Table 4 Factors associated with actual/preferred work in rural locations of Asia-Pacific LMICs medical graduates and students

A. Education

1. Factors related to selecting students with particular characteristics

a) Students with rural backgrounds†

Rural background was defined as either born, spent most of childhood, or finished high school in rural locations

Overall, only 1 study, in Nepal, had proven association of rural background, as a stand-alone factor, and rural practice [26]. The rest studies [27,28,29,30,31,32] presented strong association between being enrolled under the special track, comprising rural recruitment, scholarship and receiving a rurally enhanced curricula, and rural work

There are mixed findings about association between rural recruitment and rural work preference. While the majority of studies agree that having rural background is associated with rural work preference [33,34,35,36,37,38,39,40,41,42,43,44,45,46], three studies found no difference [47,48,49]

b) Students who are native to specific locations‡

Native is defined as respondents’ places of origin, where they lived during childhood or prior entering medical school, without mentioning the rurality of the location

Three studies revealed that one of the reasons to decide work location was because they are native to that particular area [50,51,52,53]

Studies showed association between being native to and intention to work rural areas [48, 49], or preference for rural practice increased if posted in or near to native area [54], however, another found the opposite [55]

Rao et al. revealed while respondents are 1.2 – 2 times more likely to prefer rural work when it is located in their native area, but no difference in this association was found between those with and without rural upbringing [56]

c) Students with certain parental socioeconomic or educational backgrounds‡

Parental socioeconomic or educational background refers to level of income, educational attainment and sector of income

No study had explored parental socioeconomic and educational backgrounds

Students who prefer rural work were more likely to: have a parent with a lower educational background [38, 40, 46]; have parents who are farmers [37]; have parents with low or medium wealth [43, 44], and; do not have a relative who is a doctor [43]. However, some studies found no association between rural work and: parental income level [33, 34, 37, 39]; educational background [35, 48, 49]; parent’s job as a civil servant [49]; and having a parent who is physician [55]

d) Family location‡

Location of family, including parents, spouse, children, or extended family. The different findings may be due to differing definitions of first-degree and extended family members used

Three qualitative studies revealed that location of family have been among the most frequent reasons of doctors chose working rurally [51, 52, 57]. Family location was also associated with working in rural locations [43, 45]

Doctors whose family members are in urban areas regard urban jobs more highly than those without family in urban areas [58]. Likewise, medical students’ decisions about work location were associated with the location of family [36, 40, 42]. It was also uncovered that location of family as one of main reasons of intention to work in rural locations [49, 59]

Some studies, however, found no association between having extended family in rural locations and intention to work rurally [33, 34]

e) Type of entry to medical school ‡

Some countries allow different types of entry to medical school, such as direct (5 years of medical course for those completing high school) or non-direct or graduate entry (3 years of medical course for those with some tertiary degree). Some schools also offered regular and international program, in which the international program had a higher tuition fee

No difference of rural practice between doctors with paramedical or science tracks [26]

Better preference of rural work was found among those: attending the graduate entry compared to direct entry [47]; enrolled under the regular program compared to those in international program [42]

f) Other aspects that were found as strong predictors: type of high school, personal characteristics, specialty

Type of high school refers to the public (government) or private ownership of the school. Specialty was type of specialization pursued after completing a medical degree

No studies had explored association between actual rural work and type of high school

Two studies unveiled that doctors working in rural locations because of sense of altruism and spiritualism [50, 51, 60]

Medical students graduating from government secondary schools are more likely to have rural work intentions [43]

Doctors or students with personal characteristics of altruism, optimism, higher self-efficacy, or self-decision-making were more likely to be willing to work in rural areas [34, 37, 47, 53, 59, 60]

Doctors on a GP track compared prefer rural work more compared to those in clinical medicine and public health tracks [38]

g) Other aspects with no association ‡

A higher academic performance during medical school was not associated with actual rural work [26]

A higher academic performance during medical school was not associated with rural work preference [43]

2. Factors related to delivering educational programs

a) Health professional schools outside of major cities †

Location of medical school considered as ‘outside of major cities’ were: outside of capital, or any rural or remote locations as defined by the studies

Doctors graduated from medical school outside the capital cities were more likely to work rurally [46, 61]. Other studies from Thailand and the Philippines found that establishing of medical schools in rural locations, combined with rurally enhanced curricula, were associated with increased doctor supply in rural locations [27,28,29,30,31, 62,63,64,65]

