Gender Equality and Health in High-Income Countries: A Systematic Review of Within-Country Indicators of Gender Equality in Relation to Health Outcomes.

Background: Gender equality is recognized as an important political, social, and economic goal in many countries around the world. At a country level, there is evidence that gender equality may have an important influence on health. Historically gender equality has mainly been measured to allow for between-country, rather than within-country comparisons; and the association between gender equality and health outcomes within countries has been under-researched. This article thus aimed to systematically review within-country indicators of gender equality in public health studies and assess the extent to which these are related to health outcomes. Materials and Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach with two independent reviewers. Results: Data from the eight included studies revealed that there was heterogeneity in the way gender equality has been measured as a multidimensional construct. Associations between gender equality and a number of different health outcomes were apparent, including mortality, mental health, morbidity, alcohol consumption, and intimate partner violence, with gender equality mostly associated with better health outcomes. Conclusions: Further investigation into the effects of gender equality on health outcomes, including a clear conceptualization of terms, is critical for the development of policies and programs regarding gender equality.

Regional Coronavirus Hotspots During the COVID-19 Outbreak in the Netherlands.

We explore the impact of COVID-19 hotspots and regional lockdowns on the Dutch labour market during the outbreak of COVID-19. Using weekly administrative panel microdata for 50 per cent of Dutch employees until the end of March 2020, we study whether individual labour market outcomes, as measured by employment, working hours and hourly wages, were more strongly affected in provinces where COVID-19 confirmed cases, hospitalizations and mortality were relatively high. The evidence suggests that labour market outcomes were negatively affected in all regions and local higher virus case numbers did not reinforce this decline. This suggests that preventive health measures should be at the regional level, isolating hotspots from low-risk areas.

The role of financial factors in the mobility and location choices of General Practitioners in Australia.

BACKGROUND: The geographic distribution of health workers is a pervasive policy concern. Many governments are responding by introducing financial incentives to attract health care workers to locate in areas that are underserved. However, clear evidence of the effectiveness of such financial incentives is lacking. METHODS: This paper examines General Practitioners' (GPs) relocation choices in Australia and proposes a dynamic location choice model accounting for both source and destination factors associated with a choice to relocate, thereby accounting for push and pull factors associated with job separation. The model is used to simulate financial incentive policies and assess potential for such policies to redistribute GPs. This paper examines the role of financial factors in relocating established GPs into neighbourhoods with relatively low socioeconomic status. The paper uses a discrete choice model and panel data on GPs' actual changes in location from one year to the next. RESULTS: This paper finds that established GPs are not very mobile, even when a financial incentive is offered. Policy simulation predicts that 93.2% of GPs would remain at their current practice and that an additional 0.8% would be retained or would relocate in a low-socioeconomic status (SES) neighbourhood in response to a hypothetical financial incentive of a 10% increase in the earnings of all metropolitan GPs practising in low-SES neighbourhoods. CONCLUSION: With current evidence on the effectiveness of redistribution programmes limited to newly entering GPs, the policy simulations in this paper provide an insight into the potential effectiveness of financial incentives as a redistribution policy targeting the entire GP population. Overall, the results suggest that financial considerations are part of many factors influencing the location choice of GPs. For instance, GP practice ownership played almost as important a role in mobility as earnings.

What factors affect physicians' labour supply: Comparing structural discrete choice and reduced-form approaches.

Little is known about the response of physicians to changes in compensation: Do increases in compensation increase or decrease labour supply? In this paper, we estimate wage elasticities for physicians. We apply both a structural discrete choice approach and a reduced-form approach to examine how these different approaches affect wage elasticities at the intensive margin. Using uniquely rich data collected from a large sample of general practitioners (GPs) and specialists in Australia, we estimate 3 alternative utility specifications (quadratic, translog, and box-cox utility functions) in the structural approach, as well as a reduced-form specification, separately for men and women. Australian data is particularly suited for this analysis due to a lack of regulation of physicians' fees leading to variation in earnings. All models predict small negative wage elasticities for male and female GPs and specialists passing several sensitivity checks. For this high-income and long-working-hours population, the translog and box-cox utility functions outperform the quadratic utility function. Simulating the effects of 5% and 10% wage increases at the intensive margin slightly reduces the full-time equivalent supply of male GPs, and to a lesser extent of male specialists and female GPs.

