Retention of Doctors and Dentists to Serve in Remote Areas in Indonesia: A Discrete Choice Experiment

Introduction

Doctors and dentists play an important role in improving health, especially in primary care settings for disease detection and screening.¹ Health workers can provide effective health services based on their availability and distribution in the population.² However, the global shortage of health workers is expected to reach 10 million by 2030. Even within countries, rural areas experience greater shortages of adequate staff than urban areas.³ A recent document from the World Health Organization (WHO) identifies ten global health issues that must be addressed which includes strengthening the availability of the global health workforce⁴. According to WHO recommendations, there should be one doctor for every 1000 people; however, the national ratio of doctors in Indonesia is reported to be 0.68 per 1000 people; and in 88% of provinces, the ratio is even lower, such as in the Maluku-Nusa Tenggara Timur-Papua region, where the ratio is 0.24 per 1000 people.⁵ The proportion of remote area districts are 12.1% of the total districts in Indonesia, while the proportions of doctors and dentists in remote areas is only 2.2% and 1.4% of the national total, respectively.⁶ The majority of doctors and dentists are concentrated on the islands of Java and Sumatra, as opposed to Papua, East Nusa Tenggara, and Maluku.⁷ Papua Province has the highest reported proportion of doctors and dentists shortages in the country (49.5% and 79.0%, respectively)⁷.

One reason for shortages is the difficulty in retaining health workers, particularly in rural or remote areas, which depends on both macro- and micro-level factors.^8,9 Large proportions of doctors working in remote areas have very short periods of assignment.¹⁰ According to findings of a 2014 study in Argentina, 21% of doctors had a strong desire to leave remote areas, while 57.3% had a moderate desire.¹¹ When a health worker’s position becomes vacant and is not filled immediately, the health worker, health organization, and community all suffer.^12,13 This impact is especially pronounced in rural and remote areas, where the workforce may be low in terms of availability.^10,14

Since 2010, WHO has released several recommendations on four major interventions to improve the retention of health workers in remote areas: education, regulation, financial incentives, and professional and personal support for health workers in remote and rural areas.¹⁴ As mandated by Indonesia’s health transformation, the Indonesian Ministry of Health (MoH) is committed to accelerating the distribution of doctors, particularly in remote areas.⁵ The government’s efforts to increase health worker retention include special assignments placed in remote areas, such as Nusantara Sehat (NS) program and the doctor internship program. These are bundled with incentives and scholarships. However, these mechanisms are only temporary.⁵ Part of the solution includes understanding the needs and expectations of health workers in the health services.¹⁵

The Discrete Choice Experiment (DCE) is a quantitative method used to explain preferences that influence job choices.¹⁶ DCE has been used extensively in the health sector, especially in examining the preferences of health workers.^17,18 A study using DCE was conducted in Indonesia with medical, nursing, and midwifery students as subjects in 2016.¹⁹ Another DCE study conducted by Shrestha in 2017, explored preferences of prospective dentists in taking job in remote areas in Nepal.²⁰ DCE studies have also been conducted in Timor Leste (2016)²¹ and India (2013)²² to assess preferences of doctors and nurses in working in rural areas. However, more evidence is needed, especially when viewed from the context of doctors and dentists in Indonesia. Therefore, the purpose of this study was to analyze interventions for retention of doctors and dentists in remote areas using the DCE approach.

Materials and Methods

Design

This was a cross-sectional study using the DCE approach to explore the preferences of doctors and dentists regarding retention attributes in remote areas. Respondents were presented with several alternatives within a set of inherent attributes to make their choices.²³

Sampling and Sample Size

The study was conducted in 78 public health centres included in the remote area category across 22 districts spread over 15 provinces in Indonesia. The selection of these locations was based on the criteria for remote areas based on the Decree of the Director General of Health Services No. HK.02.02/11/0373/2019²⁴ and based on the availability of doctors and dentists in regional representation in Indonesia. Data collection was carried out in November 2022 for 20 days by trained enumerators. The sample consisted of 158 doctors and dentists selected through non-probability sampling (purposive) with the inclusion criteria of doctors and dentists who were placed in primary health care in remote areas for at least for 1 years. We determined the sample size based on recommendations from Pearmain et al²⁵ and Lancsar and Louviere.¹⁸ Pearmain et al advised that over 100 participants are sufficient for modeling preference data in DCE studies. Additionally, Lancsar and Louviere noted that while around 20 respondents per questionnaire can yield reliable results, a larger sample size may be needed for many attributes and more detailed analysis.

