-
Putri et al. Hum Resour Health (2020) 18:93
https://doi.org/10.1186/s12960-020-00533-4
REVIEW
Factors associated with increasing rural doctor supply
in Asia-Pacific LMICs: a scoping reviewLikke Prawidya
Putri1,2* , Belinda Gabrielle O’Sullivan3 , Deborah Jane Russell4
and Rebecca Kippen2
Abstract Background: More than 60% of the world’s rural
population live in the Asia-Pacific region. Of these, more than 90%
reside in low- and middle-income countries (LMICs). Asia-Pacific
LMICs rural populations are more impoverished and have poorer
access to medical care, placing them at greater risk of poor health
outcomes. Understanding factors associated with doctors working in
rural areas is imperative in identifying effective strategies to
improve rural medical workforce supply in Asia-Pacific LMICs.
Method: We performed a scoping review of peer-reviewed and grey
literature from Asia-Pacific LMICs (1999 to 2019), searching major
online databases and web-based resources. The literature was
synthesized based on the World Health Organization Global Policy
Recommendation categories for increasing access to rural health
workers.
Result: Seventy-one articles from 12 LMICs were included. Most
were about educational factors (82%), followed by personal and
professional support (57%), financial incentives (45%), regulatory
(20%), and health systems (13%). Rural background showed strong
association with both rural preference and actual work in most
studies. There was a pau-city in literature on the effect of rural
pathway in medical education such as rural-oriented curricula,
rural clerkships and internship; however, when combined with other
educational and regulatory interventions, they were effective. An
additional area, atop of the WHO categories was identified,
relating to health system factors, such as governance, health
service organization and financing. Studies generally were of low
quality—frequently overlooking potential confounding variables,
such as respondents’ demographic characteristics and career
stage—and 39% did not clearly define ‘rural’.
Conclusion: This review is consistent with, and extends, most of
the existing evidence on effective strategies to recruit and retain
rural doctors while specifically informing the range of evidence
within the Asia-Pacific LMIC context. Evidence, though confined to
12 countries, is drawn from 20 years’ research about a wide range
of factors that can be targeted to strengthen strategies to
increase rural medical workforce supply in Asia-Pacific LMICs.
Multi-faceted approaches were evident, including selecting more
students into medical school with a rural background, increasing
public-funded universities, in combination with rural-focused
education and rural scholarships, workplace and rural living
support and ensuring an appropriately financed rural health system.
The review identifies the need for more
© The Author(s) 2020. Open Access This article is licensed under
a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in
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Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the
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will need to obtain permission directly from the copyright holder.
To view a copy of this licence, visit http://creat iveco mmons
.org/licen ses/by/4.0/. The Creative Commons Public Domain
Dedication waiver (http://creat iveco mmons .org/publi cdoma
in/zero/1.0/) applies to the data made available in this article,
unless otherwise stated in a credit line to the data.
Open Access
*Correspondence: [email protected]; [email protected];
[email protected] Department of Health Policy and Management,
Faculty of Medicine, Public Health and Nursing, Universitas Gadjah
Mada, IKM Building 2nd Floor, Jl. Farmako, Sekip Utara, 55281
Yogyakarta, IndonesiaFull list of author information is available
at the end of the article
http://orcid.org/0000-0002-3467-4615http://orcid.org/0000-0003-4068-3240http://orcid.org/0000-0003-2221-7334http://orcid.org/0000-0002-4823-5832http://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/http://creativecommons.org/publicdomain/zero/1.0/http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-020-00533-4&domain=pdf
-
Page 2 of 21Putri et al. Hum Resour Health (2020)
18:93
IntroductionContinuing to strengthen the rural health workforce
is crucial as part of building universal health coverage and
achieving Sustainable Development Goals [1–4]. Even when rural
people, who account for nearly half of the world’s population, are
covered by universal health insur-ance, service coverage may be
poor without a sufficient number of skilled local health workers
[3, 5].
Higher doctor-to-population ratios correlate with lower
maternal, child, and neonatal mortality [6, 7] and lower all-cause
morbidity and mortality rates [8, 9], sug-gesting that access to
tertiary qualified doctors is essen-tial. Countries at all levels
of socioeconomic development are investing in strategies to improve
the supply and retention of qualified doctors in rural areas.
High-income countries such as the United States, Canada, and
Aus-tralia have implemented numerous policies and pub-lished
extensively about various interventions, including financial
incentives, rural education pathways, regula-tory, and personal and
professional support strategies to address rural doctor shortages
[10–15]. In low- and middle-income countries (LMICs), stand-alone
policies of compulsory rural healthcare-professional placements
have also been implemented [16, 17]. However, the range of research
informing how to improve access to qualified rural doctors in LMICs
remains to be summarized. An additional quality issue is the lack
of evidence relating to doctors at various career stages, since
medical workforce dynamics may change by stage professional
development [18].
The Asia-Pacific region is home to more than half of the global
population, with approximately 98% of the Asia-Pacific population
living in 29 LMICs, and just over half of these LMIC populations
living rurally [19]. Doc-tor-to-population ratios in Asia-Pacific
LMICs are well below the World Health Organization (WHO)’s
bench-mark of 1.15-to-1000 population [19], which is essential to
achieve its Sustainable Development Goals [1]. Thus, it is critical
to understand the effectiveness of strategies implemented to
increase rural medical workforce supply in Asia-Pacific LMICs.
With this background in mind, this review summarizes and
synthesizes existing evidence about factors associ-ated with
preferences and actual work locations of medi-cal students and
doctors in Asia-Pacific LMICs. This is done with a view to
identifying effective strategies for recruiting and retaining
doctors in rural areas. Additional
aims are to describe how studies define rural or remote and to
determine the spread of evidence by career stage, so as to inform
how to target strategies better.
MethodsNature of reviewThe scoping review method was used
as it was most relevant to answering the primary research question
about the range and extent of existing evidence. Scoping reviews,
unlike traditional systematic reviews, place less emphasis on the
critical appraisal of the included evi-dence, thus allowing the
inclusion of a broader range of literature potentially relevant to
capturing emerging evi-dence in Asia-Pacific LMICs [20]. The
protocol for this review was developed iteratively by the
authorship team according to Preferred Reporting Items for
Systematic Reviews and Meta-analysis Extension for Scoping Review
(PRISMA-Scr) [21].
Search strategyThe authors, with assistance of an experienced
librar-ian, developed a Boolean string from key search terms
(Table 1) and tested hits against ten key articles known to
the first author with 100% sensitivity. Included were terms that
covered LMICs, sub-regions and country groups in the Asia-Pacific
as at 2019, using the World Bank 2019 definition of Asia-Pacific
LMICs [22]. Other search terms addressed the population of interest
(medi-cal doctors), exposures of interest, and location of
practice.
Both peer-reviewed and non-peer-reviewed literature published in
the last 20 years (July 1999–June 2019) were retrieved.
Pubmed, Medline, CINAHL, EMBASE, Psy-cINFO, Web of Science, and
SCOPUS were searched. Human Resources for Health and Rural and
Remote Health journals were also searched. Grey literature searches
included Proquest dissertations; first 10 pages of Google Scholar
for each country; hrhresourcecenter.org (category: rural/urban
imbalance, deployment); WHO website; and Global Health Workforce
Alliance website. We searched the eligible articles’ references to
identify any additional materials.
Study selectionIncluded were studies investigating the following
out-comes: (1) actual work, referring to current work, and; (2)
preference, referring to attitude towards, intention
studies in a broader range of Asia-Pacific countries, which
expand on all strategy areas, define rural clearly, use
multi-variate analyses, and test how various strategies relate to
doctor’s career stages.