Do Financial Incentives Influence GPs' Decisions to Do After-hours Work? A Discrete Choice Labour Supply Model.

This paper analyses doctors' supply of after-hours care (AHC), and how it is affected by personal and family circumstances as well as the earnings structure. We use detailed survey data from a large sample of Australian General Practitioners (GPs) to estimate a structural, discrete choice model of labour supply and AHC. This allows us to jointly model GPs' decisions on the number of daytime-weekday working hours and the probability of providing AHC. We simulate GPs' labour supply responses to an increase in hourly earnings, both in a daytime-weekday setting and for AHC. GPs increase their daytime-weekday working hours if their hourly earnings in this setting increase, but only to a very small extent. GPs are somewhat more likely to provide AHC if their hourly earnings in that setting increase, but again, the effect is very small and only evident in some subgroups. Moreover, higher earnings in weekday-daytime practice reduce the probability of providing AHC, particularly for men. Increasing GPs' earnings appears to be at best relatively ineffective in encouraging increased provision of AHC and may even prove harmful if incentives are not well targeted. Copyright © 2017 John Wiley & Sons, Ltd.

The supply of general practitioners across local areas: accounting for spatial heterogeneity.

BACKGROUND: The geographic distribution of general practitioners (GPs) remains persistently unequal in many countries despite notable increases in overall supply. This paper explores how the factors associated with the supply of general practitioners (GPs) are aligned with the arbitrary geographic boundaries imposed by the use of spatially referenced GP supply data. METHODS: Data on GP supply in postcodes within Australia are matched to data on the population characteristics and levels of amenities in postcodes. Tobit regression models are used that examine the associations between GP supply and postcode characteristics, whilst accounting for spatial heterogeneity. RESULTS: The results demonstrate that GPs do not consider space in a one-dimensional sense. Location choice is related to both neighbourhood-specific factors, such as hospitals, and broader area factors, such as area income and proximity to private schools. Although the proportion of females and elderly were related to GPs supply, mortality rate was not. CONCLUSIONS: This paper represents the first attempt to map the factors influencing GP supply to the appropriate geographic level at which GPs may be considering that factor. We suggest that both neighbourhood and broader regional characteristics can influence GPs' locational choices. This finding is highly relevant to the design and evaluation of relocation incentive programmes.

What do nurses and midwives value about their jobs? Results from a discrete choice experiment.

OBJECTIVES: To examine nurses' and midwives' preferences for the characteristics of their jobs. METHODS: A discrete choice experiment of 990 nurses and midwives administered as part of a survey of nurses and midwives in Victoria, Australia. RESULTS: Autonomy, working hours, and processes to deal with violence and bullying were valued most highly. Nurses and midwives would be willing to forgo 19% and 16% of their annual income for adequate autonomy and adequate processes to deal with violence and bullying, compared to poor autonomy and poor processes for violence and bullying. They would need to be paid an additional 24% to increase their working hours by 10% ($73 per hour). Job characteristics that were less important were shift work, nurse to patient ratios, and public or private sector work. CONCLUSIONS: Policies to improve retention and job satisfaction of nurses and midwives should initially focus on autonomy, processes to deal with violence and bullying, and reasonable working hours. Further research on the cost-effectiveness of these different policies is needed.

Nurses' labour supply elasticities: the importance of accounting for extensive margins.

We estimate a multi-sector model of nursing qualification holders' labour supply in different occupations. A structural approach allows us to model the labour force participation decision, the occupational and shift-type choice, and the decision about hours worked as a joint outcome following from maximising a utility function. Disutility from work is allowed to vary by occupation and also by shift type in the utility function. Our results suggest that average wage elasticities might be higher than previous research has found. This is mainly due to the effect of wages on the decision to enter or exit the profession, which was not included in the previous literature, rather than from its effect on increased working hours for those who already work in the profession.

