Suppose you’ve just graduated from nursing school in Vientiane, Lao People’s Democratic Republic. Would you accept a post at a health center so remote that getting there requires a bus trip to Vietnam and a long walk back across the border? You may have one other colleague there, but otherwise you’ll be on your own. It’s unclear how long you’ll have to remain, or what your career options may be. Or would you prefer to stay in the capital?

“I think the health workers don’t want to go [to rural posts] after they graduate because they don’t feel confident,” says Dr. Chanthakhath Papassarang, deputy chief of the Education and Training Division, Department of Organization and Personnel in the Ministry of Health. “If they meet with a problem they don’t know who to ask. Another thing is that the conditions of living there [are challenging] and the environment for working is very poor.”

It’s not surprising that health workers are concentrated in cities, but more than 80% of Laotians make their homes in rural areas. In the past, says Dr. Phouthone Vangkonevilay, deputy director general of personnel in the Ministry of Health, “the MOH had the intention to provide some incentives for staff in rural areas…but I think [it was] not enough.”

Determining health workers’ preferences

The Lao government needed to figure out the most effective way to increase access to care, working with limited resources. In response, IntraHealth International’s global project, CapacityPlus, and the World Health Organization teamed up with the Ministry of Health to assess health workers’ preferences, using CapacityPlus’s Rapid DCE Tool.

DCE stands for discrete choice experiment, a powerful research method to determine the relative importance workers place on different characteristics related to employment options. The Rapid DCE Tool contains step-by-step directions and sample formats that countries can adapt to carry out a retention survey specific to their context.

Health workers and/or students are presented with a series of questions, each containing two sample job postings with various attributes or incentives—such as a salary of a certain amount, improved quality of the health facility, tuition support, accelerated career promotion, opportunities for professional development, or a housing allowance, among others—and asked to select the job they would prefer.

Their choices reveal which trade-offs they’re willing to make to work in rural areas based on what they would receive—in short, which incentives matter the most. The results are used to create evidence-based incentive packages to attract and retain health workers in rural areas.

Some surprising results

“It is interesting to know what people want,” comments Dr. Outavong Phathammavong, project assistant at WHO/Lao PDR. “Before we implemented the survey [to 483 health workers and 970 students in three provinces] many people said, ‘We don’t need to do the research. We already know: we need money!’” They assumed that salary was the only issue. “Once I see the results, [I realize that] money is not the issue. Instead, career promotion and continuing education is the most important thing.”

Developing an effective and affordable package

Following a final report and recommendations, the next step is to cost the various options using iHRIS Retain, an Open Source retention intervention costing tool jointly developed by CapacityPlus and the WHO. Then, says Dr. Phathammavong, “we will know the most appropriate incentive package for the health workers in Lao PDR.”

“I think this information is very useful to improve our policy and [learn] how to retain staff to work in remote areas,” concludes Dr. Papassarang.

A version of this piece was originally published as CapacityPlus Voices #8, on the CapacityPlus website.