Rural practice preferences of medical students in Ghana: a discrete choice experiment

1. Rural practice preferences of medical students in Ghana: a discrete choice experiment Margaret E. Kruk, MD, MPH Department of Health Policy and Management Columbia University Mailman School of Public Health

2. Research team Margaret E. Kruk Jennifer C. Johnson Mawuli Gyakobo Peter Agyei-Baffour Kwesi Asabir S. Rani Kotha Janet Kwansah Emmanuel Nakua Rachel C. Snow Mawuli Dzodzomenyo Kruk ME, Johnson JC, Gyakobo M, et al. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ. May 2010;88(5):333-341.

3. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

4. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

5. Establishing preferences: random utility theory • Random utility theory states that: • A good or service can be described on the basis of its characteristics • The individual’s value for the good or service depends on the levels of those characteristics • Assumes that users are economically rational and utility maximizing • Utility is a latent construct; all we observe is the choice made

6. Random utility model • Utility of an alternative (of several options) is a function of its component attributes and attribute levels such that Yiq is the utility of individual q for the ith alternative: where Xiq is the vector of attributes for the ith choice facing individual q and εiqis the error due to taste heterogeneity and measurement error Lancaster K. A new approach to consumer theory. The Journal of Political Economy. 1966;74:132-157

7. Utility function • Dependent variable is alternative chosen (A, B, or C) • A generic utility function is modeled as: where is the change in utility from moving from alternative A to alternative B, X is the difference in attribute levels between A and B, and are the coefficients to be estimated. Breidert, Hahsler, & Reutterer, 2006

8. Analysis • DCE data can be modeled using: • Multinomial logit • Conditional logit (conditionality within tasks) • Mixed logit or probit (accounts for correlated observations within respondents and conditionality within tasks) • Hierarchical Bayesian models (as above and estimates preferences at individual level) • Results are utility coefficients or part-worths (interval data)

9. Revealed versus stated preferences • Can assess utility using revealed or stated preferences (or combination) • Revealed data demonstrate actual behavior and so are preferred by • But revealed preference data have limitations, particularly in health care: • Markets are imperfect or non-existent; subsidies mask true costs • Regulations limit range of behavior • RP data difficult to disaggregate into single attributes • RP data cannot incorporate unavailable attributes

10. Discrete choice experiments • One of several methods of assessing stated preference • Akin to other contingent valuation methods such as standard gamble • High internal consistency and test-retest reliability • Results consistent with a priori expectations (criterion validity) • Also consistent with results of related instruments such as standard gamble (convergent validity)

11. Discrete choice experiments • Can obtain willingness to pay by calculating marginal rate of substitution between an attribute and the price/cost variable • May be more realistic than simple rankings or ratings as it incorporates multiple attributes thereby better approximating real life consumer decision making • Easy to administer (choose to “buy” A or B) • Used in marketing, transport, environmental economics • Increasingly used in health care

12. DCEs in health have been used to: • Elicit physician preferences in priority setting • Obtain patient preferences for structure of physician practice • Identify preferred clinical management strategies • To indicate relative value of health services to patients • Unlike C/E analysis takes account of relative importance of different aspects of health care: structure, process and health and non-health outcomes Ryan M, Farrar S. Using conjoint analysis to elicit preferences for health care. Bmj. Jun 3 2000;320(7248):1530-1533

13. DCEs in HRH • Chomitz K, Setiadi G, Azwar A, Ismail N, Widiyarti. What do doctors want? Developing incentives for doctors in serve in Indonesia's rural and remote areas. Washington, DC: World Bank; 1998. • Hanson K, Jack W. Health worker preferences for job attributes in Ethiopia: Results from a discrete choice experiment. Washington: Working paper, Georgetown University; 2008 • Kolstad JR. How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania. Health Econ. Jan 21 2010;21:21. • Blaauw D, Erasmus E, Pagaiya N, et al. Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bull World Health Organ. May 2010;88(5):350-356.

14. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

15. Ghana

16. Ghana • Population 22.2 million; 62% in rural areas • GNI $1320 PPPs per capita • Major urban rural disparities in infrastructure and health service utilization • 80% of urban households have electricity; 31% of rural do • 85% of urban women deliver in a health facility; 39% of rural women

17. Human resources for health and outmigration • 2442 MDs were working in Ghana in 2009 • Huge source of emigrant physicians: 61% of medical school graduates between 1985 and 1994 emigrated, primarily to UK and US • This has slowed recently, attributed to increase in salaries • Additional Duty Hours Allowance increased salaries by 75-150% to approximately $14,000 annually

18. Geographic distribution • 69% of physicians practice in Accra region or the Kumasi teaching hospital (Komfo Anokye) • Physician to population ratios: • 1:5000 in Greater Accra region • 1:92,000 in Northern region

19. Medical education in Ghana • Medical education in Ghana consists of: • 3 years of basic sciences • 3 years of medical studies • 2 year housemanship in which students rotate through general medicine, obstetrics and gynaecology, surgery and paediatrics • There are 4 medical schools in Ghana: the University of Ghana (UG), Kwame Nakrumah University of Science and Technology (KNUST), University for Development Studies (UDS) and University of Cape Coast (UCC). • The UCC medical school began accepting students in 2007 and had no fourth year students yet. • At the time of the study, all fourth year students in the country were training at UG or KNUST

20. Postings • After completing housemanship, medical students are provided with available MoH postings; majority of these are in under-served areas (rural or peri-urban) • There is no return-of-service obligation (bonding) for vast majority of students

21. Research question • What job attributes influence senior medical students’ choice of rural practice posts?

22. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

23. Designing a DCE • Identify characteristics (attributes) • Policy options, focus groups, literature • Assign levels to attributes • Plausible, can be cardinal, ordinal, categorical • Choose subset of scenarios • Experimental design used to reduce number while maximizing efficiency • Establish preferences • Analyze data

24. Attributes • Identified long list of policy-ameable attributes from extant literature • Conducted 7 focus groups with 3rd and 5th year medical students at UG and KNUST • Discussion on career plans, motivation for rural practice, important attributes to encourage rural practice, trial rankings of attributes

25. Attributes and levels

26. Selecting a subset of scenarios • Total of 384 possible alternatives • Assumed independence of attributes • Selected scenarios that maximized orthogonality (low correlation between levels of attributes), maximized level balance, and minimized overlap among levels within one task (efficient design) • Selected 22 alternatives (paired for 11 tasks) and 1 fixed task using Sawtooth Software

28. Fielding • Invited all 4th year medical students in Ghana to participate • Gave electronic survey on background, career plans, motivation for rural practice along with DCE module (12 choice tasks) in computer labs with trained surveyors

29. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

30. Response • Out of 310 fourth-year students enrolled in Ghana’s medical schools, • 307 (99.0%) students participated in the survey • 5 survey files were corrupted by viruses or lost due to computer malfunction • Analysis conducted with 302 total records • The survey took a mean of 31.6 (SD 12.45) minutes.

31. Demographics

32. Demographics

33. International and rural practice

34. Mixed logit results Model 1

35. Mixed logit results Model 2

36. Mixed logit results Model 2

37. Policy simulations

38. Agenda • Discrete choice experiments • Human resources for health in Ghana • Methods • Results • Discussion

39. Summary of findings • Students valued rural job attributes that enabled them to perform well clinically (improved infrastructure and equipment) and enabled their professional growth (supportive management) • This was equivalent to a bonus of 100% of base starting salary • Consistent with focus group findings

40. Supportive management • Supportive work culture and management especially important to women—one of only two attributes for which there was a gender difference • Consistent with results of some studies showing supportive management increased motivation

41. Two year contract • Highly valued: this was echoed in focus groups • Possible that some students would be willing to accept a guaranteed short-term placement (with other incentives)

42. Housing • Basic housing is considered a pre-requisite for rural practice by students • This is due to low availability of quality housing in rural towns in Ghana and students’ awareness that this is a standard offering by rural hospitals • Consistent with Hanson and Jack study in Ethiopia

43. Salary • High utility, particularly for bonuses of 50- 100% salary • Literature mixed on salaries needed to change behavior (may be more important to practicing MDs than medical students) • Students may also be willing to forego urban salary for a brief rural experience, particularly if well supported

44. Other factors • Allowances for children’s education not as important; possibly as students were young • Car not important—relatively well off students may have or expect to buy their own car

45. Research to policy?

47. Reference: Kruk M, Johnson J, Gyakobo M, Agyei-Baffour P, Asabir K, Kotha R, Kwansah J, Nakua E, Snow R, Dzodzomenyo M. Preferences for rural practice incentives among medical students in Ghana: A discrete choice experiment. Bull WHO. Submitted 1 Oct 2009.

48. Validation? • Do a policy experiment that includes top incentives and compares against standard offering but need to keep in mind…

49. Validation? • Policy resistance (2 year contract!) • Civil service regulations • How to measure effect with small n/low variation?

50. Other uses of DCE….