This survey of doctors living and practicing in Maluku province Indonesia offers valuable insights into factors significant to both recruiting and retaining a sustainable rural workforce.
Doctors currently working in rural and remote Maluku were more likely to be of younger age, single, graduated from Pattimura University, working for less than five years in current practice and since having graduated, report no additional practice, and have a smaller monthly salary and take home pay. Rural and remote practice in Maluku were predicted by shorter length of work since graduation, the absence of additional practice, and smaller salary and take home pay.
Length of work since graduation up to 5 years was the strongest predictor of RR practice location, and currently practising rural was the strongest predictor for future RR practice preference and intention to remain in RR practice.
These data inform an argument for dedicated government support of recruiting people from areas of medical workforce shortage into medical school, and support for students and graduate doctors through training and attractive opportunities to sustain their practices, which can subsequently retain the doctors in areas of workforce shortage.
This study identified more doctors practicing rurally were female (70%). This finding is notably different from other international studies describing characteristics of rural doctors, where male doctors tend to be the majority.21,30,47 While not predictive in this sample, another study in Australia has reported that more women are applying to Rural Clinical Schools34 and proportionately more are going on to rural work26, thus beginning to redress rural workforce shortages in female practioners.26
The majority of doctors practicing in Maluku graduated from medical schools in regional or provincial capitals, including almost a third from Pattimura University, Maluku. Given that most of our respondents were Maluku-born, this finding confirms that regional students come back to their regions48–50, and implies that significant efforts should be put into development of regional medical schools in order to improve distribution of doctors to the regions.48–50 While not significantly associated with rural practice location, we found that most doctors experienced rural exposure during their medical training. This is similar to the Australian requirement that all students experience rural work during their medical training.51 Clearly more directed positive strategies are needed.
Interestingly, rural exposure during medical training which is one of the most widely reported factors in other studies, was not associated with or predictive for RR practice location, rural preference, and intention to stay in a rural post. This was also found a study from Canada52, however, that study was from 1999 when medical schools were in the early stages of advancing rural experiences for their students. A 10 year longitudinal cohort study from Australia showed that rural exposure during medical training related to rural work.51
Another important factor reported elsewhere as a determinant of RR practice uptake is rural background19–35, but in this study it was not associated with or predictive for rural practice location. However, rural born and rural living experiences were associated with the preference of future rural practice location also intention to remain in RR practice. Rural living experience was also a predictor for prefered future RR practice, and born rurally was a predictor for intention to remain in rural practice among doctors working in Maluku Province. All of these factors should inform development of pro-rural work policies for this archipelago.
These positive policies are not only the domain of Western countries, as we confirm that a geographical maldistribution exists even in this developing province.9 But since our findings suggest that rural living experience and being rural born were associated with future rural work preference and intention to remain in rural practice, more focus and attention should be given to the recruitment of students and doctors with a rural background. Although this finding is not novel, this study importantly confirms the pattern among the limited number of studies from developing countries.
Additionally, evidence suggests that widening access to medical course enhanced care to underserved communities.53–57 A more comprehensive approach is needed to widen the participation and aspirations for medicine of under-represented socio-economic and educationally disadvantaged groups. This could include regent government early education programs and support including scholarships aimed at these under-represented groups.
Regarding future preference of practice type, doctors in Maluku preferred to work in specialist practices, namely Internal Medicine, Paediatrics, Obstetrics and Gynaecology, and Surgery. Specialist practice, especially within the four major specialties, is an opportunity to earn more income and the four specialty areas align with international preferences among doctors and medical students.58–60 Although there are currently few specialists in Maluku and there is a great need for more specialists, priority should be given to primary care, rural practice, rural generalist, and family medicine for these areas of practice are associated with improved recruitment and retention of RR medical human resources. 21,23,24,27,28,32,61,62
We found that monthly salary and take home pay were relatively low regardless of the length of work (IDR 5 million, equal to USD 350/GBP 250 and IDR 34.5 million equal to USD 2400 or GBP 1750 respectively), and low salary was associated with and predicted current rural practice. Smaller take home pay deterred doctors from future rural preference and intention to stay rural, highlighting the call from others internationally that meaningful reward for rural work is needed.63
This study shows that being a graduate of Pattimura University was significantly associated with all three outcome variables, and predicted the intention to remain practising in rural and remote Maluku. From this result, it can be said that Pattimura University has successfully produced doctors who are willing to serve in the RR areas of Maluku Province. This evidence supports the achievement of Pattimura University Medical School philosophy, akin to the vision of the Philippines medical school64 and the vision for rural clinical schools in Australia.26,34,65
Considerable evidence shows that a medical school intentionally established in a region of workforce shortage pays much greater attention to the region's health status and concern. This is the case in both the developed.22,66−68 and developing world.49,64,69 The medical school in The Philippines, Zamboanga64, has a similar rural, archipelago, and developing country context as Indonesia so its findings are likely to be immediately relevant. This medical school showed that effective and sustainable medical education is possible in poor rural areas.64,70 Compared to James Cook University which strongly favours applicants with rural backgrounds and requires a commitment to work rurally after graduation22,66−68, Pattimura University only stresses the philosophical value to practise rurally and offers rural exposure during medical training without any requirement for a rural background or commitment to work rurally.
From the successful experience of other universities24,26,28,49,64,69,71, and based on this study’s findings, Pattimura University could expand even further into the rural areas of the region. Stressing the university’s values by increasing the proportion of students with a rural background and ensuring rural exposure is offered at different year levels for a range of disciplines during the medical course will likely increase the number of graduates serving the RR areas of Maluku Province.
It is evident from this study that younger doctors were more likely to work rurally and to stay rurally, perhaps reflecting this generations’ ethical stances around the world.72,73 Those who start working in the last five years were more likely to take up and prefer rural practice, however, they received a lower salary and smaller take-home pay which reduces their intention to stay in RR practice. The rural work experience requirement and recommendation from the rural government for scholarship in specialist training from the Ministry of Health74 means these rural posts are likely to temporarily attract younger doctors to rural service in Maluku. However, retaining doctors in rural and remote Maluku Province requires more than financial incentives. Evidence from elsewhere shows that educational61,75−80, multi dimensional81–85, and professional development strategies86,87 improves retention of doctors in RR areas. Consequently, collaboration between medical schools and local government is required to ensure relevant strategies are implemented to improve the recruitment and retention of doctors in RR areas.
Pertaining to the sampling frame, we noted difference in the number of doctors working in Maluku compare to the list provided from provincial and regents health offices, and the medical school. There was no integrated database listing all doctors working in this province. The use of the Pattimura University alumni database to identify additional medical graduates augments the denominator for sampling but may potentially bias the participant sample.
This study is cross sectional, so it is not possible to draw inferences of causality and outcomes of individual preferences and inclination to remain in rural practice which can easily change. A longitudinal study is needed to track whether the participants are still in rural practice 5 to 10 years from now. Secondly, despite the high response rate, the study may not have had power to detect less strong associations between rural exposure in medical training and subsequent practice location.
The definition of rurality used in this study was the Indonesian national classification which may differ to that used by other countries and make comparison challenging.