International Journal of Health Policy and Management

International Journal of Health Policy and Management

Cost-Effectiveness of Rural Incentive Packages for Graduating Medical Students in Lao PDR

Document Type : Original Article

Authors
Eric Keuffel 1
Wanda Jaskiewicz 2
Khampasong Theppanya 3
Kate Tulenko 2
1 Health Finance & Access Initiative, Bryn Mawr, PA, USA
2 IntraHealth International, Washington, DC, USA
3 Ministry of Health (Lao PDR), Vientiane, Lao PDR
10.15171/ijhpm.2016.141
Abstract
Background
The dearth of health workers in rural settings in Lao People’s Democratic Republic (PDR) and other developing countries limits healthcare access and outcomes. In evaluating non-wage financial incentive packages as a potential policy option to attract health workers to rural settings, understanding the expected costs and effects of the various programs ex antecan assist policy-makers in selecting the optimal incentive package.
 
Methods
We use discrete choice experiments (DCEs), costing analyses and recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the costeffectiveness of 15 voluntary incentives packages for new physicians in Lao PDR. Our data sources include a DCE survey completed by medical students (n = 329) in May 2011 and secondary cost, economic and health data. Mixed logit regressions provide the basis for estimating how each incentive package influences rural versus urban location choice over time. We estimate the expected rural density of physicians and the cost-effectiveness of 15 separate incentive packages from a societal perspective. In order to generate the cost-effectiveness ratios we relied on the rural uptake probabilities inferred from the DCEs, the costing data and prior World Health Organization (WHO) estimates that relate health outcomes to health worker density.
 
Results
Relative to no program, the optimal voluntary incentive package would increase rural physician density by 15% by 2016 and 65% by 2041. After incorporating anticipated health effects, seven (three) of the 15 incentive packages have anticipated average cost-effectiveness ratio less than the WHO threshold (three times gross domestic product [GDP] per capita) over a 5-year (30 year) period. The optimal package’s incremental cost-effectiveness ratio is $1454/QALY (quality-adjusted life year) over 5 years and $2380/QALY over 30 years. Capital intensive components, such as housing or facility improvement, are not efficient.
 
Conclusion
Conditional on using voluntary incentives, Lao PDR should emphasize non-capital intensive options such as advanced career promotion, transport subsidies and housing allowances to improve physician distribution and rural health outcomes in a cost-effective manner. Other countries considering voluntary incentive programs can implement health worker/trainee DCEs and costing surveys to determine which incentive bundles improve rural uptake most efficiently but should be aware of methodological caveats.

Highlights

 

 

Watch the Video Summary here. 

 

Keywords
Health Workers (Rural)
Health Economics (Cost-Effectiveness Analysis)
Discrete Choice Experiment (DCE)
Subjects

Supplementary File 1 (Download)

 

 

 

