Assessing the effectiveness of potential incentive packages to attract medical students to rural areas in vietnam

According to the statistic result of Ministry of Health, it is undoubtable that the distribution of health workforce in Vietnam is not geographically balanced between urban and rural are

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY -

NGUYEN THI NGUYET

ASSESSING THE EFFECTIVENESS OF POTENTIAL INCENTIVE PACKAGES TO ATTRACT MEDICAL STUDENTS TO RURAL

AREAS IN VIETNAM

MASTER'S THESIS

Hanoi, 2018

VIETNAM NATIONAL UNIVERSITY, HANOI

VIETNAM JAPAN UNIVERSITY -

NGUYEN THI NGUYET

ASSESSING THE EFFECTIVENESS OF POTENTIAL INCENTIVE PACKAGES TO ATTRACT MEDICAL STUDENTS TO RURAL

AREAS IN VIETNAM

MAJOR: PUBLIC POLICY

SUPERVISORS:

Associate Prof Morimitsu Kurino

Dr.Vu Hoang Linh

Hanoi, 2018

ACKNOWLEDGEMENT

In order to complete this paper, I have received a lot of assistances and motivation Therefore, I would like to give the acknowledgement to their help and support during the time conducting this study

Firstly, I would like to give my endless thanks to two supervisors, Prof Morimitsu Kurino and Dr Vu Hoang Linh Enthusiastic guidances, useful advices and motivation words have encouraged me a lot in solving difficult issues happening during the time writing the research The problem of shortage doctors in rural areas is a concrete problem and takes a lot of time to read and understand, but under the guidance and recommendations, I dealt with this issue quite smoothly

On the other hand, I also want to express my special thanks to other professors, Dr Thuy Anh, Prof Okamoto, Prof Fujmoto, Prof Kawashima, Prof Tsutsumi and Taro gave me suggestion to contribute for my study better Besides, I also acknowledge my thanks to Ms Ha and Ms Phuong who also support me a lot

in completing all the processes and documents

Lastly, I would like to give deeply thanks to all my friends who are studying

at medical universities in Vietnam They were really kind and enthusiastic to help

me in conducting survey and collecting data All of their kindly care, motivation pushed me a lot to overcome difficulties to complete this study

ASTRACT

With the aim of solving the problem of shortage doctor in rural areas in Vietnam, the paper studied the motivation of final year medical students for rural practice There are a vast of approaches to study this problem such as using quanlitative method, cross sectional method or mixed method but my study applied

a quite new technique that is Discrete choice experiment This technique is much more advantage than the other approaches because it can help policy maker can prioritize the importance of each policy intervention By using DCEs, the study pointed out that the attribute ―possibility to enter the advance training after 2 years‖ was the strongest factor influencing the preference of medical student (β=1.103) Besides, the study also estimated the willingness to pay and uptake rate for each attribute The result of the study showed that medical student willing to sacrifice to enter advance medical training course after 2 years is highest with 7.355 million VND Furthermore, it is noticeable that when we combine incentive the uptake rate will increase significantly compared incentive alone The study combined both financial incentive (at salary level is 10 million VND) and non-financial incentives The combination between possibility to enter advance medical training after 2 years and the salary level at 10 million VND shows the highest uptake rate (86%) Finally, the study gave some discussions and implication to recommend for Ministry of Health in Vietnam

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION 1

1.1 Research background 1

1.2 Problem statement 2

1.3 Purpose of the study 4

1.4 Research questions 5

1.5 The significant of study 5

1.6 Methodology 5

1.7 The structure and overview of the thesis 7

CHAPTER 2: LITERATURE REVIEW 9

2.1 Theory framework of motivation to work in rural area 9

2.2 Framework for evaluating cost of health policy interventions 12

2.3 Literature review method studying motivation to work in rural area 14

2.4 Literature review papers studying in motivation of health worker in Vietnam 17

CHAPTER 3: THE MEDICAL LABOR MARKET IN VIETNAM 19

3.1 General situation of human resource for health in Vietnam 19

CHAPTER 4: METHODOLOGY 23

4.1 Qualitative interview 23

4.1.1 Desk review policies 23

4.1.2 Focus Group Discussion 30

4.2 Quantitative 32

4.2.1 Developing DCEs instrument 32

4.2.2 Behaviour model foundation 32

4.2.3 Experimental design and construction of choice sets 34

4.2.4 Checking properties 37

4.3 Questionnaire instrument 40

4.3.1 Supplemental questions 40

4.3.2 Sampling and data collection 40

4.3.3 Pilot questionnaire 40

4.3.4 Data 41

4.3.5 Model 43

4.4 Cost estimation for incentive package 43

CHAPTER 5: RESULTS 45

5.1 Demographic 45

5.2 DCEs 48

5.2.1 The basic regression model 48

5.2.2 Willingness to pay 51

5.2.3 Uptake rate 52

CHAPTER 6: DISCUSSION AND IMPLICATION 54

LIST OF TABLES

Table 3.1: Health personnel by years 19

Table 3.2: Number of doctors per 10000 habitants in 2014 - 2015 in Vietnam 20

Table 4.1: Intervention strategies recommended by WHO (2010) 24

Table 4.2: Attributes and levels for DCEs in studying preference of medical students in Vietnam 30

