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

An adequate health workforce is critical to the delivery of health services. With approximately 61% of Zambia’s population living in rural areas [1], ensuring access to services in rural areas is central to achieving national health goals. Zambia suffers from a national human resources for health (HRH) shortage, with 11.2 doctors, nurses, and midwives per 10 000 persons, which is well below the WHO minimum recommended threshold of 22.8 doctors, nurses, and midwives per 10 000 persons [2]. As of 2017, approximately 10% of Zambia’s health workforce was lost each year to attrition [3]. Although there has been an overall increase in the number of clinical health workers since 2008, shortages remain highest in rural areas. While the majority of Zambia’s population live in rural areas, the total number of doctors, nurses, and midwives in rural areas stands at 7677 compared to 9285 in urban areas [2]. An analysis of the workforce in 2016 showed that 45% of doctors, clinical officers, nurses, and midwives were working in rural areas [2].

In 2003, the Ministry of Health (MOH) launched the Zambian Health Workers Retention Scheme (ZHWRS) pilot program to attract and retain medical doctors in rural and remote areas of the country. The scheme was expanded in 2007 to include environmental health technicians, nurses, medical teaching staff, medical consultants, medical licentiates, and clinical officers. The ZHWRS ranks districts by level of remoteness and offers various benefits to health worker in each district, such as hardship allowances, housing rehabilitation funds, vehicle loans, utility equipment (solar panels or a bore hole), radio equipment, and professional development priority [4]. Evaluations of the ZHWRS have suggested that the policy has had limited effectiveness and that none of the included incentives are significantly associated with higher retention in rural areas [5‐7]. In response, the MOH developed the ZHWRS Sustainability Strategy (ZHWRS-SS) in 2014. The ZHWRS-SS called for an effectiveness evaluation and cost-benefit analysis of other potential non-monetary incentives in order to inform the selection of sustainable incentives that could replace those included in the ZHWRS.

The aim of this study was to identify policy-applicable strategies that are most likely to attract and retain health workers in rural areas of Zambia, and to examine the relative costs and benefits of the strategies. A multi-country study in South Africa, Kenya, and Thailand found that nurses’ preferences varied significantly across countries and recommended that intervention packages should be tailored to local conditions [8]. So while MOH policymakers in Zambia could gain general information from the global evidence base, data emerging from their specific context was critical. Furthermore, few past studies have rigorously examined the costs of proposed incentives and considered health worker preferences in light of costs per health worker year worked.

This study adopted a discrete choice experiment (DCE) design. In recent years, DCEs have emerged as an important tool for examining the potential effects of HRH interventions by understanding the preferences of health workers and the probability of uptake of defined jobs [9, 10]. Previous research has highlighted several key types of strategies or incentives for attracting and retaining health workers in rural areas [11‐13], including educational opportunities, financial incentives, professional support and recognition, improved living conditions and personal transportation, regulatory policy change, and improved facility conditions. The details of these packages are, however, contextually dependent on the status quo, health worker preferences, and political and financial feasibility.

This study was approached through two phases: development of a DCE questionnaire based on interviews with health workers, focus group discussions (FGDs) with students, and government consultations, and execution and analysis of a DCE questionnaire to elicit information on preferences for attribute packages from practicing health workers and health professional students.

Data was collected from 474 participants, including 259 (54.6%) active health workers (sampled from health facilities and regional in-service training) and 215 (45.4%) students (sampled from five training institutions). Table 2 presents the demographic characteristics of the participants. The sample is balanced across key demographic characteristics, and cadres are represented in a way that is roughly proportionate to their size within the national health workforce (see table notes).

The results of this study indicate that superior housing and education incentives in the form of a full scholarship for education are most likely to influence health worker job preferences. Additionally, improvements to facility quality and working environment can support health worker attraction and retention in rural areas. Against the backdrop of Zambia’s rural health workforce shortages, our findings provide evidence to enable retention policies to be shaped around health worker preference. Indeed, these results were considered for and incorporated into the prioritization of retention approaches in the 2018–2024 Zambia Human Resources for Health Strategic Plan [3].

While many DCEs have included some form of housing incentive, a limited number of DCEs have explored superior housing as an offering in comparison to basic housing. These studies did not find superior housing to be a highly influential attribute, though the definition of superior housing varies across studies [8, 20]. Still, in Zambia, superior housing was found to be extremely influential in health worker choices, with an effect estimate that was substantially higher than that of any other attribute, possibly pointing to differences in the local context and typical conditions confronted by health workers in Zambia. As with all potential strategies, the impact should be measured against the costs. When costs are considered on a per health worker year basis and relative to the percentage point increase in job uptake, housing is a cost-effective investment.

This study explored several dimensions of education incentives, including whether a scholarship was offered at all, whether the scholarship was guaranteed, and service time before receiving study leave. These results indicated that health workers are willing to delay study leave if some level of scholarship is offered and have a preference for waiting longer if the scholarship is guaranteed. The costing component of this study showed that the most significant costs associated with study leave are those required to pay salary and basic allowance while health workers are in school, rather than the scholarship itself. When study leave is delayed and those salary costs are distributed over a larger number of working years, costs are offset. As a result, delayed education incentives may offer substantial benefit at relatively low cost. When assessing the appropriateness and feasibility of educational incentives, it is also important to consider the demand for health workers with various levels of credentials. Based on the preferences of health workers, the cost of education, and the skills mix needed in Zambia, education incentives should be considered for a limited number of hard-to-fill positions, but should not be offered widely to all health workers in rural areas.

