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Abstract Background Health worker shortage and maldistribution are among the biggest threats to health systems in Africa. New medical graduates are prime targets for recruitment to deprived rural areas. However, little research has been done to determine the influence of workers' background and future plans on their preference for rural practice incentives and characteristics. The purpose of this study was to identify determinants of preference for rural job characteristics among fourth year medical students in Ghana. Methods We asked fourth-year Ghanaian medical students to rank the importance of rural practice attributes including salary, infrastructure, management style, and contract length in considering future jobs. We used bivariate and multivariate ordinal logistic regression to estimate the association between attribute valuation and students' socio-demographic background, educational experience, and future career plans. Results Of 310 eligible fourth year medical students, complete data was available for 302 students (97%). Students considering emigration ranked salary as more important than students not considering emigration, while students with rural living experience ranked salary as less important than those with no rural experience. Students willing to work in a rural area ranked infrastructure as more important than students who were unwilling, while female students ranked infrastructure as less important than male students. Students who were willing to work in a rural area ranked management style as a more important rural practice attribute than those who were unwilling to work in a rural area. Students studying in Kumasi ranked contract length as more important than those in Accra, while international students ranked contract length as less important than Ghanaian students. Conclusions Interventions to improve rural practice conditions are likely to be more persuasive than salary incentives to Ghanaian medical students who are willing to work in rural environments a priori. Policy experiments should test the impact of these interventions on actual uptake by students upon graduation.

Abstract Background Retaining health workers in rural areas is challenging for a number of reasons, ranging from personal preferences to difficult work conditions and low remuneration. This paper assesses the influence of intrinsic and extrinsic motivation on willingness to accept postings to deprived areas among medical students in Ghana. Methods A computer-based survey involving 302 fourth year medical students was conducted from May-August 2009. Logistic regression was used to assess the association between students' willingness to accept rural postings and their professional motivations, rural exposure and family parental professional and educational status (PPES). Results Over 85% of students were born in urban areas and 57% came from affluent backgrounds. Nearly two-thirds of students reported strong intrinsic motivation to study medicine. After controlling for demographic characteristics and rural exposure, motivational factors did not influence willingness to practice in rural areas. High family PPES was consistently associated with lower willingness to work in rural areas. Conclusions Although most Ghanaian medical students are motivated to study medicine by the desire to help others, this does not translate into willingness to work in rural areas. Efforts should be made to build on intrinsic motivation during medical training and in designing rural postings, as well as favour lower PPES students for admission.

Abstract Background The ability of many countries to achieve national health goals such as the Millennium Development Goals remains hindered by inadequate and poorly distributed health personnel, including doctors. The distribution of doctors in Ghana is highly skewed, with a majority serving in two major metropolitan areas (Accra and Kumasi), and inadequate numbers in remote and rural districts. Recent policies increasing health worker salaries have reduced migration of doctors out of Ghana, but made little difference to distribution within the country. This qualitative study was undertaken to understand how practicing doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions. Methods In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors currently practicing in 3 regions (Greater Accra, Brong Ahafo, and Upper West); these 3 regions were chosen to represent progressively more remote distances from the capital of Accra. Results and discussion All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. There was considerable stress placed on the need for rural doctors to have periodic contact with mentors through rural rotation of specialists, or remote learning centers, and reliable terms of appointment with fixed end-points. Also raised, but given less emphasis, were concerns about the adequacy of clinical equipment in remote facilities, and remote accommodations. Conclusions In-depth discussions with doctors suggest that while salary is important, it is career development priorities that are keeping doctors in urban centers. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.

