Delivering Effective Health Care for AllMonday 29th March, 2010
What policies would attract health professionals to rural areas? Evidence from South Africa, Thailand and Kenya
Duane BlaauwCentre for Health Policy, South Africa
Possible interventions to attract health workers to under-served areas?Selection Geographic origin
EthnicityGenderCareer intentionService orientation
Education Location of training collegesCurriculum contentRural exposureFellowships
Coercion Registration requirementSpecialisation requirementInternational recruitment
Incentives Bursaries & scholarshipsDirect financial incentives (rural allowance)
Support Professional supportPersonal support
Grobler et al (2009)
Evidence of policy effectiveness?•Cochrane review (2009) found no rigorous
controlled studies •Need more rigorous evaluations of impact•Methodological challenges▫RCTs may not be possible▫RCTs may not be sufficient
• Interim solutions?▫Longitudinal HR databases▫Modelling of stated preference data
Study methods
•Discrete choice experiment (DCE) with nursing graduates in South Africa, Thailand & Kenya
•DCE Design•DCE Analysis•Used statistical model to investigate:▫Rural uptake for different policy combinations▫Cost-effectiveness of different interventions
Which of these two public sector facilities would you choose to work in?
RURAL Facility URBAN Facility
Type of facility Hospital Clinic
Monthly salary R120,000 per year R120,000 per year
Rural allowance An additional R12,000 per year None
The number of years you would have to work before getting study leave to specialise
2 years 6 years
The housing provided None None
The number of years you would have to work before being eligible for promotion
2 years 2 years
The car allowance offered None None
The workplace culture and style of management This facility is formal and structured. The
managers emphasise stability, following rules, and keeping things running smoothly.
This facility is personal and supportive. The
managers emphasise teamwork, loyalty, and developing the full potential of staff.
Which facility would you choose? Rural Facility Urban Facility
Annual Salary
DCE designLabelled designTwo choices
6 different rural policy interventions
16 choice sets
Different country preferences
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
30%
rura
l allo
wan
ce
Pref
eren
tial t
rain
ing
30%
rura
l allo
wan
ce
0% 20% 40% 60% 80% 100%
16.9%
3.3%
15.2%
39.0%
5.8%
36.4%
8.1%
5.4%
6.5%
35.5%
1.2%
21.9%
8.6%
6.7%
17.0%
52.9%
87.5%
58.6%
75.0%
90.0%
79.8%
44.1%
89.6%
49.9%
71.5%
85.4%
65.3%
44.6%
90.9%
60.4%
% Choosing Rural Job
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
30%
rura
l allo
wan
ce
Pref
eren
tial t
rain
ing
30%
rura
l allo
wan
ce
0% 100%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
% Choosing Rural Job
Impact of single interventions
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
30%
rura
l allo
wan
ce
Non
-fina
ncia
l int
erve
ntio
nsAl
l int
erve
ntio
ns10
% ru
ral a
llow
ance
+ tr
aini
ng
0% 20% 40% 60% 80% 100%
39.0%
5.8%
36.4%
50.3%
13.9%
39.1%
59.2%
14.5%
51.7%
46.0%
3.3%
34.0%
75.0%
90.0%
79.8%
86.3%
98.1%
82.5%
95.2%
98.7%
95.1%
82.0%
87.5%
77.4%
% Choosing Rural Job
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
ZA
TH
KN
30%
rura
l allo
wan
ce
Non
-fina
ncia
l int
erve
ntio
nsAl
l int
erve
ntio
ns10
% ru
ral a
llow
ance
+ tr
aini
ng
0% 100%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
36.0%
84.2%
43.4%
% Choosing Rural Job
Impact of packages of interventions
Cost-effectiveness of interventions (ZA)
Policy Scenario Additional Effect(Rural Nurse Years)
Additional Cost(ZAR, R1=£11)
Cost-Effectiveness(ZAR / Rural Nurse Year)
Individual Interventions
Base scenario - - -
Promoted faster 64 46 124 497 720 695
Better housing 136 58 736 999 431 890
Car allowance 415 121 034 432 291 649
Earlier study leave 515 128 885 182 250 262
10% rural allowance (RA) 629 308 091 306 489 811
20% rural allowance 985 557 401 459 565 890
30% rural allowance 1 259 801 537 625 636 646
Packages of Interventions
Quick promotion + Car 461 166 454 292 361 072
Better housing + Car 625 201 971 262 323 154
Quick promotion + 20% RA 1 067 629 126 154 589 622
Earlier study leave + Car 1 362 393 988 330 289 272
10% Rural allowance + Car 1 390 546 995 962 393 522
Better housing + Car + 20% RA 2 273
1 036 555 469 456 030
Study leave soon + 10% RA + Car 2 445 954 698 686 390 470
Study leave soon + 20% RA 3 233
1 420 449 751 439 360
0 500 1,000 1,500 2,000 2,500 3,000R
R 200,000,000
R 400,000,000
R 600,000,000
R 800,000,000
R 1,000,000,000
R 1,200,000,000
R 1,400,000,000
Incremental number of rural nurse-year
Incr
e-
me
nta
l co
st
E1
E2
E4
E5
Early study leave + carICER: R 313,096
Early study leave + car + 10% rural allowanceICER: R 517,831
Early study leave + 20% rural allowanceICER: R 590,988
Early study leaveICER: R 250,065
MORE COST-EFFECTIVE
Incremental cost-effectiveness ratios
Base costICER: R 238,324
0 500 1,000 1,500 2,000 2,500 3,000R
R 200,000,000
R 400,000,000
R 600,000,000
R 800,000,000
R 1,000,000,000
R 1,200,000,000
R 1,400,000,000
Incremental number of rural nurse-year
Incr
e-
me
nta
l co
st
E1E1 (#3)
E2
E2 (#3)
E4
E5
E4 (#3)
E5 (#3)
Base (#3)
Original sample
Sample #3 (75% rural)
Base cost: R 213,170
ICER: R 252,608
ICER: R 318,519
ICER: R 558,983
Incremental cost-effectiveness ratios
ICER: R 590,988
Base costICER: R 238,324
Implications for policy and practice•Policymakers in LMICs should make more
use of modelling data to inform the design of HR policies.
•There are no generic HR solutions. HR policies need to be tailored to individual country contexts.
•A combination of financial and non-financial HR strategies is required.
•Non-financial interventions can be as effective as salary increases and are more cost-effective.
•Changing student selection is a very cost-effective strategy to increase health professionals in under-served areas.
Partners
Kenya Medical Research Institute, NairobiKethi Mullei, Sandra Mudhune, Jackie Wafula, Catherine Goodman, Mike English
Centre for Health Policy, JohannesburgDuane Blaauw, Ermin Erasmus
International Health Policy Program, BangkokNonglak Pagaiya, Thinakorn Noree, Viroj Tangcharoensathien
London School of Hygiene and Tropical MedicineMylene Lagarde