Enhancements to the facility can lead to important improvements in the quality of services offered to patients. Facility conditions are basic in most rural facilities in Zambia, so the base attribute level was designed to reflect this current reality, with higher-level attributes representing potential investments that could be made to enhance facility quality. Taken individually, facility-based improvements in working environment for health workers, in the form of transport for facility use or improved medical equipment, had limited impact on the job preferences of health workers in this study. However, other research suggests that a bundle of improvements to address multiple needs of health workers, including housing, educational opportunities, and improved working environment, are most likely to be effective in retaining health workers in the long term [21]. This study found that implementing multiple types of facility improvements together could have a larger influence on health worker preferences, and this impact can be increased by including housing and/or education incentives. The idea of facility bundles is in line with the policy direction of the ZHWRS Sustainability Strategy (ZHWRS-SS), which recommended investing in facility-based incentives over individual incentives. Beyond potential health worker recruitment and retention benefits, facility-level improvements are likely to have important and direct impacts on the accessibility and quality of patient care, but these benefits are not measured in this study. Although many health worker retention schemes internationally, including the ZHWRS in Zambia, have focused on the provision of financial incentives for rural service, results from this study indicate that non-monetary incentives such as education and housing benefits have more impact on health worker preferences than rural salary allowances. This is consistent with the results from other research, which indicates that increased salaries alone are not necessarily a sufficient tool for addressing poor retention and health worker motivation. For example, two studies in South Africa have demonstrated that higher salaries alone were not cost-effective in attracting health professionals to rural areas [22, 23] and other DCE studies have indicated that salary was not the most influential of job attributes [18]. Another analysis using data from multiple African countries found that wage differentials were not a major factor influencing health worker migration [24].

Although this study can offer valuable insights into the job preferences of health workers, several limitations should be considered. First, no questionnaire, including a DCE, can capture the full complexity of real-life choices. For example, reference to a “rural” job may invoke a range of different assumptions for various individuals, and other characteristics that are not addressed in this questionnaire, such as language or distance to one’s family home, may play a role in decision. Second, the sample for this DCE was selected using both convenient and purposeful sampling strategies and may not be representative of the national workforce in some ways. The sampling strategy aimed to and provided a sample that reflects the national workforce in several key demographic ways, such as in the cadre breakdown, and includes health workers from a wide range of geographic regions. Third, the DCE questionnaire included 10 possible incentives which were deemed administratively and financially feasible by policymakers in Zambia, but it is possible that other incentives or job characteristics not included here could have influence on health worker job preference. However, the purpose of the qualitative assessment and stakeholder consultations was to ensure that the DCE included the incentives most likely to be influential and feasible to implement. Fourth, this study was meant to examine the role of specific job characteristics in attracting and retaining health workers in rural service, but we are not able to differentiate the impact of job attributes at various time points in a health worker’s career. From a policy standpoint, the government is unlikely to offer different incentives to existing and new employees, so we opted for an approach that included current health workers and new graduates in the sample and where the survey was framed such that participants were asked to consider which job they would be more likely to choose and stay in. Finally, 16% of the participants in this study expressed a dominant preference for jobs with one characteristic. While the responses of these individuals were internally consistent with their responses to background questions, it was necessary to remove these individuals from the analysis because their responses violate model assumptions. Accordingly, our results represent the preferences of the 84% of participants that were willing to trade off between attributes or incentives. The preferences of other 16% of the participants are unlikely to be influenced by incentives provided.

This study focused on strategies that were feasible to be offered by the MOH. However, many factors well beyond the scope of the MOH will influence the quality of life of that health worker and his or her family, such as the job opportunities for spouses, reliability of public utilities, commercial life of the area, quality of the schools for dependents, and the quality of road networks. Therefore, rural development will require an effort from many governmental sectors. The MOH should explore opportunities to partner with other ministries that may be experiencing similar rural retention challenges, such as the Ministry of Education, in order to identify areas for collaboration.

There is an urgent need for new strategies to improve rural health worker attraction and retention in rural Zambia to address Zambia’s rural health workforce shortages. This study provides valuable evidence on the policy interventions that are most likely to be effective, relative to the cost of the investment. It builds on previous research which found that the salary incentives offered under the previous ZHWRS were not effective in improving health workers’ job satisfaction, likelihood of leaving, or frequency of considering leaving [7]. This study investigated a different set of interventions, developed and prioritized through qualitative research with health workers and students. The results indicate that housing incentives and educational scholarships for rural health workers are likely to be most effective in strengthening the rural health workforce, and based on an analysis of the costs of these incentives, housing incentives offer the best value for money. This study provides policymakers in Zambia with practical information that can be used to inform decisions about how to invest in strengthening the rural health workforce. Beyond Zambia, these results can inform policy discussions, though context-specific information is likely to be needed in other countries. Our approach to costing of incentives represents a unique view not taken in other published literature and could inform the methodology for studies in other locations.