Table 4.3: Choice sets for medical student in Vietnam 35

Table 4.4: Correlation matrix 37

Table 4.5: Level balance 39

Table 4.6: Description the variables 41

Table 5.1: Frequency of variables 45

Table 5.2: Regression results and willingness to pay 48

Table 5.3: The final regression result and willingness to pay 49

Table 5.4: Uptake rate 52

LIST OF FIGURES

Figure 2.1: The impact of different types of environments to attract and retain health workforce 10 Figure 2.2: Motivation of medical student to work in rural areas following graduation 11 Figure 2.3: Framework from costing health policy interventions 13 Figure 5.1: Willingness to pay for job attributes for medical student 51

LIST OF ABBREVIATIONS

CHAPTER 1: INTRODUCTION

1.1 Research background

One of the most prominent health issues that almost all developing or developing countries face is the lack of doctors in rural areas Governments or international organizations are interested in researching and have implemented a number of measures and supportive policies to attract physicians in difficult areas However, this is still a persistent and difficult issue According to report of WHO (2006), more than half of the world's population lives in rural areas, but fewer than 25% of health workers serve the world

Because of the poor access to the health services, millions of rural people in African or South Asian countries are experiencing extremely unfavorable conditions Not only that, it also affects in the health indicators as well as the development of countries because it can lead to the poverty of the rural population Therefore, tackling this issue is also one of the top priorities for countries to achieve sustainable development

Like other countries, Vietnamese government also has to struggle with the unbalanced geographically distribution of health workforces, especially doctors According to the statistic result of Ministry of Health, it is undoubtable that the distribution of health workforce in Vietnam is not geographically balanced between urban and rural areas According to the statistics of Ministry of Health, in 2014, the number of doctors per 10000 habitants in the whole country was 7.75 doctors However, this indicators in urban was 16.97 doctors and in rural was just 2.42 doctors It is clearly that there is a big gap between the number of health workers in rural and urban in Vietnam

The status of shortage doctors in rural areas has caused the unequal access to health service which can affect in the quality of treatment in disadvantage areas and also creates overloading pressure on higher level hospitals

Therefore, increasing the ratio of doctors in rural areas is one of the policy priorities for Vietnam Although there is no specific policy at national level relating retention and recruitment of doctors to rural areas, provinces has also implemented

a various programs and policies to attract physicians such as offering chances to enter further education for doctors, providing financial benefits, constructing more supportive working environments, compelling health workers to work in rural areas However, these policies have proved ineffective As in Dak Nong province, more than a year of implementing the project "policy of attracting qualified health workers" in the period 2014-2020, only attracted a traditional medicine doctors working in The provincial general hospital, while continuing to have doctors to move the work The "Young Volunteer Doctor" program has been launched by the government and the Ministry of Health in 2013 The program offers many incentives and supports to attract 500 students by 2016 They work in 62 poor and disadvantaged districts So far, only 29 students have participated in this program

1.2 Problem statement

There were a lot of papers studying the preference of medical students in working in rural areas of both high-income countries and low and middle-income countries Through some literature review systems, the factor that has the significant influence to motivation of medical students in both of these countries is rural background

The method research on this issue is also various In particularly, by using qualitative method, Baily (2012) showed that in Malawi, the motivation for health workforce to practice in rural were getting closely with district people The study showed cases that health worker did not chose to work in central hospitals, but served health service for people from home district, to get hospital administration skills and to perform the loyalty to the community Besides, there were some studies used mixed methods such as Ross (2007), Arscott-Mills (2016) Another method which was also used commonly is cross – sectional: Deressa (2012), Huntington

(2012), Kotha (2012), Larkins (2015), Nallala (2015), Shankar (2012), van Wyk (2010), Zimmerman (2012)

However, those approaches exists some limitations because they just listed factors influencing the motivation of health workforce to work in rural or urban areas which can make the policy makers find difficult to prioritize such factors Recently, stated preference discrete choice experiments (DCEs) are commonly used

in health service research for evaluating the relative influence of different attributes

on preferences This is a quantitative method for assessing the various factors influencing the selection of jobs This method is much more outstanding than traditional qualitative assessments since it gives information about the relative significance of the variety of working characteristics which affect the decision of doctors, and information on the trade-offs between these factors and the probability

of identified work Therefore, in the thesis, I plan to collect the data and use the DCEs to evaluate incentive schemes on attracting doctors to rural areas in Vietnam

There are a lot of studies using DCEs to evaluate the relative influence of different attributes on preference of final medical students, doctors, nurses and other health workforce Recently, the studies using this method have been quickly increased and the objectives were really diversified For example, Hanson and Jack (2010) studied about the impacts of government policy to enhance the provision of health workers in countryside, Sivey et al (2010) studied the factors affecting the selection of final-year medical students for working in remote area

In Vietnam, Vujicic M et al (2011) used DCEs to find the preference of doctors This research studies labour market dynamics for doctors in Vietnam, which specially focus on geographic distribution and dual employment Under this study, a significant wage premium is a factor influencing the decision of doctors This premium comes from significantly higher income from dual employment

rather than formal job earnings Finally, the findings from an innovative discrete

choice experiment show that the provision of long-term education and the

improvement of equipment are the most effective tools for attracting doctors to remote areas

Recently, the DCEs method has been grown to study relative influence of different incentive packages in multi-country and the cost-effectiveness of different policy interventions attracting health workers to work in rural areas

 D Blaauw et al (2009) used DCEs in multi country to assess the impact of policy interventions attracting nurse to remote area

