Family physicians’ location decisions in Vietnam
In 2015, the World Health Organization (WHO) and World Bank released a report announcing that at least 400 million out of the 7.2 billion people on earth, about one-fifteenth of the global population, lack access to essential health services (WHO, 2015). One measure of health care access is having an adequate health workforce to provide a regular source of care (Starfield, Shi, & Macinko, 2005). Alarms signaling a health workforce shortage are growing more urgent from the most developed to the poorest countries (Johnson, 2008). Another WHO report warns the current shortage of 7.2 million skilled health professionals (midwives, nurses, and physicians) will increase to 12.9 million by 2035 (Truth, 2013). The three key causes are an aging health workforce with staff leaving without being replaced, not enough young people entering the profession, and increasing risks of non-communicable diseases (Crisp, 2010; Truth, 2013). One of the main recommended actions by WHO to address health workforce shortages in the era of universal health coverage is to maximize the role of health workers in primary health care (PHC) and family medicine (FM), the heart of PHC, in order to make frontline health services more accessible (Khayyati et al., 2011; Truth, 2013; Van Lerberghe, 2008). However, in developing and under-developing countries, it is the critical shortage of PHC and FM health workforce, especially in socioeconomically disadvantaged areas, that is considered as one of the greatest challenges in meeting the nationwide health coverage (Celletti, Holloway, De Cock, & Dybul, 2007; Dussault & Franceschini, 2006; Jerome & Ivers, 2010; Kober & Van Damme, 2004; Organization, 2014). Strategies to boost nationwide health coverage by attracting and retaining family physicians in socioeconomically disadvantaged areas vary according to different context fragmentation of health systems of each country (Campbell, Braspenning, Hutchinson, & Marshall, 2002; Dieleman, Cuong, & Martineau, 2003; Dussault & Franceschini, 2006; Huicho et al., 2010; Mandeville, Lagarde, & Hanson, 2014; Mathauer & Imhoff, 2006; Willis-Shattuck et al., 2008).
In Vietnam, lack of access to PHC is a widely acknowledged problem (G. Bloom, 1998; Duong, Binns, & Lee, 2004; Fritzen, 2007; Gien et al., 2007; Huong, Van Minh, Janlert, & Byass, 2006; Khe et al., 2002; Montegut, Cartwright, Schirmer, & Cummings, 2004). Physicians often complete training in urban medical centers and end up setting their initial practice in an urban location, further exacerbating the problem in rural and remote areas. According to government figures, the patient capacity rates in urban public hospitals range from 150 to 250 percent (Swenden, 2015). The extreme overcrowding gives rise to a paradox: even in central hospitals with the highest concentration of doctors, the medical personnel shortage is still severe enough to attract more doctors to come there, creating a more severe doctor shortage situation in the rural areas.
Critically, the chronic doctor shortage experienced by underserved areas in Vietnam has brought a concern for the reduction on continuity of care and lack of trust by patients. Given its expertise in outpatient clinical care across the life span of patients, FM, which has been a first-degree specialty since 2001, becomes an ideal fit to partially relieve the doctor shortage in underserved areas, thus improves PHC in Vietnam. However, despite the gradually increased number of trainees enrolled in recent years, the number of family physicians with rural working experiences is much smaller than those who did not. Furthermore, only a small portion of FM graduates decided to return to community health stations after getting their degree (Le, 2011).
A number of strategies were implemented to develop health human resources in underserved areas in Vietnam, categorizing into four broad categories: education, regulations, financial incentives, and personal and professional support. However, the promulgated policies have been considered inefficient. Moreover, currently, there is no policy to attract and retain family physicians to underserved areas in Vietnam. Proposing strategies to encourage family doctors to work in rural settings is still an underexplored area in the literature. This study seeks to add to the dearth of knowledge in this area, discussing the findings of a literature review of factors that influence health workers’ decision of job location in the context of different countries in general and Vietnam in particular; and the preliminary findings of the qualitative research with family doctors in Vietnam.
- Health care profile of Vietnam
Vietnam has a long history of being ruled by foreign powers and fighting for its independence. On September 2, 1945, Ho Chi Minh proclaimed the independent Democratic Republic of Vietnam, free of French colonial rule. In 1954, Vietnam was temporarily divided into North and South by the Geneva Accords. The North, led by Ho Chi Minh, followed a socialist orientation and the South was under the Bao Dai regime which was supported and influenced by the French and the U.S. government.
