Education for Health

GENERAL ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 3  |  Page : 122--126

From one-district-one-doctor to the inclusive track: Lessons learned from a 12-year special recruitment program for medical education in Thailand


Win Techakehakij1, Rajin Arora2,  
1 Department of Social Medicine, Lampang Hospital, Lampang, Thailand
2 Advanced Clinical Education Academic Center, HRH Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand

Correspondence Address:
Win Techakehakij
Department of Social Medicine, Lampang Hospital, Amphur Muang, Lampang 52000
Thailand

Abstract

Background: The One-District-One-Doctor (ODOD) medical education program was launched in 2005 with the purpose of increasing the production of rural doctors through special recruitment in Thailand. This article provides details of the ODOD program, together with its successes and challenges. Comparisons of the applied interventions between ODOD, the conventional rural recruitment program (Collaborative Project to Increase Production of Rural Doctors [CPIRD]), and the Inclusive track are also described. Methods: Compared with the CPIRD program, additional interventions are applied to the ODOD program, including (1) recruitment from remote rural areas; (2) subsidized education in return for service; and (3) extended compulsory service in rural areas with a higher penalty fine. While ODOD students have shown a relatively high rural retention rate, the program challenges include low admission rate, adverse consequences from an extended compulsory service, restriction on specialist training, and high penalty fee. Results: As a consequence of the program interventions, another special medical education program, the Inclusive track, was introduced as a replacement. Strategies through the Inclusive track to recruit students from remote rural areas are similar to those of ODOD. However, unlike ODOD, the Inclusive track has a reduced duration of compulsory service and penalty fine to match those of the standard requirements in the Normal track and CPIRD students. Discussion: Building on past experience, the Inclusive track pursues a balance of pros and cons from the other medical production programs. Program evaluation and close monitoring will be crucial to measure the feedback from the Inclusive track to further improve the sustainability of long-term retention of rural physicians.



How to cite this article:
Techakehakij W, Arora R. From one-district-one-doctor to the inclusive track: Lessons learned from a 12-year special recruitment program for medical education in Thailand.Educ Health 2019;32:122-126


How to cite this URL:
Techakehakij W, Arora R. From one-district-one-doctor to the inclusive track: Lessons learned from a 12-year special recruitment program for medical education in Thailand. Educ Health [serial online] 2019 [cited 2020 Aug 12 ];32:122-126
Available from: http://www.educationforhealth.net/text.asp?2019/32/3/122/282873


Full Text



 Background



Inequitable distribution of physicians is a crucial obstacle to improving health-care access worldwide. This concern is particularly prominent in remote and rural areas;[1] Thailand is no exception. Despite a number of efforts being initiated to alleviate a lack of rural physicians during the past five decades, this problem remains unsolved in the Thai health-care context.[2] Statistics have shown that only one-half of medical graduates continued to work in rural areas.[3]

To increase physicians in rural services, previous research has clearly indicated that a successful program must not focus solely on increasing physician production and delivering them to the rural areas, but it also has to be designed to promote the long-term retention of physicians.[1] Methods used to increase retention can be implemented through medical student and health professions recruitment, education programs, and the terms of compulsory service.[1]

 Collaborative Project to Increase Production of Rural Doctors: Dawn of the Special Medical Recruitment Program to Improve Rural Retention



Launched in 1994 with the aim of increasing the number of physicians in rural areas, the Collaborative Project to Increase Production of Rural Doctors (CPIRD) has become a key player to increase the retention of rural physicians through a special recruitment system.[4] Interventions, in line with the WHO's guidance,[1] were adopted in the development of this special track to produce physicians (CPIRD physicians) with high rural retention.[5] These interventions include (1) recruitment of medical students from secondary schools in rural areas; (2) having medical schools located outside major cities; (3) compulsory service in the Ministry of Public Health (MoPH) hospitals in rural areas; and (4) opportunities for specialist training.

While results from the national medical license examinations have guaranteed the program's success to ensure medical competency,[6] a high rural retention rate of CPIRD physicians, compared with that of the Normal track physicians, was indicated.[7],[8] Up to 2009, with an additional contribution of more than 2700 CPIRD physicians to serve publicly in rural and remote hospitals,[7] the proportion of physician to population between rural and urban areas has subsequently increased, from 1 in 10 in 2001 to 1 in 5 in 2009.[9] A recent study has shown that, in relation to the normal track physicians, CPIRD physicians are 51.6% less likely to resign from MoPH hospitals each year. In addition, the probability of completing a 3-year rural service among CPIRD graduates is 138.9% higher than that of their normal track counterparts.[7],[10]

