The role of private education in the selection of primary care careers in low and middle-income countries. Findings from a representative survey of medical residents in Brazil.

BACKGROUND: Primary health care (PHC) doctors' numbers are dwindling in high- as well as low-income countries, which is feared to hamper the achievement of Universal Health Coverage goals. As a large proportion of doctors are privately educated and private medical schools are becoming increasingly common in middle-income settings, there is a debate on whether private education represents a suitable mean to increase the supply of PHC physicians. We analyse the intentions to practice of medical residents in Brazil to understand whether these differ for public and private schools. METHODS: Drawing from the literature on the selection of medical specialties, we constructed a model for the determinants of medical students' intentions to practice in PHC, and used secondary data from a nationally representative sample of 4601 medical residents in Brazil to populate it. Multivariate analysis and multilevel cluster models were employed to explore the association between perspective physicians' choice of practice and types of schools attended, socio-economic characteristics, and their values and opinions on the profession. RESULTS: Only 3.7% of residents in our sample declared an intention to practice in PHC, with no significant association with the public or private nature of the medical schools attended. Instead, having attended a state secondary school (p = 0.028), having trained outside Brazil's wealthy South East (p < 0.001), not coming from an affluent family (p = 0.037), and not having a high valuation of career development opportunities (p < 0.001) were predictors of willingness to practice in PHC. A low consideration for quality of life, for opportunities for treating patients, and for the liberal aspects of the profession were also associated with future physicians' intentions to work in primary care (all p < 0.001). CONCLUSIONS: In Brazil, training in public or private medical schools does not influence the intention to practice in PHC. But students from affluent backgrounds, with private secondary education, and graduating in the rich South East were found to be overrepresented in both types of training institutions, and this is what appears to negatively impact the selection of PHC careers. With a view to increasing the supply of PHC practitioners in middle-income countries, policies should focus on opening medical schools in rural areas and improving access for students from disadvantaged backgrounds.

Passing through - reasons why migrant doctors in Ireland plan to stay, return home or migrate onwards to new destination countries.

BACKGROUND: International recruitment is a common strategy used by high-income countries to meet their medical workforce needs. Ireland, despite training sufficient doctors to meet its internal demand, continues to be heavily dependent on foreign-trained doctors, many of whom may migrate onwards to new destination countries. A cross-sectional study was conducted to measure and analyse the factors associated with the migratory intentions of foreign doctors in Ireland. METHODS: A total of 366 non-European nationals registered as medical doctors in Ireland completed an online survey assessing their reasons for migrating to Ireland, their experiences whilst working and living in Ireland, and their future plans. Factors associated with future plans - whether to remain in Ireland, return home or migrate to a new destination country - were tested by bivariate and multivariate analyses, including discriminant analysis. RESULTS: Of the 345 foreign doctors who responded to the question regarding their future plans, 16 % of whom were Irish-trained, 30 % planned to remain in Ireland, 23 % planned to return home and 47 % to migrate onwards. Country of origin, personal and professional reasons for migrating, experiences of training and supervision, opportunities for career progression, type of employment contract, citizenship status, and satisfaction with life in Ireland were all factors statistically significantly associated with the three migratory outcomes. CONCLUSION: Reported plans may not result in enacted emigration. However, the findings support a growing body of evidence highlighting dissatisfaction with current career opportunities, contributing to the emigration of Irish doctors and onward migration of foreign doctors. Implementation of the WHO Global Code, which requires member states to train and retain their own health workforce, could also help reduce onward migration of foreign doctors to new destination countries. Ireland has initiated the provision of tailored postgraduate training to doctors from Pakistan, enabling these doctors to return home with improved skills of benefit to the source country.

Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution.

BACKGROUND: Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision. METHODS: We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach. RESULTS: Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70). CONCLUSION: There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need.

Outcome and impact of Master of Public Health programs across six countries: education for change.

BACKGROUND: The human resources for health crisis has highlighted the need for high-level public health education to add specific capacities to the workforce. Recently, it was questioned whether Master of Public Health (MPH) training prepared graduates with competencies relevant to low- and middle-income countries (LMICs). This study aims to examine the influence of the MPH programs geared towards LMICs offered in Vietnam, China, South Africa, Mexico, Sudan, and the Netherlands on graduates' careers, application of acquired competencies, performance at the workplace, and their professional contribution to society. METHODS: A self-administered questionnaire was sent to graduates from six MPH programs. Frequency distributions of the answers were calculated, and a bivariate analysis and logistic regression of certain variables was performed. RESULTS: The response rate was 37.5%. Graduates reported change in leadership (69%), in technical position (69%), acquiring new responsibilities (80%), and increased remuneration (63%); they asserted that MPH programs contributed significantly to this. Graduates' attribution of their application of 7 key competencies 'substantially to the MPH program' ranged from 33% to 48%. Of the 26 impact variables, graduates attributed the effect they had on their workplace substantially to the MPH program; the highest rated variable ranged from 31% to 73% and the lowest ranged from 9% to 43%. Of the 10 impact variables on society, graduates attributed the effect they had on society substantially to the MPH program; for the highest rated variable (13% to 71%); for the lowest rated variable (4% to 42%). Candidates' attribution of their application of acquired competencies as well as their impact at the workplace varied significantly according to institution of study and educational background. CONCLUSIONS: This study concludes that these MPH programs contribute to improving graduates' careers and to building leadership in public health. The MPH programs contribute to graduates' application of competencies. MPH programs contribute substantially towards impact variables on the workplace, such as development of research proposals and reporting on population health needs, and less substantially to their impact on society, such as contributing equitable access to quality services. Differences reported between MPH programs merit further study. The results can be used for curriculum reform.

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

Thailand special recruitment track of medical students: a series of annual cross-sectional surveys on the new graduates between 2010 and 2012.

BACKGROUND: Comprehensive policies for rural retention of medical doctor and other health professional, including education strategy and mandatory service, have been implemented in Thailand since the 1970s. This study compared the rural attitudes, intention to fulfil mandatory rural service and competencies between medical graduates' from two modes of admission, normal and special tracks. METHODS: Three cross-sectional, self-administered questionnaire surveys were conducted in April 2010, 2011 and 2012. The questionnaire was distributed to all new medical graduates in the annual Ministry of Public Health meeting to allocate workplaces for the 3-year mandatory service. FINDINGS: The majority of students were recruited through the normal track (56 to 77%) from medical schools in Bangkok (56 to 66%), having mostly attended secondary schools in Bangkok. A majority of special track graduates came from secondary schools in provincial cities (76 to 79%). All three batches came from well-educated parents.A slight difference in rural attitudes was observed between tracks. Univariable analysis found statistical associations between the intention to fulfil the 3-year obligation and special track recruitment and attributes on rural exposure. Multivariable analysis showed that graduates recruited through the special track had a 10 to 15% higher probability of fulfilling the mandatory service.Special track graduates scored higher on four out of five competencies, notably procedural skills, but normal track graduates had higher competency on clinical knowledge in major clinical subjects. CONCLUSION: Since special track recruitment resulted in a higher probability of fulfilling mandatory service and competency, increasing the proportion of special track recruitment and improving the effectiveness of policies addressing physician shortage were recommended.

The value of survival analyses for evidence-based rural medical workforce planning.

BACKGROUND: Globally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making. METHODS: A secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1(st) 2003 and December 31(st) 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover. RESULTS: Multivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations. CONCLUSIONS: This study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical 'remoteness' classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking 'reasonable' lengths of practice in different geographic settings that might guide service obligation requirements.