Table 1 Attributes and Levels of DCE

Attributes and Levels Development

Attributes and levels were identified through a literature review and focus group discussions (FGDs). Literature studies from academic databases such as Scopus, Web of Science, EBSCO, Proquest, and PubMed were used to determine the attributes and levels. The search technique employed keywords such as retention, doctor, dentist, rural areas, and remote areas. The FGD involved doctors, dentists, the National Research and Innovation Agency, MoH, and academics. The participants discussed various aspects that would influence their decision to work in remote areas. The discussions yielded eight attributes with 2–3 levels each, encompassing both non-monetary and monetary factors (see Table 1 for details).

DCE Questionnaire Design

A DCE questionnaire was created after finalizing the attributes and levels. Each attribute was divided into levels before being incorporated into the questionnaire. Seven of the eight determined DCE attributes had three levels, and one had two levels. The questionnaire design was created using the package “support.CEs” from the R software²⁶ through an orthogonal fractional factorial design, resulting in 18 choice sets, each with two alternative options. To gather more information about dentists’ and doctors’ preferences regarding the offered attributes, the design purposefully omitted the “opt-out” option.²⁷ We developed the questionnaire with rigor to overcome the content validity issue based on WHO guidelines.²⁸

The questionnaire was divided into three sections (Figure 1): the characteristics question section included demographic variables and profession-related attributes for doctors and dentists (Figure 1A); a cheap talk script provided an explanation about the attributes and levels, assisting respondents in understanding the purpose of each question in the early stages of the questionnaire (Figure 1B); and the DCE retention section contained 18 choice sets with two alternative options for dentists and doctors to choose (Figure 1C). Each choice set was presented on a separate page to ensure respondents could focus on the options provided.

Figure 1 The DCE Questionnaire. ((A) Respondent Characteristics Question; (B) Cheap Talk Script; and (C) Round 1 from 18-Choice set DCE Recruitment Section).

To ensure content validity, a group of experts in the field, including the Director of Health Worker Empowerment, the National Research and Innovation Agency, the Health Development Policy Agency, as well as doctors and dentists, assessed the content validity of the instrument. Their insights and expertise greatly aided this process. Furthermore, to validate the content further, input on the qualities and levels of relevance and clarity of the questionnaire was sought throughout the 30-health worker through pilot test. Due to expert evaluation and revision following target audience comments during the pilot test, the questionnaire’s acceptability and relevance were maintained.

Data Analysis

Demographic characteristics were examined through univariate statistics. Descriptive statistics were employed to analyze respondent profiles, providing detailed insights into their characteristics. The DCE question variables underwent evaluation using conditional logit regression, generating mean utility coefficients and odds ratios. Statistical significance was determined at a 5% p-value, with 95% confidence intervals (CI) established. Conditional logit regression was applied to estimate preferences in DCE retention questions, analyzing the entire sample and subgroups. This approach facilitated the exploration of preference variations among different respondent segments. Positive coefficients indicated a preference for a specific attribute level over the reference level, while odds ratios (OR) were utilized to assess the likelihood of liking or disliking attribute levels.

