Physician shortages in rural Vietnam: using a labor market approach to inform policy

This paper investigates labor market dynamics for physicians in Vietnam, paying particular attention to geographic distribution and dual job holding. The analysis is based on a survey of a random sample of physicians in 3 regions in 2009-10. We found that the labor market for physicians in Vietnam is characterized by very little movement among both facility levels and geographic areas. Dual practice is also prominent, with over one-third of physicians holding a second job. After taking account of the various sources of income for physicians and controlling for key factors, there is a significant wage premium associated with locating in an urban area. This premium is driven by much higher earnings from dual job holding rather than official earnings in the primary job. There are important policy implications that emerge. With such low job turnover rates, policies to increase the number of physicians in rural areas could focus on initial recruitment. Once in place, physicians tend to remain in their jobs for a very long time. Lastly, findings from an innovative discrete choice experiment suggest that providing long-term education and improving equipment are the most effective instruments to recruit physicians to work in rural areas.     

An Intervention to Increase the Condom Supply in Rural Zambia

More than US$800 million per year is spent on programs in low‐ and middle‐income countries to increase demand for condoms, yet in rural areas of Africa condoms are often distributed for free only by regional health clinics that may be located far from home. Anecdotal evidence suggests that limited supply, resulting primarily from long travel times to acquire condoms, is a major barrier to use. This study investigates the potential unmet demand for condoms in rural sub‐Saharan Africa. I provide empirical evidence of the importance of supply effects, based on an evaluation of a distribution program in which nine agents were enlisted to sell condoms across 92 rural villages in Zambia. I find that the number of individuals acquiring condoms tripled and the number of condoms distributed rose by more than 250 percent. The study demonstrates that individuals in poor rural areas are willing to pay for condoms and provides a model whereby public health goods can be acquired through market forces without the government incurring large costs and without detracting from public health services.     

Rocky Mountain HMO

Rocky Mountain HMOs two-decade history of success on the western slope of Colorado is due not only to the conscious decisions of its managers but also to the geography and demography of its primary market area. The managers of Rocky Mountain HMO sought to build a managed care plan that was physician friendly and that had a local face, explicitly recognizing that their success hinged on the ability to satisfy the needs of both providers and purchasers. Isolated by the Rocky Mountains from major population centers of the state and located beyond the pull of the Salt Lake City, Utah, market to the west, Rocky Mountain HMO had no real managed care competitors on the western slope during its formative years. This lack of competition, combined with the ability to defuse physician resistance to managed care and to provide a satisfactory array of benefits at a reasonably low price, gave Rocky Mountain HMO an impressive share of the western slope health insurance market. Rocky Mountain HMOs expansion plans, in part, are a reaction to real and anticipated increases in managed care competition along the western slope. To maintain competitive premium rates, Rocky Mountain HMO executives perceive the need to spread the fixed costs of its infrastructure by increasing enrollment. As Rocky Mountain HMO expands its market to include all areas of the state, three issues relative to rural areas emerge. First, will Rocky Mountain HMO be able to import its successful rural HMO development strategies to other rural areas of the state at the same time it attempts to develop urban markets, or will rural expansion areas be treated in the same manner as urban expansion areas? Second, what are the consequences of the HMO's change in strategic focus for Rocky Mountain HMO providers and consumers on the western slope? Third, how will increased competition on the western slope affect Rocky Mountain HMO's relationship with its providers and consumers?     

农村医疗保障制度建设研究

基于我国城乡分治、二元经济的国情，我国农村医疗保障体系的建设要与农村的经济水平相适应，只有通过政府职能的转换和市场机制的运作。大力发展农村经济，培育和扩大农村市场，才能培育起多元化的农村医疗保障体系；只有通过市场优化配置农村医疗资源，才能缓解因病致贫现象。     

加快农村卫生人才引进培养促进农村卫生持续健康发展

2009年新医改以来,各级政府加大了对农村卫生的投入,农村卫生得到了前所未有的发展。但是农村卫生人才总体数量不足、学历层次不高、人员结构不合理已经成为制约农村卫生进一步发展的瓶颈。主要原因在于人才培养渠道不通畅,引进政策不宽松;待遇偏低,激励机制没有形成;工作条件较差,生活环境艰苦。建议以“扩大总量,盘活存量,优化结构,提升素质”为目标,建立部门协同合作、医学教育培养、科学用人、人才激励、投入保障、对口合作交流6大机制,造就一批适应基本卫生制度建设需要的农村卫生人才队伍。     

Partnering with communities to address the mental health needs of rural veterans

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups—clergy, postsecondary educators, and criminal justice personnel—are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center‐based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2‐hour workshop and an intensive 2.5‐day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.     