Keywords: Physicians, Rural health services, Professional
practice location, Career choice, Developing countries
-
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18:93
Tabl
e 1
Sear
ch te
rms
appl
ied
in th
e sc
opin
g re
view
Key
conc
epts
Rela
ted
keyw
ords
Rela
ted
subj
ect t
erm
1Po
pula
tion
Doc
tors
; gen
eral
pra
ctiti
oner
; med
ical
pra
ctiti
oner
; med
ical
gra
duat
e; p
hysi
-ci
an; p
rimar
y ca
re p
hysi
cian
; med
ical
offi
cer;
med
ical
inte
rnG
ener
al p
ract
ition
ers;
fam
ily p
hysi
cian
s; pr
imar
y ca
re p
hysi
cian
s; m
edic
al s
taff
; m
edic
al g
radu
ate;
med
ical
pra
ctiti
oner
; med
ical
inte
rn; h
ealth
per
sonn
el;
heal
th w
orks
hop;
inte
rnsh
ip a
nd re
side
ncy
2Co
ncep
t: ex
posu
res
of in
tere
stRe
crui
t; re
crui
ting;
recr
uitm
ent;
reta
in; r
eten
tion;
turn
over
; att
ritio
n; c
aree
r; w
ork
loca
tion;
pra
ctic
e lo
catio
n; g
eogr
aphi
c di
strib
utio
n; g
eogr
aphi
c im
bal-
ance
; sho
rtag
e
Care
er c
hoic
e; jo
b sa
tisfa
ctio
n; m
otiv
atio
n; p
erso
nnel
dev
elop
men
t; ch
oice
be
havi
or; p
hysi
cian
ince
ntiv
e sc
hem
e
3Co
ncep
t: lo
catio
n of
pra
ctic
eIn
rura
l or r
emot
e or
non
-met
ropo
litan
or n
on-u
rban
or u
nder
serv
ed o
r und
er-
serv
iced
or r
egio
nal
Rura
l hea
lth s
ervi
ces;
rura
l hea
lth; p
rofe
ssio
nal p
ract
ice
loca
tion;
med
ical
ly
unde
rser
ved
area
; rur
al p
opul
atio
n
3Co
ntex
tEa
ch o
f the
low
and
mid
dle-
inco
me
coun
trie
s in
Asi
a-Pa
cific
regi
on, a
s de
fined
by
the
Wor
ld B
ank
that
incl
ude
Sout
h A
sia
as w
ell a
s Ea
st A
sia
and
Paci
fic
[22]
: Afg
hani
stan
, Ban
glad
esh,
Bhu
tan,
Cam
bodi
a, C
hina
, Fiji
, Ind
ia, I
ndon
esia
, Ki
ribat
i, D
PR K
orea
, Lao
, Mal
aysi
a, M
aldi
ves,
Mar
shal
l Isl
and,
Mic
rone
sia,
M
ongo
lia, M
yanm
ar, N
auru
, Nep
al, P
akis
tan,
Pal
au, P
apua
New
Gui
nea,
Phi
lip-
pine
s, Sa
moa
, Sol
omon
Isla
nd, S
ri La
nka,
Tha
iland
, Tim
or-L
este
, Ton
ga, T
uval
u,
Vanu
atu,
Vie
tnam
Dev
elop
ing
coun
trie
s; lo
w a
nd m
iddl
e-in
com
e co
untr
ies;
Asi
a; A
sia-
Paci
fic; E
ast
Asi
a; S
outh
Asi
a; S
outh
east
Asi
a; W
este
rn P
acifi
c; P
acifi
c Is
land
s; O
cean
ia
-
Page 4 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 2
Incl
usio
n an
d ex
clus
ion
crit
eria
app
lied
in th
e sc
opin
g re
view
Incl
usio
n cr
iteri
aEx
clus
ion
crite
ria
1En
glis
h la
ngua
geN
on-E
nglis
h la
ngua
ge
2Ye
ar o
f pub
licat
ion
1999
–201
9 (J
uly
1999
–Jun
e 20
19)
Year
of p
ublic
atio
n be
fore
199
9 or
aft
er Ju
ly 2
019
3Co
untr
ies
of s
tudy
cla
ssifi
ed a
s lo
w- o
r mid
dle-
inco
me
(LM
ICs)
and
wer
e lo
cate
d in
the
Asi
a-Pa
cific
regi
on, a
s de
fined
by
East
Asi
a an
d Pa
cific
and
Sou
th A
sia
regi
on b
y th
e W
orld
Ban
k [2
2]
Coun
trie
s of
stu
dy c
lass
ified
as
not L
MIC
s, or
not
Eas
t Asi
a an
d Pa
cific
or S
outh
Asi
a, o
r LM
ICs
in
Asi
a-Pa
cific
that
are
ove
rsea
s te
rrito
ries
of o
ther
nat
ions
, or i
nclu
de p
opul
atio
ns fr
om L
MIC
s in
Asi
a-Pa
cific
but
not
sep
arat
ely
repo
rtin
g th
e re
sults
for t
his
grou
p fro
m o
ther
non
-LM
ICs
or
non-
Asi
a-Pa
cific
cou
ntrie
s
4In
vest
igat
es o
utco
me
as p
refe
renc
e or
inte
ntio
n (i.
e., a
ttitu
de to
war
ds o
r int
entio
n fo
r rur
al
wor
k, in
tent
ion
to s
tay)
or a
ctua
l wor
k (i.
e., c
urre
nt ru
ral w
ork
or ru
ral r
eten
tion)
No
pref
eren
ce o
r int
entio
n fo
r rur
al w
ork
or s
tayi
ng o
r act
ually
wor
king
in ru
ral l
ocat
ion
repo
rted
5In
vest
igat
es w
ork
in ru
ral o
r in
any
rem
ote
area
or i
n an
y un
ders
erve
d ar
ea d
efine
d by
ge
ogra
phic
-rel
ated
crit
eria
or b
y th
e au
thor
s or
repo
rts
for r
ural
, rem
ote
or u
nder
serv
ed
sepa
rate
ly
Inve
stig
ates
wor
k in
met
ropo
litan
or i
n un
spec
ified
geo
grap
hic
loca
tion
with
out s
epar
atel
y re
port
ing
wor
k in
rura
l, re
mot
e or
und
erse
rved
loca
tions
6Ex
plor
ing
fact
ors
rela
ted
to th
e ou
tcom
e as
men
tione
d in
crit
eria
4D
id n
ot e
xplo
re fa
ctor
s re
late
d to
the
outc
ome,
for e
xam
ple:
pre
sent
ed th
e pr
opor
tion
of
resp
onde
nts
wor
king
in ru
ral l
ocat
ion
with
out e
xplo
ring
why
7A
naly
zes
the
resu
lts fo
r eith
er d
octo
rs w
ho c
ompl
eted
thei
r med
ical
qua
lifica
tions
at t
ertia
ry
(uni
vers
ity) l
evel
, or m
edic
al s
tude
nts
trai
ning
at t
ertia
ry le
vel,
or b
oth
Art
icle
s in
clud
ing
othe
r typ
es o
f hea
lth w
orke
rs w
ithou
t sep
arat
e re
port
ing
for t
ertia
ry q
ualifi
ed
doct
ors
or m
edic
al s
tude
nts
8Fu
ll-te
xt o
f the
art
icle
s av
aila
ble
usin
g on
line
data
base
, bro
wsi
ng o
r acc
essi
ble
thro
ugh
the
Uni
vers
ityFu
ll-te
xt ir
retr
ieva
ble
afte
r att
empt
ing
sear
chin
g on
line
data
base
, bro
wsi
ng o
r via
sup
port
from
th
e U
nive
rsity
libr
ary
9Em
piric
al re
sear
ch o
r rev
iew
art
icle
with
a c
lear
sea
rch
stra
tegy
Non
-em
piric
al o
r rev
iew
art
icle
s w
ithou
t cle
ar s
earc
h st
rate
gies
-
Page 5 of 21Putri et al. Hum Resour Health (2020)
18:93
to work and remain, in the rural and remote areas. As the 2010
WHO global policy recommendations to improve rural health worker
recruitment and retention emphasize the importance of educational
interven-tions, and to specifically explore career stage [23], the
review included studies of doctors, medical students and interns.
This review was restricted to university-qualified doctors or
students undertaking tertiary (uni-versity-level) degree training
(Table 2).
After retrieving articles and removing the duplicates, we
screened titles and abstracts against inclusion/exclusion criteria.
We worked independently, then in pairs, to compare assessments and
reach agreement. When eligibility for inclusion differed, the team
con-ferred to resolve difference.
Data charting and analysis methodsA spreadsheet of key
factors was developed to extract relevant data. Two authors tested
and refined the data extraction tool using 10 eligible studies.
Information extracted covered key areas such as country, sample,
rural work outcomes, and factors related to the out-comes, and
organized using the categories and sub-categories of the WHO global
policy recommendations [23].
