1 Introduction
Township hospitals, the main provider of primary healthcare [
1] with a wide-ranging set of general medical services by delivering curative and preventive activities in China, are to serve the majority (60%) of almost 850 million people in rural areas [
2]. At the intermediate level, township hospitals ensure the linkage between village health clinics and county or above-level hospitals. Researchers have found that aimless governmental investment, insufficient health workers, and low-level healthcare services are the main problems that inhibit the development of township hospitals [
3−
5]. The Chinese government has currently committed to pushing forward a systematic health reform to solve the problems of township hospitals and established a series of health policies for rural healthcare system through the reform of New Rural Cooperative Medical System and the development of health infrastructure [
6−
8].
Nonetheless, the inadequacy of health workforce with a suitable skill set in township hospitals has been identified as a major impediment in the implementation of healthcare reform policies [
9] and achieving the policy goals [
6,
8]. The health workforce has been recognized as the key to health services in rural and remote areas [
10,
11], where health workers are underprovided in both quality and quantity [
6]. Today the most reported staff-related problem is the shortage of health workforce in township hospitals [
11]. In 2011, there were 7.97 health workers for every 1000 people in China in urban areas, but only 1.32 in rural areas. Among the health workers, there is a more than twofold difference in the density (per 1000 population) of doctors and nurses between urban (3.03, 3.32) and rural (1.32, 0.98) areas in China [
12]. This inequitable distribution of health personnel contributes to the disparities in health outcomes between the urban and rural population [
11,
13]. Hence, more attention should be focused on how to sustain health workforce recruitment and retention in rural areas.
A massive expanse of global research exists on the recruitment and retention of health workers in hard-to-staff regions. Studies from North America and Australia have shown that the decisive predictor of rural practicing of health workers is effective exposure to rural healthcare practice during training or rural background that the individuals had been born in a rural spot [
14,
15]. Studies in Norway have shown that younger physicians are inclined to prefer leisure to higher income, and physicians with higher workload expressed a desire to move to a district with lower workload [
13,
16,
17]. Vocational and personal elements for rural employment, such as access to continuing professional education and acceptance of rural lifestyle, have also been identified in other studies [
14−
16,
18,
19]. Although studies have suggested that incentive packages for sustaining health worker retention and recruitment may need a combination of non-financial and financial incentives, systematic research [
11,
13], in which the implementation of continuing professional training is as important as the other elements, has defined multidimensional policy packages to improve health workforce in rural areas [
9,
20,
21]. Several studies have been conducted previously; however, as a result of the current economic and social changes in China, these studies have failed to reflect the actuality of what health workers in township hospitals think. In addition, several accepted predictors of recruitment and retention could be applied in China, but have not been verified based on the Chinese rural healthcare system. Moreover, the systematic research, which is grounded on perspectives of directors of township hospitals toward rural retention and recruitment of health workers, has been absent. Therefore, more studies on staffing health service in the Chinese rural context are needed.
The current study aims to (1) learn the latest conditions of health workers and find out the existing core problems; (2) juxtapose and categorize the perspectives of the directors that are relevant to the recruitment and retention of health workers in township hospitals according to the core problems; (3) and arrive at a systematic framework of non-financial and monetary elements that could contribute in determining the implications of facilitating rural recruitment and retention.
This study was undertaken by employing an integration of quantitative and qualitative methods in Kaixian County of Chongqing, China. Kaixian County, located in the north-east of Chongqing and characterized by mountainous areas. As an agricultural county, Kaixian County has 40 township hospitals that provide rural medical services for 1.15 million people (total 1.65 million). The GDP per capita in Kaixian County (US $3146), which is lower than the national average (GDP per capita US $6100) in 2012, ranks 31st in Chongqing. Furthermore, according to the official Statistical Yearbook [
22,
23], this county has shortage of health workers. However, the statistics of health worker conditions was collected two years ago and did not cover health worker structures of detailed distribution and turnover status from this geographical area.
