How Using the Rapid Retention Survey Toolkit Resulted in Policy Change in Lao PDR

Rachel DeussomLast week, the Rapid Retention Survey Toolkit was published and is now available to all to conduct a rapid discrete choice experiment (DCE) survey in order to design evidence-based health worker incentives. As one of the authors, I’m proud of how this toolkit was inspired from two intensive in-country applications. Developed from field testing experiences in both Uganda and Lao People’s Democratic Republic (PDR), it documents the entire survey process from planning and logistics to implementation to data analysis and presenting results to key stakeholders. The toolkit has already been used to incite real change for the health workforce.

Soon after joining the CapacityPlus project in early 2012, I contributed to the Rapid Retention Survey Toolkit’s refining stages, capturing step by step how a rapid DCE survey can be implemented. I worked through my own test rapid DCE survey exercise to ensure that every step in the toolkit was written clearly and using a common language. I included screenshots so that visual learners could also be guided by what they are seeing on their computer screens during the survey development, implementation, and analysis stages. I feel confident that this tool can be a valuable resource for any country or context. The toolkit guides users to determine what retention issues they are seeking to address and how to engage with various stakeholders in the process. It also outlines how to involve key decision-makers and communicate survey results to garner political will for policy change.

Here is an illustration of how the toolkit was developed, based on the rapid DCE survey process undertaken in Lao PDR, which recently resulted in policy change!

With only 0.59 doctors per 1,000 people, Lao PDR faces a severe health workforce shortage, especially for the two-thirds of Laotians that are living in rural or remote areas. Our story begins back in June 2010 when CapacityPlus participated in a technical workshop in Lao PDR, which promoted diverse stakeholder engagement and was sponsored by the Ministry of Health and the World Health Organization (WHO). A key goal for the workshop was to develop a plan of action to implement health worker retention strategies in the country. At that time CapacityPlus was in the process of developing the toolkit and proposed providing technical assistance to assist the Ministry to identify incentive strategies that would increase access to skilled health professionals in rural and remote areas of the country. 

Agreement was reached to conduct a rapid DCE survey, a simplified version of a research method that identifies the trade-offs professionals are willing to make between specific job characteristics and determines their preferences for various incentive packages. For Lao PDR, the survey’s results promised to provide a clearer understanding of what attracts medical graduates and retains health professionals to jobs, especially posts in rural areas.

By May 2011, Wanda Jaskiewicz and Laura Wurts arrived in Lao PDR to provide support to the rapid DCE survey implementation. They partnered with Ministry team members, who collected over 1,500 survey questionnaires from medical students and currently practicing doctors, nurse midwives, and medical officers.

Then the survey team presented preliminary results to the Ministry’s Human Resources for Health Steering Committee, which included staff from the Ministry, university of health sciences, Public Health Institute, and WHO/Lao PDR, and discussed next steps to finalize the report and conduct a costing of the results. The steering committee wanted to use this very timely data to fund national retention strategy implementation.

With CapacityPlus support, the Ministry costed out several options of incentive packages that resulted from the rapid DCE survey using iHRIS Retain, the retention intervention costing tool developed by CapacityPlus and the WHO.

In October 2012, the Lao PDR Ministry of Health announced its new recruitment and retention policy, which stipulates that all new graduates in medicine, nursing, midwifery, pharmacy, and dentistry, as well as postgraduates in family medicine, must complete three years of rural service in order to receive their licenses to practice. The policy provides specific incentives (e.g., housing and eligibility for continued education), based on the survey and costing results, to motivate health workers to provide high-quality services while carrying out their rural service, as well as encourage them to stay after the compulsory service has ended.

As the Lao PDR experience illustrates, it can take time for new evidence to bring policy change. It will be exciting to follow how Lao PDR’s new retention policy is implemented, and how it impacts the population’s access to health services.

Making the Rapid Retention Survey Toolkit further accessible to users, an eLearning course is available for free on the HRH Global Resource Center. The course can be used alongside the toolkit and includes video demonstrations for guiding users through using the specialized software required.

On behalf of the Rapid Retention Survey Toolkit team, I am happy to share this resource with many others. May it be well used so that more health workers can be successfully attracted to and retained in rural areas, benefiting the health of many!

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