To understand how eligible articles defined ‘rural’ or ‘remote’
areas, we searched for explicit and implied def-initions in the
text according to categories described in previous studies such as:
non-metropolitan area, popula-tion density and characteristics,
distance from the near-est town and environmental characteristics
[24, 25].
The authors discussed, agreed on, summarized and synthesized
findings and implications for future research, policy and practice.
Although not the main purpose of this scoping review, an overall
exploration of study qual-ity was undertaken to identify issues in
research quality and support ongoing research.
ResultsSource of evidenceThe search retrieved 3425
articles. After removing dupli-cates and screening titles and
abstracts, 71 articles were included in this review (Fig. 1).
Ninety-two percent of the 71 eligible articles (see Additional
file 1) were published after 2009 (Fig. 2).
Although the search was for low- and middle-income country
studies, Nepal was the only low-income country (LIC; as classified
in 2019) addressed in articles that met the search criteria.
However, Nepal has been classified as a middle-income country (MIC)
since 2020. No study from Pacific Island nations met the inclusion
criteria.
Study characteristicsThe majority (69%) of studies were
quantitative, about one-quarter (24%) were qualitative, with the
remainder (7%) policy analyses and review. More than half of
stud-ies (62%) included only tertiary-qualified doctors (at any
career stage) as respondents, one-quarter (25%) of studies included
only medical students and nine studies included both. Of 53 studies
involving doctors (44 stud-ies with doctors only and 9 studies with
both doctors and students), half (53%) explored preference for
rural work while the remaining (47%) investigated actual rural work
(Table 3).
Factors associated with doctors working in rural
locationsWe present results of factors associated with preference
or actual work in rural locations according to the WHO areas
(educational, regulatory, financial incentives, and professional
and personal support), and an additional category of factors
related to health system contexts. Some rural work predictors
identified in the MIC-based studies—such as rurally located medical
school, rural clerkship and rural internship—were not identified in
the studies of Nepal (the only LIC in studies that met the search
criteria). Differences were due to the scope of covariates
explored. Given this, and because only one LIC was included in the
studies considered, we present the results of both low- and
middle-income countries as a unified analysis.
There were mostly concurrences in factors associated with
preference and actual rural work when studies of similar factors
were explored as to their findings. There-fore, we discuss the
findings in an integrated way while noting them separately in
Table 4. Where relevant, any differences in preference and
actual rural work outcomes are discussed.
EducationalEighty-two percent of the articles—from 12
Asia-Pacific LMICs—were about educational factors, categorized into
2 areas: (1) student selection, and; (2) delivering medical
education. For student selection, most studies demon-strated rural
background was associated with both rural preference [33–46, 54]
and actual work [26], while sev-eral found no association with
rural preference [47–49, 56]. Being enrolled through the ’special
track’, which consists of rural student recruitment, scholarships
and receive a rural-oriented curriculum, were associated with
actual work in rural areas [27–32]. Other student selec-tion
factors associated with rural preference were: hav-ing parents with
lower educational level or wealth [38, 40, 43, 46] or with an
income source from the agricul-tural sector [37, 44], entering
medical school through a
-
Page 6 of 21Putri et al. Hum Resour Health (2020)
18:93
graduate track [47], and having graduated from a
govern-ment-owned high school [43]; however, there was no evi-dence
for such association with the actual work. Studies exploring the
delivery of medical education found asso-ciations for both rural
preference and actual work with rurally located medical schools
[40, 46, 61], rural clerk-ship [37], and rural-oriented curricula
combined with other educational strategies [27–31, 62–65]. Students
in public medical schools were more likely to prefer rural work
compared to those from private ones [43, 55]. Rural internship was
cited as a negative experience leading to poorer intention to work
rurally in Indonesia [80], while, when delivered as part of a
rural-oriented curricula, it was associated with better rural
doctor supply [64].
RegulatoryOne-fifth (20%) of articles, from China, Nepal,
Thailand, and Timor-Leste, examined regulatory strategies.
Com-pulsory rural service periods, whether implemented as a
stand-alone strategy [31, 81, 82], combined with scholar-ships
only [43, 47, 66, 81], or combined with combined with scholarship
and recruiting students from rural areas [27, 29–31, 47–49, 72],
were associated with higher rural preference or actual work.
Financial incentivesForty-five percent of the studies—from 12
Asia-Pacific LMICs—explored associations between rural prefer-ence
or actual work and financial incentives. Despite many demonstrating
that appropriate financial incen-tives were essential for rural
doctor recruitment, it was not clear what increment of incentive
was needed for optimal results. One study revealed the actual
income is higher among urban than rural doctors [46]. Across
stud-ies applying discrete choice experiment (DCE) methods, the
proportion of increased salary or allowances tested varied, ranging
from 0 to 300%. One study demonstrated doctors and medical students
were 1.1–1.3 times more
Fig. 1 PRISMA diagram of article selection process
-
Page 7 of 21Putri et al. Hum Resour Health (2020)
18:93
likely to consider rural jobs if offered 16% higher salaries
[56], while others suggested that incentives worth 45% or 50% of
doctors’ salary had the highest coefficient for rural work
preference [54, 74, 76]. Nonetheless, some studies found that
salary increases had lower utility com-pared to other
recruitment/retention strategies such as good working environment
[37], study assistance and
supportive management [75], and support for profes-sional
development [58]. Opportunities to do private work were associated
with better doctor supply or prefer-ence to work in rural areas
[32, 45, 50, 90].
In term of retention, good salary was the second high-est reason
for Filipinos doctors’ willingness to stay in rural areas after
completing the rural deployment