2 Methods
Based on literature and an official questionnaire, a self-administered questionnaire was given to 120 directors of 40 township hospitals. Consultations with local health administrators, health policy researchers, statisticians, and sociologists were performed to discuss the content of this questionnaire, and a major revision was undertaken. In March 2013, a pretest was conducted in Kaixian County, and 40 directors of township hospitals were interviewed with this questionnaire by interviewers from Chongqing Medical University. Several questions were modified and deleted to develop this questionnaire.
The questionnaire, which was aimed to learn the latest conditions of health workers and find out existing core problems, was composed of following four parts: (1) demographic characteristic of directors (gender, age, tenure, educational background, job title, and professional title); (2) numbers and composition of health workers (doctor, nurse, public health worker, pharmacist, radiographer, dental technician, laboratorian and technician, and health management and support), which is intended to measure the geographical density and specialty structure distribution of health workers to indicate the key problem through comparison with references; (3) status of educational level [master’s degree holders, bachelor’s degree holders, junior college graduates, secondary technical school graduates, and high school (and below) graduates], which aims to explore the regional educational level percentage of health workforce to indicate the key problem through comparison with references; and (4) turnover status of health workers (over the last three years in-/out-migration of health workers in township hospitals). Out-migration of health workers in township hospitals indicates that health workers leave from township hospitals because of a specific reason, whereas in-migration of health workers in township hospitals indicates that health workers go to township hospitals for future work. This category reveals that local mobility characteristics and numbers of migrating health workers are measured, and in contrast to another region of mobility conditions, the key problem is indicated.
Based on our consultation with executives of the health bureau, we selected three persons who are primarily in charge from each township hospital (the director who is mainly responsible for administrative management, the deputy president who is mainly responsible for assisting the director in other relevant work, and the secretary who is mainly responsible for nosocomial political and ideological work) to obtain more feedback on a diverse set of directors. Considering that not every township hospital had all three principals, other leaders were selected to fill in the vacancies. Thus, the total sampling was 120 cadres (24 substituents). Furthermore, 10 interviewers, who are postgraduate students from Chongqing Medical University, were chosen for this research. After receiving training from experienced researchers, the interviewers were sent to Kaixian County. In April 2013, on the premise that confidentiality and anonymity were ensured, 120 directors were instructed to fill in the questionnaire. Aside from stating the study objectives, explaining several questions, and standardizing the survey process, the interviewers may offer assistance if required. Despite absentees and incomplete data, a total of 110 questionnaires were completed, yielding an effective response rate of 91.6%.
After consultation with statisticians, health policy researchers, and sociologists, the main problems extracted out from this survey were gathered and given back to the 120 directors. For every problem, these cadres were to write their own analysis and comprehension for reasons influencing the attraction and retention of health workers in township hospitals using pre-prepared pens and papers; mutual discussion among directors was allowed. In the end, 40 directors from every different township hospital were selected for a focus group discussion to probe into the underlying elements. A total of four focus groups were facilitated by a senior researcher from Chongqing Medical University. A one-hour interview gave the directors the opportunity to voice their suggestions and concerns and enabled a deeper exploration of relevant associations.
Data entry was accomplished using EpiData 3.0. Data analyses about density, quantity, composition, and educational level of health workers were descriptive. Statistical analyses were undertaken to evaluate the turnover characteristics and difference between in-migration and out-migration using SPSS 14.0. Thematic framework analysis was performed to inductively analyze the qualitative information [
24,
25]. Meanwhile, the recordings were transcribed verbatim in Mandarin and were not directly translated into English to avoid loss of meaning. Based on the qualitative data, the same group of researchers read and listed the common themes and recurring viewpoints, which formed the juxtaposing thematic framework. Using this framework, every segment of this text was categorized and coded. Segments concerned with each theme were divided to identify major perspectives and minor viewpoints. The rough thematic framework of findings was then generated. After a consultative process among researchers, the framework was improved and refined, while the reasons were redefined. The final framework focused on individual factors, factors with professional environment, and factors with treatment environment.