The North-South divide and the associated ideological orientations within these two parts of Vietnam are reflected in the government policies enacted. For instance, while health care in the South followed a market system of operation, the communist ideology in the North called for equity as the top priority, hence, government health care policies in the North aimed at ensuring equal access to health care for everyone (Ha, Berman, & Larsen, 2002). The government in the North not only invested heavily in its PHC system but also boosted the percentage of population with access to preventive and curative health services (Fritzen, 2007).
After the fall of the government in the South in 1975, the North and South of Vietnam were reunited to form the Socialist Republic of Vietnam. After the unification, the government made efforts to continue its principal goal, providing free health services for all people nationwide. Unfortunately, the health system in the South had been disrupted due to the civil war between the North and South and was barely functioning as a result of issues such as limited public health budget, thinly spread skilled health care workers, and serious shortages of basic equipment and drugs. However, the pursuit of free health care after the unification increased access to health care services (Ha et al., 2002).
In 1986, “Doi Moi”, an economic reform was initiated with the goal of creating a market-driven economy after the abolition of the command economy. The Doi Moi reform, marking the integration of Vietnam into the international political economic system after decades of isolation, led to dramatic social and economic changes (Dinh, 1999; Riedel, 1997). However, at the same time, income disparities increased in what had been a remarkably egalitarian society (Dinh, 1999; Heo & Doanh, 2009). Additionally, the privatization of services, including health care, drove up prices. The public health service saw several changes such as the introduction of service and drug fees at market rates (Segall et al., 2002). As a result, access to health care services dropped—for example, outpatient visits per capita per annum decreased from 2.1 in 1987 to 0.9 in 1993 (Witter, 1996).
Though the transition from a centrally planned to an open market economy marked a significant improvement in health care services, the improvement was not uniform. The intensity of health care services use varied considerably across different geographical regions, urban and rural areas, and amongst various population groups (Thuan, Lofgren, Lindholm, & Chuc, 2008; Tuan, Dung, Neu, & Dibley, 2005). While the high-income populations tended to utilize central hospitals, low-income populations relied heavily on the use of commune health centers (Gien et al., 2007; Khe et al., 2002) or even self-treatment (Thuan et al., 2008). Health professionals, especially the most qualified physicians, tended to move to and concentrate in urban well-to-do areas at their free will, which was not the case under the central planning system. Hence, the district and primary health centers in the rural areas were left mostly with paramedics (Witter, 1996). Meanwhile, overwhelming health problems such as infectious and parasitic diseases in the economically disadvantaged rural areas (Dinh, 1999) and increased number of chronic non-communicable disease since the late 1990s were difficult to tackle without qualified physicians (Harper, 2011; Pham et al., 2009).
Compared with the period right after the Doi Moi, Vietnam’s current health system has achieved significant and lasting improvements, such as reduction in infant mortality rate and improvement in age-specific death ratio (Tien, Phuong, Mathauer, & Phuong, 2011). These improvements are attributed to the positive policy reforms and consensus within the country to prioritize healthcare spending (Tien et al., 2011). Vietnam spends 6.4 percent of its GDP on healthcare, while short of WHO recommendations, is still more than many of its neighboring countries such as Cambodia (5.6 percent), Laos (4.5 percent), Myanmar (2 percent). It is also estimated that per capita health expenditures in Vietnam doubled, from $66 in 2008 to $142 in 2014 (World Bank, 2015; Tien et al., 2011; WHO, 2010). These improvements are also attributed to the widespread health care delivery network comprised of a significant increase in the number of qualified health workers and the expansion of national public health programs (Tien et al., 2011).
However, with an aging and diverse population (92 million people, 56 ethnic groups, and with the population over the age of sixty growing at faster rate) coupled with the dynamics in a market driven economy, Vietnam has been struggling with chronic health care service challenges, particularly with respect to two issues (Asia, 2014). First, there is the burden of increased medical cost because of the increased number of people diagnosed with treatable, long-term non-communicable diseases such as heart disease, cancers, and diabetes. According to the World Bank Report, Asia (2014), chronic and non-communicable diseases account for approximately two-thirds of mortality. Krakauer, Cham, and Khue (2010) reported about 150,000 cancer cases were diagnosed annually in Vietnam, of which 80 percent were in the advanced stages. Second, there is the widening divide between urban versus rural areas in term of quality health care, access to health facilities and physicians, and affordability. For instance, even though only 28 percent of Vietnam’s population live in urban areas, about 53 percent physicians are concentrated in these urban areas (Asia, 2014). Ngoan, Long, Lu, and Hang (2006) reported about 50 percent of cancer patients in the wealthier, northern provinces survived more than one year, while in the rural areas, that number was only between 21-25 percent. Similarly, maternal and child mortality remains higher in economically disadvantaged areas. There are three-fold differences in under-five mortality rates between the lowest and the highest economic quintiles, and the inequalities have increased over time (Asia, 2014).
