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