 Eric Keuffel et al (2016) evaluated the cost effectiveness of health workforce rural incentive programs

However, there is no study assessing the relative influence of different packages of medical student interventions in Vietnam At the master level, I have solved this problem by studying the motivation of medical student to work in rural area Nonetheless, studying the preference of student just can solve the very minor

of shortage doctor in rural area problem Therefore, for further research in the future, I would like to continue study the motivation of doctors in comparison with medical students and estimate the cost effectiveness of each incentive package by using the DCEs method

1.3 Purpose of the study

The purpose of the study is to find the most effective incentive package for attracting the medical student in rural area in Vietnam and the estimated effect of those packages on rural and urban distribution of health The study uses DCEs method and does survey with the final year students from medical schools in Vietnam Firstly, the paper studies about the status of medical labor market in Vietnam as well as the mechanism and policies relating to health management of Vietnam Second, through the literature reviews about using DCEs method, the health policies in Vietnam and some focused group discussion with medical students, the study identifies the attributes and levels to conduct DCEs method Third, after collecting the data from surveys, the study uses DCEs method and runs

conditional logit model to find which is the most effective package for attracting the medical student in rural areas in Vietnam through calculating the willingness to pay and the predicted preference impact (PPI) for incentive packages

1.4 Research questions

The research seeks to answer the following main questions: What is the most effective incentive package for attracting the medical student in rural area in Vietnam?

Besides, the study also answer the following sub questions:

 What is the status and current mechanism of medical labor market in Vietnam?

 What is the attributes and levels for conducting DCEs method?

 What is the estimated willingness to pay of incentive packages?

 What is the estimated uptake rate in rural postings of each incentive packages?

1.5 The significant of study

The shortage of doctor in rural areas is one of the concrete problem that Vietnamese government has to concern too much Therefore, studying in the motivation of medical students is one of the important stages to implement sufficient and efficient policies

1.6 Methodology

The study uses both qualitative and quantitative method

 Qualitative: in depth interview and literature review

 Quantitative: Discrete choice experiment (DCEs), costing analysis, recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the cost effectiveness

 The target object: The sixth year – medical student

 Sample size: 216 medical students from medical university in three parts of Vietnam

 Data: primary data from DCE survey, secondary cost, economic and health data

Through review of literature and the current policies attracting doctors to rural areas of some province in Vietnam the study identified six attributes including salary (with 4 levels), long term education (with 3 levels), skill development (with 2 levels), house (with 3 levels), equipment (with 2 levels) and career promotion (3 levels) for DCEs

The theory framework of DCEs is the random utility model In this model, individual n is supposed to select between J alternative jobs based on the utility (benefit or satisfaction) Therefore, this person will choose job i over job j if and only if:

The deterministic component 𝒏 is a function of m job attributes (x1, x2, …, xm) which are observed and random component, and 𝒏 is the function of unobserved job attributes and individual-level variation in tastes

Equation (2) can be estimated using standard econometric techniques and software, giving estimates of 𝒎

Therefore, the results can be determined: which attributes are important and how important one attribute is compared to another attribute, the trade-off between attributes of the work, how much income they are willing to pay for different job attributes, the probability of take-up a job with given attributes

1.7 The structure and overview of the thesis

The thesis consists of six chapters including:

Chapter 1: Introduction – provides the introduction of research background

and purpose of the study

Chapter 2: Literature review – presents an overview of studies relating to

topics motivation of health workforce to work in rural areas, DCEs method and the effectiveness of incentive packages in health sector

Chapter 3: The status of medical labor market in Vietnam – describes

overview of the inequity in health sector especially the unbalanced geographically distribution of health workforce in Vietnam Besides, this part also introduces the current policies and incentive packages implementing in districts of Vietnam It then provides some evidence about the ineffectiveness of these policies in Vietnam which suggests to research and find some other solution for this concrete problem

Chapter 4: Methodology – This chapter discusses about the advantage of

DCEs and how to conduct a DCEs

Chapter 5: Results – After conducting and running logit model accordingly

to DCEs method this chapter will analyse which is the effective incentive package for attracting medical students to rural areas in Vietnam through valuation of incentive components and predicted preference impact estimates of incentive

package On the other hand, based on the DCEs results this chapter also estimate the effect of incentive packages on rural and urban distribution of health

Chapter 6: Conclusion and recommendation – This chapter first summarizes

the finding of the study and then implies some recommendations for Ministry of Health in Vietnam

CHAPTER 2: LITERATURE REVIEW

2.1 Theory framework of motivation to work in rural area

There were a vast of theories coming from multidiscipline have contributed

to study in the motivation of health workforce to work in rural areas According to Neoclassic wage theory, the determinant motivations for a choice were primarily influenced by financial incentives and the possibility of finding a job

On the other hand, one of the most common theories studying in the motivation and job satisfaction is Maslow’s Hierarchy of Needs This behavioral theory introduced five basic needs that people need to satisfy These five needs are described as the following order: physiological need (income, working conditions); safety need (job security, safety at work); love/belonging need (relationship with manager and colleague); esteem need (recognition, career promotion, respected by others); self-actualization (autonomy, fulfillment)