One study found that those studying in medical schools in rural locations were more likely to prefer rural work [40], while no difference on rural work preference between newly graduates from rural and urban medical school [48, 49]

b) Clinical placements (clerkships) in rural areas during studies †

Clerkship is a clinical placement or rotation phase, usually took place in the final year(s) of study. During the clerkship, students were rotating in different departments and treating patients under supervision

Being enrolled in a special track, comprising rural recruitment, rural medical school, rural clerkship, scholarship tie to compulsory service [19,20,21,22], and rurally enhanced curricula [62,63,64,65], was associated with rural work. No study had explored how a rural clerkship, as a stand-alone factor, was associated with actual rural work

Rural clinical clerkships were found to be associated with rural preference for students with an urban background [38]. Being enrolled in special track, comprising rural recruitment, rural medical school, rural clerkship, scholarship tie to compulsory service was associated with rural preference [25, 26]

c) Curricula that reflect rural health issues †

Curricula designed for rural- or community-based comprising: additional or extended exposures to community or rural settings

Curricula designed for rural- or community-based medical education—whether combined with other educational interventions such as scholarships [66], spending part of medical school in rural locations [62,63,64,65], or as a stand-alone intervention [30]—was associated with better doctor supply in rural areas

A fellowship program in a rural hospital, contains a community-based project work, exposures to cases in a rural (secondary hospital), has improved positive attitude toward rural career [67]

d) Continuous professional development for rural health workers †

Professional development refers to activities to improve skills and knowledge of health workers including short-term and long-term trainings, postgraduate study and specialization

Doctors in rural locations are less likely to have opportunities for postgraduate training compared to those in urban locations [68]. Evidence indicates that guaranteed professional development (i.e., continuing education, a higher score for postgraduate enrollment) was related to doctors’ rural work [50, 60, 66, 69,70,71] or staying in rural locations [53, 72]

Opportunities for professional development, whether of short duration like workshops or longer duration like postgraduate study, is one of the pivotal attributes considered by doctors in deciding to work [54, 56, 58, 60, 73, 74] or stay working [16, 50] in rural or remote locations

Medical students are more likely to prefer rural posts if being offered opportunities to continue education or enhance their professional development [47, 59, 75,76,77,78,79]

e) Rural internship‡

Medical internship is a phase medical graduates have an official medical doctor degree (such as MBBS or MD) but have yet to obtain license to practice unsupervised

Rural internships, delivered with rurally enhanced curriculum, were found to be positively associated with subsequent rural work [64]

Unpleasant experience while completing internship program in rural areas had discouraged doctors to continue working there [80]

f) Students from certain type of medical school ‡

Type of medical school refers to the public or private ownership of the school

No study had explored association between actual rural work and type of medical school

Two studies showed that students in public medical schools are more likely to prefer rural work compared to those in private schools [43, 55], whereas another study found no difference [56]

B. Regulatory

a) Compulsory service †

Compulsory service refers to any posting mandated for doctors with full practice license

Compulsory rural service policies post-graduation for 1–3 years have a positive association with increased rural doctors in Thailand [31, 81, 82]

It was found that those having completed 2 years of compulsory service were more likely to prefer rural jobs compared to those who completed 1 year [54]

b) Subsidized education for return-of-service †

Return-of-service refers to an obligatory assignment for doctors who received scholarships

Doctors [66, 81] who received a scholarship tied to compulsory service were more likely to stay working in rural compared to their counterparts

Being enrolled in a special track, in which the scholarship tied to compulsory service provided for those recruited from rural areas, was associated with improved rural doctor supply [27,28,29,30, 72]

Students [43, 47] who received a scholarship tied to compulsory service were more likely to prefer rural work compared to those without scholarship

Being enrolled in a special track, in which the scholarship tied to compulsory service provided for those recruited from rural areas, in addition to being recruited from rural areas and received a rurally enhanced curriculum, was associated with better rural preference [48, 49]

C. Financial incentives

a) Appropriate financial incentives †

Financial incentives refer to salary, hardship allowances or any additional money received by doctors with regard to their service in rural locations