- Development of Family Medicine in Vietnam
Family Medicine (FM) is at the center of PHC, aiming to reintegrate and personalize health care for patients. It is a move from traditional physician-centered to patient-centered models of care and is the cornerstone of providing community-based care. There are a very unique set of attributes differentiating family physicians from other specialists. A family physician is able to 1) address all health problems that are present to him/her from an entire population, 2) provide continuous and comprehensive medical care, and 3) equip patients with knowledge of disease prevention, health promotion, psychological support, and social support (WHO, 2003). Given its expertise in comprehensive disease prevention, health promotion, and collaborative work with the resources of the local community, FM becomes an ideal fit to protect community health, especially in rural and remote areas. Moreover, having a proper FM system in underserved areas would reduce the workload on other health specialists and lower treatment fees. The WHO suggests FM is the core of the world’s efforts to achieve the goal of quality improvement, cost effectiveness, and health equity in the health care system (Khayyati et al., 2011).
The Barefoot doctor is the first form of family physician in Vietnam. The development of barefoot doctor in Vietnam was inspired from China’s tradition of barefoot doctor in past, in which the care from barefoot doctors was developed in order to address China’s healthcare needs in rural areas (D. Li, 2016). The 1960s to late 1980s was the period of barefoot doctors in Vietnam (An Le, Family Medicine Program Director, personal communication, October 9, 2016, University of Medicine and Pharmacy at Ho Chi Minh City). Mostly, barefoot doctors provided medical duties based on the needs of people who lived close by (Wen, 1974). The majority of barefoot doctors originated from farmers and had basic medical knowledge after graduated from primary medical schools with several months of training in public health and primary care.
Massive economic reform since 1986 brought rapid transformation to many socioeconomic aspects, including a health care system barefoot doctors were not able to adapt themselves to. Modernization, convenient transportation, new technologies, and social media explosion caused the cooperative medical system with barefoot doctors as its mainstay to crumble. For example, social media explosion and more convenient means of transportation led to the public lack of trust to engage with barefoot doctors and preferred to squeeze into central hospitals. These changes in the Vietnam’s health system were not planned. First, they were the unintended consequences of economic reforms that exerted direct and indirect effects on the organization, financing, and delivery of health care. Second, they were due to lack of self-learning ability of barefoot doctors to adapt themselves to the development of scientific and technological advancement and the changing nature of health problems that connected with ecological environment and lifestyles (An Le, Family Medicine Program Director, personal communication, October 9, 2016, University of Medicine and Pharmacy at Ho Chi Minh City).
The government of Vietnam, therefore, committed to improve the quality of health workers through training. However, only until 1995, with the support of the China Medical Board, an independent American foundation that aims to advance health in Asian countries through strengthening public health research and education, FM was successfully brought into Vietnam. Family physicians are specially trained to provide comprehensive care for entire family, from prenatal care and the delivery of babies to the care of children, parents, and grandparents. In 2001, MOH established FM as first-degree specialty training program. MOH recently announced a plan to further develop FM in the period 2016-2020, which focusing on training thousands more family physicians to integrate family medicine services in existing PHC network, especially at the grass-roots level, in order to meet the nation’s health care needs.
- Statement of problem
- Primary health care workforce
In Vietnam, lack of access to primary health care is a widely acknowledged problem (G. Bloom, 1998; Duong et al., 2004; Fritzen, 2007; Gien et al., 2007; Huong et al., 2006; Khe et al., 2002; Montegut et al., 2004). The WHO estimates that fewer than 2.3 health workers (physicians, nurses, and midwives only) per 1,000 would be insufficient to achieve coverage of primary health care needs (Scheffler, Liu, Kinfu, & Dal Poz, 2008). In Vietnam, the ratio of health care worker to population is 1.19 per 1,000 population as of 2013 (FactBook, 2013; GSOV, 2017).
Health workers are concentrated in the economically better-off regions. Living and working in remote areas are less desirable for healthcare professionals. This has led to a severe shortage of health professionals at the grass-roots level in the least economically better off areas. In Vietnam, commune health stations (CHSs ) serve as gatekeepers of the public health system and provide primary health care, including both curative and preventive services and referrals to higher levels (Tran, Van Minh, & Hinh, 2013). It is estimated that CHSs manage 80 percent of the local demands for health care in a timely manner (Tran et al., 2013). However, there is a severe shortage of health workers at CHSs, especially CHSs in disadvantaged areas. It is estimated in the poorest 62 districts, only 30 percent of CHSs are staffed with a physician which is below the government’s target of staffing 80 percent of CHSs with physicians. This is partly due to the fact that less than 18 percent of the total health workers currently work at the commune level (Asia, 2014).