According to Lehmann (2008), the decision for an individual to move, leave

or stay was impacted by different types of environments (figure 2.1) Individual factors includes the information about the characteristics of each person such as gender, age, ethnic, marital status and rural background… A part from the individual factors, the local environment (home and social) factors also contribute

to health worker’s decisions in choosing the career locations These attributes include the condition of facilities, equipment, drugs, staff accommodation, transport… The third environment influencing the motivation of physician was work-related factors Together with salary, working conditions such as the pressure

of work, management support, opportunities for entering the training course and career promotion… are the main work-related factors affecting in the job motivation and satisfaction of each individual In a paper studying in the role of wage in immigration of health workers, Vujicic M et al (2004) showed that health care personal would like to immigrate from a low and middle income countries where offered a low salary level to high income countries The fourth environment

according to Lehmann was national environment The factors that also contributed

to the reason for immigration of health workforce were the growth economic and stable politic For instance, Awases et al (2004) illustrated that the most important reason for the emigration of people in Zimbabwean was the economic decline (55%) and followed by the lack of access to the health service, shortage of facilities and the hopelessness about the future of the country Finally, Lehmann showed that the international situation of significantly lacking health worker in many developed countries also caused the concern in attracting and retaining doctors in global

Figure 2.1: The impact of different types of environments to attract and retain

health workforce

Source: Uta Lehmann (2008)

However, this framework most used for studying in high income countries Therefore, the study applied the conceptual framework which was built by Bland (1995) (Figure 2.2) because this model studied in the motivation of medical student

in low and middle income countries In this model, Bland pointed out the factors influencing the medical students to choose the medical specialty which were policy factors, medical school related factors, medical training and curriculum factors, personal and lifestyle factors, health facility related factors

Figure 2.2: Motivation of medical student to work in rural areas following

graduation

Source: Bland (1995)

Health facility related factors including salary, accommodation, management style, equipment, career promotion were found as the motivating factors for rural practice in many studies Kaye (2010) showed that the medical students in Uganda expected a better working environment where had supportive staff and provided opportunities for career development Besides, Nallala (2015) found that financial incentives and provision of house had the positive impact in decision of medical students The second factor that is personal and lifestyle factors also contributes to the motivation of medical student Huntington (2012) and Ross (2007) found that male students were more willing to practice in rural than female students Furthermore rural background and rural experience factors also were demonstrated

as the motivating factor to attract health workers in Bostwana by Arscott-Mills (2016) and in Ghana by Kotha (2012) The fourth factor is medical training and curriculum which includes community-based medical curriculum and training in rural area The fifth factor that is medical school related were found to have positive influence in motivating students to work in rural areas in Philippines, South Africa

and Sudan by Larkins (2015) He said that the selection criteria of medical university to choose students who have a rural background was a motivating factor Finally, according to Bland, policy related factors such as government scholarship for students who have rural background and the shorter contracts were also the potential incentive package for rural practice

2.2 Framework for evaluating cost of health policy interventions

Stuyding the preference of health workers plays an important role in increasing the availability of health workforce in rural areas However, not all proposals are feasible because most countries especially the low and middle income countries (LMICs) have limited funding to address this problem Therefore, evaluating and estimating costs for policies will help policy makers make better decisions

However, currently there is still a considerable shortage of information on the cost – effectiveness of potential incentive packages to attract and maintain health workers in rural areas Untill now, according to my best knowledge of research, there was only one paper studied in this issue and conducted a general framework for evaluating the cost of health policy interventions Pascal Zurn (2011) identified the key elements of a framework for estimating cost in health workforce retention schemes in rural areas (Figure 2.3)

Figure 2.3: Framework from costing health policy interventions

Source: Pascal Zurn (2011)

According to Pascal Zurn, there were three core elements contributed in the framework: costing evaluation, source and modes of financing, financial sustainability In order to evaluate the cost of in the retention scheme, five stages should be implemented Firstly, it is necessary to identify and select the policy interventions which usually taken from the recommendations of WHO (2010) After that, the second step is selecting the key inputs or resources for intervention in order

to make the initial plan and distinguish the capital and recurrent resources The third step is determining the additional resources or key incremental policies Next, the cost of each policy intervention can be estimated in monetary units The estimated

cost is the opportunity cost of using the resourses of the specific policy intervention instead of the other Lastly, after predicting the cost, it is also important to consider the cost over time

The second key element of the framework is the source and mode of finaning

of the policy In fact, implementing the policy intervention usually must be comprised of many sources of funding not just from the government (the ministry of health) but also from international organizations and NGOs, civil societies and private sector Therefore, it is necessary to identify which are the direct or indirect stakehoders involing in increasing the availability of health workers in rural areas

Finally, after the policy intervention are estimate the cost and the source of funding, it is important to evaluate the sustainability of their finance This means that the intervention will be assessed if it can be secured in the medium term or in the long term

2.3 Literature review method studying motivation to work in rural area

Studying preference of health workforce and also medical students in rural practice has attracted the interest of many researchers Therefore, there were a lot of papers contributing to job motivation research and a variety of approaches have been applied to study this issue

Firstly, by using qualitative method, Bailey (2012) studied the intention of medical students in deciding their career plans after graduating The study found that the most important factor influencing the preference of medical students in career choice was opportunity to enter post graduate training courses which played

a core role to their career promotion Furthermore, most of the students preferred pursuing of further study after graduation to having higher salary However, the study pointed out that some students currently intended to work in the private hospital

On the other hand, Husna Razee et al (2012) did a research to explore the factors encouraging the health workers in rural area of Papua New Guinea to work

