Academic journal article Bulletin of the World Health Organization

Rural Practice Preferences among Medical Students in Ghana: A Discrete Choice experiment/Preferences Concernant la Pratique Rurale Exprimees Par Les Etudiants En Medecine Ghaneens : Experience a Choix discrets/Preferencias Por Destinos Rurales Entre Los Estudiantes De Medicina En Ghana: Experimento De Eleccion Discreta

Academic journal article Bulletin of the World Health Organization

Rural Practice Preferences among Medical Students in Ghana: A Discrete Choice experiment/Preferences Concernant la Pratique Rurale Exprimees Par Les Etudiants En Medecine Ghaneens : Experience a Choix discrets/Preferencias Por Destinos Rurales Entre Los Estudiantes De Medicina En Ghana: Experimento De Eleccion Discreta

Article excerpt

Introduction

In many low-income countries, health worker shortages hamper progress towards meeting the health-related Millennium Development Goals. (1) Africa is the region of the World Health Organization (WHO) with the lowest health worker density (doctors and nurses or midwives per capita) -2.3 health workers per 1000 population. Europe has, by comparison, a health worker density of 18.9. (2) Recent projections suggest that while the supply of physicians will approximate demand by 2015 in the world as a whole, the African region will still experience substantial shortages. According to a recent analysis from 12 African countries, at current rates of training and attrition, it would take 36 and 29 years, respectively, to meet the minimum recommended density of physicians and nurses. (3)

In Africa, physicians' tendency to locate in urban areas cause them to be in short supply in rural areas, which are left with insufficient medical coverage. For example, in Zambia there are 20 times more physicians in urban than in rural areas, and in Malawi 97% of all physicians have urban practices, despite the fact that both countries have a predominantly rural population. (4) This highly uneven distribution between urban and rural areas is rooted in the fact that cities offer better incomes (e.g. the potential for private practice), more opportunities for career progression, better infrastructure and more social amenities than rural areas. (5) While it is difficult to tell just how the recent rise in the number of women entering the medical profession in Africa will affect the supply of physicians in rural areas, evidence from other regions suggests that women prefer urban practice. (5) They may be influenced, for example, by spousal dual career considerations and by the prospects offered by the city of having greater control over their work schedules and more opportunities to work part time. (5)

Relatively little research has been conducted on effective strategies to promote rural practice, particularly in low-income countries. (6) One promising new area of research is the use of discrete choice experiments (DCEs) to study health workers' stated preferences for certain features of rural practice. (7) DCEs present respondents with a series of hypothetical choices (e.g. job postings) having different attributes (e.g. in terms of salary, housing, contract length). Respondents select their preferred alternative, and the influence of each attribute on their choice is then mathematically estimated. Unlike an analysis of actual choices, DCEs make it possible to include features that have not actually been implemented and thus provide information about the potential effectiveness of various policy options. DCEs have proved easy to administer and have demonstrated good test-retest reliability. (8,9) Furthermore, there is evidence that the stated preferences obtained from DCEs approximate actual choices, although DCEs' predictive validity depends on a strong experimental design?

Ghana is a low-income country in western Africa. It is listed by the United Nations as having medium human development and as ranking 135th among 177 countries on the basis of life expectancy, adult literacy, educational enrolment and per capita income. (10) Of Ghana's population of 22.2 million, 62% live in rural areas. (11) Substantial urban-rural disparities exist in infrastructure and access to health services. For example, 80% of urban households have electricity as opposed to 31% of rural households, and 86.0% of urban women deliver in a health facility compared with 39% of rural women. (12)

In 2009, 2442 physicians were working in Ghana, (13) a country with one of the highest physician emigration rates in the world. (14) One study reports that 61% of those who graduated from medical school between 1985 and 1994 emigrated, primarily to the United Kingdom of Great Britain and Northern Ireland and the United States of America (USA), although emigration appears to have slowed recently. …

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