DDI_IDN_1997_ADRA_v01_M
Olivier Dupriez
2010-10-24
NADA
Version 01 (October 2010)
Attracting Doctors to Rural Areas 1997
ADRA 1997
IDN_1997_ADRA_v01_M
Kenneth M. Chomitz, Gunawan Setiadi, Azrul Azwar, Nusye Ismail and Widiyarti
NADA
Development Research Group
Dataset used for Chomitz, Kenneth, "What do doctors want? developing incentives for doctors to serve in Indonesia". World Bank Policy Research Working Paper Number 1888, May 2001.
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.
Indonesia
Survey of Medical Students: Final year medical students were surveyed at fourteen medical schools.
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.
Sample survey data [ssd]
The scope of IDN 1997 ADRA includes:
- Final year medical students' preferences on locational amenities, compensation packages, and career paths
- Contract doctors' current contract, salary (income), housing conditions, work environment
Mail Questionnaire [mail]
See the following appendixes to the Working paper:
- APPENDIX B 1: Medical Student Survey - Cover sheet
- APPENDIX B2: Background questionnaire, survey of medical students
- APPENDIX B3: Instructions to respondents, medical student questionnaire
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including acronym and year of implementation)
- the survey reference number
- the source and date of download
Example:
Kenneth M. Chomitz et al. Indonesia Attracting Doctors to Rural Areas (ADRA) 1997. Ref. IDN_1997_ADRA_v01_M. Dataset downloaded from http://microdata.worldbank.org on [date].
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.
ppt
Data from 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.
Question 7a (University), b6 (Spouse's birthplace) were dropped for confidentiality.
21348
66
studsp
Data from 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.
10530
63
Date of filling-in questionnaire
Date of filling-in questionnaire
Date of filling-in questionnaire
Date of filling-in questionnaire
Date of filling-in questionnaire
21348
10/23/1977
4/15/1977
4/15/1997
6/12/1997
6/30/1997
6/8/1997
6/9/1997
7/1/1997
7/10/1925
7/10/1997
7/11/1997
7/12/1997
7/13/1997
7/14/1908
7/14/1997
7/15/1997
7/16/1937
7/16/1997
7/17/1997
7/18/1997
7/19/1937
7/19/1989
7/19/1993
7/19/1997
7/2/1997
7/20/1997
7/21/1997
7/22/1997
7/23/1977
7/23/1997
7/24/1997
7/25/1937
7/25/1997
7/26/1987
7/26/1997
7/27/1997
7/28/1979
7/28/1997
7/29/1997
7/30/1997
7/31/1997
7/4/1997
7/5/1997
7/6/1997
7/7/1997
7/8/1977
7/8/1987
7/8/1997
7/9/1997
8/1/1997
8/10/1997
8/11/1997
8/12/1997
8/13/1997
8/14/1997
8/15/1997
8/18/1997
8/19/1997
8/2/1997
8/20/1997
8/21/1997
8/23/1997
8/24/1997
8/25/1997
8/26/1997
8/27/1997
8/28/1997
8/29/1997
8/3/1997
8/4/1997
8/5/1997
8/6/1997
8/7/1997
8/8/1997
8/9/1997
Province of posting
Province of posting
Province of posting
Province of posting
Province of posting
Wilayah Propinsi tempat anda bertugas saat ini: [province of posting]
21348
Not java
1
Java
Health center or not
Health center or not
Health center or not
Health center or not
Health center or not
Saat ini, anda bertugas di: [health center/not at health center]
21348
1
Health center
2
Not at health center
Remoteness
Remoteness
Remoteness
Remoteness
Remoteness
21276
72
1
Remote
2
Non remote
3
Very remote
Sysmiss
Location
Location
Location
Location
Location
21276
72
1
Provincial capital
2
Other city
3
Rural area
Sysmiss
Accessibility
Accessibility
Accessibility
Accessibility
Accessibility
21276
72
1
1
2
2
3
3
Sysmiss
A5B
A5B
A5B
A5B
A5B
21276
72
1
1
2
2
3
3
Sysmiss
A5C
A5C
A5C
A5C
A5C
21276
72
1
1
2
2
3
3
Sysmiss
Length of time to reach county seat
Length of time to reach county seat
Length of time to reach county seat
Length of time to reach county seat
Length of time to reach county seat
21348
1
< 1 hour
2
1-4 hours
3
4-24 hours
4
> 24 hours
