The MOPH resignation records indicated that there were increased numbers of doctor who did not complete their rural service obligations. Lower workloads and higher incentives in the private sector were among several main reasons given . The existing financial incentive regimes alone may not be able to overcome stronger pull factors; policymakers need to revisit the question of what are effective interventions for sustaining rural retention.
Graduates from the CPIRD and ODOD programs had slightly better rural attitudes than those from the normal track, albeit medical students from all tracks were exposed to rural health services such as preventive or community medicines, as required by the curriculum, for a few months in their clinical years.
The significantly higher intention to fulfil their compulsory service among graduates from the special track can be explained by a few factors: greater satisfaction when posted in their hometown, in neighboring districts or in provinces which shared the same culture, dialect and social network. Graduates from CPIRD and ODOD were trained in MOPH-affiliated hospitals during clinical years which can provide professional peer support later in their career. This study confirmed previous findings that, after 3 years of mandatory service, 83% of graduates from CPIRD and 52% from the normal track continued in rural practice . Graduates from CPIRD track served for a longer period with a median of 10 years in the public sector; this contrasted with a median of 6.5 years for graduates from the normal track [22, 23].
Clinical competencies among CPIRD and ODOD graduates were clearly higher than those from the normal track; this likely came from the greater opportunities to handle cases for students in affiliated MOPH provincial or regional hospitals. By contrast, between normal track medical students and patients, there were layers of first- to third-year residents undertaking their specialty training in university medical faculties; this meant that opportunities to handle cases by medical students were reduced. In addition, patients in affiliated MOPH hospitals presented with more common complaints, like those found in clinical practice after graduation (for example, patients in university hospitals tend to present with more complicated problems, or are referred from elsewhere); they therefore commonly require specialist services, not easily handled by medical students.
Based on the two merits of the special track (higher intention to complete the mandatory 3-year public service, and better clinical competencies) policymakers should expand the proportion of enrolment from CPIRD and ODOD. Unfortunately, the proportion of students recruited through the special track was less than 20% of the total annual medical student enrolment over the past decade, though this had improved recently (30% of new students graduating in the 2013 academic year were recruited through the special track [23, 24]).
The ODOD program is more effective at solving shortages than the CPIRD scheme; the districts with chronic shortages are targets for ODOD enrolment and placement upon graduation and ODOD enrolment comes with a longer period of mandatory service. The ODOD design precisely addresses the problem of districts with chronic shortage. Problems have arisen because most students from these remote districts have not been able to pass the special track examination, while medical faculties maintain education standards. Between 2007 and 2009, the balance between the two special track programs saw CPIRD at 63% and ODOD at 37% . The potential merits of ODOD justify seeking to increase the proportion of students recruited through this program.
Higher commitment to rural work among graduates recruited from rural areas was reported from Japan, while Canadian doctors with rural backgrounds had higher interests in rural family practice once they graduated [8–10]. In Australia, students who spent their clinical years in non-traditional medical schools had higher confidence and were better prepared than those who studied in traditional medical schools; this was the result of more hands-on experience and closer patient contact .
A few limitations of this study have been identified. Compared with a case–control or cohort design, multiple cross-sectional surveys cannot document causal relationships . It was recognized that the graduates who gathered on the survey date did not represent the whole population; some 20% of total graduates chose to work in non-MOPH hospitals such as military or psychiatric hospitals [26, 27] and they therefore did not show up on the survey date. It should be noted that variations in curriculum and pedagogy between universities resulted in variations in competencies. It should be remembered that the intention to work in rural areas is influenced by various contextual environments. Since the recovery from the 1997 economic crisis in early 2000, the private sector’s demand for physicians has grown significantly and contributed to a domestic brain drain of physicians from the public sector . In the context of the upcoming 2015 inauguration of the Association of Southeast Asian Nations Economic Community , the growth in economic centers may also stimulate losses of medical professionals from rural areas. The intention to fulfil the mandatory service can be very subjective and unreliable; however, the intention not to fulfil can be very reliable.
Conclusion and policy recommendations
Evidence suggests that special track recruitment is better than normal track recruitment in terms of the intention to fulfil the mandatory rural service and higher clinical competency. Furthermore, ODOD provides a more precise method of solving chronic shortage in certain districts than CPIRD. Based on this evidence, it is recommended to expand the proportion of recruitment from the special track, while reducing normal track recruitment. Within the special track, efforts should be given to increase the proportion of students recruited through the ODOD program.
The National Ethical Review Committee waived ethical clearance as this is a regular monitoring work conducted by the Government, confirmed by ethical review committee: IHRP 47.2/2553 date 28 January 2553 BE (2010 AD). However, informed consent was sought and the protection of confidentiality was strictly followed.