Fig. 2 Peer- and non-peer-reviewed articles on effective rural
medical workforce strategies by country and year. *Countries
included in multi-country studies: Bangladesh (3 articles),
Cambodia (1 article), China (2 articles), India (3 articles), Nepal
(2 articles), Thailand (2 articles), and Vietnam (2 articles)
Table 3 Summary of the characteristics
of the eligible articles
71 articles were originated from 12 countries: 1 low-income
country (Nepal), and 11 middle-income countries (Bangladesh,
Cambodia, China, India, Indonesia, Lao, Pakistan, Philippines,
Thailand, Timor-Leste, and Vietnam)a Includes: doctors at
internship; any doctors before, during and after attending
postgraduate study or specializationb Includes: medical students at
all levelsc Preference refers to intentions or attitude to work or
stay working in rural or remote locations among respondents who
were not working in such locations at the time of data collectiond
Actual refers to current work or retention in rural or remote
locations at the time of data collection
Data collection method and analysis Population analyzed
Medical graduatesa Medical studentsb Both medical graduates
and students
Method Number of studies
Preferencec Actuald Preferencec Preferencec Actuald
Quantitative 48 12 19 16 5 0
Descriptive analysis 12 3 9 1 0 0
Univariate analysis only 10 3 4 1 3 0
Multivariate analysis 26 6 6 14 2 0
Qualitative 15 4 6 2 3 2
Policy analysis 3 1 2 0 0 0
Review 2 0 2 0 0 0
Mixed method 3 1 2 0 0 0
Total 71 44 18 9
-
Page 8 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
Fact
ors
asso
ciat
ed w
ith
actu
al/p
refe
rred
wor
k in
rura
l loc
atio
ns o
f Asi
a-Pa
cific
LM
ICs
med
ical
gra
duat
es a
nd s
tude
nts
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
A. E
duca
tion
1. F
acto
rs re
late
d to
sel
ectin
g st
uden
ts w
ith p
artic
ular
cha
ract
eris
tics
a) S
tude
nts
with
rura
l bac
kgro
unds
†Ru
ral b
ackg
roun
d w
as d
efine
d as
eith
er b
orn,
sp
ent m
ost o
f chi
ldho
od, o
r fini
shed
hig
h sc
hool
in ru
ral l
ocat
ions
Ove
rall,
onl
y 1
stud
y, in
Nep
al, h
ad p
rove
n as
soci
atio
n of
rura
l bac
kgro
und,
as
a st
and-
alon
e fa
ctor
, and
rura
l pra
ctic
e [2
6]. T
he re
st
stud
ies
[27–
32] p
rese
nted
str
ong
asso
ciat
ion
betw
een
bein
g en
rolle
d un
der t
he s
peci
al
trac
k, c
ompr
isin
g ru
ral r
ecru
itmen
t, sc
hola
r-sh
ip a
nd re
ceiv
ing
a ru
rally
enh
ance
d cu
r-ric
ula,
and
rura
l wor
k
Ther
e ar
e m
ixed
find
ings
abo
ut a
ssoc
iatio
n be
twee
n ru
ral r
ecru
itmen
t and
rura
l wor
k pr
ef-
eren
ce. W
hile
the
maj
ority
of s
tudi
es a
gree
that
ha
ving
rura
l bac
kgro
und
is a
ssoc
iate
d w
ith ru
ral
wor
k pr
efer
ence
[33–
46],
thre
e st
udie
s fo
und
no d
iffer
ence
[47–
49]
b) S
tude
nts
who
are
nat
ive
to s
peci
fic lo
ca-
tions
‡N
ativ
e is
defi
ned
as re
spon
dent
s’ pl
aces
of
orig
in, w
here
they
live
d du
ring
child
hood
or
prio
r ent
erin
g m
edic
al s
choo
l, w
ithou
t men
-tio
ning
the
rura
lity
of th
e lo
catio
n
Thre
e st
udie
s re
veal
ed th
at o
ne o
f the
reas
ons
to d
ecid
e w
ork
loca
tion
was
bec
ause
they
are
na
tive
to th
at p
artic
ular
are
a [5
0–53
]
Stud
ies
show
ed a
ssoc
iatio
n be
twee
n be
ing
nativ
e to
and
inte
ntio
n to
wor
k ru
ral a
reas
[48,
49
], or
pre
fere
nce
for r
ural
pra
ctic
e in
crea
sed
if po
sted
in o
r nea
r to
nativ
e ar
ea [5
4], h
owev
er,
anot
her f
ound
the
oppo
site
[55]
Rao
et a
l. re
veal
ed w
hile
resp
onde
nts
are
1.2
– 2
times
mor
e lik
ely
to p
refe
r rur
al w
ork
whe
n it
is
loca
ted
in th
eir n
ativ
e ar
ea, b
ut n
o di
ffere
nce
in
this
ass
ocia
tion
was
foun
d be
twee
n th
ose
with
an
d w
ithou
t rur
al u
pbrin
ging
[56]
c) S
tude
nts
with
cer
tain
par
enta
l soc
ioec
o-no
mic
or e
duca
tiona
l bac
kgro
unds
‡Pa
rent
al s
ocio
econ
omic
or e
duca
tiona
l bac
k-gr
ound
refe
rs to
leve
l of i
ncom
e, e
duca
tiona
l at
tain
men
t and
sec
tor o
f inc
ome
No
stud
y ha
d ex
plor
ed p
aren
tal s
ocio
econ
omic
an
d ed
ucat
iona
l bac
kgro
unds
Stud
ents
who
pre
fer r
ural
wor
k w
ere
mor
e lik
ely
to: h
ave
a pa
rent
with
a lo
wer
edu
catio
nal
back
grou
nd [3
8, 4
0, 4
6]; h
ave
pare
nts
who
are
fa
rmer
s [3
7]; h
ave
pare
nts
with
low
or m
ediu
m
wea
lth [4
3, 4
4], a
nd; d
o no
t hav
e a
rela
tive
who
is a
doc
tor [
43].
How
ever
, som
e st
udie
s fo
und
no a
ssoc
iatio
n be
twee
n ru
ral w
ork
and:
pa
rent
al in
com
e le
vel [
33, 3
4, 3
7, 3
9]; e
duca
-tio
nal b
ackg
roun
d [3
5, 4
8, 4
9]; p
aren
t’s jo
b as
a
civi
l ser
vant
[49]
; and
hav
ing
a pa
rent
who
is
phys
icia
n [5
5]
d) F
amily
loca
tion‡
Loca
tion
of fa
mily
, inc
ludi
ng p
aren
ts, s
pous
e,
child
ren,
or e
xten
ded
fam
ily. T
he d
iffer
ent
findi
ngs
may
be
due
to d
iffer
ing
defin
ition
s of
firs
t-de
gree
and
ext
ende
d fa
mily
mem
bers
us
ed
Thre
e qu
alita
tive
stud
ies
reve
aled
that
loca
tion
of fa
mily
hav
e be
en a
mon
g th
e m
ost f
requ
ent
reas
ons
of d
octo
rs c
hose
wor
king
rura
lly [5
1,
52, 5
7]. F
amily
loca
tion
was
als
o as
soci
ated
w
ith w
orki
ng in
rura
l loc
atio
ns [4
3, 4
5]
Doc
tors
who
se fa
mily
mem
bers
are
in u
rban
ar
eas
rega
rd u
rban
jobs
mor
e hi
ghly
than
thos
e w
ithou
t fam
ily in
urb
an a
reas
[58]
. Lik
ewis
e,
med
ical
stu
dent
s’ de
cisi
ons
abou
t wor
k lo
ca-
tion
wer
e as
soci
ated
with
the
loca
tion
of fa
mily
[3
6, 4
0, 4
2]. I
t was
als
o un
cove
red
that
loca
tion
of fa
mily
as
one
of m
ain
reas
ons
of in
tent
ion
to
wor
k in
rura
l loc
atio
ns [4
9, 5
9]So
me
stud
ies,
how
ever
, fou
nd n
o as
soci
atio
n be
twee
n ha
ving
ext
ende
d fa
mily
in ru
ral l
oca-
tions
and
inte
ntio
n to
wor
k ru
rally
[33,
34]
-
Page 9 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
e) T
ype
of e
ntry
to m
edic
al s
choo
l ‡So
me
coun
trie
s al
low
diff
eren
t typ
es o
f ent
ry
to m
edic
al s
choo
l, su
ch a
s di
rect
(5 y
ears
of
med
ical
cou
rse
for t
hose
com
plet
ing
high
sc
hool
) or n
on-d
irect
or g
radu
ate
entr
y (3
yea
rs o
f med
ical
cou
rse
for t
hose
with
so
me
tert
iary
deg
ree)
. Som
e sc
hool
s al
so
offer
ed re
gula
r and
inte
rnat
iona
l pro
gram
, in
whi
ch th
e in
tern
atio
nal p
rogr
am h
ad a
hig
her
tuiti
on fe
e
No
diffe
renc
e of
rura
l pra
ctic
e be
twee
n do
ctor
s w
ith p
aram
edic
al o
r sci
ence
trac
ks [2
6]Be
tter
pre
fere
nce
of ru
ral w
ork
was
foun
d am
ong
thos
e: a
tten
ding
the
grad
uate
ent
ry c
ompa
red
to d
irect
ent
ry [4
7]; e
nrol
led
unde
r the
regu
lar
prog
ram
com
pare
d to
thos
e in
inte
rnat
iona
l pr
ogra
m [4
2]
f) O
ther
asp
ects
that
wer
e fo
und
as s
tron
g pr
edic
tors
: typ
e of
hig
h sc
hool
, per
sona
l ch
arac
teris
tics,
spec
ialty
Type
of h
igh
scho
ol re
fers
to th
e pu
blic
(gov
ern-
men
t) o
r priv
ate
owne
rshi
p of
the
scho
ol.