The study illustrated that the working environment had the significant effect to motivation of health workers The core factor in their working environment is the local community The study indicated that the strong support of local community could help health workers to practice and contribute for that community development

Another study also pointed out some strategies contributing to attract health workers to work in rural areas Firstly, the decision for rural practice might be facilitated through training courses in rural hospitals, the understanding of the shortage of status of health workforce shortage in rural and introduction about the rural health care system Besides, of the condition of working environment such as offering chances for developing skills, opportunities to have long-term education and career promotion could have positive affect in motivating health workers to move to rural areas Furthermore, the other individual factors including the encouragement of family and friends, and a good relationship with the community also could increase the participation and retention of health workers in rural areas

A part from qualitative approach, the cross sectional approach was commonly applied by researcher when study the motivation and job satisfaction of health workforce For instance, Marc Bonenberger et all (2014) conducted cross sectional survey to study the influence of motivating factors and job satisfaction on turnover intention Overall, 69% of the respondents reported to have turnover intentions The study showed that motivating factors and job satisfaction such as career development, the management style, the commitment with organisation and workload influence significantly in the turnover intentions

On the other hand, Larkins et al (2015) conducted a cross sectional surveys

to administer medical students from five countries The study identified four distinct strategies influencing the intention of medical student for rural practice which were: the capacity of school, the selection criteria based on individual attributes, the participation of community, and the university marketing strategies Those selected

strategies was proved to contribute to to a various medical student body with high probability to health serve in underserved areas

Besides, there were several papers using the mixed methods to study the perception of health workforces in rural practice Arscott-Mills (2016) conducted both questionnaires and semi-structured interview with the third and fifth year medical students in Botswana to study the influence of rural training on medical student’s perception towards rural practice The study showed that most of the medical students want to participate in training specialisation outside Botswana but intended to practice in Botswana There were some demotivating factors for medical students to work in rural areas including lack of professional, inadequate health facilities, limitation of learning opportunities Besides, the heavy workload and poor infrastructure were barriers to rural practice However, the supportive staff and monetary compensation were seen as positive factors for rural practice

On the other hand, discrete choice experiment approach is well known as useful technique in addressing a diversity policy fields For instance, Hensher et al (2005) applied the DCEs technique in transport economics, Hanley et al (2001) used

in the field of environment Furthermore, recently DCEs have become common in the field of health economics (Ryan et al 2008)

On the other hand, because of having some advantages this technique also has been applied a lot in studying the preference and motivation of health workers

to work in rural areas In comparison with traditional method in studying motivation

of doctor to work in rural areas like qualitative, mix method and cross sectional, this technique has some advantages which can evaluate relative influence of various factors in preference of health workforce to work in rural areas Furthermore, this quantitative method also can provide useful information about willingness to pay, trade off and probability take up between each attributes

Margaret E Kruk (2010) conducted discrete choice experiment to study the preference for hypothetical rural job postings of medical students in Ghana The

study selected and identified six attributes influencing the motivation of students including salary, providing free house, support tuition fee for children, upgraded equipment, supportive management and provision of car The result of mixed logit model showed that better working conditions such as upgraded equipment and supportive management were the most strongly associated with job choice Besides, the study also found out that the men’s preference were more affected by provision

of house, meanwhile the women’s motivation by the supportive management

2.4 Literature review papers studying in motivation of health worker in

Vietnam

In Vietnam, there were several papers studying in motivation and satisfaction

of health workforce as well to work in rural hospital

Marjolein Dieleman et al (2003) determined the factors influencing the choice of doctors to work in remote areas in Vietnam’s Northern Under this article, health workers, managers and also policy makers in 2 provinces were interviewed about the motivation and perception of the job Using qualitative method, the findings of this research was that both financial and non-financial benefits influenced the motivation The primary motivators for doctors were a stable work, high salary, education opportunity and the appreciation of community, managers and colleagues Meanwhile, the factors that discouraged health workforces were low wages and poor working environments

Bui Thi Ha et al (2011) also investigated factors affecting the recruitment and retention of physicians in Vietnam’s countryside This research studied the motivation of health workers to enter the profession; the perceptions of national stakeholders about issues; opinions on the various factors influencing the selection

of working in remote areas These factors includes different salaries, workload, working environment, support and monitoring, relationships with colleagues, career development, equipment, education and living conditions The findings of this study were about the satisfaction, the sequence of various attributes, and the readiness to agree various types of jobs

Nguyen Hoai Thu (2015) investigated the motivation and demographic factors that affect the provision of maternal health services in Vietnam rural areas

By using multivariate analysis, there were three factors that influencing the motivation of doctors: access to training, ability to perform key tasks, and shift schedule Higher motivation was for competent health-care workers, while lower motivation was in those who worked night shifts more often and who had been trained in a year in the past The respondents determined the reason for the latter situation since they felt that the training was unrelated to them, and in many circumstances, they had no chance to practice their learnt skills Besides, using qualitative data, other factors related to organizational management practices and service context also affect the motivation

Vujicic M et al (2011) studied the shortage of physician in rural Vietnam which used labor market approach to inform policy This paper investigated labor market dynamics for physicians in Vietnam, paying particular attention to geographic distribution and dual job holding After taking account of the various sources of income for physicians and controlling for key factors, there was a significant wage premium associated with locating in an urban area This premium was driven by much higher earnings from dual job holding rather than official earnings in the primary job

