Policy Interventions That Attract Nurses to Rural Areas: A Multicountry Discrete Choice experiment/Comment Attirer le Personnel Infirmier Dans Les Zones Rurales? Resultats D'une Experience a Choix Discrets Realisee Dans Plusieurs pays/Intervenciones De Politica Para Atraer a Las Enfermeras a Las Zonas Rurales: Modelo De Eleccion Discreta Multinacional

Introduction The shortage of health workers in the areas where they are most needed is an important problem for health systems. Patients who have the greatest need for health care tend to live in remote and rural areas, but attracting skilled health workers to such areas and retaining them there has proved difficult. (1) Such an uneven distribution of health workers contributes directly to the global burden of ill health and inequity in health outcomes. Thus, it will not be possible to improve health outcomes globally unless more health professionals are attracted to work in rural and remote areas. (2) The factors that often motivate health workers to stay in remote areas have been extensively studied. (3-5) Several strategies have been proposed to address the problem, including changing student selection criteria; improving educational opportunities for workers; introducing financial incentives; creating more supportive working environments; and making it compulsory for health professionals to work in underserved areas. (6,7) However, the potential impact of these policy interventions, either singly or in combination, remains undetermined. Recent systematic reviews have invariably concluded that few rigorous studies evaluating the impact of rural recruitment and retention strategies have been conducted. (3,6-9) In the Cochrane review, (6) for example, not a single controlled study met the inclusion criteria. What is needed is more evidence, not more reviews, yet just how such new evidence will be generated remains unclear, particularly for low- and middle-income countries. Evaluating the effectiveness of human resource interventions is not the same as testing a drug for efficacy. Many human resource strategies require national policy changes and few are amenable to controlled studies. (10) Governments and donors should be encouraged to introduce human resource interventions under more controlled conditions that allow proper evaluation, but previous calls to strengthen the monitoring and evaluation of health reforms in low- and middle-income countries have had little impact. (11) In addition, statistically significant evidence of impact in well controlled trials may not be sufficient for informing practical policy decisions. The results of many human resource strategies are, in some measure, self-evident. Rural financial incentives are likely to improve rural recruitment and retention, but the critical questions are how much money is required to achieve a certain impact and how do financial strategies compare to other policy options, either individually or in combination. The answers to these questions will certainly vary between settings. What policy-makers actually need is information on the relative impact and cost-effectiveness of different packages of human resource interventions in a variety of contexts. Rigorous evaluation methods to answer such questions are not currently available. In the meantime, more modelling studies could be carried out to determine the probable outcomes of different policy scenarios. Stated preference discrete choice experiments (DCEs) are a promising method for conducting human resource research in low- and middle-income countries. (12) They are a quantitative technique for evaluating the relative influence of different product attributes on consumer choices (13) and have come to be used widely in health services research, primarily to assess patients' preferences and willingness to pay for different models of health service delivery. (14-16) However, DCEs have been used in recent studies to assess the relative importance of different factors on health workers' job choices. (17-19) The objective of this study was to use data from a DCE to model the relative effectiveness of different policy interventions on the recruitment of nurses to rural areas in three different countries. Methods This study was conducted in Kenya, South Africa and Thailand, all three of which have documented shortages of professional health workers in rural areas. …