Spec
ialty
was
type
of s
peci
aliz
atio
n pu
rsue
d af
ter c
ompl
etin
g a
med
ical
deg
ree
No
stud
ies
had
expl
ored
ass
ocia
tion
betw
een
actu
al ru
ral w
ork
and
type
of h
igh
scho
olTw
o st
udie
s un
veile
d th
at d
octo
rs w
orki
ng in
ru
ral l
ocat
ions
bec
ause
of s
ense
of a
ltrui
sm
and
spiri
tual
ism
[50,
51,
60]
Med
ical
stu
dent
s gr
adua
ting
from
gov
ernm
ent
seco
ndar
y sc
hool
s ar
e m
ore
likel
y to
hav
e ru
ral
wor
k in
tent
ions
[43]
Doc
tors
or s
tude
nts
with
per
sona
l cha
ract
eris
tics
of a
ltrui
sm, o
ptim
ism
, hig
her s
elf-
effica
cy, o
r se
lf-de
cisi
on-m
akin
g w
ere
mor
e lik
ely
to b
e w
illin
g to
wor
k in
rura
l are
as [3
4, 3
7, 4
7, 5
3, 5
9,
60]
Doc
tors
on
a G
P tr
ack
com
pare
d pr
efer
rura
l wor
k m
ore
com
pare
d to
thos
e in
clin
ical
med
icin
e an
d pu
blic
hea
lth tr
acks
[38]
g) O
ther
asp
ects
with
no
asso
ciat
ion
‡A
hig
her a
cade
mic
per
form
ance
dur
ing
med
ical
sc
hool
was
not
ass
ocia
ted
with
act
ual r
ural
w
ork
[26]
A h
ighe
r aca
dem
ic p
erfo
rman
ce d
urin
g m
edic
al
scho
ol w
as n
ot a
ssoc
iate
d w
ith ru
ral w
ork
pref
eren
ce [4
3]
2. F
acto
rs re
late
d to
del
iver
ing
educ
atio
nal p
rogr
ams
a) H
ealth
pro
fess
iona
l sch
ools
out
side
of m
ajor
ci
ties
†Lo
catio
n of
med
ical
sch
ool c
onsi
dere
d as
‘out
-si
de o
f maj
or c
ities
’ wer
e: o
utsi
de o
f cap
ital,
or a
ny ru
ral o
r rem
ote
loca
tions
as
defin
ed b
y th
e st
udie
s
Doc
tors
gra
duat
ed fr
om m
edic
al s
choo
l out
side
th
e ca
pita
l citi
es w
ere
mor
e lik
ely
to w
ork
rura
lly [4
6, 6
1]. O
ther
stu
dies
from
Tha
iland
an
d th
e Ph
ilipp
ines
foun
d th
at e
stab
lishi
ng o
f m
edic
al s
choo
ls in
rura
l loc
atio
ns, c
ombi
ned
with
rura
lly e
nhan
ced
curr
icul
a, w
ere
asso
ci-
ated
with
incr
ease
d do
ctor
sup
ply
in ru
ral
loca
tions
[27–
31, 6
2–65
]
One
stu
dy fo
und
that
thos
e st
udyi
ng in
med
ical
sc
hool
s in
rura
l loc
atio
ns w
ere
mor
e lik
ely
to
pref
er ru
ral w
ork
[40]
, whi
le n
o di
ffere
nce
on
rura
l wor
k pr
efer
ence
bet
wee
n ne
wly
gra
du-
ates
from
rura
l and
urb
an m
edic
al s
choo
l [48
, 49
]
b) C
linic
al p
lace
men
ts (c
lerk
ship
s) in
rura
l are
as
durin
g st
udie
s †
Cle
rksh
ip is
a c
linic
al p
lace
men
t or r
otat
ion
phas
e, u
sual
ly to
ok p
lace
in th
e fin
al y
ear(s
) of
stu
dy. D
urin
g th
e cl
erks
hip,
stu
dent
s w
ere
rota
ting
in d
iffer
ent d
epar
tmen
ts a
nd tr
eatin
g pa
tient
s un
der s
uper
visi
on
Bein
g en
rolle
d in
a s
peci
al tr
ack,
com
pris
ing
rura
l rec
ruitm
ent,
rura
l med
ical
sch
ool,
rura
l cl
erks
hip,
sch
olar
ship
tie
to c
ompu
lsor
y se
r-vi
ce [1
9–22
], an
d ru
rally
enh
ance
d cu
rric
ula
[62–
65],
was
ass
ocia
ted
with
rura
l wor
k. N
o st
udy
had
expl
ored
how
a ru
ral c
lerk
ship
, as
a st
and-
alon
e fa
ctor
, was
ass
ocia
ted
with
act
ual
rura
l wor
k
Rura
l clin
ical
cle
rksh
ips
wer
e fo
und
to b
e as
soci
-at
ed w
ith ru
ral p
refe
renc
e fo
r stu
dent
s w
ith
an u
rban
bac
kgro
und
[38]
. Bei
ng e
nrol
led
in
spec
ial t
rack
, com
pris
ing
rura
l rec
ruitm
ent,
rura
l m
edic
al s
choo
l, ru
ral c
lerk
ship
, sch
olar
ship
tie
to c
ompu
lsor
y se
rvic
e w
as a
ssoc
iate
d w
ith ru
ral
pref
eren
ce [2
5, 2
6]
-
Page 10 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
c) C
urric
ula
that
refle
ct ru
ral h
ealth
issu
es †
Curr
icul
a de
sign
ed fo
r rur
al- o
r com
mun
ity-
base
d co
mpr
isin
g: a
dditi
onal
or e
xten
ded
expo
sure
s to
com
mun
ity o
r rur
al s
ettin
gs
Curr
icul
a de
sign
ed fo
r rur
al- o
r com
mun
ity-
base
d m
edic
al e
duca
tion—
whe
ther
com
-bi
ned
with
oth
er e
duca
tiona
l int
erve
ntio
ns
such
as
scho
lars
hips
[66]
, spe
ndin
g pa
rt o
f m
edic
al s
choo
l in
rura
l loc
atio
ns [6
2–65
], or
as
a st
and-
alon
e in
terv
entio
n [3
0]—
was
ass
oci-
ated
with
bet
ter d
octo
r sup
ply
in ru
ral a
reas
A fe
llow
ship
pro
gram
in a
rura
l hos
pita
l, co
ntai
ns
a co
mm
unity
-bas
ed p
roje
ct w
ork,
exp
osur
es
to c
ases
in a
rura
l (se
cond
ary
hosp
ital),
has
im
prov
ed p
ositi
ve a
ttitu
de to
war
d ru
ral c
aree
r [6
7]
d) C
ontin
uous
pro
fess
iona
l dev
elop
men
t for
ru
ral h
ealth
wor
kers
†Pr
ofes
sion
al d
evel
opm
ent r
efer
s to
act
iviti
es to
im
prov
e sk
ills
and
know
ledg
e of
hea
lth w
ork-
ers
incl
udin
g sh
ort-
term
and
long
-ter
m tr
ain-
ings
, pos
tgra
duat
e st
udy
and
spec
ializ
atio
n
Doc
tors
in ru
ral l
ocat
ions
are
less
like
ly to
hav
e op
port
uniti
es fo
r pos
tgra
duat
e tr
aini
ng c
om-
pare
d to
thos
e in
urb
an lo
catio
ns [6
8]. E
vi-
denc
e in
dica
tes
that
gua
rant
eed
prof
essi
onal
de
velo
pmen
t (i.e
., co
ntin
uing
edu
catio
n, a
hi
gher
sco
re fo
r pos
tgra
duat
e en
rollm
ent)
w
as re
late
d to
doc
tors
’ rur
al w
ork
[50,
60,
66,
69
–71]
or s
tayi
ng in
rura
l loc
atio
ns [5
3, 7
2]
Opp
ortu
nitie
s fo
r pro
fess
iona
l dev
elop
men
t, w
heth
er o
f sho
rt d
urat
ion
like
wor
ksho
ps o
r lo
nger
dur
atio
n lik
e po
stgr
adua
te s
tudy
, is
one
of th
e pi
vota
l att
ribut
es c
onsi
dere
d by
do
ctor
s in
dec
idin
g to
wor
k [5
4, 5
6, 5
8, 6
0, 7
3,
74] o
r sta
y w
orki
ng [1
6, 5
0] in
rura
l or r
emot
e lo
catio
nsM
edic
al s
tude
nts
are
mor
e lik
ely
to p
refe
r rur
al
post
s if
bein
g off
ered
opp
ortu
nitie
s to
con
tinue
ed
ucat
ion
or e
nhan
ce th
eir p
rofe
ssio
nal d
evel
-op
men
t [47
, 59,
75–
79]
e) R
ural
inte
rnsh
ip‡
Med
ical
inte
rnsh
ip is
a p
hase
med
ical
gra
duat
es
have
an
offici
al m
edic
al d
octo
r deg
ree
(suc
h as
MBB
S or
MD
) but
hav
e ye
t to
obta
in li
cens
e to
pra
ctic
e un
supe
rvis
ed
Rura
l int
erns
hips
, del
iver
ed w
ith ru
rally
en
hanc
ed c
urric
ulum
, wer
e fo
und
to b
e po
sitiv
ely
asso
ciat
ed w
ith s
ubse
quen
t rur
al
wor
k [6