Vujicic M et al (2011) used DCEs to find the preference of doctors This research studies labour market dynamics for doctors in Vietnam, which specially focus on geographic distribution and dual employment Under this study, a significant wage premium is a factor influencing the decision of doctors This premium comes from significantly higher income from dual employment rather

than formal job earnings Finally, the findings from an innovative discrete choice

experiment show that the provision of long-term education and the improvement of equipment are the most effective tools for attracting doctors to remote areas

CHAPTER 3: THE MEDICAL LABOR MARKET IN VIETNAM

3.1 General situation of human resource for health in Vietnam

According to the statistic of health (2014) the total number of health professionals has been gradually increasing in the past decade from 382,404 health workers in 2010 and 430,496 peopole in 2014 Besides, the number of doctors also has increased rapidly, on the average of 6.5% per year (Table 3.1)

Table 3.1: Health personnel by years

Number of doctors per 10000

inhabitants

Source: The Ministry of Health (2014)

However, similar with other LMICs, the imbalanced distribution of human resource for health (HRH) between urban and rural areas was another concern About 82% of university pharmacists, 59% of doctors and 55% of nurse provided the health service for only 30% total population in urban areas (WHO, 2012)

Furthermore, according to the statistic result of Ministry of Health, it is clearly that the distribution of health workforce in Vietnam is not geographically balanced between urban and rural areas (Table 3.2) Through the table 3.2, there is considerable big gap between the number of doctor per 10000 habitants in urban and rural area in Vietnam This ratio in urban Vietnam was bigger nearly eight times than this one in rural Vietnam Besides, in 2015, although there was an improvement about the equal distribution of doctors in urban and rural areas, the unbalance was still remained

Table 3.2: Number of doctors per 10000 habitants in 2014 - 2015 in

Source: Calculated from the Statistics of Ministry of Health

Furthermore, the shortage in the rural areas was not only because of the comparatively small number of health professionals, but also due to frequent movement out of helath facilities at district and commune levels According to the results of the research conducted by the Health Strategy and Policy Institute in four rural provinces of Vietnam (2013), the number of retiring and migrating health professionals was about 50% of the number of newly recruited members at district hospitals (DHs) and health centers (HCs) Low income and poor working conditions were two main reasons for the low attraction and retention rates of rural health professionals (MOH, 2013)

On the other hand, the aggregated data from 904 hospitals and health care facilities that report on staff changes show that the number of physicians and nurses increasing during 2010-2012 was very small It is noteworthy that, in difficult areas such as the Northern Midlands and Mountains, the increase in the number of people working in rural areas was much lower than in the Red River Delta when compared

to 2010 and 2012 The increase in the number of doctors working in rural areas compared to 2010 and 2012 between the Red River Delta and the Northern Midlands and Mountains was 7.8% and 5.4% respectively

On the other hand, according to the statistics of the health sector, the shortage of doctors takes place in most provinces and cities in the country, most of them are concentrated in the difficult provinces, such as the Northwest and the Mekong River Delta In the 15 northern mountainous provinces, although the number of health workers per 10,000 population is higher than the national average, the proportion of physicians is lower

The report of the Ministry of Health (2013) also showed that if the country had an average of 7.34 doctors per 10,000 population, this rate in Lai Chau was only 6.29, in Dien Bien was 6.74 and in Lang Son and Son La the rate of doctors was even much lower In Son La province, the total health workforce was just 4275 people which was not enough both quantity and quality The rate of new doctors was 5.74 per 10 thousand people The province was estimated to lack about 1,000 doctors, health workers compared with demand The provincial general hospital has

a size of 350 beds, and is currently lacking nearly 150 staff members In fact, at the time the patient was crowded, the number of beds actually increased to 500, the number of staff needed to increase to 650 - 700 people Therefore, the current number of health workforce just meets 50% of the demand This is a really concerning problem The Resolution of the 14th Party Congress of Son La province has aimed to get the target of 7.5 to 8 doctors per 10 thousand people by 2020, which is an indicator that requires a lot of effort for the mountainous province

Similarly, The Mekong Delta provinces have about 18 million people but there are only 9.264 doctors and this number is less 3000 physicians as prescribed

In this area, Soc Trang is one of the provinces with the most serious shortage of doctors, the whole province has 4.8 doctors per 10 thousand people Soc Trang Department of Health Director Truong Hoai Phong said that in recent years, the province has taken all efforts to attract health workforce, but this amount only meets

a small part of the real needs

The lack of qualified human resources, most notably the direct medical staff working in the specialty of emergency resuscitation, surgery is also a major challenge for health care In Dac Nong, the whole province has 6.15 doctors / 10 thousand people, but most of them are young doctors who are training in specialized and postgraduate education; many doctors are trained according to the recruitment

or recruitment criteria, newly graduated, lack of practical skills and limited professional capacity At the hospitals in this area, doctors with postgraduate qualifications only reached 21.4%; Doctors with deep expertise in treatment such as neuropathy, external injuries orthopedics are also very few

Despite the lack of qualified physician recruiting for public health facilities,

it is more difficult to keep the team Many highly qualified doctors have been applying to move out of the province In the period from 2004 to 2012, Dac Nong health sector only recruited 30 doctors, but also during that period, 18 doctors resigned or transferred to other localities Similarly, many hospitals, especially in the province of Soc Trang, despite the lack of quantity, many good doctors moved

to Can Tho, Ho Chi Minh to work Attracting doctors to the province is few, only

a few dozen people each year, but the number moved to other places continuously increase, there are about half of the number of work in the province