The quality of these few health workers in these disadvantaged rural areas also comes into question. It has been noted that these health workers often lack the core competencies to perform PHC services as maternal and child health services, elderly care, and early detection of common non-communicable diseases. For example, in an evaluation of health workers within rural, disadvantaged areas, physicians and physician assistants are not able to provide correct answers to more than 50 percent of the questions on internal medicine and cardiovascular diagnosis (Asia, 2014; Montegut et al., 2004).
Rural population accounts for 72 percent of the total national population; however, only 41 percent of university doctors operate in rural CHSs. Due to the brain drain of health professionals to urban medical centers, many midwives, nurses, and physician assistants function like doctors in CHSs. Also, there is low utilization of the CHSs health care teams among citizens, likely due to people’s lack of confidence in these teams. Meanwhile, it is estimated that 70 percent of patients being treated at national level should and could be treated at provincial level; about 82 percent of patients being treated at the provincial level should and could be treated at the district level, and about 68 percent of patients being treated at the district level should and could be treated at the commune level (Oanh et al., 2009).
Vietnam realizes that strengthening primary care means not only the construction of building and purchase of equipment but to attract high qualified doctors to provide primary care and enhance people’s trust in primary care services in CHSs. Vietnam has a well-developed public health care system with extensive rural coverage (Segall et al., 2000). However, the main drawback of the health system is patients favor health services at provincial and central levels while neglect grassroots level, even though the latter may be more appropriate for their need (Ekman, Liem, Duc, & Axelson, 2008). Building family medicine network in disadvantaged areas is considered the only way to build the public trust in primary care and reduce overcrowding situation in high-level hospitals (Nguyen Van Chau, Director of Ho Chi Minh Department of Health, VN, 2015).
- Legislative instruments related to health care workforce
The National Strategy for People’s Health Care and Protection focuses on health workforce development, particularly at the grass-roots level. Moreover, the National Assembly Resolution No11/2011/QH13 calls for 1) strengthen the health care services at the district and commune level to reduce hospital overload, and 2) develop human resources. This is similar to the government’s National Benchmarks for Commune Health Care (2011-2020) which aims for achieving the goal that all CHSs have an adequate number of health workers and all are continuously trained (Asia, 2014). Vietnam has promulgated several important policies and legislations aimed at improving quality and distribution of human resources at the grass-roots level. Summaries of the most significant policies among the legislative instruments are given below:
Decree 1816/QD-BYT: In 2008, the Government of Vietnam launched Decree 1816 rotating doctors from central and provincial levels to commune level, in which three-month rural service is mandatory for all health professionals. Benefits include an increase in monthly salary (approximately 30 percent of the basic wage, equivalent to 400.000 VND, about US$20) and a certificate of merit. Though Decree 1816 is a high-level political initiative aiming at a reduction in physician shortage in rural and remote areas, several constraints exist. First, many doctors use unofficial ways to avoid mandated rotation. Second, the majority of rotated doctors have inadequate skills. Third, unattractive benefits fail to retain physicians in rural and remote areas.
Decision 75/2009/QD-TTg: Issued by the Prime Minister on May 11, 2009, the Decision entitles health workers in socioeconomically difficult communes to a monthly allowance (approximate 50 percent of the basic wage, equivalent to 600.000 VND, about US$30). The allowance, however, is considered not attractive enough to have a profound impact on physicians’ decisions of job location.
Decree 64/2009/ND-CP: Issued by the Prime Minister on July 30, 2009, the Decree entitles health workers in 2112 listed socioeconomically difficult communes in the Decree to the following benefits: a monthly allowance of 70 percent of current salary, subsidies for study visits, and professional training. However, the allowance was decreased by 40 percent recently due to no central budget allocation for the Decree.
Decision 585/QD-BYT: In 2013, the Ministry of Health operated a bonding program whereby newly graduated medical students were encouraged to deliver healthcare services in a rural area for a set number of years (usually 3 years for male and 2 years for female students). The benefits include a reserved postgraduate diploma course seat and a labor contract to a high-level health facility in an urban area. The bonding program has been expected to attract at least 500 medical students by 2016. At the end of 2015, however, only approximately 40 medical students had volunteered.
In sum, there is little evidence that appropriate interventions and favorable incentives to attract healthcare professionals to rural and remote areas have been promulgated.
