Elsevier

Social Science & Medicine

Volume 96, November 2013, Pages 33-44
Social Science & Medicine

Getting doctors into the bush: General Practitioners' preferences for rural location

https://doi.org/10.1016/j.socscimed.2013.07.002Get rights and content

Highlights

  • The aim of this study is to examine the preferences of general practitioners (GPs) for rural location.

  • The probabilities of moving, and the size of financial incentives GPs would require to move to a rural area, are estimated.

  • Sixty five per cent of GPs chose to stay where they were in all choices presented to them.

  • For attractive jobs in rural towns, GPs would be willing to forgo 8.6% ($16,000) of annual personal earnings to work there.

  • For the least attractive rural job, GPs would require incentives of at least 130% ($237,000) of personal earnings.

Abstract

A key policy issue in many countries is the maldistribution of doctors across geographic areas, which has important effects on equity of access and health care costs. Many government programs and incentive schemes have been established to encourage doctors to practise in rural areas. However, there is little robust evidence of the effectiveness of such incentive schemes. The aim of this study is to examine the preferences of general practitioners (GPs) for rural location using a discrete choice experiment. This is used to estimate the probabilities of moving to a rural area, and the size of financial incentives GPs would require to move there. GPs were asked to choose between two job options or to stay at their current job as part of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. 3727 GPs completed the experiment. Sixty five per cent of GPs chose to stay where they were in all choices presented to them. Moving to an inland town with less than 5000 population and reasonable levels of other job characteristics would require incentives equivalent to 64% of current average annual personal earnings ($116,000). Moving to a town with a population between 5000 and 20,000 people would require incentives of at least 37% of current annual earnings, around $68,000. The size of incentives depends not only on the area but also on the characteristics of the job. The least attractive rural job package would require incentives of at least 130% of annual earnings, around $237,000. It is important to begin to tailor incentive packages to the characteristics of jobs and of rural areas.

Introduction

A key issue in many countries is shortages of primary care physicians in rural and remote areas (Lawn et al., 2008, Starfield et al., 2005). Even if a country is thought to have ‘enough’ doctors overall, they may not be distributed across geographical areas according to health care need. Despite its importance, the delivery of equitable access to medical care is particularly difficult in rural and remote areas, and innovative solutions are often required. Many countries, and Australia is no exception, have a range of policies and schemes to encourage doctors to locate and practise, even if temporarily, in underserved remote and rural areas. These include financial or in-kind incentives, bonded schemes, and a range of other regulatory approaches.

Despite a considerable literature identifying factors that influence the recruitment and retention of doctors in remote and rural areas, to date there exists little rigorous evidence about which incentive schemes or policies are the most effective in increasing the supply of doctors to ‘underserved’ areas, and more specifically the amount of incentive required to encourage enough doctors to move (Barnighausen and Bloom, 2009, Buykx et al., 2010, Grobler et al., 2009). These reviews found very weak evidence of effectiveness with many poor study designs.

Designing schemes to encourage doctors to locate and remain in remote and rural areas requires an understanding of the various factors that motivate doctors' location decisions. In the absence of data on revealed preferences, discrete choice experiments (DCEs) are increasingly being used to address these issues. There have been eight DCEs published examining the job preferences of doctors (Chomitz et al., 1998, Gosden et al., 2000, Hanson and Jack, 2010, Hole and Kolstad, 2010, Kolstad, 2011, Scott, 2001, Ubach et al., 2003, Wordsworth et al., 2004). Three of these were for general practitioners (GPs) (Gosden et al., 2000, Scott, 2001, Wordsworth et al., 2004), although none included geographic location as a specific attribute. Other studies for junior doctors and nurses in developing countries have focussed largely on rural location (Chomitz et al., 1998, Hanson and Jack, 2010, Hole and Kolstad, 2010, Kolstad, 2011).

The aim of this paper is to examine the preferences of GPs for the characteristics of rural practice using a discrete choice experiment. This focuses on the decision to choose between jobs that include geographic location as an attribute. The DCE results are used to examine which attributes of rural jobs are valued the most (and least) by GPs, providing information on where policies should be focused. The probabilities of choosing a range of different rural jobs are also calculated, along with the monetary value (marginal willingness to pay or compensating differentials) of particular attributes. In addition, the paper contributes to the literature on doctors' job preferences in several ways. First, it estimates the total monetary value of different rural job packages (total willingness to pay). The monetary values are expressed in terms of the size of financial incentives that should be offered to encourage GPs to move to a rural area. Second, the DCE includes a ‘status quo’ option, which is more realistic for respondents. In addition to offering GPs a choice of job A and B, they are offered the option of staying at their current job, whereas most previous published studies have asked respondents to make a ‘forced’ choice between two types of job (Lagarde & Blaauw, 2009). Finally, the study uses the generalised multinomial logit model that accounts for scale as well as taste heterogeneity (Fiebig, Keane, Louviere & Wasi, 2010).

Section snippets

The Australian context

GPs in Australia are paid largely by fee-for-service, under the Medicare Benefits Schedule (MBS). In rural and remote areas with small populations, additional payments and different funding models are used to support GPs' small business viability and encourage GPs to work and stay in these areas. In Australia, the number of medical practitioners relative to the overall population is 235/100,000 (Australian Institute of Health and Welfare, 2012). However, this number diminishes significantly

Data

The discrete choice experiment (DCE) was included in Wave 1 (2008) of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The survey was sent to the population of 54,750 doctors undertaking clinical practice in Australia, including 22,137 GPs. The overall response rate for MABEL was 19.3% (10,498/54,750). Respondents were broadly representative of the population in terms of age, gender, doctor type, geographic location, and hours worked. Detailed

Analysis

A generalised mixed logit model (further details of the econometric modelling are shown in Appendix B) was used to calculate:

  • i)

    the probability of choosing a range of different rural alternatives,

  • ii)

    the size of the monetary incentive package required to compensate a GP who decides to move to a rural area: total willingness to pay (TWTP), and

  • iii)

    the size of the compensating differential for a change in the level of a single attribute: marginal willingness to pay (MWTP).

