Abstract
Like many large countries, Indonesia has difficulty attracting doctors to service in rural and remote areas. To guide the creation of incentives for service in these areas, the authors analyze two sets of data about physicians: 1) the locations chosen by graduating medical students before and after a major change in the incentive system, and 2) survey data on choices among hypothetical assignments differing in compensation, career prospects, and amenities at various locations. Their findings suggest that: a) The current policy of offering specialist training is incentive enough to make doctors from Java willing to serve in remote areas. (It is not necessary to also offer a civil service appointment.) But providing specialist training as an incentive to work in remote areas is not only expensive, but potentially inefficient, since specialist practice and rural public health management require different skills and attitudes. b) Moderately (but not extremely) remote areas can be staffed using modest cash incentives. c) Doctors from the Outer Islands are far more willing to serve in remote areas than their counterparts from Java. So, it may be worthwhile increasing the representation of Outer Island students in medical schools (perhaps through scholarships and assistance in pre-university preparation).
The Problem: Providing health personnel to rural and remote areas
Health problems are often the most acute in rural and remote areas, especially in developing countries. But it is difficult to get health professionals to serve in these areas. Understandably, most physicians prefer to settle in urban areas offering opportunities for professional development, education and other amenities for their families, and attractive employment opportunities. As a result, there is a mismatch between the geographic distribution of physicians and the perceived need for them.
Context: Indonesia and other large countries
The geographic distribution of physicians is of particular concern for Indonesia. Indonesia's vast size and difficult geography present a tremendous challenge to health services delivery. It is difficult to place doctors in remote island, mountain, or forest locations with few amenities, no opportunities for private practice, and poor communications with the rest of the country. In addition, Indonesia's development goals strongly emphasize equity across regions, with particular stress on improving health status in the most remote and poorly served areas. The country's success in placing health centers in all of its more than 6000 subdistricts only increases the challenge of ensuring that those centers are staffed. These problems are not unique to Indonesia. The geographic distribution of doctors has been a concern in the US, Canada, Norway, and many other countries.
How can we persuade doctors to serve in remote areas? How do we find out?
One method is to offer incentive packages. For this to be affordable, it is necessary to fine-tune the incentives so as to be attractive as possible.
What incentives should be offered? Cash? Career development? Housing? How long should tours of duty be? How should the incentives differ according to the difficulty of the posting? These questions can be answered by experiment. But experiments are expensive and difficult to set up, and require years for evaluation.
An alternative is to use survey techniques to assess doctors' reactions to potential incentive packages. This approach, often used in commercial marketing, is here applied to policy analysis.
The surveys
Three surveys of Indonesian physicians' preferences concerning postings and incentives were conducted:
- Medical students' actual choice of postings to satisfy their compulsory contract service requirement. We describe the impact of a major change in the incentives to serve in very remote areas.
- Medical students' choices among hypothetical bundles of incentives and post characteristics. Using survey techniques, we can asssess the attractiveness of a large range of yet-untried options.
- Doctors currently performing contract service at rural and remote health centers were surveyed about conditions under which they would renew their contract.
Survey of Medical Students
Final year medical students were surveyed at fourteen medical schools. The purpose of the survey was to assess students' preferences over hypothetical assignments differing in locational amenities, compensation packages, and career paths.
Survey of Serving Doctors
The mail-out survey of serving doctors was designed to complement the survey of graduating medical students. Contract doctors (recent graduates performing compulsory service) were surveyed at health centers nationwide, excluding urban areas, and very remote areas. The purpose of the mail-out survey was to determine the conditions under which serving doctors would be willing to extend their contracts. At the time of the survey, such extensions were not allowed. It was hypothesized that - at least for a subset of doctors - modest additional incentives might elicit a substantial increase in willingness to extend. The preferences of pre-service medical students are based on very fragmentary information, and these preferences may well change as a result of field experience.