- Family doctor retention
Even though family medicine is now an integral part of Vietnam’s health policies, attracting and retaining family physicians to improve PHC in rural areas present some challenges (Montegut et al., 2007). There has been a noticeable proportion of family physicians who have decided not to return to CHSs after earning their family medicine degree. Le (2011), a report conducted by Vietnam Center for Family Medicine in collaboration with Boston University Family Medicine, indicates a mass movement of family physicians from rural to urban areas after earning their specialty degree.
Figure 1 – Retention of family doctors in Vietnam (as of 2011)
Figure 1 shows the retention of family doctors in CHSs. In 2011, there were six medical universities provided family medicine program. The number of family doctors who previously worked in CHSs was relatively smaller than the number of those who did not work at the grass-roots level before seeking family medicine degree. Moreover, there was brain drain of family doctors to higher-level health facilities. The retention rate of family doctors coming back to CHSs after earning their specialty degree was about 40 – 65 percent. The fact of majority of family doctors moving from CHSs to higher-level health sectors was considered due to more opportunities for family doctors in urban areas such as higher income, higher chance of working in/ opening a private clinic (Duyet Pham, Vice president, personal communication, September 19, 2016, University of Medicine and Pharmacy at Haiphong City).
- Summary of what is known and unknown
Few tools have been used to investigate the factors driving health care workers’ decisions of job location. A popular methodology is a cross-sectional survey, which measures outcomes, such as job satisfaction and intention to leave, and evaluates individual, local, and work factors that correlate with those outcomes. The survey tool, however, is unable to reveal the relative importance of these factors over each other (Mandeville et al., 2014). Controlled experiment methodology, meanwhile, cannot be used due to ethical reasons (Mandeville et al., 2014). Another methodology is empirical studies using longitudinal ‘revealed preference’ data on health personnel. However, in many developing countries, the weak information systems for tracking health workers impede longitudinal studies. Recently, discrete choice experiment (DCE), a quantitative methodology to elicit preferences, has become increasingly popular (Mandeville et al., 2014). The DCE technique assumes that individual decisions about a good are determined by the attributes of that good (Hensher, Rose, & Greene, 2005). A systematic review of all the research using DCE in the area of human resources for health is presented after the section of the overall literature of qualitative studies.
- Overall literature of qualitative studies
This section summarizes findings of the literature review on factors impacting on the attraction and retention of doctors in underserved areas. These factors are grouped into three different types of environment surrounding doctors, including personal factors, local factors, and work factors. Personal factors refer to factors which may influence doctors’ decisions, such as age, gender, marital status, origin, and education background; local factors include general living conditions and social environment; and work factors encompass factors related to working environment, such as labor relations, management styles, education opportunity, promotion opportunity, and infrastructure. Even though these factors may interact and influence each other, literature simplifies the complexities of interaction to have a better understanding of each factor.
There have been a number of studies evaluate health workers’ characteristics and location of practice choice. Many studies are in agreement about the relationship between health workers’ decisions of job location and personal characteristics, such as origin, upbringing, marital status, and location of medical school.
First, many studies find a significant correlation between the geographical origin of health workers and their choice of practice location (Chan et al., 2005; Laven & Wilkinson, 2003). Doctors from rural hometowns are more likely to practice rurally than those from non-rural hometowns. Also, there is considerable agreement that rural upbringing increases the probability of opting for rural post (Bellinger, 2009; Mullan & Frehywot, 2008). Rural upbringing characteristic is identified as a significant difference between those who plan and do not plan to practice in a rural area (Royston, Mathieson, Leafman, & Ojan-Sheehan, 2012).
Second, regarding marital status, studies show that single health workers indicate a greater intention to leave work and have higher turnover than married workers (Lexomboon, 2003). J. P. Smith and Thomas (1998) identifies a strong influence of spouses on doctors’ mobility. B. Smith, Muma, Burks, and Lavoie (2012) conducts a nationwide cross-sectional survey of physician assistants and reveals that spouses’ support is the most important factor in these health workers’ choices of job location.
Third, studies show that health workers who previously studied in rural-located medical schools tend to work in rural areas. Thus, a number of countries have established medical schools in underserved areas in an attempt to entice graduates of these schools to work in these areas upon graduation (Curran & Rourke, 2004). Longombe (2009) finds that 81 percent of the graduates from rural-located medical school are employed in rural areas in the province where they were trained, with only 26 percent of the graduates from urban-located medical school are employed in rural areas in the province in which they were trained.