  1. The State of the Health Workforce in Sub-Saharan Africa: Evidence of Crisis and Analysis of Contributing Factors. Washington DC: World Bank; 2004.
  2. Working Together for Health: The World Health Report 2006. Geneva: World Health Organization; 2006.
  3. Second Global Forum on Human Resources for Health (Global Health Workforce Alliance). Bangkok, Thailand; 2011.
  4. Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis. Lancet. 2004;364(9449):1984-1990. doi:10.1016/s0140-6736(04)17482-5
  5. Crisp N, Gawanas B, Sharp I. Training the health workforce: scaling up, saving lives. Lancet. 2008;371(9613):689-691. doi:10.1016/s0140-6736(08)60309-8
  6. Scaling Up, Saving Lives: Task Force for Scaling Up Education and Training for Health Workers. Geneva: World Health Organization, Alliance GHW; 2008.
  7. Scheffler RM, Liu JX, Kinfu Y, Dal Poz MR. Forecasting the global shortage of physicians: an economic-and needs-based approach. Bull World Health Organ. 2008;86:516-523. doi:10.2139/ssrn.945846
  8. Scheffler RM, Mahoney CB, Fulton BD, Dal Poz MR, Preker AS. Estimates of health care professional shortages in sub-Saharan Africa by 2015. Health Aff. 2009;28(5):w849-w862. doi:10.1377/hlthaff.28.5.w849.
  9. Kuehn BM. Global shortage of health workers, brain drain stress developing countries. JAMA. 2007;298(16):1853-1855. doi:10.1001/jama.298.16.1853
  10. Anyangwe SC, Mtonga C. Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa. Int J Environ Res Public Health. 2007;4(2):93-100. doi:10.3390/ijerph2007040002
  11. Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88(5):379-385. doi:10.2471/blt.09.070607
  12. Dolea C, Stormont L, Shaw D, Zurn P, Braichet J, eds. Increasing access to health workers in remote and rural areas through improved retention. Geneva: World Health Organization; 2009.
  13. Henderson LN, Tulloch J. Incentives for retaining and motivating health workers in Pacific and Asian countries. Hum Resour Health. 2008;6:18. doi:10.1186/1478-4491-6-18
  14. Martineau T. Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health. 2003;1:10. doi:10.1186/1478-4491-1-10
  15. 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. doi:10.1186/1478-4491-4-24
  16. Jaskiewicz W, Phathammmavong O, Vangkonevilay P, Paphassarang C, Phachanh IT, Wurts L. Toward Development of a Rural Retention Strategy in Lao People's Democratic Republic: Understanding Health Worker Preferences. Washington DC: CapacityPlus; 2012.
  17. Rockers PC, Jaskiewicz W. Wurts L. Mgomella G. Determining Priority Retention Packages to Attract and Retain Health Workers in Rural and Remote Areas in Uganda. Washington DC: CapacityPlus; 2011.
  18. 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
  19. de Bekker-Grob EW, Ryan M, Gerard K. Discrete choice experiments in health economics: a review of the literature. Health Econ. 2012;21(2):145-172. doi:10.1002/hec.1697
  20. Train K. Discrete Choice Methods With Simulation. Cambridge, UK: Cambridge University Press; 2009.
  21. Train K, Weeks M. Discrete Choice Models in Preference Space and Willingness-to-Pay Space. Springer; 2005.
  22. Kolstad JR. How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania. Health Econ. 2011;20(2):196-211. doi:10.1002/hec.1581
  23. Kruk ME, Johnson JC, Gyakobo M, et al. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ. 2010;88(5):333-341. doi:10.2471/blt.09.072892
  24. Vujicic M, Alfano M, Shengalia B, Witter S. Attracting Doctors and Medical Students to Rural Vietnam: Insights from a Discrete Choice Experiment.  World Bank Health and Nutrition Policy (HNP) Discussion Paper. Washington DC; 2010.
  25. Vujicic M, Shengelia B, Alfano M, Thu HB. Physician shortages in rural Vietnam: Using a labor market approach to inform policy. Soc Sci Med. 2011;73(7):970-977. doi:10.1016/j.socscimed.2011.06.010
  26. Telser H, Zweifel P. Validity of discrete-choice experiments: evidence for health risk reduction. Appl Econ. 2007;39(1):69-78.
  27. Rockers PC, Jaskiewicz W, Wurts L, et al. Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment. BMC Health Serv Res. 2012;12(1):212. doi:10.1186/1472-6963-12-212
  28. Araújo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries: a guidance note. World Bank; 2013.
  29. 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