3 Results
3.1 Demographic characteristics of directors
The demographic characteristics of 110 respondents, comprising 102 males (92%) and 8 females (8%), are summarized in Table 1. The mean age of the respondents was 44 years, with a median of 15 years of working experience. A total of 34 respondents had a bachelor’s degree, while 76 received an associate degree. In terms of their job title, 68.18% were doctors, 18.18% were assistant doctors, and 12.73% were medical technicians. Compared with 45.45% of junior professional title, the percentage of intermediate professional title had nearly equal share (N = 49, 44.55%).
3.2 Density of health professionals
Three cadres were drawn from each township hospital, and the answers of the three directors to several questions in this questionnaire were consistent. Thus, 40 different effective questionnaires were used for partial data entry and analyses to avoid statistical duplication. The data statistics is shown below. The density of health professionals from east to west in China is shown in Table 2. Compared with Midwest China, the eastern developed regions showed great superiority. As one of the four special municipalities of China, Chongqing’s health professional density was slightly flat compared with that of the Midwest, but was lower than that of the nationwide average. Among the areas in Chongqing, the density of Kaixian County lagged behind all the other regions, excluding Fengdu County. The health professional density of Kaixian County was not only lower than the average of Chongqing, but was far below that of the national average, indicating the key problem: that is, numerical inadequacy of health workers in remote rural regions.
3.3 Quantity and composition of health workers
Table 3 shows the quantity and composition of health workers of township hospitals in Kaixian County. Among the 2419 health workers, 49.94% were doctors and 28.15% were nurses, indicating that the doctor-to-nurse proportion was 1:0.56, which is far below the standard (1:1) proposed by the Chinese Ministry of Health. Other kinds of medical technicians, such as pharmacists and radiographers, all had a low percentage. The remaining 5.21% were administrative staff and support crew. In reality, health workers in township hospitals were predominately doctors and nurses, where the percentages added up to 78.09%. The composition and numbers of health workers, as well as the doctor-to-nurse proportion, indicated that the specialty structure of health workers in township hospitals is imbalanced.
3.4 Educational level of health workers
The information about educational level of health workers in township hospitals was obtained (Table 4). In contrast to the Chongqing municipal and nationwide percentages, the educational level of health workforce in Kaixian County was lower. The percentage of health workers graduating from secondary technical school and high school (and below) was higher than that of Chongqing and the nationwide percentage; however, the proportion of health workers graduating from university and junior college was lower. Furthermore, township hospitals in Kaixian County had no postgraduates. Therefore, the geographical survey result showed scarcity of high-quality talent and lower educational level.
3.5 Turnover status of health workers
Table 5 shows the latest personnel mobility characteristics of township hospitals in Kaixian County over the last three years (2011 to 2013). For educational background (P<0.0001), 42.24% were junior college graduates, 31.20% were bachelor’s degree (and above) holders, and 26.56% were secondary technical school (and below) graduates among in-migration staff. In terms of out-migration staff, 46.89% were bachelor’s degree (and above) holders, 37.80% received junior college education, and 15.31% were secondary technical school (and below) graduates. For specialty structure (P = 0.2918), 41.44% of doctors and 34.88% of nurses were in-migration personnel, whereas 46.17% of doctors and 33.02% of nurses were out-migration personnel. Other kinds of health workers associated with in-/out-migration were 23.68% and 20.81%, respectively. Table 6 shows that the total of in-migration health workers of township hospitals in Kaixian County in three years were less than that of Yongchuan District; however, the total out-migration health staff of township hospitals in Kaixian County were more than that of Yongchuan District. Furthermore, from 2011 to 2013, the numbers of out-migration health workers in Kaixian County kept increasing every year. Hence, the key problem identified from this part, to some extent, was the increasing loss of health workers.
The key problems derived from the survey on the general status of health workers of township hospitals in Kaixian County are as follows: numerical inadequacy of health workers, unbalanced specialty structure of health workers, famine of high-quality talent, overall lower educational level, and increasing loss of health workers.