 Inception of One-district-one-doctor



Following the cabinet resolution in 2005, the One-District-One-Doctor (ODOD) program was introduced with the purpose of increasing the production of rural doctors through special recruitment.[11] In comparison with the CPIRD program, additional interventions are applied to the ODOD program throughout the production process, which include (1) recruitment of medical students from remote rural areas; (2) subsidized education in return for service; and (3) extended compulsory service in rural areas with a higher penalty fine. The first launch of ODOD was planned to produce an additional 3232 doctors between 2005 and 2012.[12]

 Successes of the One-district-one-doctor Program



Dropout during the program

Concerns have been raised whether there is any difference in drop-out rates between ODOD and CPIRD students. Regarding this, statistics from student admissions in 2005–2010 revealed no evidence of a difference in drop-out rates between the two groups, as can be seen in [Table 1].{Table 1}

Comparing physicians' retention in rural services

The research has affirmed the achievement of the ODOD program to bring about high rural retention. Evidence showed that the annual probability of leaving rural service among ODOD graduates is 71.7% lower than that of the normal track physicians and 36.6% lower than that of CPIRD physicians. Further, ODOD graduates are 2.36 times more likely to complete a 3-year rural practice in MoPH hospitals, compared with their normal track peers.[7] However, there is no statistically significant difference in the completion of a 3-year rural service between CPIRD and ODOD doctors.[7]

 Challenges of the One-district-one-doctor Program



Despite evident successes of the ODOD program, challenges have arisen from several aspects. These challenges are owing to the low admission rate, restriction on specialist training for ODOD physicians, a relatively high penalty fee for nonadherence, and adverse effects from an extensive compulsory service among ODOD physicians.

 Low Admission Rate



With regard to the criteria for entry, all ODOD applicants have to pass an entrance examination, which is comparable to the national entrance examination. However, the results showed that students from remote rural areas are less likely to achieve the minimum requirement, compared with those who reside in the cities. A summary of the proportion of admitted to expect number of ODOD students from 2005 to 2016 is illustrated in [Figure 1]. The lower-than-expected number of students who passed the entrance examination resulted in the unmet number of ODOD production.{Figure 1}

Owing to the low admission rate, the cabinet agreed in 2013 to extend the ODOD program for 4 years, which allows student admission to continue from 2013 to 2016, with the aim of reaching the additional production target of 3232 physicians.[13]

 Restriction on Specialist Training for One-district-one-doctor Physicians



One critical challenge for the ODOD program is its 12-year compulsory service as a generalist, during which a mandatory placement in the community hospitals is enforced. ODOD doctors who graduated in 2011–2012 and wished to continue their specialist training found this policy stressful. This, in turn, created subsequent pressure for the policymakers.

In 2013, MoPH administrators decided to release this pressure by allowing ODOD graduates to further their specialist training for most of the specialties after completion of at least 4 years of rural work, except in-service training in family medicine, in which ODOD physicians are allowed to participate from the first year of graduation.[11] As a result of this partial relaxation of the policy, some ODOD graduates have successfully received placement offers from the central or general hospitals, for example, as neurosurgeons, neonatologists, physical medicine and rehabilitation specialists, and cardiologists. This increase in demand by the ODOD graduates for specialist positions in the central and general hospitals raised another concern about the primary objective of the ODOD program being undermined by this relaxation.

In response to this issue, an amended announcement in 2016 has limited the choice of specialties for ODOD physicians to some of the major disciplines only, which can provide job placements in the community hospitals after graduation, such as Internal Medicine, General Surgery, OBGYN, Pediatrics, and Orthopedics.

This policy has been criticized not only by some students but also by staff in the medical schools. The opposition has argued that, considering the Thai health-care system context, it is important for new medical graduates to continue an appropriate specialist training without delay.[14]

 A Relatively High Penalty Fee for Nonadherence



Another issue that has been raised is the high financial penalization for rural nonadherence of ODOD graduates, compared with that of physicians from other medical tracks. The amount of money, which ODOD graduates are required to forfeit when they refuse to work in the specified rural areas, is five times more than that of the non-ODOD physicians. However, this excessive penalty has been criticized for being ineffective. Concerns have been raised about the effectiveness of a substantial fine to prevent rural resignation and whether it is enough to turn the tide.[15]

 Adverse Effects from an Extended Compulsory Service among One-district-one-doctor Physicians



In 2016, ODOD graduates who could not continue their planned residency programs in fields outside those allowed by the regulations expressed their frustration against the unfair contract through the online movement. As a result of their desire to pursue further specialist training, a group of ODOD physicians signed a petition requesting a solution from the MoPH administrators. To resolve this situation, a decision was made to allow ODOD physicians to take up some specialist positions in the community hospitals.