Rural doctors, despite longer total working hours, received less income compared to the urban doctors [46]. The financial incentives (i.e., salary, hardship allowances) were among major attributes or challenges of doctors working in rural or remote locations [50, 52, 53, 70, 83]. The increasing incentive with remoteness was associated with an increase of rural doctor supply in China [32, 84]. However, financial incentives were deemed less valuable for retention compared to other factors such as working environment, community and personal factor among rural doctors in Thailand [72]

Appropriate financial incentives (i.e., salary, hardship allowances) were associated with doctors preference to work [36, 46, 84] or staying in rural locations [45, 85]. Better financial incentives were desired by doctors [52, 54, 56, 58, 60, 73, 74, 85,86,87] and medical students to address rural doctor shortages [36, 40, 47, 59, 75,76,77,78,79,80, 88, 89]

b) Opportunity to earn additional income ‡

Opportunity to additional income refers to income-generating activities related to clinical service, usually in private sector, hence the term ‘private practice’

Government doctors working in rural areas have a more limited opportunity for private practice [32, 50, 73, 90]. While a study in Pakistan revealed that private practice was one of reasons of willingness to work in rural areas in Pakistan [45], a study in India discovered that aversion to private practice was among reasons of doctors chose to work in rural location [53]

Lacking private practice opportunity in rural areas has discouraged interns to continue working in rural locations [80]

D. Personal and professional support

a) Better living conditions †

Better living conditions refers to any environmental aspects related to personal amenity such as housing, transportation, electricity, water and communication, education and business facility

Any general aspects of poor living conditions [45, 50, 52, 57, 72, 83], schooling facilities [50, 53], spouse employment [53], access to electricity and water supply [36], transportation [49], were among the key reasons for unwillingness to work rurally

There is evidence that preference to work in rural locations is associated with: short travel time to work [91], availability of transportation for official and unofficial use [76], positive perception of living conditions [47], and good educational facilities and connectivity [56]. However, in other studies, associations were not found between rural preference and: housing allowance or support [58, 75], access to a vehicle [58] and spouse and child education [34]

Overall better living conditions [6, 10, 11, 35, 45, 65, 70, 71], housings [76, 92], basic infrastructure (i.e., electricity, water, communications connectivity) [52, 57, 59, 88], transportation [57, 72, 74, 76], access to nearest town [41], and children schooling facilities [73], were also important attributes to rural preference. Females regarded housing provision higher than males [58, 74]

b) Safe and supportive working environment†

Working environment comprising both human and non-human resource such as: other health or non-health professionals, facility infrastructure, drugs and medical equipment

Despite the same average working hours in their main job, doctors in rural areas had longer working hours in dual practice compared to urban doctors [46]. Higher rural doctors’ workloads, owing to inadequate supply of health professionals in rural location or difficult geographical access, was another reason doctors were unwilling to work or remain in rural posts [50, 52, 57, 70, 93]

Other important attributes for rural doctor recruitment was lack of drugs, equipment and facility infrastructure [52, 57, 66, 83], while for retention was good relationships with peer and manager [53, 72]

One study found that higher satisfaction score to work environment were associated with intention to stay working in rural area [91]

Other attributes important to improve intention to work or staying in rural areas were: adequate number of health professional [73, 85], relationship with colleagues or seniors [80], lack of drugs, equipment and poor facility infrastructure [40, 59, 60, 73, 79, 81, 88, 92, 94]

Of those studies applying discrete choice experiment methods, 2 studies found that an adequate health facility was less important to medical students than salary [75, 76], while 2 studies found the opposite among doctors [56, 58]

c) Foster interaction between urban and rural health workers†

Interaction between urban and rural health workers comprising communication or consultation of doctors in rural areas with specialists or others with higher skills in urban areas

Limited access to highly skilled colleagues was among explanations discouraging doctors to work in rural areas [70, 73]

Access to specialists or consultant was mostly considered important for increasing preference to rural work [58, 79], though, it was off less importance when compared to increased salary, posting near home province, opportunity to continue to specialization and career promotion [54]

d) Career ladders†

Career ladder refers to career path that promotes doctor to a higher position, which is generally have better salary and benefit

Poor career ladder schemes were one of reasons hindering doctors to work rurally [50, 52, 57, 70, 83]. One of Thai government’s policy to improve rural recruitment was to provide opportunity for rural doctors to attain a high position, equivalent to that in urban location [31]

Creating a clear career ladder is important to improve doctors’ preferences to work in rural or remote locations [36, 47, 59, 60, 73, 79, 85, 86, 88, 92, 93]