Graduation year
Graduation year
Graduation year
Graduation year
Graduation year
21348
26
97
94.11
3.406
Age
Age
Age
Age
Age
21348
21
71
29.847
3.603
Sex
Sex
Sex
Sex
Sex
21348
1
Male
2
Female
Place of birth
Place of birth
Place of birth
Place of birth
Place of birth
21348
Not born in Java
1
Born in Java
Place brought up
Place brought up
Place brought up
Place brought up
Place brought up
21348
1
Village
2
Town
3
County seat
4
Jakarta
5
Abroad
6
Other
7
7
Marital status
Marital status
Marital status
Marital status
Marital status
21348
1
Not married
2
Married
Number of children
Number of children
Number of children
Number of children
Number of children
14052
7296
5
1.079
0.847
Preference for this location
Preference for this location
Preference for this location
Preference for this location
Preference for this location
21348
1
1st choice
2
2nd choice
3
3rd choice
4
Not among choices
Date of registration as contract doctor (month)
Date of registration as contract doctor (month)
Date of registration as contract doctor (month)
Date of registration as contract doctor (month)
Date of registration as contract doctor (month)
21348
1
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
Date of registration as contract doctor (year)
Date of registration as contract doctor (year)
Date of registration as contract doctor (year)
Date of registration as contract doctor (year)
Date of registration as contract doctor (year)
21348
78
80
82
87
88
89
90
91
92
93
94
95
96
97
Date reported for assignment (month)
Date reported for assignment (month)
Date reported for assignment (month)
Date reported for assignment (month)
Date reported for assignment (month)
21348
1
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
Date reported for assignment (year)
Date reported for assignment (year)
Date reported for assignment (year)
Date reported for assignment (year)
Date reported for assignment (year)
21348
78
79
80
83
87
88
89
90
91
92
93
94
95
96
97
Whether received orientation
Whether received orientation
Whether received orientation
Whether received orientation
Whether received orientation
21348
1
No
2
Yes
Usefulness of orientation
Usefulness of orientation
Usefulness of orientation
Usefulness of orientation
Usefulness of orientation
20316
1032
1
Not useful
2
Rather useful
3
Very useful
Sysmiss
Date began work at this health center (month)
Date began work at this health center (month)
Date began work at this health center (month)
Date began work at this health center (month)
Date began work at this health center (month)
21276
72
1
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
Sysmiss
Date began work at this health center (year)
Date began work at this health center (year)
Date began work at this health center (year)
Date began work at this health center (year)
Date began work at this health center (year)
21276
72
78
79
83
90
91
92
93
94
95
96
97
Sysmiss
At least one civil service doctor at this health center
At least one civil service doctor at this health center
At least one civil service doctor at this health center
At least one civil service doctor at this health center
At least one civil service doctor at this health center
21276
72
1
No
2
Yes
Sysmiss
At least one other contract doctor at this health center
At least one other contract doctor at this health center
At least one other contract doctor at this health center
At least one other contract doctor at this health center
At least one other contract doctor at this health center
21276
72
3
No
4
yes
Sysmiss
One doctor explained duties at health center
One doctor explained duties at health center
One doctor explained duties at health center
One doctor explained duties at health center
One doctor explained duties at health center
Did one of this doctors explain your duties at the health center?]
