How to incentivise doctor attendance in Bangladesh: a latent class analysis of a discrete choice experiment

Objective: To elicit preferences of doctors over interventions to address doctor absenteeism in rural facilities in Bangladesh, a pervasive form of corruption across the country. Methods: We conducted a discrete choice experiment with 308 doctors across four tertiary hospitals in Dhaka, Bangladesh. Four attributes of rural postings were included based on a literature review, qualitative research and a consensus-building workshop with policymakers and key health-system stakeholders: relationship with the community, security measures, attendance-based policies, and incentive payments. Respondent choices were analysed with mixed multinomial logistic and latent class models and were used to simulate the likely uptake of jobs under different policy packages. Results: All attributes significantly impacted doctor choices (p<0.01). Doctors strongly preferred jobs at rural facilities where there was a supportive relationship with the community ({beta}=0.93), considered good attendance in education and training (0.77) or promotion decisions (0.67), with functional security (0.67) and higher incentive payments (0.5 per 10% increase of base salary). Jobs with disciplinary action for poor attendance were disliked by respondents (-.63). Latent class analysis identified three groups of doctors that differed in their uptake of jobs. Scenario modelling identified intervention packages that differentially impacted doctor behaviour and combinations that could feasibly improve doctor attendance. Conclusion: Bangladeshi doctors have strong but varied preferences over interventions to overcome absenteeism. Some were unresponsive to intervention but a substantial number appear amenable to change. Designing policy packages that consider these differences and target particular doctors could begin to generate sustainable solutions to doctor absenteeism in rural Bangladesh.