4]
Unp
leas
ant e
xper
ienc
e w
hile
com
plet
ing
inte
rn-
ship
pro
gram
in ru
ral a
reas
had
dis
cour
aged
do
ctor
s to
con
tinue
wor
king
ther
e [8
0]
f) S
tude
nts
from
cer
tain
type
of m
edic
al s
choo
l ‡
Type
of m
edic
al s
choo
l ref
ers
to th
e pu
blic
or
priv
ate
owne
rshi
p of
the
scho
olN
o st
udy
had
expl
ored
ass
ocia
tion
betw
een
actu
al ru
ral w
ork
and
type
of m
edic
al s
choo
lTw
o st
udie
s sh
owed
that
stu
dent
s in
pub
lic
med
ical
sch
ools
are
mor
e lik
ely
to p
refe
r rur
al
wor
k co
mpa
red
to th
ose
in p
rivat
e sc
hool
s [4
3,
55],
whe
reas
ano
ther
stu
dy fo
und
no d
iffer
ence
[5
6]
B. R
egul
ator
y
a) C
ompu
lsor
y se
rvic
e †
Com
puls
ory
serv
ice
refe
rs to
any
pos
ting
man
-da
ted
for d
octo
rs w
ith fu
ll pr
actic
e lic
ense
Com
puls
ory
rura
l ser
vice
pol
icie
s po
st-g
radu
a-tio
n fo
r 1–3
yea
rs h
ave
a po
sitiv
e as
soci
atio
n w
ith in
crea
sed
rura
l doc
tors
in T
haila
nd [3
1,
81, 8
2]
It w
as fo
und
that
thos
e ha
ving
com
plet
ed
2 ye
ars
of c
ompu
lsor
y se
rvic
e w
ere
mor
e lik
ely
to p
refe
r rur
al jo
bs c
ompa
red
to th
ose
who
co
mpl
eted
1 y
ear [
54]
b) S
ubsi
dize
d ed
ucat
ion
for r
etur
n-of
-ser
vice
†Re
turn
-of-s
ervi
ce re
fers
to a
n ob
ligat
ory
assi
gn-
men
t for
doc
tors
who
rece
ived
sch
olar
ship
sD
octo
rs [6
6, 8
1] w
ho re
ceiv
ed a
sch
olar
ship
tie
d to
com
puls
ory
serv
ice
wer
e m
ore
likel
y to
sta
y w
orki
ng in
rura
l com
pare
d to
thei
r co
unte
rpar
tsBe
ing
enro
lled
in a
spe
cial
trac
k, in
whi
ch th
e sc
hola
rshi
p tie
d to
com
puls
ory
serv
ice
pro-
vide
d fo
r tho
se re
crui
ted
from
rura
l are
as, w
as
asso
ciat
ed w
ith im
prov
ed ru
ral d
octo
r sup
ply
[27–
30, 7
2]
Stud
ents
[43,
47]
who
rece
ived
a s
chol
arsh
ip
tied
to c
ompu
lsor
y se
rvic
e w
ere
mor
e lik
ely
to
pref
er ru
ral w
ork
com
pare
d to
thos
e w
ithou
t sc
hola
rshi
pBe
ing
enro
lled
in a
spe
cial
trac
k, in
whi
ch
the
scho
lars
hip
tied
to c
ompu
lsor
y se
rvic
e pr
ovid
ed fo
r tho
se re
crui
ted
from
rura
l are
as, i
n ad
ditio
n to
bei
ng re
crui
ted
from
rura
l are
as a
nd
rece
ived
a ru
rally
enh
ance
d cu
rric
ulum
, was
as
soci
ated
with
bet
ter r
ural
pre
fere
nce
[48,
49]
-
Page 11 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
C. F
inan
cial
ince
ntiv
es
a) A
ppro
pria
te fi
nanc
ial i
ncen
tives
†Fi
nanc
ial i
ncen
tives
refe
r to
sala
ry, h
ards
hip
allo
wan
ces
or a
ny a
dditi
onal
mon
ey re
ceiv
ed
by d
octo
rs w
ith re
gard
to th
eir s
ervi
ce in
rura
l lo
catio
ns
Rura
l doc
tors
, des
pite
long
er to
tal w
orki
ng
hour
s, re
ceiv
ed le
ss in
com
e co
mpa
red
to th
e ur
ban
doct
ors
[46]
. The
fina
ncia
l inc
entiv
es
(i.e.
, sal
ary,
har
dshi
p al
low
ance
s) w
ere
amon
g m
ajor
att
ribut
es o
r cha
lleng
es o
f doc
tors
w
orki
ng in
rura
l or r
emot
e lo
catio
ns [5
0, 5
2,
53, 7
0, 8
3]. T
he in
crea
sing
ince
ntiv
e w
ith
rem
oten
ess
was
ass
ocia
ted
with
an
incr
ease
of
rura
l doc
tor s
uppl
y in
Chi
na [3
2, 8
4].
How
ever
, fina
ncia
l inc
entiv
es w
ere
deem
ed
less
val
uabl
e fo
r ret
entio
n co
mpa
red
to
othe
r fac
tors
suc
h as
wor
king
env
ironm
ent,
com
mun
ity a
nd p
erso
nal f
acto
r am
ong
rura
l do
ctor
s in
Tha
iland
[72]
App
ropr
iate
fina
ncia
l inc
entiv
es (i
.e.,
sala
ry, h
ard-
ship
allo
wan
ces)
wer
e as
soci
ated
with
doc
tors
pr
efer
ence
to w
ork
[36,
46,
84]
or s
tayi
ng in
ru
ral l
ocat
ions
[45,
85]
. Bet
ter fi
nanc
ial i
ncen
-tiv
es w
ere
desi
red
by d
octo
rs [5
2, 5
4, 5
6, 5
8, 6
0,
73, 7
4, 8
5–87
] and
med
ical
stu
dent
s to
add
ress
ru
ral d
octo
r sho
rtag
es [3
6, 4
0, 4
7, 5
9, 7
5–80
, 88
, 89]
b) O
ppor
tuni
ty to
ear
n ad
ditio
nal i
ncom
e ‡
Opp
ortu
nity
to a
dditi
onal
inco
me
refe
rs to
in
com
e-ge
nera
ting
activ
ities
rela
ted
to c
lini-
cal s
ervi
ce, u
sual
ly in
priv
ate
sect
or, h
ence
the
term
‘priv
ate
prac
tice’
Gov
ernm
ent d
octo
rs w
orki
ng in
rura
l are
as
have
a m
ore
limite
d op
port
unity
for p
rivat
e pr
actic
e [3
2, 5
0, 7
3, 9
0]. W
hile
a s
tudy
in P
aki-
stan
reve
aled
that
priv
ate
prac
tice
was
one
of
reas
ons
of w
illin
gnes
s to
wor
k in
rura
l are
as
in P
akis
tan
[45]
, a s
tudy
in In
dia
disc
over
ed
that
ave
rsio
n to
priv
ate
prac
tice
was
am
ong
reas
ons
of d
octo
rs c
hose
to w
ork
in ru
ral
loca
tion
[53]
Lack
ing
priv
ate
prac
tice
oppo
rtun
ity in
rura
l are
as
has
disc
oura
ged
inte
rns
to c
ontin
ue w
orki
ng in
ru
ral l
ocat
ions
[80]
D. P
erso
nal a
nd p
rofe
ssio
nal s
uppo
rt
a) B
ette
r liv
ing
cond
ition
s †
Bett
er li
ving
con
ditio
ns re
fers
to a
ny e
nviro
n-m
enta
l asp
ects
rela
ted
to p
erso
nal a
men
ity
such
as
hous
ing,
tran
spor
tatio
n, e
lect
ricity
, w
ater
and
com
mun
icat
ion,
edu
catio
n an
d bu
sine
ss fa
cilit
y
Any
gen
eral
asp
ects
of p
oor l
ivin
g co
nditi
ons
[45,
50,
52,
57,
72,
83]
, sch
oolin
g fa
cilit
ies
[50,
53]
, spo
use
empl
oym
ent [
53],
acce
ss to
el
ectr
icity
and
wat
er s
uppl
y [3
6], t
rans
port
a-tio
n [4
9], w
ere
amon
g th
e ke
y re
ason
s fo
r un
will
ingn
ess
to w
ork
rura
lly
Ther
e is
evi
denc
e th
at p
refe
renc
e to
wor
k in
rura
l lo
catio
ns is
ass
ocia
ted
with
: sho
rt tr
avel
tim
e to
w
ork
[91]
, ava
ilabi
lity
of tr
ansp
orta
tion
for o
ffi-
cial
and
uno
ffici
al u
se [7
6], p
ositi
ve p
erce
ptio
n of
livi
ng c
ondi
tions
[47]
, and
goo
d ed
ucat
iona
l fa
cilit
ies
and
conn
ectiv
ity [5
6]. H
owev
er, i
n ot
her s
tudi
es, a
ssoc
iatio
ns w
ere
not f
ound
be
twee
n ru
ral p
refe
renc
e an
d: h
ousi
ng a
llow
-an
ce o
r sup
port
[58,
75]
, acc
ess
to a
veh
icle
[58]
an
d sp
ouse
and
chi
ld e
duca
tion
[34]
Ove
rall
bett
er li
ving
con
ditio
ns [6
, 10,
11,
35,
45,
65
, 70,
71]
, hou
sing
s [7
6, 9
2], b
asic
infra
stru
ctur
e (i.
