Financial incentives for return of service in underserved areas: a systematic review
Financial incentives for return of service in underserved areas: a systematic review
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DOI：
10.1186/1472-6963-9-86
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发表时间：
2009-05-29
影响因子：
2.8
通讯作者：
Bloom, David E.
中科院分区：
文献类型：
--
作者：
Baernighausen, Till;Bloom, David E.
背景资料：在发展中国家和发达国家的许多地理区域，保健工作人员的人数不足以实现人口保健目标。对恢复服务的财政奖励旨在缓解卫生工作者短缺的问题：（未来的）卫生工作者签订合同，在服务不足的地区工作若干年，以换取财政报酬。我们对PubMed、Excerpta Medica数据库、护理和相关健康文献累积索引进行了系统的文献检索，以及国家卫生服务经济评估数据库，用于评估截至2009年2月发表的财政激励计划的结果。为了识别文章进行审查，我们结合了三个搜索主题（卫生工作者或学生，服务不足的地区，和财政奖励）。在最初的检索中，我们识别出10，495篇独特的文章，其中10，302篇根据标题或摘要被排除。我们对其余193篇文章和参考文献列表中或同事确定的26篇其他文章进行了全文审查。43篇文章被纳入最终审查。我们从这些文章中提取了有关金融激励计划的信息（名称、地点、运行期、目标、目标群体、服务不足地区的定义、财政激励措施和义务）以及关于各项研究的信息（作者、出版日期、研究成果类型、研究设计、样本标准和样本量、数据来源、成果衡量标准和研究结果、结论和方法限制）。我们回顾了计划的结果（招聘，保留和参与者满意度的描述），计划的影响（影响卫生工作者提供护理的有效性，保持，并在服务不足的地区的工作和个人生活满意），和计划的影响（影响卫生系统和健康结果的有效性）。其余研究评估了日本（5项研究）、加拿大（2项）、新西兰（1项）和南非（1项）的项目。该项目始于1930年至1998年。我们确定了五种不同类型的项目（服务要求奖学金、有服务要求的教育贷款、服务选择教育贷款、贷款偿还项目和直接经济激励）。在服务不足地区服务一年的财政奖励从2000年的1 358美元到28 470美元不等。所有综述的研究均为观察性研究。在研究时，所有符合条件的计划参与者中已经履行义务或正在履行义务的比例的随机效应估计值为71%（95%置信区间为60-80%）。七项研究比较了项目参与者和非参与者在同一（服务不足）地区的保留情况。六项研究发现，参与者比非参与者更不可能留在同一地区（五项研究报告差异具有统计学意义，而一项研究没有报告显著性水平）;一项研究没有发现在同一地区的保留方面存在显着差异。13项研究比较了参与者和非参与者在任何服务不足地区提供的护理或保留。11项研究发现，参与者更有可能（继续）在任何服务不足的地区执业（9项研究报告的差异具有统计学意义，而两项研究没有提供显著性检验的结果）;两项研究发现，计划参与者比非参与者更不可能留在任何服务不足的地区。七项研究调查了参与者的满意度，他们的工作和个人生活在服务不足areas.Conclusion：财政奖励计划返回服务是为数不多的卫生政策干预措施，旨在改善卫生人力资源的分配上存在大量的证据之一。然而，大多数研究来自美国，只有一项研究报告了来自发展中国家的结果，限制了普遍性。现有的研究表明，财政激励计划已经将大量的卫生工作者安置在服务不足的地区，从长远来看，计划参与者比非参与者更有可能在服务不足的地区工作，即使他们不太可能留在原来的位置。由于现有的研究都不能完全排除参与者和非参与者之间观察到的差异是由于选择效应，迄今为止的证据不允许推断该计划已导致卫生工作者供应不足的地区增加。
Background: In many geographic regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off.Methods: We carried out systematic literature searches of PubMed, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, and the National Health Services Economic Evaluation Database for studies evaluating outcomes of financial-incentive programs published up to February 2009. To identify articles for review, we combined three search themes (health workers or students, underserved areas, and financial incentives). In the initial search, we identified 10,495 unique articles, 10,302 of which were excluded based on their titles or abstracts. We conducted full-text reviews of the remaining 193 articles and of 26 additional articles identified in reference lists or by colleagues. Forty-three articles were included in the final review. We extracted from these articles information on the financial-incentive programs (name, location, period of operation, objectives, target groups, definition of underserved area, financial incentives and obligation) and information on the individual studies (authors, publication dates, types of study outcomes, study design, sample criteria and sample size, data sources, outcome measures and study findings, conclusions, and methodological limitations). We reviewed program results (descriptions of recruitment, retention, and participant satisfaction), program effects (effectiveness in influencing health workers to provide care, to remain, and to be satisfied with work and personal life in underserved areas), and program impacts (effectiveness in influencing health systems and health outcomes).Results: Of the 43 reviewed studies 34 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same (underserved) area between program participants and non-participants. Six studies found that participants were less likely than non-participants to remain in the same area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Thirteen studies compared provision of care or retention in any underserved area between participants and non-participants. Eleven studies found that participants were more likely to (continue to) practice in any underserved area (nine studies reported the difference to be statistically significant, while two studies did not provide the results of a significance test); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with their work and personal lives in underserved areas.Conclusion: Financial-incentive programs for return of service are one of the few health policy interventions intended to improve the distribution of human resources for health on which substantial evidence exists. However, the majority of studies are from the US, and only one study reports findings from a developing country, limiting generalizability. The existing studies show that financial-incentive programs have placed substantial numbers of health workers in underserved areas and that program participants are more likely than non-participants to work in underserved areas in the long run, even though they are less likely to remain at the site of original placement. As none of the existing studies can fully rule out that the observed differences between participants and non-participants are due to selection effects, the evidence to date does not allow the inference that the programs have caused increases in the supply of health workers to underserved areas.