建立解决农村医疗人才缺乏问题的长效机制

该文认为人才问题是制约农村卫生服务质量提高的瓶颈 ,抓好农村人才问题是贯彻胡锦涛同志十六届四中全会讲话精神 ,注重公平性的具体体现 ;指出解决农村医疗卫生人才问题必须靠政府组织、支持 ,必须建立长效机制 ;最后提出解决农村医疗卫生人才缺乏问题的四点设想。     

Allocating resources for health and social care: the significance of rurality

Whilst an allowance is made for sparsity in the allocation of resources for social care services in England, rurality is not a significant factor in health resource allocation. This lack of consistency in resource allocation criteria has become increasingly visible as health and social services departments are required to work in partnership across a range of areas. Differences in funding mechanisms also raise the question of why it is legitimate to make adjustments for rurality in the distribution of some public services, but not for others. Against this background, the present paper considers the case for a rural premium in health resource allocation which, it proposes, can be made on four grounds. First, there is evidence that the current National Health Service (NHS) formula introduces systematic biases in favour of urban areas in the way in which it expresses 'need' for healthcare. Secondly, the way in which the current system compensates for unavoidable variations in the costs of providing services takes insufficient account of the additional costs associated with rural service provision. Thirdly, with a growing emphasis on the need to attain national quality standards, rural primary care trusts and social services departments can no longer tolerate lower levels of services. Finally, a case for a rural premium can be made on the basis of precedent. England is the only country in the UK that does not make a major adjustment for rurality in its NHS formula. The paper concludes that the English NHS resource allocation system has done little to counter marked service deprivation in rural areas. Given evidence that rural local authorities also spend less on social care services and direct provision, this raises serious questions about the extent to which the needs of vulnerable people in English rural areas are being adequately served.     

Attracting physicians to underserved communities: the role of health networks

As health networks battle for additional market share and encourage additional Medicaid HMO subscribers to use their physicians and hospitals, more health executives are analyzing proposals of how to attract qualified doctors to practice in poor rural or inner-city communities. Supplying more physicians to those areas by increasing the number of medical schools, expanding the National Health Service Corps (NHSC) program, and allowing more international medical graduates (IMGs) to pursue residency training in the United States have been relatively unsuccessful strategies to improve America's geographic maldistribution of medical manpower. This article focuses on several approaches that health networks might use to increase market penetration and at the same time deliver enhanced health services to the underserved. Health networks may provide eminent leadership in the overall design and governance of soundly conceived Medicaid HMOs; strengthen existing or develop additional community health/primary care centers; interface more effectively with local schools to foster Medicaid HMOs for children of low-income families; and reimburse at "premium rates" primary care physicians who practice in underserved communities. The reluctance of physicians to practice in these areas and of middle-income and upper-income taxpayers, and therefore elected officials, to support increased spending or redirection of funds continue to be major barriers for health alliances to demonstrate willingness to invest additional resources in poor inner-city and rural environments.     

India's family planning market and opportunities for the private sector: An analysis using the total market approach

The private (commercial) sector in India can complement public sector for family planning services, but the roadmap to engage these two sectors remains a challenge. The total market approach (TMA) offers a strategy by understanding the comparative advantage of public, commercial, and nonprofit sectors. We estimated TMA indicators using data of four rounds of the National Family Health Surveys: 1992‐93, 1998‐99, 2005‐06, and 2015‐16. The contraceptive prevalence of modern methods in India did not increase in recent years, but the number of users increased, and so did the market size for the commercial sector. In rural areas, the current market size in 2015‐16 (75 million) failed to reach its potential size in 1992‐93 (84 million). In urban areas, the market of modern contraceptives is mostly composed of the users from higher wealth, and a high percentage of users obtain contraceptives from subsidized sources. The family planning market of northern part of Bihar and Uttar Pradesh and of Northeast India are in the “early” stage and need more demand generation; “matured” markets are mostly concentrated in and around big metros. Subsidization in urban areas should be offered to the targeted population who need family planning products and services at low cost.     