At the same time, there is an inconclusive relationship between decisions of job location and several other personal characteristics. First, the relation of gender and age to decisions of job location is indecisive. While some studies conclude that there is not convincing evidence of a link between gender, age and job location (Bellinger, 2009; Royston et al., 2012), some other studies find scientific evidence support this relationship. For example, Larson, Hart, Goodwin, Geller, and Andrilla (1999) and Wordsworth, Skåtun, Scott, and French (2004) are in agreement with the finding that male workers are more likely to take rural post than female workers. Second, the impact of rural-oriented medical curricula on the likelihood of health workers entering rural practice is unclear. While some studies suggest that it is indeed possible to entice physicians who grew up in urban areas into rural practice through rural-oriented medical curricular emphasis (Chan et al., 2005; Curran & Rourke, 2004), other studies reveal that exposure to rural practice is insignificantly associated with choice of rural practice (Eley & Baker, 2006; Rourke, 2010).
The literature is unanimous in indicating the profound impact of general living environment on decisions of job location. When health workers are asked what factors would make them hesitate to take rural postings, general living conditions, such as staff accommodation, schools, qualified teachers, electricity, good drinking water, roads, and transports, feature prominently in all literature. When respondents are asked what would attract them to remain in rural areas, again issues of general infrastructure, such as good schools and good drinking water, are most common (Kim, 2000; Kunaviktikul et al., 2001).
Financial incentives and non-pecuniary incentives, such as professional support, education, and regulation, have been identified as being vital factors in the attraction and retention of health workers in underserved areas. Literature reviews indicate that both financial and non-pecuniary incentives are essentially important to address the issue of health professional shortage areas. While higher salary is positively associated with increasing intention to stay work (Ditlopo, Blaauw, Bidwell, & Thomas, 2011; Kunaviktikul et al., 2001), there are other deciding factors influence health workers’ decisions. Awases, Gbary, Nyoni, and Chatora (2004) finds that only 24 percent of respondents cite better remuneration as the main reason for leaving, to give an example. Working conditions, including organizational arrangements, management support, availability of equipment, and appreciation by the community, are other particularly important factors in deciding whether to leave or stay in rural and remote areas (Awases et al., 2004; Buchan, 2004; Dieleman et al., 2003; Zurn, Dal Poz, Stilwell, & Adams, 2004).
The relationship between non-financial incentives and choice of rural practice varies in different context. For example, J. R. Bloom, Alexander, and Nichols (1992) finds no correlation between opportunity for career advancement and willingness to serve in rural areas for a set number of years. By contrast, Awases et al. (2004) reveals that health workers readily deliver health care service in underserved areas in exchange for a subsidized further professional training course after finishing their rural mission.
- A systematic review of discrete choice experiment studies
This section presents a review of discrete choice experiments looking at the health workers’ preferences of job location. I searched for discrete choice experiments that examine health workers’ preferences of job in urban versus rural areas. I searched Google Scholar and Global Health with the scope including all health workers such as doctors, nurses, pharmacists, in all high-, middle-, and low-income countries, no time restrictions, and all studies in English. Twenty-six studies were included.
In sum, jobs in health area are characterized by several attributes such as salary, location, private clinic, infrastructure, equipment, management style, training, promotion, workload, housing, and transportation (Blaauw et al., 2010; Honda & Vio, 2015; Huicho et al., 2012; Kolstad, 2011; Kruk et al., 2010; Mandeville et al., 2014; Miranda et al., 2012; Song, Scott, Sivey, & Meng, 2015). In these 26 DCE studies, the job attributes and attribute-levels are identified through literature and/ or policy reviews and qualitative work such as focus group, a pilot study with target population and policy makers.
Overall, the majority (25/26) of DCE studies were published within the last ten years and all, except three, were carried out in low- and middle-income countries (see Figure 2 below). Of the 25 studies, 18 studies published within the last five years, between 2012 and 2016, and only three of them (Holte, Kjaer, Abelsen, & Olsen, 2015; J. Li, Scott, McGrail, Humphreys, & Witt, 2014; Scott et al., 2013) were carried out in developed countries, Australia and Norway. With all DCEs set in low- and middle-income countries since 2007, the call to explore how health workers could be incentivized to work in underserved areas is needed. Doctors, nurses, and medical students are the most studied cadres, in which studies focusing on doctor cadre account for nearly 50 percent of all DCE studies (12/26 studies). In contrast, only three studies look at mid-level cadres; one study focuses on medical assistants (Rockers et al., 2013) and the two others focus on clinical officers (Kolstad, 2011; Takemura, Kielmann, & Blaauw, 2016).