In order to quantify (i) and (ii),

Results

The response rate for GPs was 17.65% (3873/22,137) with a 99.3% contact rate, and with 25.4% filling out the questionnaire online. The final numbers of GPs who completed at least part of the DCE was 3727. These were broadly representative of all Australian GPs in terms of age, gender, geographic location, and hours worked (Joyce, et al., 2010).

Table 2 shows the number of times each alternative was chosen (out of 3727 × 9 choice sets = 33,543 choice sets across all respondents), and shows that

Discussion

The paucity of evidence on how incentive policies influence doctors' decisions to work in remote and rural areas is cause for concern. In the absence of any well-designed studies using revealed preference data, we conducted a discrete choice experiment among 3727 general practitioners in Australia to provide a better understanding of GPs' preferences for different job attributes and locations. Respondents were given nine choice sets in each of which they had to choose between two hypothetical

Acknowledgements

This work was supported by a National Health and Medical Research Council Health Services Research Grant (454799) and the Commonwealth Department of Health and Ageing. The views in this paper are those of the authors alone. We thank the doctors who gave their valuable time to participate in MABEL, and the other members of the MABEL team for data cleaning and comments on drafts of this paper.

References (46)

  • J.E. Lawn et al.

    Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise

    Lancet

    (2008)
  • A. Scott

    Eliciting GPs' preferences for pecuniary and non-pecuniary job characteristics

    Journal of Health Economics

    (2001)
  • AIHW

    Health expenditure Australia 2009–10

    (2011)
  • Auditor General

    Rural and remote health workforce capacity – The contribution made by programs administered by the Department of Health and Ageing

    (2008)
  • Australian Bureau of Statistics

    Private medical practitioners

    (2002)
  • Australian Institute of Health and Welfare

    Health in rural and remote Australia

    (1998)
  • Australian Institute of Health and Welfare

    Medical labour force 2003

    (2005)
  • Australian Institute of Health and Welfare

    Medical labour force 2010

    (2012)
  • T. Barnighausen et al.

    Financial incentives for return of service in underserved areas: a systematic review

    BMC Health Services Research

    (2009)
  • M. Bech et al.

    Effects coding in discrete choice experiments

    Health Economics

    (2005)
  • H. Britt et al.

    Determinants of GP billing in Australia: content and time

    Medical Journal of Australia

    (2004)
  • P. Buykx et al.

    Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy

    The Australian Journal Of Rural Health

    (2010)
  • J. Charles et al.

    The evolution of the general practice workforce in Australia, 1991-2003

    Medical Journal of Australia

    (2004)
  • T.C. Cheng et al.

    What factors influence the earnings of general practitioners and specialists? Evidence from the medicine in Australia: balancing employment and life survey

    Health Economics

    (2012)
  • K. Chomitz et al.

    What do doctors want? Developing incentives for doctors to serve in Indonesia's rural and remote areas

    (1998)
  • Department of Health and Ageing
  • D.G. Fiebig et al.

    The generalized multinomial logit model: accounting for scale and coefficient heterogeneity

    Marketing Science

    (2010)
  • T. Gosden et al.

    How do general practitioners choose their practice? Preferences for practice and job characteristics

    Journal of Health Services Research and Policy

    (2000)
  • L. Grobler et al.

    Interventions for increasing the proportion of health professionals practising in rural and other underserved areas

    Cochrane Database of Systematic Reviews

    (2009)
  • C. Hancock et al.

    Why doctors choose small towns: a developmental model of rural physician recruitment and retention

    Social Science & Medicine

    (2009)
  • K. Hanson et al.

    Incentives could induce Ethiopian doctors and nurses to work in rural settings

    Health Affairs

    (2010)
  • R. Hays et al.

    Getting the balance right? GPs who chose to stay in rural practice

    Australian Journal of Rural Health

    (2003)
  • P. Heiligers et al.

    Career preferences and the work-family balance in medicine: gender differences among medical specialists

    Social Science & Medicine

    (2000)
  • Cited by (65)

    • Training and retention in rural and remote Australia: Examining the association between GP vocational training placements and subsequent practice location in Western Australia

      2021, Journal of Rural Studies
      Citation Excerpt :

      We also examine some of the underlying reasons why GPs might opt to practice in the rural locations that are similar to their last vocational training placement location. While the issue of geographical maldistribution of the health workforce has previously been studied in Australia (J. Humphreys et al., 2001; Humphreys et al., 2002; Russell et al., 2012; Scott et al., 2013; Jongsay Yong, Anthony Scott, Hugh Gravelle, Peter Sivey and Matthew McGrail, 2018), there is a dearth in empirical evidence on the association between vocational training placement locations and subsequent practice and how this association might depend on the interplay between rural background and RCS experience. This is particularly important for health workforce planning in Australia, given the coexistence of persistent health disparities between people living in urban compared to those in rural locations and the uneven distribution of the health workforce in these areas (Australian Bureau of Statistics, 2018).

    View all citing articles on Scopus
    View full text