 Inclusive Track: A new Solution to Produce Rural Doctors



Even though a high retention of ODOD physicians in rural services is evident, drawbacks as a consequence of the program interventions have arisen. Another special medical education program, the Inclusive track, was introduced as a replacement. The Inclusive track was first launched in 2017 to recruit medical students. Physicians from this first batch will be expected to graduate in 2024. [Table 2] compares the details of interventions applied among the three programs, CPIRD, ODOD, and the Inclusive track. It can be noticed that the strategies to recruit students from remote rural areas employed by the Inclusive track are similar to that of ODOD. Nevertheless, unlike ODOD, the Inclusive track has a reduced duration of compulsory service as well as penalty fine to match those of the standard requirements applied in the normal track and CPIRD students. This means that the subsidized education in return for service enjoyed by the ODOD students is not included in the Inclusive track.{Table 2}

 Discussion



The WHO has recommended the use of compulsory service requirements in rural and remote areas to increase the retention of physicians in these areas.[1] While the ODOD program has successfully retained physicians in rural practices, some problems have arisen, potentially owing to such an extensive period of compulsory service compared with other physician colleagues. This resonates with the drawbacks of compulsory service among Indian medical graduates.[1] We provide a good example related to an adjustment of specialist training regulation for ODOD physicians, reducing pressure from lengthy compulsory service. Similar findings have also been observed in South Africa's and Ecuador's experience.[16],[17]

Devised out of past experience, the Inclusive track is a new solution to pursue a balance of benefits and drawbacks from the other medical production programs. Program evaluation and close monitoring will play a crucial role to measure the feedback after launching the Inclusive track, with the aim of further improving the sustainability of long-term retention of rural physicians.

Acknowledgment

The authors would like to thank Andrew Sherratt for comments and proof reading.

Financial support and sponsorship

None declared.

Conflicts of interest

There are no conflicts of interest.

References

1World Health Organization. Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention: Global Policy Recommendations. Geneva, Switzerland: World Health Organization; 2010.
2Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: Four decades of experience. Hum Resour Health 2003;1:12.
3The Medical Council of Thailand. Physicians Statistics: The Medical Council of Thailand; 31 December, 2015. Available from: http://www.tmc.or.th/statistics.php. [Last accessed on 2016 Nov 07].
4Lertsukprasert S. Collaborative project to increase production of rural doctors to tackle physician shortage problem of ministry of public health (Thai). J Health Sci 2015;17:1906-14.
5Nithiapinyasakul A, Arora R, Chamnan P. Impact of a 20-year collaborative approach to increasing the production of rural doctors in Thailand. Int J Med Educ 2016;7:414-6.
6Yi Y, Chongsuvivatwong V, Sriplung H, Rueanarong C. CPIRD: A successful Thai programme to produce clinically competent medical graduates. F1000Res 2015;4:158.
7Techakehakij W, Arora R. Rural retention of new medical graduates from the collaborative project to increase production of rural doctors (CPIRD): A 12-year retrospective study. Health Policy Plan 2017;32:809-15.
8Pagaiya N, Kongkam L, Sriratana S. Rural retention of doctors graduating from the rural medical education project to increase rural doctors in Thailand: A cohort study. Hum Resour Health 2015;13:10.
9Wibulpolprasert S. Thailand Health Profile 2008-2010. Bangkok: Bureau of Policy and Strategy, Ministry of Public Health; 2011.
10Arora R, Chamnan P, Nitiapinyasakul A, Lertsukprasert S. Retention of doctors in rural health services in Thailand: Impact of a national collaborative approach. Rural Remote Health 2017;17:4344.
11The Collaborative Project to Increase production of Rural Doctors. One District One Doctor (ODOD): Knowledge Management, Ministry of Public Health, Thailand; 2012. Available from: http://kmops.moph.go.th/index.php/km-test/2012-09-19-04-16-17/175-2013-03-29-15-33-58. [Last accessed on 2016 Sep 30].
12The secretariat of the cabinet. One District One Doctor project. The Secretariat of the Cabinet; 2005.
13The Secretariat of the Cabinet. Grant to extend the One District One Doctor project period. The Secretariat of the Cabinet 2013.
14Inadequate Opportunities for Medical Specialist Training and Brain Drain in Rural Areas (Thai). Hfocus; 2013. Available from: https://www.hfocus.org/content/2013/07/4058. [Last accessed on 2016 Sep 30].
15New Physicians' Attitudes Towards Working in Rural Areas and Paying a Fine to Breach the Contract; 20 September, 2011. Available from: http://www.manager.co.th/Qol/ViewNews.aspx?NewsID=9540000121120. [Last accessed on 2016 Sep 30].
16Cavender A, Albán M. Compulsory medical service in Ecuador: The physician's perspective. Soc Sci Med 1998;47:1937-46.
17Reid SJ, Peacocke J, Kornik S, Wolvaardt G. Compulsory community service for doctors in South Africa: A 15-year review. S Afr Med J 2018;108:741-7.