e., e
lect
ricity
, wat
er, c
omm
unic
atio
ns c
onne
c-tiv
ity) [
52, 5
7, 5
9, 8
8], t
rans
port
atio
n [5
7, 7
2, 7
4,
76],
acce
ss to
nea
rest
tow
n [4
1], a
nd c
hild
ren
scho
olin
g fa
cilit
ies
[73]
, wer
e al
so im
port
ant
attr
ibut
es to
rura
l pre
fere
nce.
Fem
ales
rega
rded
ho
usin
g pr
ovis
ion
high
er th
an m
ales
[58,
74]
-
Page 12 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
b) S
afe
and
supp
ortiv
e w
orki
ng e
nviro
nmen
t†W
orki
ng e
nviro
nmen
t com
pris
ing
both
hum
an
and
non-
hum
an re
sour
ce s
uch
as: o
ther
he
alth
or n
on-h
ealth
pro
fess
iona
ls, f
acili
ty
infra
stru
ctur
e, d
rugs
and
med
ical
equ
ipm
ent
Des
pite
the
sam
e av
erag
e w
orki
ng h
ours
in
thei
r mai
n jo
b, d
octo
rs in
rura
l are
as
had
long
er w
orki
ng h
ours
in d
ual p
ract
ice
com
pare
d to
urb
an d
octo
rs [4
6]. H
ighe
r rur
al
doct
ors’
wor
kloa
ds, o
win
g to
inad
equa
te
supp
ly o
f hea
lth p
rofe
ssio
nals
in ru
ral l
ocat
ion
or d
ifficu
lt ge
ogra
phic
al a
cces
s, w
as a
noth
er
reas
on d
octo
rs w
ere
unw
illin
g to
wor
k or
re
mai
n in
rura
l pos
ts [5
0, 5
2, 5
7, 7
0, 9
3]O
ther
impo
rtan
t att
ribut
es fo
r rur
al d
octo
r re
crui
tmen
t was
lack
of d
rugs
, equ
ipm
ent a
nd
faci
lity
infra
stru
ctur
e [5
2, 5
7, 6
6, 8
3], w
hile
for
rete
ntio
n w
as g
ood
rela
tions
hips
with
pee
r an
d m
anag
er [5
3, 7
2]
One
stu
dy fo
und
that
hig
her s
atis
fact
ion
scor
e to
w
ork
envi
ronm
ent w
ere
asso
ciat
ed w
ith in
ten-
tion
to s
tay
wor
king
in ru
ral a
rea
[91]
Oth
er a
ttrib
utes
impo
rtan
t to
impr
ove
inte
ntio
n to
wor
k or
sta
ying
in ru
ral a
reas
wer
e: a
dequ
ate
num
ber o
f hea
lth p
rofe
ssio
nal [
73, 8
5], r
elat
ion-
ship
with
col
leag
ues
or s
enio
rs [8
0], l
ack
of
drug
s, eq
uipm
ent a
nd p
oor f
acili
ty in
frast
ruc-
ture
[40,
59,
60,
73,
79,
81,
88,
92,
94]
Of t
hose
stu
dies
app
lyin
g di
scre
te c
hoic
e ex
perim
ent m
etho
ds, 2
stu
dies
foun
d th
at a
n ad
equa
te h
ealth
faci
lity
was
less
impo
rtan
t to
med
ical
stu
dent
s th
an s
alar
y [7
5, 7
6], w
hile
2
stud
ies
foun
d th
e op
posi
te a
mon
g do
ctor
s [5
6, 5
8]
c) F
oste
r int
erac
tion
betw
een
urba
n an
d ru
ral
heal
th w
orke
rs†
Inte
ract
ion
betw
een
urba
n an
d ru
ral h
ealth
w
orke
rs c
ompr
isin
g co
mm
unic
atio
n or
con
-su
ltatio
n of
doc
tors
in ru
ral a
reas
with
spe
cial
-is
ts o
r oth
ers
with
hig
her s
kills
in u
rban
are
as
Lim
ited
acce
ss to
hig
hly
skill
ed c
olle
ague
s w
as
amon
g ex
plan
atio
ns d
isco
urag
ing
doct
ors
to
wor
k in
rura
l are
as [7
0, 7
3]
Acc
ess
to s
peci
alis
ts o
r con
sulta
nt w
as m
ostly
co
nsid
ered
impo
rtan
t for
incr
easi
ng p
refe
r-en
ce to
rura
l wor
k [5
8, 7
9], t
houg
h, it
was
off
less
impo
rtan
ce w
hen
com
pare
d to
incr
ease
d sa
lary
, pos
ting
near
hom
e pr
ovin
ce, o
ppor
tu-
nity
to c
ontin
ue to
spe
cial
izat
ion
and
care
er
prom
otio
n [5
4]
d) C
aree
r lad
ders
†Ca
reer
ladd
er re
fers
to c
aree
r pat
h th
at p
ro-
mot
es d
octo
r to
a hi
gher
pos
ition
, whi
ch is
ge
nera
lly h
ave
bett
er s
alar
y an
d be
nefit
Poor
car
eer l
adde
r sch
emes
wer
e on
e of
rea-
sons
hin
derin
g do
ctor
s to
wor
k ru
rally
[50,
52,
57
, 70,
83]
. One
of T
hai g
over
nmen
t’s p
olic
y to
impr
ove
rura
l rec
ruitm
ent w
as to
pro
vide
op
port
unity
for r
ural
doc
tors
to a
ttai
n a
high
po
sitio
n, e
quiv
alen
t to
that
in u
rban
loca
tion
[31]
Cre
atin
g a
clea
r car
eer l
adde
r is
impo
rtan
t to
impr
ove
doct
ors’
pref
eren
ces
to w
ork
in ru
ral o
r re
mot
e lo
catio
ns [3
6, 4
7, 5
9, 6
0, 7
3, 7
9, 8
5, 8
6,
88, 9
2, 9
3]Th
e fo
llow
ing
are
exam
ples
of c
aree
r pro
mot
ion
sche
mes
pre
ferr
ed fo
r rur
al d
octo
r rec
ruitm
ent:
asso
ciat
ed w
ith h
ighe
r rur
al w
ork
pref
eren
ces
wer
e: p
rom
oted
as
perm
anen
t sta
ff [5
4, 7
6],
poss
ibili
ty to
tran
sfer
to o
ther
mor
e de
velo
ped
area
s af
ter c
erta
in p
erio
d of
em
ploy
men
t [56
]
e) P
rofe
ssio
nal n
etw
ork†
Prof
essi
onal
net
wor
k re
fers
to o
ppor
tuni
ty to
co
nnec
t and
com
mun
icat
e w
ith o
ther
pee
rs
in ru
ral h
ealth
ser
vice
A s
tudy
foun
d pr
ofes
sion
al is
olat
ion
was
a
dete
rren
t to
wor
k ru
rally
[52]
, whi
le th
e pr
es-
ence
of n
etw
ork
of ru
ral d
octo
r is
belie
ved
to im
prov
e do
ctor
s’ w
illin
gnes
s to
pra
ctic
e ru
rally
[31]
A d
isco
nnec
ted
heal
th s
ervi
ces
betw
een
urba
n an
d ru
ral w
as a
mon
g th
e pr
iorit
ized
att
ribut
es
desi
rabl
e by
doc
tors
for w
orki
ng in
rura
l are
as.
