Getting doctors into the bush: General Practitioners' preferences for rural location
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)
- et al.
Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise
Lancet
(2008) Eliciting GPs' preferences for pecuniary and non-pecuniary job characteristics
Journal of Health Economics
(2001)Health expenditure Australia 2009–10
(2011)Rural and remote health workforce capacity – The contribution made by programs administered by the Department of Health and Ageing
(2008)Private medical practitioners
(2002)Health in rural and remote Australia
(1998)Medical labour force 2003
(2005)Medical labour force 2010
(2012)- et al.
Financial incentives for return of service in underserved areas: a systematic review
BMC Health Services Research
(2009) - et al.
Effects coding in discrete choice experiments
Health Economics
(2005)
Determinants of GP billing in Australia: content and time
Medical Journal of Australia
Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy
The Australian Journal Of Rural Health
The evolution of the general practice workforce in Australia, 1991-2003
Medical Journal of Australia
What factors influence the earnings of general practitioners and specialists? Evidence from the medicine in Australia: balancing employment and life survey
Health Economics
What do doctors want? Developing incentives for doctors to serve in Indonesia's rural and remote areas
The generalized multinomial logit model: accounting for scale and coefficient heterogeneity
Marketing Science
How do general practitioners choose their practice? Preferences for practice and job characteristics
Journal of Health Services Research and Policy
Interventions for increasing the proportion of health professionals practising in rural and other underserved areas
Cochrane Database of Systematic Reviews
Why doctors choose small towns: a developmental model of rural physician recruitment and retention
Social Science & Medicine
Incentives could induce Ethiopian doctors and nurses to work in rural settings
Health Affairs
Getting the balance right? GPs who chose to stay in rural practice
Australian Journal of Rural Health
Career preferences and the work-family balance in medicine: gender differences among medical specialists
Social Science & Medicine
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