Along with that, a sad fact for many local health care is that many physicians are provided with financial support to improve their professional skills but after graduation they did not work at the local sent They are willing to pay back the compensation and transfer costs This causes difficulties for the local in developing training plans and implementing professional activities

CHAPTER 4: METHODOLOGY

In this chapter, the study introduced about the research method Both qualitative and quantitative method have been applied in conducting the DCEs There are five stages in implementing the DCEs and this chapter was presented based on these steps The first step is identifying the main attribute and level influencing the preference of medical students The second step is experimental design of the choice sets The third step is constructing the questionnaire and data collection Next, the fourth step is inputting data and the last step is analyzing the data

4.1 Qualitative interview

4.1.1 Desk review policies

The initial step for conducting Discrete Choice Experiment is literature review and focus group discussion to identify attributes and levels The study reviewed strategies and policies from Word Health Organization (2010), some countries succeeding in attracting health workforce to work in rural areas and provinces in Vietnam

4.1.1.1 Strategies and policies from recommendation of WHO

Recommendations of WHO (2010) are various from the four main categories including education, regulation, financial incentives, personal and professional support The most important factors influencing the motivation of doctors have been suggested for all countries over the world are salary, remoteness, housing, equipment and drugs at the facility, length of commitment, study assistance, management, training and type of employment All these recommendations are reviewed through the quality of the evidence and strength of the recommendation

Table 4.1: Intervention strategies recommended by WHO (2010)

Source: WHO (2010) 4.1.1.2 Review policies and interventions in Vietnam

Apart from the recommendation of WHO (2010), the study also reviewed the current policies in Vietnam to attract health workforce and focus on young doctor recruitment policies The Vietnamese government has applied three categories of interventions to build a strong and stable health workforce in the rural and remote areas The interventions covered the training, financial incentives and personal and professional support

APs were able to correctly identify the risk factors of pregnancy complications Approximately only half of the health professionals mastered the diagnosis of hypertension and only 54.3% of physicians could accurately diagnose and treat the dehydration caused by diarrhea (MOH, 2013) Strengthening HRH was urgent in Vietnam Although the training could not expand the pool of rural health professionals, training was needed to strengthen rural HRH capacity, to decrease professional isolation at rural health facilities and improve attractiveness of rural positions

The Vietnamese government focused on improving the capacity of HRH through diverse programs In 2012, for example, 1816 training projects were conducted at different levels of health facilities, especially in the rural areas, to strengthen HRH The training projects were short‑term or long‑term, depending on the topics and involved health professionals

Study interviews confirmed that a great number of short‑term training projects were conducted at rural and remote commune HCs and DHs in Vietnam Most of the training projects were decentralized from the central government to district health centers (DHCs) Several projects came from DHs Based on the current structure of the health system, the commune health stations (HSs) were under the management of DHCs who were responsible for training health professionals at commune HSs Most training programs were in long-term service training and short‑term, lasting about three to five days

The topics ranged from reproductive health to food safety and hygiene The formats also varied The staff of DHCs attended the training organized by the provincial or the national health facilities, and transferred the knowledge and skills

to the commune HSs Sometimes they also invited the health professionals of commune HSs to the DHCs for training in disease prevention and health promotion The interviewees also described long‑term training projects that were available at rural health facilities For example, dentists and traditional medicine professionals

were able to attend six to nine month professional training programs in some medical universities, such as Thai Nguyen medical University

In 2006, there was another training project among APs, aimed at upgrading their qualifications to be physicians The commune HSs first proposed excellent candidates, then sent the proposed list to DHC and PHD for approval Once the eligibility was confirmed, the selected APs were required to attend a four year training in the universities After training, the APs were upgraded to physician status This project to upgrade qualifications was only available in specific areas, depending on the priority list announced by the central government In addition, there was also a limitation on the total number of AP participants able to upgrade their qualifications The maximum volume was four APs at the commune level, and two APs at the district level During these long term training projects, the health professionals were still able to receive their basic salary and some other allowances This program stopped in 2012 because the provinces thought they had already produced enough physicians

Furthermore, as reported in the National Summary of Vietnamese Interventions from the local collaborating institution, some of the training projects showed preferences toward minorities In 2007, the Vietnamese government issued Decision No.1544 to implement the training projects among the nominated minorities in the disadvantaged and mountainous areas in Northern and Central Vietnam and in the Mekong River delta This project selected about 200 students every year for participation in the training

Financial incentive interventions:

In response to the ubiquitous dissatisfaction with the low income of rural positions, the Vietnamese government issued a series of policies to provide extra allowance to increase the income for rural health professionals The information about these policies was extracted from the study interviews and the National Summary of Vietnamese Interventions

In 2009, the central government issued Decree No 64 among the health professionals in economically disadvantaged areas The health professionals working in these areas were eligible for a basic salary, with 70% of that basic salary

as allowance, plus a leadership and seniority allowance per month for five years In addition, the fees during the training, like tuition, housing and transportation were covered, if applicable