Getting doctors into the bush: general practitioners' preferences for rural location.

A key policy issue in many countries is the maldistribution of doctors across geographic areas, which has important effects on equity of access and health care costs. Many government programs and incentive schemes have been established to encourage doctors to practise in rural areas. However, there is little robust evidence of the effectiveness of such incentive schemes. The aim of this study is to examine the preferences of general practitioners (GPs) for rural location using a discrete choice experiment. This is used to estimate the probabilities of moving to a rural area, and the size of financial incentives GPs would require to move there. GPs were asked to choose between two job options or to stay at their current job as part of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. 3727 GPs completed the experiment. Sixty five per cent of GPs chose to stay where they were in all choices presented to them. Moving to an inland town with less than 5000 population and reasonable levels of other job characteristics would require incentives equivalent to 64% of current average annual personal earnings ($116,000). Moving to a town with a population between 5000 and 20,000 people would require incentives of at least 37% of current annual earnings, around $68,000. The size of incentives depends not only on the area but also on the characteristics of the job. The least attractive rural job package would require incentives of at least 130% of annual earnings, around $237,000. It is important to begin to tailor incentive packages to the characteristics of jobs and of rural areas.

How do rural GPs' workloads and work activities differ with community size compared with metropolitan practice?

Rural communities continue to experience shortages of doctors, placing increased work demands on the existing rural medical workforce. This paper investigates patterns of geographical variation in the workload and work activities of GPs by community size. Our data comes from wave 1 of the Medicine in Australia: Balancing Employment and Life longitudinal study, a national study of Australian doctors. Self-reported hours worked per usual week across eight workplace settings and on-call/ after-hours workload per usual week were analysed against seven community size categories. Our results showed that a GP's total hours worked per week consistently increases as community size decreases, ranging from 38.6 up to 45.6h in small communities, with most differences attributable to work activities of rural GPs in public hospitals. Higher on-call workload is also significantly associated with smaller rural communities, with the likelihood of GPs attending more than one callout per week ranging from 9% for metropolitan GPs up to 48-58% in small rural communities. Our study is the first to separate hours worked into different work activities whilst adjusting for community size and demographics, providing significantly greater insight to the increased hours worked, more diverse activities and significant after-hours demands experienced by current rural GPs.

Who should receive recruitment and retention incentives? Improved targeting of rural doctors using medical workforce data.

OBJECTIVE: The objective of this study was to define an improved classification for allocating incentives to support the recruitment and retention of doctors in rural Australia. DESIGN AND SETTING: Geo-coded data (n = 3636 general practitioners (GPs)) from the national Medicine in Australia: Balancing Employment and Life study were used to examine statistical variation in four professional indicators (total hours worked, public hospital work, on call after-hours and difficulty taking time off) and two non-professional indicators (partner employment and schooling opportunities) which are all known to be related to difficulties with recruitment and retention. MAIN OUTCOME MEASURES: The main outcome measure used for the study was an association of six sentinel indicators for GPs with practice location and population size of community. RESULTS: Four distinct homogeneous population size groups were identified (0-5000, 5001-15,000, 15,001-50,000 and >50,000). Although geographical remoteness (measured using the Australian Standard Geographical Classification-Remoteness Areas (ASGC-RA)) was statistically associated with all six indicators (P < 0.001), population size provided a more sensitive measure in directing where recruitment and retention incentives should be provided. A new six-level rurality classification is proposed, based on a combination of four population size groups and the five ASGC-RA levels. A significant increase in statistical association is measured in four of six indicators (and a slight increase in one indicator) using the new six-level classification versus the existing ASGC-RA classification. CONCLUSIONS: This new six-level geographical classification provides a better basis for equitable resource allocation of recruitment and retention incentives to doctors based on the attractiveness of non-metropolitan communities, both professionally and non-professionally, as places to work and live.