为郊区农村定向培养医生的探讨

当前农村医疗卫生人才培养面临着严峻的挑战，应届毕业生到贫困山区工作的甚少，农村医疗卫生人才缺乏。建立面向农村山区和贫困地区定向招生、定向就业的医疗卫生人才培训基地，是在短期内解决农村基层医疗卫生人才匮乏的有效机制，促进了具有特色的面向农村基层培养临床医学专业人才课程体系的建设。建立城市医疗卫生人力资源支持农村医疗卫生事业发展的长效机制，对发展农村在职教育和非学历培训提供了强有力的保障。     

The Relationship of Rural Clinical Rotations to Where Registered Nurses Practice

An objective of exposing health profession students to rural clinical experiences was to overcome problems of geographic maldistribution of health personnel. Nevertheless, little can be said about the impact of rural training rotations on the supply of health personnel in rural areas or on students' decisions about where to practice. To assess the relationship between rural clinical rotations and practice locales, surveys were administered to all applicants taking registered nurse exams in Arizona in July 1990, February 1991, and July 1991. The students most likely to be working in rural locations were rural high school graduates with rural clinical experience during nursing school. Students who were urban high school graduates with rural clinical experience were only slightly less likely to locate in rural areas. Rural and urban high school graduates with no rural clinical experience were far less likely to choose rural practice. Rural rotations were associated with rural job selection only if students attended rural educational programs.     

2008-2012年山东省乡村两级卫生人力资源现状及对策分析

目的 回顾分析山东省近5年（2008-2012年）的乡村两级卫生人力资源的现状及其存在的问题,并有针对性地提出建议.方法 通过查阅文献、年鉴和数据分析等方法进行研究.结果 山东省乡村两级卫生人力资源总量优于全国平均水平,护士数量增长较快,但医护比例仍亟需改善;卫生技术人员学历、技术水平普遍较低,全科医生有待发展;农村卫生人员执业程度低,执业（助理）医师数量比重少,新鲜力量注入较少.结论 推进医护比例优化,注重医护质量的提高;引导高等医学人才流向基层,优化基层卫生人员的结构;发展高等全科医学教育;加强农村卫生人员的继续教育与科学管理工作.     

Defining rural hospital markets.

OBJECTIVE. The purpose of this study is to examine the geographic scope of rural hospital markets. DATA SOURCES. The study uses 1988 Medicare patient discharge records (MedPAR) and hospital financial information (HCRIS) for all rural hospitals participating in the Medicare Program. STUDY DESIGN. Hospital-specific market areas are compared to county-based market areas using a series of geographic and socioeconomic-demographic dimensions as well as indicators of market competitiveness. The potential impact of alternative market configurations on health services research is explored by estimating a model of rural hospital closure. DATA COLLECTION/EXTRACTION METHODS. Hospital-specific market areas were defined using the zip code of patient origin. Zip code-level data were subsequently aggregated to the market level. FINDINGS. Using the county as the hospital market area results not only in the inclusion of areas from which the hospital does not draw patients but also in the exclusion of areas from which it does draw patients. The empirical estimation of a model of rural hospital closure shows that the definition of a hospital market area does not jeopardize the ability to identify major risk factors for closure. CONCLUSIONS. Market area definition may be key to identifying and monitoring populations at risk from rural hospital decisions to downsize or close their facilities. Further research into the market areas of rural hospitals that have closed would help to develop alternative, and perhaps more relevant, definitions of the population at risk.     