Introduction In many low-income countries, health worker shortages hamper progress towards meeting the health-related Millennium Development Goals. (1) Africa is the region of the World Health Organization (WHO) with the [...], Objective To determine how specific job attributes influenced fourth year medical students' stated preference for hypothetical rural job postings in Ghana. Methods Based on discussions with medical student focus groups and physicians in practice and in the Ministry of Health, we created a discrete choice experiment (DCE) that assessed how students' stated preference for certain rural postings was influenced by various job attributes: a higher salary, free superior housing, an educational allowance for children, improved equipment, supportive management, shorter contracts before study leave and a car. We conducted the DCE among all fourth year medical students in Ghana using a brief structured questionnaire and used mixed legit models to estimate the utility of each job attribute. Findings Complete data for DCE analysis were available for 302 of 310 (97%) students. All attribute parameter estimates differed significantly from zero and had the expected signs. In the main effects mixed logit model, improved equipment and supportive management were most strongly associated with job preference (/3 = 1.42; 95% confidence interval, Ch 1.17 to 1.66, and [beta] = 1.17; 95% CI: 0.96 to 1.39, respectively), although shorter contracts and salary bonuses were also associated. Discontinuing the provision of basic housing had a large negative influence ([beta]= -1.59; 95% Ch-1.88 to -1.31). In models including gender interaction terms, women's preferences were more influenced by supportive management and men's preferences by superior housing. Conclusion Better working conditions were strongly associated with the stated choice of hypothetical rural postings among fourth year Ghanaian medical students. Studies are needed to find out whether job attributes determine the actual uptake of rural jobs by graduating physicians. Objectif Determiner comment les preferences d'etudiants en quatrieme annee de medecine pour des postes de travail hypothetiques en milieu rural au Ghana ont ete influencees par les caracteristiques specifiques de ces postes. Methodes A partir de discussions avec des groupes thematiques d'etudiants en medecine, des medecins en exercice et des employes du Ministere de la sante, nous avons mis sur pied une experience a choix discrets (DCE), qui a permis d'evaluer comment les preferences exprimees par les etudiants pour certains postes en milieu rural etaient influencees par les diverses caracteristiques de ces postes : salaire plus eleve, logement confortable gratuit et indemnite pour l'education des enfants, equipement perfectionne, encadrement cooperatif, contrats plus courts avant la fin des etudes et vehicule de fonction. Nous avons applique cette DCE a l'ensemble des etudiants ghaneens en quatrieme annee de medecine a l'aide d'un bref questionnaire structure, puis employe des modeles logit a effets mixtes pour estimer l'utilite de chaque caracteristique des postes. Resultats Nous disposions de donnees completes se pretant a une analyse de la DCE pour 302 etudiants sur 310 (97%). Toutes les estimations des parametres lies aux caracteristiques differaient significativement de zero et presentaient les signes attendus. La modelisation logit des effets mixtes principaux faisait apparaitre une forte association entre la presence d'un equipement perfectionne ou d'un encadrement cooperatif et la preference pour le poste ([beta] = 1,42; intervalle de confiance a 95%, IC: 1,17a 1,66, et [beta] = 1,17; IC a 95% : 0,96 a 1,39, respectivement), meme si la possibilite de contrats plus courts et l'existence de primes salariales etaient aussi associees a cette preference. Ne pas mettre a disposition un logement de base avait une forte influence negative (p = -1,59; IC a 95%: -1,88 a -1,31). Les modeles integrant les termes d'interaction entre les sexes indiquaient que les preferences des femmes etaient plus influencees par la presence d'un encadrement cooperatif et celles des hommes par la mise a disposition d'un logement confortable. Conclusion II existait une forte association entre de meilleures conditions de travail et le choix declare par les etudiants ghaneens en quatrieme annee de medecine d'un poste rural hypothetique. Des etudes sont necessaires pour determiner si les caracteristiques des postes conditionnent l'acceptation reelle des postes en milieu rural par des medecins ayant obtenu leur diplome. Objetivo Determinar que condiciones especificas de empleo influyen en la preferencia declarada de alumnos de cuarto ano de medicina por puestos de trabajo hipoteticos en zonas rurales en Ghana. Metodos Basandonos en conversaciones mantenidas con grupos de discusion de estudiantes de medicina y medicos en ejercicio en el Ministerio de Salud, creamos un modelo de eleccion discreta (MED) para evaluar el efecto de diversas condiciones de empleo en la preferencia declarada de los estudiantes por determinados destinos rurales; a saber: sueldos mas altos, alojamiento gratuito de mayor calidad, subsidios de educacion para los ninos, mejores equipos, gestion de apoyo, contratos mas cortos antes de la licencia de estudios, y entrega de un coche. Ensayamos sobre el terreno el MED y un breve cuestionario estructurado entre todos los estudiantes de cuarto ano de medicina en Ghana, y usamos modelos logit mixtos para estimar la utilidad de cada caracteristica del trabajo. Resultados Se consiguio usar en el analisis MED los datos completos de 302 de un total de 310 estudiantes (97%). Todas las estimaciones de los parametros de las condiciones estudiadas fueron significativamente distintas de cero y tuvieron el signo previsto. En el modelo logit mixto de efectos principales, un mejor equipo y la gestion de apoyo fueron los factores mas estrechamente relacionados con la preferencia por el trabajo ([beta] = 1,42, intervalo de confianza del 95%: 1,1 7-1,66, [beta] = 1,1 7, IC95%: 0,96-1,39, respectivamente), si bien se observo tambien una asociacion con los contratos mas cortos y las bonificaciones salariales. La interrupcion de la prestacion de alojamiento basico tuvo una enorme influencia negativa (6 = 1,59, IC95%: 1,88-1,31). En los modelos que incluian la interaccion del factor genero, las preferencias de las mujeres respondian en mayor medida a la gestion de apoyo y las de los hombres, a una vivienda mejor. Conclusion Se observo una solida relacion entre unas condiciones de empleo mejores y la eleccion declarada de puestos de trabajo rurales hipoteticos entre estudiantes de cuarto ano de medicina de Ghana. Es necesario realizar nuevos estudios para averiguar si las condiciones de empleo determinan la ocupacion real de puestos de trabajo rurales por los medicos que acaban la carrera.