The following are examples of career promotion schemes preferred for rural doctor recruitment: associated with higher rural work preferences were: promoted as permanent staff [54, 76], possibility to transfer to other more developed areas after certain period of employment [56]

e) Professional network†

Professional network refers to opportunity to connect and communicate with other peers in rural health service

A study found professional isolation was a deterrent to work rurally [52], while the presence of network of rural doctor is believed to improve doctors’ willingness to practice rurally [31]

A disconnected health services between urban and rural was among the prioritized attributes desirable by doctors for working in rural areas. [88]

f) Public recognition†

It refers to official or non-official recognitions received by the doctors

Rural doctors acknowledged the lack of recognition, especially as a primary care doctor, as one of challenges working in rural locations [57, 83]. An award for rural doctors was one of policies in Thai that was believed increased rural doctor supply [31]. Another Thai study confirmed that professional recognition was among important attributes for doctors to stay in rural region [72]

No study had identified public recognition as the major attribute for rural work preference

g) Security‡

It refers to situations related to personal safety of the doctors

Lack of security has been one of deterrents to work in rural or remote locations [50, 72], and two studies in India highlighted that this issue was especially raised by female respondents [57, 83]

Poor security was among major issues that should be tackled to improve doctors preferring to work in rural areas [40, 73, 79, 88, 92]

h) Community support‡

Community support comprising appreciation, reception, support, literacy, language and cultural compatibility

Connection and the absence of language barrier with community [83], or community appreciation, growth and support [72], was important attributes in attracting doctors to work or remain in rural locations

Community appreciation, literacy, attitude to western medicine have been mentioned as one of factors motivated doctors and students to work in rural locations [39, 41, 79, 89]

i) Career stages‡

Career stages refers to the length of employment as a doctor

No study had explored association between actual rural work and career stages

While one study found doctors completed 2 years compulsory service are more likely to prefer rural jobs compared to those with doctors completed 1 year [54], another one found no difference between career stages [91]

j) Human resource management‡

This refers to the management of hiring, firing and incentivizing health workers, usually performed by local or national government

No study had explored association between actual rural work and local-level human resource management

Although the definition is unclear, support from local government was among the most selected attributes influencing rural work preferences of medical students [75] and intention for rural retention among doctors [80, 85]

k) Gender‡

There is evidence that male are more likely to working in rural areas [27, 29]

Half of the studies investigating gender (n = 16) found no difference in rural preference between male and female [33, 34, 36, 39,40,41,42, 44,45,46, 48, 49, 55, 56, 91, 93]. While some studies found that, after adjusting for other variables, being male was strongly associated with preference to work in rural areas [43, 47, 77], several other studies found the opposite [35, 37]. Some DCE studies also found that males and females value job attributes differently: males are more responsive to workplaces near their home province and salary increases [54, 58], while females value housing more highly [58, 74]

l) Marital status‡

None had investigated association between marital status and actual rural work, despite such information was collected in the survey or interview

While one study found a weak association between being unmarried and willingness to take a rural job [45], most found no difference in rural preference or work according to marital status [33, 34, 39, 44, 88, 91]

E. Health systems‡

a) Governance‡

This refers to any aspect related to leadership and governance beyond the health facility

Political favoritism was shown to interfere with processes and procedures for doctors’ career development in rural locations [50, 70, 83]

It was perceived that political interference and instability were attributable to poor rural work preference [59, 73, 93]

b) Service delivery (organizational policy)‡

This refers to aspects related to health service organization and management

Changes in hospital autonomy, allowing more flexible financial management, has supported hospitals in urban areas to recruit more doctors thus reducing those working in primary healthcare clinics in rural areas [32]. Privatization of rural health have been associated with doctors moving to bigger health facilities in urban locations and away from rural health facilities [95]

No study had investigated the service delivery-related aspects with regard to rural work preference

c) Health financing‡

This refers to any aspect related to financing of the health systems

Capitation of staff at the hospital level had encouraged urban hospitals that were typically overstaffed to cease doctor recruitment, which could have resulted in more doctors working in rural hospitals [31]. In Cambodia, the government developed a package of healthcare services that required doctors to provide care at the hospitals. This policy resulted in doctors moving to hospitals, which were located in urban areas, and thus was associated with reduced availability of doctors in rural areas [32]

No study had investigated the health financing-related aspects with regard to rural work preference