Furthermore, we performed a Willingness to Accept (WTA) analysis specifically for non-monetary attributes. The WTA values were denominated in Indonesian Rupiah (IDR), with a larger value indicating a higher compensation required for accepting a contract change. This analysis aimed to estimate the compensation doctors and dentists desired for alterations in non-monetary attributes. The Marginal Willingness to Accept (mWTA) values, also expressed in Indonesian Rupiah (IDR), denote the compensation respondents are willing to accept due to changes in attribute levels. Higher mWTA values signify a greater compensation that respondents seek for specific attribute levels. The mWTA calculation is grounded in the assumption of maximizing respondent utility and is expressed as follows:²⁹

Ethical Approval

This research was approved by the Ethics Committee of Faculty of Nursing, Universitas Airlangga (Number 2683-KEPK) on 10 November 2022. Participants were informed about the study, and provided informed consent prior to study participation. Respondents participated voluntarily and had given their written consent.

Results

Respondent Profile

A total of 158 respondents answered DCE questions which were divided into 113 doctors and 45 dentists. The respondents were mostly female (69%) and between the ages 20 and 29 years (72.8%). The majority were graduates of private universities (60.1%) with marital status data showing most were single (75.9%) and did not have children (84.2%). According to their birthplace, 110 (69.6%) were born in non-rural or remote areas. Furthermore, 141 (89.2%) of those surveyed were not civil servants. The majority of respondents (61.4%) had work experience of 1–2 years. According to current placement status 57.6% respondents were from the Nusantara Sehat program, with 63.9% placed outside from their home province. The region with the highest number of respondents was the western region (41.8%) (Table 2).

Table 2 Respondents Profile (N=158)

Preferences for Retention of Doctor and Dentists in Remote Areas

Table 3 presents the findings of a study examining the factors influencing doctors’ and dentists’ decisions to remain in remote areas. Non-monetary attributes such as location, facilities, study opportunities, security, commitment length, and incentives significantly influence their preferences. Overall, respondents’ preferences for most attributes did not differ between the two professions. However, differences in the importance level of certain attributes were observed. Specialist study opportunities ranked highest in importance for the retention of doctors, whereas for dentists, it was the fourth highest important attribute (for dentist OR = 3.56; and for doctor OR = 5.65; with p-value < 0.001). Security guarantees from the local government emerged as the second most preferred attribute for doctors (OR 4.17, p-value < 0.001) and the first preferred for dentists (OR = 4.87, p-value < 0.001). Official housing facilities ranked third in their hierarchy of preferences (OR = 3.6, p-value < 0.001 for both professions), while medical facilities exceeding standard held substantial importance, especially for dentists, ranking second in preference (OR = 3.74, p-value < 0.001), and fourth for doctors (OR = 2.94, p-value < 0.001). They preferred incentives from regional or central government over medical services (dentist OR = 2.76 and doctor OR = 1.72; p < 0.001). When it comes to staying time, doctors preferred shorter commitments, like two years instead of four (OR = 0.6, p < 0.05), whereas dentists preferred not to stay until retirement, opting for shorter durations (OR = 0.36, p-value < 0.001). Both groups were less likely to want to work in very remote areas compared to rural or urban places (dentist OR = 0.18; doctor OR = 0.21; p < 0.001). In terms of the monetary attribute, namely net income per month, indicating that both dentists and doctors strongly desired a higher monthly net income.

Table 3 Conditional Logit Estimation of Retention Doctors and Dentists

Discussion

In general, respondents’ preferences for most attributes in each group did not differ. The difference between the two professions was in the level of preference importance in several attributes. The opportunity for specialist study was the attribute rated as most important for retention in the doctor group, but in the dentist group, it was rated as the fourth most important attribute. Several existing studies show that specialist study opportunities can add skills in health services.^30–33 In addition, specialist study opportunities play a role in career advancement.^30,31 But the cost for specialist studies tends to be very high with quite fierce competition,³⁴ so that priority and scholarships provided by the government would be an attraction for doctors and dentists to be willing to be retained in remote areas. Specialist study opportunities are widely offered by the government through various mechanisms.^35,36 This opportunity may be seen by specialist candidates as a golden opportunity to advance their career.