21276
72
1
1
2
2
3
3
Sysmiss
Average number of patients served per day
Average number of patients served per day
Average number of patients served per day
Average number of patients served per day
Average number of patients served per day
21348
304
34.615
31.438
Number of subcenters reporting to this center
Number of subcenters reporting to this center
Number of subcenters reporting to this center
Number of subcenters reporting to this center
Number of subcenters reporting to this center
21348
65
3.734
3.712
Nb days per month spent on average at health center
Nb days per month spent on average at health center
Nb days per month spent on average at health center
Nb days per month spent on average at health center
Nb days per month spent on average at health center
21348
90
19.835
7.175
Nb days per month spent on average at subcenter/in the field
Nb days per month spent on average at subcenter/in the field
Nb days per month spent on average at subcenter/in the field
Nb days per month spent on average at subcenter/in the field
Nb days per month spent on average at subcenter/in the field
21348
50
6.96
5.453
Average nb days per month you have activities at county seat
Average nb days per month you have activities at county seat
Average nb days per month you have activities at county seat
Average nb days per month you have activities at county seat
Average nb days per month you have activities at county seat
21348
60
3.149
4.311
Average days per month outside kabupaten
Average days per month outside kabupaten
Average days per month outside kabupaten
Average days per month outside kabupaten
Average days per month outside kabupaten
21348
99
13.5
14.81
Nb patients/day personally serve at health center
Nb patients/day personally serve at health center
Nb patients/day personally serve at health center
Nb patients/day personally serve at health center
Nb patients/day personally serve at health center
21348
605
18.25
22.963
Electricity at health center
Electricity at health center
Electricity at health center
Electricity at health center
Electricity at health center
21276
72
1
Yes
2
No
Sysmiss
Availability of medicine at health center
Availability of medicine at health center
Availability of medicine at health center
Availability of medicine at health center
Availability of medicine at health center
21276
72
1
Good
2
Adequate
3
Inadequate
Sysmiss
Availability of equipment at health center
Availability of equipment at health center
Availability of equipment at health center
Availability of equipment at health center
Availability of equipment at health center
21276
72
4
Good
5
Adequate
6
Inadequate
Sysmiss
Telephone available within 500 meters of health center
Telephone available within 500 meters of health center
Telephone available within 500 meters of health center
Telephone available within 500 meters of health center
Telephone available within 500 meters of health center
20628
720
1
1
2
2
Sysmiss
Radio SSB available within 500 meters of health center
Radio SSB available within 500 meters of health center
Radio SSB available within 500 meters of health center
Radio SSB available within 500 meters of health center
Radio SSB available within 500 meters of health center
20388
960
3
3
4
4
Sysmiss
Other communication available within 500 meters of health center
Other communication available within 500 meters of health center
Other communication available within 500 meters of health center
Other communication available within 500 meters of health center
Other communication available within 500 meters of health center
18024
3324
5
5
6
6
Sysmiss
Stay in officially-provided housing
Stay in officially-provided housing
Stay in officially-provided housing
Stay in officially-provided housing
Stay in officially-provided housing
21276
72
1
Yes
2
No
Sysmiss
Condition of housing
Condition of housing
Condition of housing
Condition of housing
Condition of housing
21276
72
1
Good
2
Needs some repair
3
Needs much repair
Sysmiss
House has electricity
House has electricity
House has electricity
House has electricity
House has electricity
21276
72
1
Yes
2
No
Sysmiss
Command of local language
Command of local language
Command of local language
Command of local language
Command of local language
21276
72
1
Speaking and listening
2
Listening and some speaking
3
Listening only
4
None
Sysmiss
Average additional income/month outside of official salary