What factors influence the earnings of general practitioners and medical specialists? Evidence from the medicine in Australia: balancing employment and life survey.

To date, there has been little data or empirical research on the determinants of doctors' earnings despite earnings having an important role in influencing the cost of health care, decisions on workforce participation and labour supply. This paper examines the determinants of annual earnings of general practitioners (GPs) and specialists using the first wave of the Medicine in Australia: Balancing Employment and Life, a new longitudinal survey of doctors. For both GPs and specialists, earnings are higher for men, for those who are self-employed and for those who do after-hours or on-call work. GPs have higher earnings if they work in larger practices, in outer regional or rural areas, and in areas with lower GP density, whereas specialists earn more if they have more working experience, spend more time in clinical work and have less complex patients. Decomposition analysis shows that the mean earnings of GPs are lower than that of specialists because GPs work fewer hours, are more likely to be female, are less likely to undertake after-hours or on-call work, and have lower returns to experience. Roughly 50% of the income gap between GPs and specialists is explained by differences in unobserved characteristics and returns to those characteristics.

A randomised trial and economic evaluation of the effect of response mode on response rate, response bias, and item non-response in a survey of doctors.

BACKGROUND: Surveys of doctors are an important data collection method in health services research. Ways to improve response rates, minimise survey response bias and item non-response, within a given budget, have not previously been addressed in the same study. The aim of this paper is to compare the effects and costs of three different modes of survey administration in a national survey of doctors. METHODS: A stratified random sample of 4.9% (2,702/54,160) of doctors undertaking clinical practice was drawn from a national directory of all doctors in Australia. Stratification was by four doctor types: general practitioners, specialists, specialists-in-training, and hospital non-specialists, and by six rural/remote categories. A three-arm parallel trial design with equal randomisation across arms was used. Doctors were randomly allocated to: online questionnaire (902); simultaneous mixed mode (a paper questionnaire and login details sent together) (900); or, sequential mixed mode (online followed by a paper questionnaire with the reminder) (900). Analysis was by intention to treat, as within each primary mode, doctors could choose either paper or online. Primary outcome measures were response rate, survey response bias, item non-response, and cost. RESULTS: The online mode had a response rate 12.95%, followed by the simultaneous mixed mode with 19.7%, and the sequential mixed mode with 20.7%. After adjusting for observed differences between the groups, the online mode had a 7 percentage point lower response rate compared to the simultaneous mixed mode, and a 7.7 percentage point lower response rate compared to sequential mixed mode. The difference in response rate between the sequential and simultaneous modes was not statistically significant. Both mixed modes showed evidence of response bias, whilst the characteristics of online respondents were similar to the population. However, the online mode had a higher rate of item non-response compared to both mixed modes. The total cost of the online survey was 38% lower than simultaneous mixed mode and 22% lower than sequential mixed mode. The cost of the sequential mixed mode was 14% lower than simultaneous mixed mode. Compared to the online mode, the sequential mixed mode was the most cost-effective, although exhibiting some evidence of response bias. CONCLUSIONS: Decisions on which survey mode to use depend on response rates, response bias, item non-response and costs. The sequential mixed mode appears to be the most cost-effective mode of survey administration for surveys of the population of doctors, if one is prepared to accept a degree of response bias. Online surveys are not yet suitable to be used exclusively for surveys of the doctor population.

Australian doctors' satisfaction with their work: results from the MABEL longitudinal survey of doctors.

OBJECTIVE: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists. DESIGN, PARTICIPANTS AND SETTING: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia - Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training). MAIN OUTCOME MEASURES: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics. RESULTS: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39-0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41-2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25-1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20-1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23-0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08-0.83]). CONCLUSION: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.

Professional satisfaction in general practice: does it vary by size of community?

