Employment preferences of obstetricians and gynecologists to work in the district hospitals: evidence from a discrete choice experiment in Nepal
Bishnu Gautam, Vishnu Prasad Sapkota, Rajendra Raj Wagle
Human Resources for Health · 2019 · DOI: 10.1186/s12960-019-0427-8
Countries: Nepal
What Was Studied
This study used a discrete choice experiment (DCE) to identify which job attributes would attract obstetrician-gynecologists (OBs-GYNs) to work in Nepal's district hospitals. Eight attributes (minimum duration of service, children's education provision, professional development opportunities, technological support, workplace team composition, monthly salary, private practice rights, and car allowance) were identified through key-informant interviews and focus groups with policymakers and OB-GYNs, then combined into 48 choice sets using a fractional factorial design. Conducted as a near-census of Nepal's OB-GYN workforce between January and March 2016, the study approached all 325 OB-GYNs eligible after exclusions (out of 370 nationally); 189 completed the DCE (58.15% response rate). A multinomial logistic regression model estimated marginal utilities and willingness-to-pay/accept for each attribute, with subgroup analyses by gender, age, marital status, and workplace type.
What They Found
OBs-GYNs placed the highest value on having a full clinical team (OB-GYN, pediatrician, and anesthesiologist) at the workplace -- marginal utility 0.416 (p<0.001), equivalent to a willingness-to-pay of NPR 195,749 (USD 1,673) per year. Provision of secondary and primary education for children was also strongly valued (marginal utilities 0.252 and 0.182 respectively; willingness-to-accept NPR 118,592 and NPR 85,646 per year), as was the opportunity for private practice (marginal utility 0.111; WTP NPR 52,288/year). Conversely, each additional year of mandatory minimum service was a strong deterrent (marginal utility -0.262, p<0.001), requiring NPR 123,602 (USD 1,026) per year in compensation to accept, and a car allowance was mildly dispreferred (marginal utility -0.070). Notably, the preference for a full clinical team reversed into a disutility (-0.262, p<0.01) among OB-GYNs aged 36-45, and professional development only carried significant value for those based at medical colleges (+0.207, p<0.05).
What This Means for Nepal
For Nepal's Ministry of Health and Population (MoHP) and Department of Health Services (DoHS), these findings argue against a one-size-fits-all salary top-up for CEONC district hospitals and for a bundled, non-monetary-heavy package: guaranteeing a full clinical team (pediatrician and anesthesiologist alongside the OB-GYN), pairing rural postings with school access for staff children, and capping mandatory rural tenure at around two years with a defined pathway back to professional development -- since a longer minimum duration of service was the single strongest deterrent in this study. This directly informs the recruitment strategy needed to staff CEONC-designated district hospitals, especially in Karnali province, where 0% of sanctioned physician posts are filled, and complements the training-side investment already made through KAHS in Jumla. As Nepal's post-2017 federal structure has split hospital staffing coordination across provincial and local tiers, any redesigned incentive package will need explicit provincial buy-in to be deliverable at district level.
Contextualisation
Nepal's OB-GYN shortage at the district level is measurable, not speculative: national fill rates for sanctioned physician/GP posts stand at just 37.9% (down from 56.5% in 2015), and Karnali province reports 0% of its sanctioned consultant and physician posts filled. Nepal also loses an estimated 2,000-2,400 doctors a year to emigration via NMC 'Good Standing Certificates,' over 70% of them permanently -- making retention packages for scarce specialists like OB-GYNs central to reducing Nepal's maternal mortality ratio of 151 per 100,000 live births (NDHS 2022). This DCE, designed to inform exactly the recruitment packages CEONC centres need, offers evidence directly usable by MoHP/DoHS and rural training institutions such as KAHS in Jumla.