Figure 2 – Publication date of reviewed DCE studies
Though studies pool results from heterogeneous subgroups, they extrapolate these results to whole health worker population (Lagarde, Pagaiya, Tangcharoensathian, & Blaauw, 2013; Rockers et al., 2013; Vujicic, Alfano, Ryan, Wesseh, & Brown-Annan, 2010). Of the 12 studies that study doctor cadre, only three studies focus on the specific type of medical specialist (J. Li et al., 2014; Rafiei, Arab, Rashidian, Mahmoudi, & Rahimi-Movaghar, 2015; Robyn et al., 2015). All other studies generalize findings pooled from heterogeneous sample to the whole population. Moreover, some studies oversample or undersample. For example, characteristics of the final sample of doctors in Vujicic et al. (2010) differ from those provided by the health worker census since the study undersamples district and oversampled provincial and national doctors.
Generalization of target participants’ incentives and findings beyond a single study and even beyond single subgroup is challenging. According to Campbell et al. (2002), findings of interventions may only be applied locally and internally. Lagarde and Blaauw (2009) and Mandeville et al. (2014) point out that the relative importance of different incentives varies according to context and the skills of health professionals. In Blaauw et al. (2010), nurses’ preferences for each intervention vary significantly among three countries Kenya, South Africa, and Thailand. While in Kenya and South Africa, salary and educational opportunities would influence most nurses’ decisions, nurses in Thailand evaluate health insurance coverage the highest. Moreover, different subgroups in same study setting also hold different preferences. For example, Vujicic et al. (2010) finds that location of the workplace is the most important attribute for doctors, but long-term education benefit is the most important attribute factor for medical students.
- Vietnam context studies
Few studies focus on healthcare providers in Vietnam. These studies have yielded mixed findings of effective interventions. Dieleman et al. (2003), Ngoc (2008), and Oanh (2012) bring a “laundry list” of deciding factors, including adequate remuneration, being local natives or having families living locally, good working conditions, appreciation by managers, colleagues, and the community, training opportunities, and a stable job. Witter, Ha, Shengalia, and Vujicic (2011) and Nguyen (2011), meanwhile, reveal that salary is the most crucial factor encourages doctors to take up a rural post. By contrast, findings from Vujicic et al. (2010), the only DCE-based study focusing on Vietnam health care workers, suggest that long-term education is the most effective instruments to recruit doctors to work in rural areas.
All studies focus on healthcare workers in general but ignore their different specialties, including family medicine specialty, and subjective preference variability regardless. Literature, meanwhile, suggests that interventions should vary according to the stage of life of the health care workers. In addition, it is particularly important to have interventions tailored to the professional needs of health workers (Honda & Vio, 2015). In terms of methodology, Vujicic et al. (2010) is the only quantitative study to explore the key factors influence health care workers’ decisions. However, studies that have final sample representing doctor population rather than focusing on specific specialty or the stage of life of the health care workers, which could lead to inappropriate incentive findings.
- The progress and findings of the qualitative research
The preliminary findings of this qualitative study are pooled from extensive practice including literature and policy reviews, a focus group with doctors currently study or practice family medicine specialty, and in-depth interviews with key decision-makers at national and provincial levels. There are eight universities providing family medicine training program in Vietnam. This study is conducted in Haiphong University of Medicine and Pharmacy (HPMU), which has been considered as one of major family medicine training institutions in Vietnam. Figure 3 illustrates the qualitative component used to elicit the feasible interventions.
Figure 3 – Qualitative component
Literature & policy review
factors & levels
factors & levels
The first stage of the questionnaire development phase involves literature and policy reviews. The findings of this stage are discussed in the previous sections. Regarding literature review, the scope of the review is DCE studies and studies focus on Vietnam context which all look at job preferences of doctors and physician assistants. Regarding policy review, the scope of the review is all legislative instruments incentivizing health workers to work in underserved areas in Vietnam. I look at policy documents and government reports. All the factors in literature review and benefits offered to health workers in policy reviews are combined (Table 1) and used for next stage.