Thematic findings based on these key problems were perceived to be important elements from directors, which were related with the individual, professional, and treatment environment influencing the retention and recruitment of health workers in township hospitals. The major findings are summarized in Table 7.
3.6 Individual factors
3.6.1 Grueling commute between workplace and home
Many health workers who live at the local county town and work in rural areas have to commute between their workplace and home day in and day out. Limited assigned housing for foreign health workers resulted in inadequate accommodation for local health workers, which was a serious concern among directors. According to many directors, the round trip took up to 2 h if bad weather and terrible road conditions were considered. Rural bus was usually the first choice for commuters, and few had their own vehicles in addition to motorcycle; commuters usually pay more money for commuting. The long-time commuting, increasing living cost, and lowering work efficiency were mentioned as a demotivating factor affecting job choices.
3.6.2 Unbearable to live apart from families
Several respondents mentioned that nearly two thirds of the health workers in their hospitals were from other counties. Many health workers, especially those newly-married, had to experience separation from their families. Young workers from other counties were unfamiliar with the lifestyle in local areas with poor access to recreational amenities, thereby making their solitary life worse. As the directors stated, without establishing a kind of rapport with the local community, several workers were passive about their jobs and even asked for leaves for several days to go home. Based on the responses of the directors, female workers, particularly married nurses, were prone to move because of family stability and responsibilities.
3.6.3 Quality of growth environment for children
To an extent, health workers, who either grew up in rural area or attracted to rural lifestyle, feel that the countryside is a good place to take up medical service because of affordable housing and reasonable cost of raising children. However, this factor was outweighed by the primitive small-town environment and the insufficiency of qualified teachers for children. All respondents emphasized that a quality growing-up environment for children was the key predictor to make health workers leave when their children start formal schooling. Convenient community infrastructure and amenities, favorable urban sociocultural environment, and high-quality schooling constitute quality growth environment; children growing up in urban regions had better prospects in the future. According to half of the directors interviewed, highly educated health workers paid more attention to the growth of their children.
3.6.4 Parents’ incitement for leave
Family consideration is one of the contributing factors influencing health workers to choose their practice location. The things associated with family obligations (caring for aging parents and children, job opportunity for spouse, and adequate accommodation for families) had been important stimuli in decisions on where to practice. In this survey, another familial factor is that several parents incited their children working at township hospitals to leave for a more lucrative career. According to several directors, this factor was becoming a universal phenomenon at township hospitals. The truth emerged from the respondent interviewed that the one child policy in China increases parent expectations. One couple may make strenuous efforts and pay large amount of money for tuition to cultivate their children to be a college student. Even if a vast majority of loans had resulted in families to be in debt, rural families were more eager to loan money because rural parents hope their children to have a more respectable job in the future. When their children graduate to be a health worker and are willing to go back to their hometown to serve the community, the parents found that their original investment for cultivation was unworthy because the low income that their children receive from township hospital cannot repay their debts within a short time. Therefore, these parents persuade their children to leave for high-paying jobs. Notably, the limited salary at the grass roots level lessens the determination of health workers with rural background to devote themselves to rural healthcare service.
3.7 Professional factors
3.7.1 Serious tendency of “pulling out turnips from bottom to top”
When provincial hospitals with great advantages have attracted and recruited medical professionals from municipal hospitals for convenience of filling vacancies, the municipal hospital import substitutes from county-level hospitals and county-level hospital have to “dig the eminent variety out” from township hospitals. This tendency of pulling out turnips means loss of high-quality talents, but also indicates the unfairness between urban and rural healthcare system. At present, many county-level hospitals and above are expanding to maximize common interests because this phenomenon is exacerbated by the loss of qualified medical staff in township hospitals. Most directors mentioned that poaching excellent workers from lower-level hospitals had weakened the capacities of rural medical service, and this serious tendency had been the major obstacle to retain health workers in township hospitals. Simultaneously, among the directors, a demand exists for the limitation to the outflow of staffing system applied by the government.
