Date of Award

Spring 2020

Document Type

Open Access Dissertation

Department

Health Services and Policy Management

First Advisor

Brian Chen

Abstract

Financial incentive is one of the common strategies used to attract healthcare workers in rural and remote areas. Both high-income and low-income countries extensively use financial strategy to tackle the disparity distribution of healthcare workers. However, most studies were conducted in developed countries and assessed positive incentives programs. Previous studies showed the effectiveness of financial incentives on recruitment and retention of healthcare workers. Current studies show that most of the financial incentives supported for education such as scholarships and loan repayment programs are effective. A few studies assessed the effectiveness of direct payment incentive programs, especially in low-middle income countries. The evaluated studies of the effect of financial incentive reduction on the health workers’ decision to stay or leave their practice location and the relationship between the health providers’ age and their location choice after the reduction of financial incentive are required also.

This study have three specific aims. First aim is to examine the effectiveness of direct payment (Hardship Allowance) on retaining dentists in rural and remote areas. Second aim is to examine the impact of financial incentive reduction, due to the changed HA areas categorization, on rural and remote healthcare workers. The last one is to examine the relationship between dentists’ age and dentists’ location choice on financial incentive reduction, due to the recategorization of Hardship Allowance (HA) areas in Thailand.

A retrospective observational study was conducted for answering all three specific aims. Data used for aim#1 is the resignation data of dentists from 2003 to 2016 and an annual report on dentist’s location. This data set were obtained from the Human Resource Management and the Policy and Strategy Bureau, Ministry of Public Health (MoPH) in Thailand. The fixed effect panel analysis and difference in difference regression was used to analyze the effectiveness of Hardship Allowance implemented in 2008.

Data used for aim#2 and #3 is the rural and remote dentist's location annual report, including the relocation and resignation from 2013 to 2018. This data set were obtained from the Human Resource Management Department and the Policy and Strategy Bureau at the Ministry of Public Health (MoPH) in Thailand. The difference in difference regression with fixed effect panel analysis was used to analyze the effect of Hardship Allowance reduction on dentists’ decision to stay or leave their location. The triple differences regression with random effect estimation was used to analyze the panel data of dentists’ resignation and relocation by age groups, in changed areas after the policy implementation.

Data from 2003 to 2016 showed that 2,351 dentists who resigned from the hospital under the MoPH. Over than 60% of resigned dentists were between 22-28 years old. The resignation rate from 2003 to 2016 showed that dentists who were located in rural areas had the highest rate compared with dentists in urban and remote areas. The highest resignation rate in rural areas in 2004 was at 29.4%. When the Hardship Allowance policy was implemented in 2008, the resignation rate started decreasing dramatically in all areas, but especially in rural areas. Additionally, the regression analysis showed that the resignation rate of dentists in rural areas significantly decreased

after 2008 at 10.09% (p-value <0.001), while in urban areas after 2008 the resignation rate decreased at 2.23% (p-value <0.001). Data of 2,384 rural and remote dentists is used to determine the location choice between the changed and unchanged areas categorization after the policy implementation in December 2016 which answer the specific aim#2 of the study. The outcome shows that the resignation of dentists in unchanged and changed areas is not significantly different. However, the relocation of dentists from rural to urban in changed areas after the policy implementation is more likely to increase significantly.

Data of 2,384 rural and remote dentists from 2013 to 2018 were used for specific aim#3 of the study. The percentage of dentists by age groups 22-28, 29-35, 36-45, and 46-60-year-old is 28%, 42%, 23%, and 5.4%, respectively. About 70% of 22-28-yearolds, and 29-35-year-olds are in rural areas, while approximately 60% of the other two groups are in urban areas. The regression analysis of dentists’ resignation and relocation on dentists’ age in changed areas after the policy implementation shows that the oldest group in changed areas is the less likely to resign significantly from their location after the policy implementation compared with the youngest group.

In conclusion, the study showed that after the policy

implementation the resignation rate of dentists decreased in all areas. When comparing the resignation rate in rural and urban areas, the resignation rate in rural areas decreased higher than in urban areas after 2008. Therefore, the Hardship Allowance programs could retain dentists in rural and remote areas in Thailand. Furthermore, our findings show that the direct payment reduction does not affect the number of resignations, but the relocation of dentists. The dentists decide to leave their location after the direct payment HA reduction policy was implemented. Therefore, the reduction of financial incentives could deteriorate the retention of health workers in rural and remote areas. We also found that dentists’ age is related with the dentists’ decision to leave or stay in rural and remote areas when the HA was reduced. Although, the policy implementation caused the reduction of financial incentives, most of the oldest group decided to stay in their practice location. Besides financial incentive, age is another factor that influences that the dentists’ decision to leave or stay in rural and remote areas.

Rights

© 2020, Rakchanok Noochpoung

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