THE USE OF SPECIALTY TRAINING TO RETAIN DOCTORS IN MALAWI: A DISCRETE CHOICE EXPERIMENT

Purpose:

   Emigration has contributed to a shortage of doctors in many sub-Saharan African countries. Specialty (residency) training is highly valued by doctors and a potential tool for retention, yet not all training may be valued equally. We carried out a discrete choice experiment to ascertain the preferences of Malawian doctors for different types of specialty training. 

Method(s):

   A literature review and semi-structured interviews were used to identify attributes and levels, which included: salary, location before training, time before training, location of training and specialty. An efficient design was used to construct 16 generic choice tasks with an opt-out option. All Malawian doctors within five years of graduation and not yet in specialty training were targeted, with 140 participants out of 153 eligible. A latent class model was used to analyse choice data and calculate a novel measure of willingness to stay. Simulations were run to compare policy options for maximising retention and increasing uptake of priority specialties. 

Result(s):

   Doctors preferred timely training outside of Malawi in core specialties (general medicine, general surgery, paediatrics, obstetrics & gynaecology). A doctor would work for an additional 1.3 to 8.5 years if guaranteed training in their 1^st choice core specialty, but just two to five months for an extra 10% in basic salary. Training undertaken in Malawi would require a 36% to 79% increase in basic salary and training in ophthalmology, representing a bundle of unpopular but priority specialties, would require a 200% to 350% increase. The best model fit was found with four latent classes. These represented groups of doctors with distinct preferences, including the rich rejecters (high current salary, frequently refused jobs); the money motivated (greatest preference for salary increases); the stubborn specialists (strong specialty preferences with little flexibility); and the pliant patriots (flexible specialty preferences, no preference for training outside Malawi). Policy simulations showed that time spent working in rural areas of Malawi could be increased in most groups in exchange for training in core specialties, but providing incentives to improve the uptake of priority specialties is only effective for pliant patriots. 

Conclusion(s):

   Despite evidence that specialty training is highly sought after, Malawian junior doctors do not value all training equally. Policymakers can exploit differences in preferences to support workforce planning and improve retention.