  30. Rao KD, ed. How to attract health workers to rural areas? Findings from a Discrete Choice Experiment in India. BMC Proc. 2012;6(suppl 5):O1. doi:10.1186/1753-6561-6-s5-o1
  31. Robyn PJ, Shroff Z, Zang OR, et al. Addressing health workforce distribution concerns: a discrete choice experiment to develop rural retention strategies in Cameroon. Int J Health Policy Manag. 2015;4(3):169-180. doi:10.15171/ijhpm.2015.27
  32. Vujicic M, Alfano M, Shengelia B, Witter S. Attracting doctors and medical students to rural Vietnam: insights from a discrete choice experiment. World Bank; 010.
  33. Lagarde M, Blaauw D, Cairns J. Cost-effectiveness analysis of human resources policy interventions to address the shortage of nurses in rural South Africa. Soc Sci Med. 2012;75(5):801-806. doi:10.1016/j.socscimed.2012.05.005
  34. Lagarde M, Cairns J. Modelling human resources policies with Markov models: an illustration with the South African nursing labour market. Health Care Manag Sci. 2012;15(3):270-282. doi:10.1007/s10729-011-9184-5
  35. World Development Indicators [database on the Internet]. World Bank website. 2016. http://data.worldbank.org/products/wdi. Accessed March 7, 2016. Published 2016.
  36. World Health Organization (WHO). Health Service Delivery Profile: Lao PDR. WHO; 2012.
  37. World Urbanization Prospects, the 2011 Revision [database on the Internet]. United Nations (Department of Economic and Social Affairs, Population Division) website. http://www.un.org/en/development/desa/publications/world-urbanization-prospects-the-2011-revision.html. Accessed July 17, 2013. Published 2011.
  38. Laos Country Health Profile. World Health Organization; 2012.
  39. Speybroeck N, Kinfu Y, Dal Poz MR, Evans DB. Reassessing the relationship between human resources for health, intervention coverage and health outcomes. Background paper prepared for The world health report. Published 2006.
  40. Country Health Report (Laos) [database on the Internet]. World Health Organization; 2012.
  41. Jaskiewicz W, Deussom R, Wurts L, Mgomella G. Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers. Washington, DC: CapacityPlus; 2012.
  42. World Directory of Medical Schools website. World Federation for Medical Education and Foundation for Advancement of International Medical Education and Research (FAIMER). http://www.wdoms.org. Accessed June 15, 2015. Published 2015.
  43. Ryan M, Gerard K, Amaya-Amaya M. Using Discrete Choice Experiments to Value Health and Health Care. Netherlands: Springer Science & Business Media; 2007.
  44. Hole AR. A Comparison of approaches to estimating confidence intervals for willingness to pay measures. Health Econ. 2007;16(8):827-840. doi:10.1002/hec.1197
  45. Bhutta ZA, Chen L, Cohen J, et al. Education of health professionals for the 21st century: a global independent Commission. Lancet. 2010;375(9721):1137. doi:10.1016/s0140-6736(10)60450-3
  46. Stern DT, Wojtczak A, Schwarz MR, et al. Commissioned papers for education of health professionals for the 21st century: a Global Independent Commission. 2010.
  47. Jaskiewicz W, Duessom R, Wurts L, Mgomella G. Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers. Washington, DC: CapacityPlus; 2012.
  48. Ryan M, J. Kolstad, P.C. Rockers, C. Dolea. How to Conduct a Discrete Choice Experiment for Health Workforce Recruitment and Retention in Remote and Rural Area: A User's Guide for Policy Makers and Researchers. Geneva: World Health Organization; 2011.
  49. Chee GP, Vanakanevilav P, Phachanh IT. Costing of Incentives to Attract and Retain Rural Health Workers in Lao PDR. Washington DC: CapacityPlus; 2012.
  50. Claxton K, Soares M, Rice N, et al. Methods for the Estimation of the NICE Cost Effectiveness Threshold. York, UK: University of York, Centre for Health Economics; 2013.
  51. Drummond MF, Sculpher MJ, Torrance GW, O'brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2005.
  52. Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
  53. Rockers PC, Jaskiewicz W, Kruk ME, 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.
International Journal of Health Policy and Management
Volume 6, Issue 7
2017
Pages 383-394

  • Received Date 09 February 2016
  • Revised Date 17 October 2016
  • Accepted Date 17 October 2016
  • First Published Date 01 July 2017
  • Published Date 01 July 2017