3.7.2 “Doctors valued, others despised”
The motivating attribute affecting job satisfaction is perceived as appreciation by colleagues, managers, and even the local community. However, more than half of the directors admitted that nurses and technical professionals in township hospitals enjoyed lower prestige and recognition than clinical doctors, which had been a determining element for some workers to leave. From directors’ perspectives, clinical doctors were able to earn more income for township hospitals than nurses, technical professionals, and public health workers. To pursue more interests, a habit of recruitment bias for clinical doctors was developed by managers. Better treatment and higher social respect were enjoyed by clinical doctors, whereas heavy workload and service-type job accompanied with poor income make nurses feel devalued and drive them to leave. Moreover, in contrast to clinical doctors, medical technical professionals obtained inadequate professional backup from managers, as manifested by less support for purchasing facilities and continuing professional development access. Hence, this differential treatment appeared to be a potential contributor to the increase in personnel leaving and upset the balance of specialty structure of health workers.
3.7.3 Workload and working conditions
Working conditions were less satisfactory in township hospitals. According to the directors’ feedback, multidimensional factors constitute the unsatisfactory working environment, such as lack of sophisticated equipment, insufficiency of experienced colleagues, few comfortable accommodations and offices, more low-quality patients, and poor geographical environment. Most directors felt that a bad working environment had been the deterrent for the retention and attraction of health workers. For instance, few sophisticated equipment meant that technical professionals had no chance to practice and enrich their diagnostic skills. Several rural patients encountered difficulties with the health workers from somewhere else, such as communication, cooperation, and choice bias. Furthermore, mountainous areas were not helpful for preventive healthcare. As directors mentioned, the young workers who did not live through hardship were unwilling to stay.
Directors agreed that the workload was higher in township hospitals. They thought that the New Rural Cooperative Medicine System had made township hospitals more dynamic and competitive than before by orienting rural patients toward the utilization of low-level medical resource. Health workers had to undertake more workload because of their original work (preventive and curative work) and increased healthcare needs. Meanwhile, poor working environment has imposed burdens on health workers and caused several difficulties to medical activities.
3.7.4 Career advancement and continuing professional development
The issue often raised by directors was the limited continuing professional development (CPD) access. In essence, CPD provides a platform for health workers to remain up to date with medical practice and acquire professional development. The directors agreed that CPD was the stepping stone for prospective career advancement. Directors reported that they were biased against choosing and recommending particular health workers for CPD because of the limited opportunities for CPD access. In-depth discussions showed that managers were unlikely to send off the demanders for study because of heavy workload. The directors all agreed that a culture of job dissatisfaction and frustration from someone was elicited by this topic.
The directors indicated that almost everyone desired to have a better career advancement as reflected by higher recognition, senior working roles, and more remuneration. The main criteria for promotion were management skills, high technical expertise, popularity in colleagues, and sufficient qualifications. Another concern among directors was the long time taking the higher levels to support promotion. When questioned about promotion procedures, majority of the directors acknowledged that, post promotion sometimes lacked transparency and democracy, although a guide on management of postings and promotion procedures in township hospitals was developed by the local health bureau.
3.7.5 Rewards and punishments
A reward and punishment system was taken as a non-ignorable predictor correlated with health workers leaving township hospitals. Several directors expressed that health workers with rich working experience were demotivated by the current reward and punishment system in township hospitals. From the statements of one director, at present, oral commendations were often given to hardworking and prominent staff, but no material rewards were given to improve job performance. Meanwhile, the punishment system was linked with health worker salary and bonus. To an extent, non-pecuniary rewards and pecuniary punishments discourage health workers to remain in rural posts.
3.8 Treatment factor
3.8.1 Limited income
Directors had a long time discussing about limited income. Its significance was assured among respondents, and remuneration constitutes the most fundamental factor on the rural practice of health professionals. All directors acknowledged that the financial remuneration in township hospitals was inadequate even if government investment in rural healthcare had increased more than before. By far, the overall context of limited income is to keep close contact with zero profit and performance-based wage system, as mentioned by the directors.