OBJECTIVE: To investigate whether the level of professional satisfaction of Australian general practitioners varies according to community size and location. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, population-level national survey using results for a cohort of 3906 GPs (36% were "rural" participants) from the first wave of a longitudinal study of the Australian medical workforce, conducted between June and November 2008. Geographical differences in levels of professional satisfaction were examined using five community size categories: metropolitan, > or = 1 million residents; regional centre, 50,000-999,999; medium-large rural, 10,000-49,999; small rural, 2500-9999; and very small rural, < 2500. MAIN OUTCOME MEASURES: Level of professional satisfaction expressed by GPs working in different sized communities with respect to various job aspects. RESULTS: Professional satisfaction of GPs did not differ by community size for most aspects of the job. Overall satisfaction was high, at about 85% across all community sizes. Satisfaction with remuneration was slightly higher in smaller rural towns, even though the hours worked there were less predictable. Professional satisfaction with freedom of choosing work method, variety of work, working conditions, opportunities to use abilities, amount of responsibility, and colleagues was very high across all community sizes, while difficulties with arranging locums and the stress of running the practice were commonly reported by GPs in all community sizes. CONCLUSIONS: GPs working in different sized communities in Australia express similar levels of satisfaction with most professional aspects of their work.

The "medicine in Australia: balancing employment and life (MABEL)" longitudinal survey--protocol and baseline data for a prospective cohort study of Australian doctors' workforce participation.

BACKGROUND: While there is considerable research on medical workforce supply trends, there is little research examining the determinants of labour supply decisions for the medical workforce. The "Medicine in Australia: Balancing Employment and Life (MABEL)" study investigates workforce participation patterns and their determinants using a longitudinal survey of Australian doctors. It aims to generate evidence to support developing effective policy responses to workforce issues such as shortages and maldistribution. This paper describes the study protocol and baseline cohort, including an analysis of response rates and response bias. METHODS/DESIGN: MABEL is a prospective cohort study. All Australian doctors undertaking clinical work in 2008 (n = 54,750) were invited to participate, and annual waves of data collections will be undertaken until at least 2011. Data are collected by paper or optional online version of a questionnaire, with content tailored to four sub-groups of clinicians: general practitioners, specialists, specialists in training, and hospital non-specialists. In the baseline wave, data were collected on: job satisfaction, attitudes to work and intentions to quit or change hours worked; a discrete choice experiment examining preferences and trade-offs for different types of jobs; work setting; workload; finances; geographic location; demographics; and family circumstances. DISCUSSION: The baseline cohort includes 10,498 Australian doctors, representing an overall response rate of 19.36%. This includes 3,906 general practitioners, 4,596 specialists, 1,072 specialists in training, and 924 hospital non-specialists. Respondents were more likely to be younger, female, and to come from non-metropolitan areas, the latter partly reflecting the effect of a financial incentive on response for doctors in remote and rural areas. Specialists and specialists in training were more likely to respond, whilst hospital non-specialists were less likely to respond. The distribution of hours worked was similar between respondents and data from national medical labour force statistics. The MABEL survey provides a large, representative cohort of Australian doctors. It enables investigation of the determinants of doctors' decisions about how much, where and in what circumstances they practice, and of changes in these over time. MABEL is intended to provide an important resource for policy makers and other stakeholders in the Australian medical workforce.

Health status and labour force participation: evidence from Australia.

This paper examines the effect of health on labour force participation using the Household, Income and Labour Dynamics in Australia (HILDA) Survey. The potential endogeneity of health, especially self-assessed health, in the labour force participation equation is addressed by estimating the health equation and the labour force participation equation simultaneously. Taking into account the correlation between the error terms in the two equations, the estimation is conducted separately for males aged 15-49, males aged 50-64, females aged 15-49 and females aged 50-60. The results indicate that better health increases the probability of labour force participation for all four groups. However, the effect is larger for the older groups and for women. As for the feedback effect, it is found that labour force participation has a significant positive impact on older females' health, and a significant negative effect on younger males' health. For younger females and older males, the impact of labour force participation on health is not significant. The null-hypothesis of exogeneity of health to labour force participation is rejected for all groups.