Background: The ability of many countries to achieve national health goals such as the Millennium Development Goals remains hindered by inadequate and poorly distributed health personnel, including doctors. The distribution of doctors in Ghana is highly skewed, with a majority serving in two major metropolitan areas (Accra and Kumasi), and inadequate numbers in remote and rural districts. Recent policies increasing health worker salaries have reduced migration of doctors out of Ghana, but made little difference to distribution within the country. This qualitative study was undertaken to understand how practicing doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions.Methods: In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors currently practicing in 3 regions (Greater Accra, Brong Ahafo, and Upper West); these 3 regions were chosen to represent progressively more remote distances from the capital of Accra.Results and Discussion: All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. There was considerable stress placed on the need for rural doctors to have periodic contact with mentors through rural rotation of specialists, or remote learning centers, and reliable terms of appointment with fixed end-points. Also raised, but given less emphasis, were concerns about the adequacy of clinical equipment in remote facilities, and remote accommodations.Conclusions: In-depth discussions with doctors suggest that while salary is important, it is career development priorities that are keeping doctors in urban centers. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement. [ABSTRACT FROM AUTHOR]

Introduction: Health worker shortages and maldistribution have important implications for the capacity of health systems. Ghana has one of the highest physician emigration rates in the world, and over 75% of those who remain work in Ghana's two largest cities. The aim of this study was to investigate the contribution of experiential factors across Ghanaian medical students' lifespans on intent to practice in a rural area and intent to emigrate., Methods: All fourth year medical students in Ghana were surveyed on demographics, rural and international experience, and future career plans. Key outcomes of interest were students' stated likelihood of practicing in a deprived rural area or emigrating after graduation. Lifecourse predictors of interest were parental socioeconomic status, gender, relationship status, rural and international living experience, and school of study. Bivariate and multivariate logistic regression were used to estimate associations between predictors and outcomes of interest., Results: Of 310 eligible students, 307 (99%) participated in the survey. Of these, 228 were Ghanaian and the focus of this analysis. It was found that 131 (57.5%) were willing to work in a deprived area in Ghana and 148 (64.9%) had considered emigrating after graduation. In the multivariate regression models, willingness to work in a deprived area was predicted by male gender (OR: 2.31, 95%CI: 1.23-4.35), having lived in a rural area but never lived abroad (OR: 2.77, 95%CI: 1.08-7.13), and low parental professional and educational status (OR: 2.33, 95%CI: 1.23-4.43). Consideration of emigration was predicted by having lived abroad but never in a rural area (OR: 3.39, 95%CI: 1.15-9.97). A sub-set of 80 individuals (35%) reported that they were willing to work in a deprived area in Ghana but also considering emigration. These subjects were more likely to be male., Conclusions: Students with parents of a lower socioeconomic class, those with rural experience, and those without international experience are more likely to stay in Ghana and are also more likely to work in a deprived area after graduation. Selective admissions policies based on lifecourse factors combined with exposure to rural practice in medical school may have a role in increasing the number of rural physicians.