Average additional income/month outside of official salary
Average additional income/month outside of official salary
Average additional income/month outside of official salary
Average additional income/month outside of official salary
21276
72
1
< Rp. 200.000
2
Rp. 200,000 to 400,000
3
Rp. 400,000 to 600,000
4
Rp. 600,000 to 800,000
5
Rp. 800,000 to 1,000,000
6
> Rp. 1,000,000
Sysmiss
21276
72
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
Sysmiss
Date of end of contract (month)
Date of end of contract (month)
Date of end of contract (month)
Date of end of contract (month)
Date of end of contract (month)
21276
72
1
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
Sysmiss
Date of end of contract (year)
Date of end of contract (year)
Date of end of contract (year)
Date of end of contract (year)
Date of end of contract (year)
21276
72
1997
1998
1999
2000
Sysmiss
Most likely plans after contract completion
Most likely plans after contract completion
Most likely plans after contract completion
Most likely plans after contract completion
Most likely plans after contract completion
21276
72
1
Civil service
2
Continue education
3
Private sector medical
4
Change profession
5
Unemployment
Sysmiss
Preferred place of residence after contract completion
Preferred place of residence after contract completion
Preferred place of residence after contract completion
Preferred place of residence after contract completion
Preferred place of residence after contract completion
21276
72
1
Jakarta
2
Capital of this province
3
Capital of some other province
4
Other city in this province
5
Other city in other province
6
Rural area
Sysmiss
Expected length of unemployment after contract completion
Expected length of unemployment after contract completion
Expected length of unemployment after contract completion
Expected length of unemployment after contract completion
Expected length of unemployment after contract completion
21276
72
1
< 1 month
2
1-3 months
3
3-6 months
4
> 6 months
5
Won't seek work
Sysmiss
Expected post-contract salary
Expected post-contract salary
Expected post-contract salary
Expected post-contract salary
Expected post-contract salary
21348
9900000
1924867.907
1226925.093
Expectation of employer-provided housing, post-contract
Expectation of employer-provided housing, post-contract
Expectation of employer-provided housing, post-contract
Expectation of employer-provided housing, post-contract
Expectation of employer-provided housing, post-contract
21276
72
1
Yes
2
No
Sysmiss
Expectation of employer-provided vehicle, post-contract
Expectation of employer-provided vehicle, post-contract
Expectation of employer-provided vehicle, post-contract
Expectation of employer-provided vehicle, post-contract
Expectation of employer-provided vehicle, post-contract
21276
72
1
Yes
2
No
Sysmiss
KODE
KODE
KODE
KODE
KODE
21348
131
711601
117346.835
65047.752
QN
QN
QN
QN
QN
21348
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
PANJANG
PANJANG
PANJANG
PANJANG
PANJANG
21348
1
1
VERSION
VERSION
VERSION
VERSION
VERSION
21348
1
50
25.227
14.544
SALARY
SALARY
SALARY
SALARY
SALARY
21348
500
3000
1541.559
828.419
LENGTH
LENGTH
LENGTH
LENGTH
LENGTH
21348
1
1
2
2
3
3
COMPETIT
COMPETIT
COMPETIT
COMPETIT
COMPETIT
21348
1
1
2
2
TRAINING
TRAINING
TRAINING
TRAINING
TRAINING
21348
30
15
11.181
SEMINAR
SEMINAR
SEMINAR
SEMINAR
SEMINAR
21348
1
1
2
2
3
3
4
4
HOUSE
HOUSE
HOUSE
HOUSE
HOUSE
21348
1
1
CAR
CAR
CAR
CAR
CAR
21348
1
1
10530
1
10530
500
3000
1645.584
879.665
10530
500
3000
1566.239
845.566
10530
10
90
51.14
28.021
10530
10
90
48.877
28.494
10530
10
90
49.578
28.403
10530
10
90
50.403
28.149
10530
1
50
25.234
14.69
10530
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
10530
1
2
3
10530
1
2
3
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
10530
1
585
293
168.883
10530
60
62
63
64
65
66
67
68
69
70
71
72
73
74
75
10530
82
83
84
85
86
87
88
89
90
91
92
93
10530
8
99
17.679
21.499
10458
72
1996
1997
1998
1999
2000
2001
Sysmiss
10530
99
6.412
20.779
10530
99
2.318
12.772
10530
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
10530
1
10530
1
10530
1
10530
1
2
3
684
9846
1
2
3
Sysmiss
10530
1
2
3
4
5
10530
1
10530
1
10530
1
10530
-2
-1
1
2
10530
-2500
2500
79.345
1299.327
10530
-80
80
2.262
44.6
10530
-80
80
-0.824
45.678
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
-1
1
10530
1