC: The World Bank; 2010.
  8. Bärnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: a systematic review. BMC Health Serv Res 2009; 9: 86. doi: 10.1186/1472-6963-9-86
  9. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Serv Res 2008; 8: 19. doi: 10.1186/1472-6963-8-19
  10. Franco L, Bennett S, Kanfer R. Health sector reform and public health worker motivation: a conceptual framework. Soc Sci Med 2002; 54: 1255-66.
  11. Blaauw D, Erasmus E, Pagaiya N, Tangcharoensathein V, Mullei K, Mudhune S, et al. Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bull World Health Organ 2010; 88: 350-6.
  12. Mathauer I, Imhoff I. Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Hum Resour Health 2006; 4: 24.
  13. Ministry of Public Health (MoPH). Cameroon Health Workforce Census, 2011. Cameroon: MoPH; 2012.
  14. The World Bank. Policy Brief: Improving the Governance of the Health system in Cameroon. Yaounde: The World Bank; 2013.
  15. Demographic and Health Survey (DHS). Cameroon Demographic and Health Survey-MICS 2012. Macro International, Inc.; 2012.
  16. Demographic and Health Survey (DHS). Cameroon Demographic and Health Survey 2004. Macro International, Inc.; 2004.
  17. Mba R, Messi F, Ongolo-Zogo P. Retaining Human Resources for Health in Remote Rural Areas in Cameroon. Policy Brief. Yaoundé: Centre for Development of Best Practices in Health; 2011.
  18. Lancsar E, Louviere J. Conducting discrete choice experiments to inform healthcare decision making: a user’s guide. Pharmacoeconomics 2008; 26: 661-77.
  19. Mangham LJ, Hanson K, McPake B. How to do (or not to do) ... Designing a discrete choice experiment for application in a low-income country. Health Policy Plan 2009; 24: 151-8. doi: 10.1093/heapol/czn047
  20. Kolstad J. How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania. Health Econ 2011; 20: 196-211. doi: 10.1002/hec.1581
  21. Mangham LJ, Hanson K. Employment preferences of public sector nurses in Malawi: results from a discrete choice experiment. Trop Med Int Health 2008; 13: 1433-41. doi: 10.1111/j.1365-3156.2008.02167.x
  22. Kruk ME, Johnson JC, Gyakobo M, Agyei-Baffour P, Asabir K, Kotha SR, et al. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ 2010; 88: 333-41. doi: 10.2471/BLT.09.072892
  23. Rockers PC, Jaskiewicz W, Wurts L, Kruk ME, Mgomella GS, Ntalazi F, et al. Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment. BMC Health Serv Res 2012; 12: 212. doi: 10.1186/1472-6963-12-212
  24. Rockers PC, Jaskiewicz W, Kruk ME, Phathammavong O, Vangkonevilay P, Paphassarang C, et al. Differences in preferences for rural job postings between nursing students and practicing nurses: evidence from a discrete choice experiment in Lao People’s Democratic Republic. Hum Resour Health 2013; 11: 22. doi: 10.1186/1478-4491-11-22
  25. Mandeville KL, Lagarde M, Hanson K. The use of discrete choice experiments to inform health workforce policy: a systematic review. BMC Health Serv Res 2014; 14: 367. doi: 10.1186/1472-6963-14-367
  26. Araújo E, Maeda A. How to Recruit and Retain Health Workers in Rural and Remote Areas in Developing Countries: A Guidance Note. Washington, DC: The World Bank; 2013.
  27. Choice Metrics. Ngene Software. 2012 [cited 2012 June 10].Available from:
  28. Street DJ, Burgess L, Louviere JJ. Quick and easy choice sets: constructing optimal and nearly optimal stated choice experiments. International Journal of Research in Marketing 2005; 22: 459-470.
  29. Jaskiewicz W, Deussom R, Wurts L, Mgomella G. Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers. Washington, DC: CapacityPlus; 2012.
  30. Lancsar E, Louviere J, Flynn T. Several methods to investigate relative attribute impact in stated preference experiments. Soc Sci Med 2007; 64: 1738-53.