The policy of zero profit was carried out in 2008, which aimed at regulating inflated medicine prices. As directors explained before, this policy was put into force, and the government had allowed additional markup percentage based on the purchasing price of drugs. The markup percentage of Western medicine and Chinese herbal medicines were 15% and 25% respectively. To prevent price increase, doctors obtained brokerage and bonus matched with the prescriptions and the numbers of patients from hospital. Although doctors promote medicines proposed by drug retailers through specific prescriptions, they were able to get a dual portion of payments from drug retailers and commission from drug sales, aside from informal payments from patients. However, at present, doctors’ benefits have been influenced by the implementation of zero profit. Most respondents emphasized that compared with doctors in better environment, doctors at township hospitals were confronted with more pessimistic income conditions.
In addition, the performance-based wage system, which involves basic and rewarding wages, was carried out at township hospitals to stabilize grassroots medical healthcare service in 2009. Basic wage accounts for a large proportion of 70%, which every health worker can acquire without influence, and the remaining 30% is for the rewarding wage, which must be related with workload and job performance. It was revealed from in-depth interviews that although the average income of all health workers increased, the income of high-professional-title workers decreased. Rewarding wage takes up an unsatisfactory proportion because holds no substantive incentives for outstanding workers. It was said by the directors that no matter how well you worked, there was no distinct income gap between low-professional-title and high-professional-title workers. It seems that the performance-based wage system just sends health workers to the 1960s of “everybody ate together from the same big pot,” which means egalitarian in China.
4 Discussion
This study, based on the diversity of perspectives of directors, is limited by several elements. First, the sampling of same-level directors rather than a variety of respondents were limited to establish correlation. Second, open-ended pen-and-paper surveys that elicit irrelevant or short answers limit response options and affect the nature and completeness of collected information. Thus, it was imperative to mitigate these through in-depth probing and prolonged engagement. Third, given that this group of respondents was from the remote mountainous areas, their perspectives may be different from those who were from the regions near the metropolitan area.
Even so, directors of township hospitals with various types and years of experience were interviewed to understand the motivations of health workers [
26,
27]. The framework of factors elucidated in the results reflects the elements of multiplicity and aligns well with the findings of international studies [
9,
13,
28,
29]. It is clear that this kind of multiplicity highlights a bundled combination of non-pecuniary and monetary incentives for recruitment and retention of health workforce in China, thereby giving prominence to multidimensional changes focused on what these health workers at rural posts think and feel. Thus far, the policy mechanisms instituted by the Chinese government to attract health human resources to rural regions just focus on individual incentives, such as improving infrastructure or increasing special allowances. The obtained framing of the three main constituents presented here suggests that to better increase or maintain motivation among health workers in township hospitals, it is helpful for policy makers to examine the elements identified in this study and to implement a package of non-monetary and fiscal incentives replacing singular stimuli. In fact, in 2006, Dussault
et al. [
13] painted a complete picture of detailed factors affecting the attraction and retention of health workers within five domains from the individual to the sociocultural. Although several factors identified in this study had been discussed earlier, the systematic research for framework of factors influencing the attraction and retention of health workers in township hospitals fills the gap in the Chinese context, which, to an extent, makes the policy setting of derivation easier [
9] and offers a salutary lesson to meet the challenge relevant to maintaining a balance of health workers at different levels of Chinese health system.