浙江省乡村医生社会保障现状调查

目的分析影响浙江省乡村医生社保情况的重要因素,探讨解决浙江省乡村医生社会保障问题的对策。方法采取分层随机调查,结合问卷调查与个案访谈、文献分析等方法对浙江省乡村医生参保情况进行调查,收集数据并进行统计学处理。结果 429位被调查乡村医生未参保比例为23%,其中参保情况在乡村医生的学历水平、职称及工资水平上差异有统计学意义（P〉0.05）。结论浙江省乡村医生未参保比例较高,社保费用的缴纳方式、乡村医生的工资水平是重要影响因素。     

Deficient information in developing countries: Internet alone is no solution

Health-care personnel in developing countries have poor access to information, partly because the books are out of date and journals and Internet access are lacking, and partly because the information that is available is not appropriate for the local situation. There is too little research aimed at the problems of the Third World. This is due to a lack of interest in Western countries and because local scientists have done too little research. Internet solves the problem of access to information for health-care personnel in large hospitals and institutes, but there is still a shortage of relevant information for them as well. The editorial boards of professional journals could make a contribution by facilitating the publication of relevant research. Health-care personnel in rural areas will remain dependent upon basic books. This basic component of the provision of information should continue to receive attention. For the time being, Internet will remain inaccessible for rural health-care personnel. One of the initiatives being undertaken in order to improve the provision of information to health-care personnel in developing countries is the distribution of the 'blue trunk library' of the WHO with a selection of more than 100 basic books in every trunk. A number of journals have also taken action: the BMJ Publishing Group offers access to its journals free of charge to the 118 poorest countries and the Canadian Medical Association Journal provides free copies to libraries in developing countries. Moreover, a number ofwebsites have been started with a view to enlarging the information for health-care personnel in the Third World.     

我国农村不同地区孕产妇保健情况分析

目的:了解农村地区孕产妇保健现状,分析其影响因素,从而寻找适当的改进措施。方法:利用现有资料对一类、二类、四类农村,以及城乡之间进行比较分析。结果:孕产妇卫生保健利用率二、四类农村要低于一类农村,特别是四类农村孕产妇住院分娩率较低;孕产妇死亡率边远地区显著高于沿海和内地;四类农村产妇分娩地点主要在家里(73·9%),且接生人员主要是家人(58%);在家分娩的主要原因是经济困难、认为住院分娩没必要、来不及等。结论:加大国家对西部妇幼卫生工作的投入;提高农村卫生机构的服务能力和人力资源素质;加强妇女保健的健康教育工作,进一步提高住院分娩率,将有助于改善西部贫困地区的妇女保健状况。     

四川省民族地区乡村两级卫生人力资源配置及需求预测研究

目的 了解四川省民族地区乡村两级卫生人力资源配置现状并进行需求预测,为进一步优化民族地区及其他边远落后地区的乡村卫生人力资源配置提供决策依据。方法 运用卫生资源集聚度（HRAD）评价乡村卫生人员配置公平性;使用卫生资源密度指数（HRDI）测算乡村卫生人员按地理和人口分布的需求量和缺乏量。结果 全省民族地区乡镇卫生院专科及以下学历的卫技人员占92.40%,初级及以下职称占93.46%,40岁及以上的乡村医生和卫生员占69.15%;乡镇卫生院卫技人员、执业（助理）医师、注册护士及乡村医生和卫生员的HRAD值分别为0.28、0.23、0.26和0.31,通过HRDI计算的缺乏比例分别是81.18%、118.82%、96.97%和63.06%。结论 民族地区乡村两级卫生人员结构不合理、人员素质整体偏低,按地理面积配置公平性差,按人口和地理综合配置的需求量大。应进一步优化乡村两级卫生人员结构和配置公平性,壮大和稳定乡村两级卫生人才队伍。     

我国"乡聘村用"政策典型地区实践经验与启示

目的:分析我国"乡聘村用"政策进展和典型地区实践经验,分析推进"乡聘村用"政策的问题与挑战,为推进乡村医生队伍建设提供政策建议。方法:利用我国卫生健康统计年鉴相关数据进行定量分析;收集我国典型地区政策、报告等资料,进行案例分析。结果:"乡聘村用"在我国具有一定的政策基础,在全国范围内已经具有一定实践规模。从人员资质、人事管理和养老保障及资金来源方式等角度看,在典型地区的实践对推进"乡聘村用"政策的挑战是增加财政支出、乡村医生队伍老龄化和县乡管理能力不足。结论与建议:典型地区经验表明"乡聘村用"政策是转变乡村医生身份、解决乡村医生养老等社会保障问题的有效途径。建议各地借鉴典型经验积极推进"乡聘村用"政策,加大地方财政支持力度;加强县级和乡镇卫生院管理能力;同时,稳步推进政策,避免各类乡村医生之间产生矛盾。