Table 1 – All possible factors
|Equipment and drugs|
|Night shifts (call) per month|
|Number of years you have to wait to be promoted|
|Presence of a consultant in the facility|
|Time in post before getting permanent job|
|Free days for continuous medical education|
|Performance-based financial award|
|Opportunities for social interaction (face-to-face, email, travel, etc.)|
|Arranging a locum on short notice|
|Practice team (the primary health care team with whom the doctor would be working)|
|Average consultation length (a proxy for workload intensity)|
|Respect from the community|
|Short-term training (skills development)|
|Long-term education (specialist training)|
With these factors in mind, the next stage is to conduct a focus group with family doctors to refine these factors based on the choices family doctors actually make concerning work-setting alternatives in Vietnam. Six family doctors participate in the focus group to probe factors that might influence their job decisions. These six participants are chosen purposely. Three of them are currently studying family medicine specialty in HPMU, of which one is working as a general doctor in HPMU, one is working as a physician assistant in a district level health facility, and one is working as a physician assistant in a CHS in Haiphong. The three other ones are serving as family doctors in HPMU, of which one is teaching family medicine specialty in HPMU and one is operating a private health facility. The focus group is conducted at HPMU. The question guide for the focus group with these family doctors focus on what factors would influence their job decision. All the desired factors stated by the focus group participants are included in the factors package generated from the first stage (Table 1). Then, the participants are asked to rank the factors in Table 1 from the most preferred to the least. After this stage, five most preferred factors are selected. Table 2 comprises top five ranked factors by participants.
Table 2 – Ranked factors
|1 (6)||Net monthly income|
|1 (6)||Living condition|
|2 (5)||Process to start private medical practice|
|2 (5)||Career development|
The income factor includes government salaries for health workers, calculated by standard scale, and allowances comprised of experience allowances and allowances of responsibilities, mobility, initial allowance, area shifting for health professionals in disadvantaged areas. The income factor has many suggested levels, ranging up to 300 percent increase. Career development factor represents the number of years to be spent in a facility until eligible for promotion; it is considered as a vital factor which significantly influences family doctors’ decisions. All participated family doctors agree that the factor which might influence their decision is being promoted within one year. The factor of the process to start private medical practice is another important factor, which also partly distinguishes the family medicine specialty degree from those of other medical specialties. In Vietnam, the option of prohibiting private practice is not realistic for policy makers. However, only family doctors are allowed to open a private clinic that provides treatments from a variety of medical specialties without hiring medical professionals of other specialties. Family doctors need to meet the documentary and regulatory requirements, which are considered as a hindrance to open a private medical practice. The fourth factor, living condition, is actually an umbrella factor encompassing housing, transport, schooling and social activities such as entertainment, restaurants et al. All these aspects of life are implicitly present in the living condition factor. This factor also influences the choice of workplace among health workers. It could be CHSs in rural areas or district, provincial and national health facilities in relatively urban and urban areas. The last factor is equipment in a health care facility, including medical tools and facilities needed to support medical work.
Following the focus group with family doctors is in-depth interviews with key decision-makers at national and provincial levels to capture their views relating to the top five interventions suggested focus group with family doctors. Interventions have to be relevant for policy makers because it is the policy makers who could and might alter or implement them. The questions for the policy makers focus on problem identification, their perception of feasible interventions, and the feasibility of the top five interventions pooled from a focus group. Equipment in health facility was often mentioned by family doctors, but policy makers consider that interventions inappropriate due to two reasons: 1) majority of CHSs are currently well-equipped with support from both national resource and foreign funding, 2) MOH and provincial Departments of Health are implementing many projects upgrading CHSs with all necessary medical equipment so that commune family doctors can perform diagnostic procedures without referring patients to hospitals. Since the characteristics of family medicine are to perform simple diagnosis, provide primary care, and treat common diseases rather than limit to particular disease treatment, not much advanced equipment need to be allocated to this level. Therefore, the factor of well-equipped health facility was discarded. The other four job factors: income, career development, living condition, and process to start private medical practice were considered as feasible by all interviewed policy makers. However, for the income intervention, the highest feasible level increase was 100 percent. Table 3 summarizes the final factors have the highest influence on family doctors’ job decision as well as being considered as feasible by policy makers.
Table 3 – Feasible interventions
|Career development||Be promoted within 1 year|
|Living condition||Urban vs. Rural|
|Process to start private medical practice||Hard vs. Easy|
As far as I am aware, the majority of studies on health workforce have focused on health workers in general while disregarded their medical specialty. However, a large sample representing wide variability in preferences could indeed yield less precise results than a small, more homogenous sample. Since health care workers of different specialties often have various options in the labor market, a significant risk accompanies using findings from a study which employs heterogeneous sample to inform general recruitment and incentive policies that apply to the entire workforce. In Vietnam, the preferences of family physicians have never been investigated properly, though family medicine has gradually formed the backbone of the primary health care.There exists a gap in the literature of feasible interventions influencing the deployment and retention of family physicians in rural and remote areas in Vietnam. This research is the first study to examine which factors influence family physicians’ choice of practice location in Vietnam. The findings pooled from this study can be fed into the design of a discrete choice experiment of attracting family doctors to rural Vietnam.
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