Health Finance & Access Initiative, Bryn Mawr, PA, USA.
IntraHealth International, Washington, DC, USA.
Int J Health Policy Manag. 2017 Jul 1;6(7):383-394. doi: 10.15171/ijhpm.2016.141.
The dearth of health workers in rural settings in Lao People's Democratic Republic (PDR) and other developing countries limits healthcare access and outcomes. In evaluating non-wage financial incentive packages as a potential policy option to attract health workers to rural settings, understanding the expected costs and effects of the various programs ex ante can assist policy-makers in selecting the optimal incentive package.
We use discrete choice experiments (DCEs), costing analyses and recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the cost-effectiveness of 15 voluntary incentives packages for new physicians in Lao PDR. Our data sources include a DCE survey completed by medical students (n = 329) in May 2011 and secondary cost, economic and health data. Mixed logit regressions provide the basis for estimating how each incentive package influences rural versus urban location choice over time. We estimate the expected rural density of physicians and the cost-effectiveness of 15 separate incentive packages from a societal perspective. In order to generate the cost-effectiveness ratios we relied on the rural uptake probabilities inferred from the DCEs, the costing data and prior World Health Organization (WHO) estimates that relate health outcomes to health worker density.
Relative to no program, the optimal voluntary incentive package would increase rural physician density by 15% by 2016 and 65% by 2041. After incorporating anticipated health effects, seven (three) of the 15 incentive packages have anticipated average cost-effectiveness ratio less than the WHO threshold (three times gross domestic product [GDP] per capita) over a 5-year (30 year) period. The optimal package's incremental cost-effectiveness ratio is $1454/QALY (quality-adjusted life year) over 5 years and $2380/QALY over 30 years. Capital intensive components, such as housing or facility improvement, are not efficient.
Conditional on using voluntary incentives, Lao PDR should emphasize non-capital intensive options such as advanced career promotion, transport subsidies and housing allowances to improve physician distribution and rural health outcomes in a cost-effective manner. Other countries considering voluntary incentive programs can implement health worker/trainee DCEs and costing surveys to determine which incentive bundles improve rural uptake most efficiently but should be aware of methodological caveats.
老挝人民民主共和国（老挝）和其他发展中国家农村地区卫生工作者短缺，限制了医疗保健的可及性和结果。在评估非工资性财政激励措施作为吸引卫生工作者到农村地区的潜在政策选择时，了解各种方案的预期成本和效果可以帮助决策者选择最佳的激励方案。
我们使用离散选择实验（DCE）、成本分析和将卫生工作者密度与健康结果联系起来的最新实证结果来估计医生的未来位置决策，并确定老挝 15 个新医生自愿激励方案的成本效益。我们的数据来源包括 2011 年 5 月完成的医学生 DCE 调查（n=329）和二级成本、经济和健康数据。混合对数回归为估计每个激励方案如何随时间影响农村与城市的位置选择提供了基础。我们从社会角度估计预期的农村医生密度和 15 个单独激励方案的成本效益。为了生成成本效益比，我们依赖于 DCE、成本数据和先前世界卫生组织（WHO）的估计，这些估计将健康结果与卫生工作者密度联系起来。
与无方案相比，最佳的自愿激励方案将使 2016 年农村医生密度增加 15%，2041 年增加 65%。在纳入预期健康效果后，在 5 年（30 年）期间，15 个激励方案中有七个（三个）方案的预期平均成本效益比低于世卫组织阈值（人均国内生产总值的三倍）。最优方案的增量成本效益比为每 QALY（质量调整生命年）1454 美元（5 年）和每 QALY 2380 美元（30 年）。资本密集型组成部分，如住房或设施改善，效率不高。
在使用自愿激励措施的前提下，老挝应强调非资本密集型选择，如高级职业晋升、交通补贴和住房津贴，以以具有成本效益的方式改善医生的分布和农村健康结果。其他考虑实施自愿激励方案的国家可以实施卫生工作者/学员 DCE 和成本调查，以确定哪些激励方案能够最有效地提高农村参与度，但应注意方法上的注意事项。