[88]
-
Page 13 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
f) P
ublic
reco
gniti
on†
It re
fers
to o
ffici
al o
r non
-offi
cial
reco
gniti
ons
rece
ived
by
the
doct
ors
Rura
l doc
tors
ack
now
ledg
ed th
e la
ck o
f rec
og-
nitio
n, e
spec
ially
as
a pr
imar
y ca
re d
octo
r, as
on
e of
cha
lleng
es w
orki
ng in
rura
l loc
atio
ns
[57,
83]
. An
awar
d fo
r rur
al d
octo
rs w
as o
ne
of p
olic
ies
in T
hai t
hat w
as b
elie
ved
incr
ease
d ru
ral d
octo
r sup
ply
[31]
. Ano
ther
Tha
i stu
dy
confi
rmed
that
pro
fess
iona
l rec
ogni
tion
was
am
ong
impo
rtan
t att
ribut
es fo
r doc
tors
to
stay
in ru
ral r
egio
n [7
2]
No
stud
y ha
d id
entifi
ed p
ublic
reco
gniti
on a
s th
e m
ajor
att
ribut
e fo
r rur
al w
ork
pref
eren
ce
g) S
ecur
ity‡
It re
fers
to s
ituat
ions
rela
ted
to p
erso
nal s
afet
y of
the
doct
ors
Lack
of s
ecur
ity h
as b
een
one
of d
eter
rent
s to
w
ork
in ru
ral o
r rem
ote
loca
tions
[50,
72]
, and
tw
o st
udie
s in
Indi
a hi
ghlig
hted
that
this
issu
e w
as e
spec
ially
rais
ed b
y fe
mal
e re
spon
dent
s [5
7, 8
3]
Poor
sec
urity
was
am
ong
maj
or is
sues
that
sh
ould
be
tack
led
to im
prov
e do
ctor
s pr
efer
-rin
g to
wor
k in
rura
l are
as [4
0, 7
3, 7
9, 8
8, 9
2]
h) C
omm
unity
sup
port
‡Co
mm
unity
sup
port
com
pris
ing
appr
ecia
tion,
re
cept
ion,
sup
port
, lite
racy
, lan
guag
e an
d cu
ltura
l com
patib
ility
Conn
ectio
n an
d th
e ab
senc
e of
lang
uage
ba
rrie
r with
com
mun
ity [8
3], o
r com
mun
ity
appr
ecia
tion,
gro
wth
and
sup
port
[72]
, was
im
port
ant a
ttrib
utes
in a
ttra
ctin
g do
ctor
s to
w
ork
or re
mai
n in
rura
l loc
atio
ns
Com
mun
ity a
ppre
ciat
ion,
lite
racy
, att
itude
to
wes
tern
med
icin
e ha
ve b
een
men
tione
d as
one
of
fact
ors
mot
ivat
ed d
octo
rs a
nd s
tude
nts
to
wor
k in
rura
l loc
atio
ns [3
9, 4
1, 7
9, 8
9]
i) Ca
reer
sta
ges‡
Care
er s
tage
s re
fers
to th
e le
ngth
of e
mpl
oy-
men
t as
a do
ctor
No
stud
y ha
d ex
plor
ed a
ssoc
iatio
n be
twee
n ac
tual
rura
l wor
k an
d ca
reer
sta
ges
Whi
le o
ne s
tudy
foun
d do
ctor
s co
mpl
eted
2
year
s co
mpu
lsor
y se
rvic
e ar
e m
ore
likel
y to
pr
efer
rura
l job
s co
mpa
red
to th
ose
with
doc
-to
rs c
ompl
eted
1 y
ear [
54],
anot
her o
ne fo
und
no d
iffer
ence
bet
wee
n ca
reer
sta
ges
[91]
j) H
uman
reso
urce
man
agem
ent‡
This
refe
rs to
the
man
agem
ent o
f hiri
ng, fi
ring
and
ince
ntiv
izin
g he
alth
wor
kers
, usu
ally
per
-fo
rmed
by
loca
l or n
atio
nal g
over
nmen
t
No
stud
y ha
d ex
plor
ed a
ssoc
iatio
n be
twee
n ac
tual
rura
l wor
k an
d lo
cal-l
evel
hum
an
reso
urce
man
agem
ent
Alth
ough
the
defin
ition
is u
ncle
ar, s
uppo
rt
from
loca
l gov
ernm
ent w
as a
mon
g th
e m
ost
sele
cted
att
ribut
es in
fluen
cing
rura
l wor
k pr
ef-
eren
ces
of m
edic
al s
tude
nts
[75]
and
inte
ntio
n fo
r rur
al re
tent
ion
amon
g do
ctor
s [8
0, 8
5]
k) G
ende
r‡Th
ere
is e
vide
nce
that
mal
e ar
e m
ore
likel
y to
w
orki
ng in
rura
l are
as [2
7, 2
9]H
alf o
f the
stu
dies
inve
stig
atin
g ge
nder
(n =
16)
fo
und
no d
iffer
ence
in ru
ral p
refe
renc
e be
twee
n m
ale
and
fem
ale
[33,
34,
36,
39–
42,
44–4
6, 4
8, 4
9, 5
5, 5
6, 9
1, 9
3]. W
hile
som
e st
udie
s fo
und
that
, aft
er a
djus
ting
for o
ther
var
iabl
es,
bein
g m
ale
was
str
ongl
y as
soci
ated
with
pre
fer-
ence
to w
ork
in ru
ral a
reas
[43,
47,
77]
, sev
eral
ot
her s
tudi
es fo
und
the
oppo
site
[35,
37]
. Som
e D
CE
stud
ies
also
foun
d th
at m
ales
and
fem
ales
va
lue
job
attr
ibut
es d
iffer
ently
: mal
es a
re m
ore
resp
onsi
ve to
wor
kpla
ces
near
thei
r hom
e pr
ov-
ince
and
sal
ary
incr
ease
s [5
4, 5
8], w
hile
fem
ales
va
lue
hous
ing
mor
e hi
ghly
[58,
74]
-
Page 14 of 21Putri et al. Hum Resour Health (2020)
18:93
Tabl
e 4
(con
tinu
ed)
Cate
gory
bas
ed o
n W
HO
fram
ewor
k [2
3]Su
mm
ary
of fi
ndin
gsA
ctua
laPr
efer
ence
b
l) M
arita
l sta
tus‡
Non
e ha
d in
vest
igat
ed a
ssoc
iatio
n be
twee
n m
arita
l sta
tus
and
actu
al ru
ral w
ork,
des
pite
su
ch in
form
atio
n w
as c
olle
cted
in th
e su
rvey
or
inte
rvie
w
Whi
le o
ne s
tudy
foun
d a
wea
k as
soci
atio
n be
twee
n be
ing
unm
arrie
d an
d w
illin
gnes
s to
ta
ke a
rura
l job
[45]
, mos
t fou
nd n
o di
ffere
nce
in ru
ral p
refe
renc
e or
wor
k ac
cord
ing
to m
arita
l st
atus
[33,
34,
39,
44,
88,
91]
E. H
ealth
sys
tem
s‡
a) G
over
nanc
e‡Th
is re
fers
to a
ny a
spec
t rel
ated
to le
ader
ship
an
d go
vern
ance
bey
ond
the
heal
th fa
cilit
yPo
litic
al fa
vorit
ism
was
sho
wn
to in
terf
ere
with
pr
oces
ses
and
proc
edur
es fo
r doc
tors
’ car
eer
deve
lopm
ent i
n ru
ral l
ocat
ions
[50,
70,
83]
It w
as p
erce
ived
that
pol
itica
l int
erfe
renc
e an
d in
stab
ility
wer
e at
trib
utab
le to
poo
r rur
al w
ork
pref
eren
ce [5
9, 7
3, 9
3]
b) S
ervi