In 2010, a similar policy Decree No.116 was issued and expanded to cover all the cadres and civil servants and employees in the Armed Forces in economically disadvantaged areas Compared to Decree No 64, Decree No.116 was more beneficial for rural health professionals because it provided a lifetime allowance The allowance varied over a professional’s working time, ranging from 70% of the basic salary in the first five years, to 50% of the minimum salary between the 5th‑10th year, to 70% of the minimum salary between the 11th‑15th year until ultimately rising to 100% of the minimum salary after 15 years Thus, most rural health facilities implemented Decree No.116

Apart from Decree No 64 and Decree No.116 issued on general health professionals in the rural and remote areas, several other decrees paid extra attention

to special health workers

Although village health workers (VHWs) were not government officials in the Vietnamese health system, their benefits were guaranteed under Decree No 75 Based on the HRH structure in Vietnam, each village was equipped with one or two VHWs One VHW received 9 month professional training to be a traditional birth attendant to provide delivery services in the villages Because the VHWs were not officials within the health system, they could not receive a regular salary However, they contributed to maternal and infant health in the rural and remote areas Thus, in order to motivate the VHWs, the government issued Decree No 75 to provide them with a monthly allowance The monthly allowance was set at up to 0.5 of the minimum salary, about 600,000 VND (about 27 USD) in the poor areas, while it

was set at 0.3 of minimum salary, about 360,000 VND (about 16 USD) in the normal areas

In 2011, the Vietnamese government announced Decision No 73 to benefit the health workers for epidemic prevention They were able to receive 75,000‑150,000 VND (about 2.2‑6.6 USD) per day plus shift allowance of 100,000 VND (about 4.4 USD) The allowance was higher during the public holidays, up to 1.3‑1.8 times more than the normal allowance

In 2014, Circulation No 10 was implemented to grant a night shift allowance

to the commune health professionals According to the regulation, the number of health workers receiving the night shift benefits was limited to a maximum of 14 health workers per 100 beds per night In return, each health professional could get 25,000 VND (about 1.1 USD) per night and 15,000 VND (about 0.7 USD) as food allowance, plus a one day break If the night shift occurred on public holidays, the break extended to 2 days

Personal and professional support interventions:

Poor living and working conditions, and professional isolation were widely reported as the main barriers to attracting and retaining the health professionals in the rural and remote areas A study of identifying factors for job motivation of rural health workers in North Vietnam reported that difficult transportation, lack of updated health information and heavy workload without positive feedback were the main challenges of working at rural health facilities (Nguyen, 2015) Both the central and regional government have made efforts to strengthen personal and professional support

Due to the limited revenue and limited budget from the central government, the primary health facilities, like HSs, did not have enough funding to cover the expense of improving the infrastructure and updating the medical equipment In

2008, the Vietnamese government issued Decree No 47 to financially invest in all DHs in the country and Decree No 950 for increasing investment in all commune

HSs in the disadvantaged areas (MOH, 2013) In addition, some provinces increased investment in improving the living conditions through offering housing subsidies

In 2014, the Vietnamese government issued Decree No 117 to promote the primary health professionals Before 2015, the health professionals at the commune level were contract workers Working at the commune level health centers was regarded as unstable employment After the issue of Decree No.117, the health professionals who had been working longer than 36 months could be promoted the status of civil servants This provided good motivation for rural health professionals

Moreover, through other research related to doctor attraction and retention such as Vujicic (2010b), Eric Keuffel (2017), Barnighausen and Bloom (2009), Blaauw et al (2010), the study compiled an initial list of potential attributes for

recruiting medical students

Box 4.1: Initial list of potential attributes

 Opportunity for higher long term education

 Opportunity to become permanent staff

 Availability of equipment

 Skill development and supportive supervisor

 Length of contract

4.1.2 Focus Group Discussion

After having the list of potential job attributes, the study revised and brought

to focus group discussions (FGDs) to identify the final list of attributes and levels for DCEs The FGDs included eight medical students from eight medical schools in Vietnam

The FGDs participants firstly was asked questions about their experience living in rural areas and working in the health sector Then they also was asked about the knowledge and perceptions of the current policies in Vietnam to encourage young doctor to work in rural areas Besides, they also were provided information about the health care services in rural areas and the strategies on recruitment and retention of health workforce in Vietnam

Next, the participants were given question on what aspects they would consider to accept working in rural area upon graduation They were asked individually to rank the most important attributes encouraging them to choose rural After that, the participants will discuss each attribute and identify levels which were realistic and appropriate in rural area The discussion was continued until get the final list of attributes and levels

Based on the result of FGDs, the final version included six attributes including salary, housing, skill development and supportive supervisor, higher long term education, career promotion, equipment (Table 4.2)

Table 4.2: Attributes and levels for DCEs in studying preference of medical

1 5.000.000

2 10.000.000

3 15.000.000

4 20.000.000 Equipment Equipment includes the facilities

and tool that support for the

1 Adequate

2 Inadequate

works of doctors The criteria adequate and inadequate are

government standard package for each type of hospital

Long term

education

This attribute means that after graduating if the medical student practice in rural areas for 2 or 3 years, they will have the opportunity to go back to their formal medical university for training or study to obtain a specialization degree

1 Possibility to enter advance medical training after 2 years

2 Possibility to enter advance medical training after 3 years

1 No skill development program

2 Short term course and supportive supervisor

Housing The attribute indicates if the

government provide free house

or giving an allowance which is nearly one million VND per month or not

at the beginning time, they can become the permanent staff

1 Permanent staff after 2 years

2 Permanent staff after 1 year

3 Permanent staff upon posting