Security assurance is an attribute that is highly considered by dentist and doctors.. Security in this assessment was aimed at guaranteeing security while they work in primary health care. Security and safety factors are the main factors that need to be of common concern, especially in areas of conflict and those prone to violence.^14,37,38 According to a physician working in Chad’s rural district, security issues for unaccompanied female health workers in the periphery may arise and hinder them from working in difficult areas³⁹. This security aspect needs to be discussed in the field with local government and local law enforcement agencies, because health workers’ safety must be ensured if they are to remain in remote areas for an extended period of time.

This study shows that living facilities with official residence a higher preference than housing allowance. Similar results were found in a study of health workers in rural Zambia who were five times more willing to be retained if given official housing rather than housing allowances.⁴⁰ The existence of housing facilities is worth considering for doctors and dentists because they will be greatly assisted by basic living facilities. Ministry of Health decree number 75 of 2014⁴¹ mandates that every primary health care centre must have housing facilities or official housing buildings for health workers. As they have been supporting those working in remote areas, this policy is a source of leverage for them.

Medical facilities that are more than just standard are preferred over those that are merely adequate for the retention of doctors and dentists. Medical facilities are closely related to the quality of care and readiness to practice. Doctors and dentists without adequate medical facilities will experience limited skills in providing health services to patients.^30,42,43 In addition, medical facilities can influence people’s confidence in their abilities to produce a specified level of performance in remote areas.^43,44 Efforts to improve medical facilities will support the attraction and retention of doctors and dentists in remote areas.^45,46 The fulfillment of health facilities, infrastructure and medical devices at the primary healthcare level must be accompanied by increased good governance and financial allocation.

In this study, regional or central incentives were more likely preferred by doctors and dentists than all other incentives. Previous studies have assessed that incentives, both financial and non-financial, have less effect on retention of doctors and dentists.^46–49 However, the effectiveness of incentives, both financial and non-financial, on retention has been questioned, possibly due to limited work facilities in remote areas.⁵⁰ Junior doctors tend to place more importance on incentives than senior doctors.^49,51 It is crucial to identify and enhance the available incentives, considering the fiscal capacity of the district. Although income ranks relatively low in importance, several studies suggest that higher income is associated with better retention rates and fewer movements of healthcare professionals.^52–54 Insufficient income may hinder doctors and dentists in remote areas from meeting their daily needs and impede their motivation to improve service quality.^52,53,55 The government has established income regulations, especially for civil servants, to address this issue.⁵⁶ Additionally, the income gap among doctors and dentists in remote areas is relatively narrow, particularly for those working in primary healthcare settings.

Placement location and length of commitment were found to be the least concerning for both doctors and dentists. Although this attribute is considered not very important, our results find that doctors and dentists have a positive preference for working in rural or urban areas compared to remote areas. This is reasonable considering that village or city infrastructure is better when compared to remote areas.⁵⁷ Previous research has shown that length of commitment is beneficial for the community in remote areas, because the presence of doctors and dentists allows access to the healthcare through an inclusive approach.^14,58–60 To retain doctors and dentists in remote areas, it is critical to consider the unique challenges and benefits of each location.

Conclusion

In conclusion, both doctors and dentists prefer special study scholarships with assigned duties. Dentists also place significant importance on government security guarantees. To keep doctors in remote Indonesia, giving them chances for more education through government scholarships is crucial, especially if they commit to serving for a certain time. This study provides valuable information to policymakers in determining strategies for retaining doctors and dentists in remote areas of Indonesia. Understanding doctors’ and dentists’ preferences can support determining the best retention policy. This study demonstrates that maintaining a medical workforce in remote areas of Indonesia requires a variety of interventions, with a primary focus on non-financial interventions, and giving priority for government scholarship recipients with bonding assignment. Policy options in non-financial and financial intervention packages can be combined, adapted to local circumstances, and linked to stakeholder interests. The study’s outcomes carry substantial health equity implications. By identifying the preferences of doctors and dentists and tailoring retention strategies to meet their needs, the healthcare workforce in remote areas can be stabilized. This directly contributes to enhancing access to quality healthcare services for remote and underserved populations.