What affects the career choices of health workers? Four essays on preferences, incentives and career choices in a low-income context
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The geographical imbalance of the health workforce in Tanzania represents a serious problem when it comes to delivering crucial health services to a large share of the population. The Tanzanian health system, like many others in low-income countries, needs better incentive systems to attract dedicated workers to the health sector, to bring more qualified health workers to rural areas, and to induce them to use their knowledge and skills efficiently. However, creating better incentive and recruitment systems requires thorough knowledge of health workers’ motivations and preferences, as well as the relative valuations of different job attributes. The aim of this Ph.D. project has been to contribute to the base of knowledge about health workers’ individual motivations and preference structures. It has also been an important goal to examine how jobs with different characteristics can be matched with these preferences in order to provide high-quality health services on a larger scale. The first essay, ‘How to make rural jobs more attractive to health workers: findings from a discrete choice experiment in Tanzania’, published in ‘Health Economics’ (2010), provides new quantitative information about how health authorities can make jobs in rural areas more attractive to newly educated clinical officers. A data set stemming from a discrete choice experiment with clinical officer finalists in Tanzania is applied. The results show that offering additional education after a certain period of service is one of the most powerful recruitment instruments the authorities have available. Increased salaries and hardship allowances are also likely to substantially increase recruitment in rural areas. Offers of decent housing and good infrastructure, including the provision of equipment, can also increase recruitment to rural remote areas but not as much as higher wages and offers of education. In the second essay, ‘Mixed logit estimation of willingness to pay distributions: a comparison of models in preference and WTP space using data from a health-related choice experiment’, co-authored with Arne Risa Hole, different approaches to modelling the distribution of WTP are compared using mixed logit models and the same data set as in essay 1. The standard approach of specifying the distributions of the coefficients and deriving WTP as the ratio of two coefficients (estimation in preference space) is compared to specifying the distributions for WTP directly at the estimation stage (estimation in WTP space). The results suggest that sensitivity testing using a variety of model specifications, including estimation in WTP space, is highly recommended when using mixed logit models to estimate willingness to pay distributions. In the third essay, ‘How does additional education affect willingness to work in rural remote areas?: an application to health workers in a low-income context’, the main objective is to evaluate the effect of offering education opportunities as a strategy to recruit health workers to rural areas. A dataset capturing stated job preferences among freshly educated Tanzanian health workers with basic and more advanced clinical education is applied in order to investigate how additional education as an incentive mechanism affects the willingness to work in rural areas. In order to control for selection effects into the additional education scheme, the two cadres are matched on propensity scores. It turns out that the health workers with advanced clinical education would have been more likely to prefer a job in a rural remote area had they not received the advanced clinical education. The result goes a long way in suggesting that a policy aiming at recruiting health personnel with basic clinical education to rural remote areas by offering jobs that include possibilities of upgrading after a certain period of service, may be a temporary measure only. The fourth essay, “Pro-social preferences and self-selection into the public health sector: evidence from economic experiments” co-authored with Ida K. Lindkvist, studies the extent to which differences in pro-social preferences are related to career choices. We test whether preferences vary systematically between Tanzanian health worker students who prefer to work in the private health sector and those who prefer to work in the public health sector. Despite its important policy implications, this issue has received hardly any attention to date. By combining data from a questionnaire and two economic experiments, we find that students who prefer to work in the public health sector have stronger pro-social preferences than those who prefer to work in the private sector. We also show that the extent to which these students care about others can be conditional and linked to inequality aversion. A systematic selfselection of pro-socially motivated health workers into the public sector suggests that it is a good idea to have two sectors providing health services: this can ensure efficient matching of individuals and sectors by allowing employers in the two sectors to use different payment mechanisms tailored to attract and promote good performance from different types of health workers.
Paper I: Health Economics 20 (2), Julie Riise Kolstad. How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania, pp. 196–211. Copyright 2010 John Wiley & Sons, Ltd. Full text not available in BORA due to publisher restrictions. The published version is available at: http://dx.doi.org/10.1002/hec.1581Paper II: Arne Risa Hole & Julie Riise Kolstad (2010), Mixed logit estimation of willingness to pay distributions: a comparison of models in preference and WTP space using data from a health-related choice experiment. Draft version.Paper III: Julie Riise Kolstad (2010), How does additional education affect willingness to work in rural remote areas? An application on health workers in a low-income context. Draft version.Paper IV: Julie R. Kolstad & Ida Lindkvist (2010), Pro-social preferences and self-selection into the public health sector: evidence from economic experiments. Draft version.