Individual factors are perceived as being the determining obstacles in sustaining efforts to attract and retain health workers [
11,
13] in township hospitals that offer policy options beyond financial incentives. These factors not only depend on one person’s demographic characteristics, such as educational level and marital status, but are also closely linked with familial or social contextual issues. This result does resonate with Lehmann
et al.’s systematic literature review of attraction and retention [
11]. He identified that it was unanimous that individual characteristics integrated with general external environment and social obligations were considerable elements in decisions where to practice. In this study, foreign married female workers in local township hospitals are more inclined to move under the conditions of family responsibility because marital status shows association with intention to leave. Similarly, the researchers found that female health workers who were married had a lower intention to leave because of the presence of relatives in the local community [
30]. Thus, the moves of female workers are related to family consideration and the existence of family members in remote rural areas, and the probability that health workers will consider these locations for their healthcare practice is improved, which echoes the finding proposed by Bilodeau
et al. [
31]. With regard to educational level, there is little evidence in literature indicating that this demographic characteristic is a disincentive for the attraction and retention of health workers. This study provides a good example of highly educated health workers’ initiatives in choosing to leave with the induction of a family issue: children’s education. Given this important role, which is mainly negative, that children’s education seems to play in health workers motivation, international studies highlight this family issue as a key source of discouragement for retention [
9,
14,
28]. In China, the one child policy makes parents have greater ambitions for their children and project their own dreams onto their children, and the reason why highly educated health workers pay more attention to the cultivation of their children. Family disapproval relevant to the individual element—parents’ incitement for leave—reveals the reason for leaving. This observation is in agreement with international research, which have shown that familial disfavor is found to be the barrier for rural working [
28,
32], in particular for health workers with rural origin to develop health service in this study. Given the unacceptable income in facilitating familial disapproval for retaining and encouragement for leaving, it is difficult for these health workers to continue health service. From this part, rural origin has been a predictor of rural practicing, as was concluded by international studies, in advance and had affected the establishment of particular policies or programs [
14]. The program of “rural directional medical students,” initiated and promoted in China since 2010, proclaimed that rural students may be enrolled without tuition fee on the promise that they will work in township hospitals in the future. This program offers underlying benefits not only for rural healthcare but also for facilitating to boost rural workforce in this country. However, to make this program sustainable, implementers and policy-makers must value this element bound up with income problem and regulate a package of incentives on how to alleviate this disapproval that health workers get from their families.
Professional factors, such as workload, working conditions, career advancement, continuing professional development, vocational respect, and rewards and punishments in this study, have been documented in literature as disincentives for the attraction and retention of health workers [
9,
11,
13,
33], and the findings further highlight the significance of these elements. Another interesting finding of this study is that a new kind of professional factor— “pulling out turnips from bottom to top”—has been determined in the Chinese context, something that has been barely explored in any depth within international studies relevant to poaching skilled medical staff. In one of these few studies, Chen [
7] mentioned that health workers migrating to richer countries has been condemned as poaching or a case of theft, whereas Dussault [
13] had described that industrialized countries had been shifting immigration legislations to open more opportunities for highly trained health workers who migrated to search for higher pay and better quality of life. Similarly, in this study, better working environment, satisfactory income, and urban lifestyle made talents in township hospitals accept offers from better hospitals. Even though there is a growing recognition, both in developing and developed countries, of the hazards posed by the indiscriminate poaching of skilled health workers [
34], little effort has been made to settle this problem. The findings call for giving more attention to curtail the tendency of poaching the scarce health human resources from township hospitals.
Inadequate salary is the important stimulus that affect the recruitment and retention of health workers in township hospitals and resonates with evidence from other studies [
9,
11,
13,
26]. The performance-based wage system and zero profit policy can be considered the cause why the income of health workers in township hospitals had been unacceptable because the multi-channel compensation mechanism for health workers in township hospitals, frankly, had not been improved [
35]. A culture of dissatisfaction and dismay from most of health workers was confirmed. According to the Chinese Health Accounts [
22], the total health expenditure of GDP in 2010 was 5.1%, which is below the average (6.6%) of that in middle-income countries. International comparisons suggest that there is much scope for an increase in rural health workers’ benefits. Directors acknowledged that salary alone was unable to provide enough encouragement for health workers. This statement is supported by Zurn’s multiple financial incentives to attract health personnel to unattractive areas [
36]. They identified that special monetary allowance, such as bonuses based on length or experience of commitment and tuition reimbursement, integrated with increased salary should make working in rural regions more appealing. Hence, the degree of importance of this upon health workers motivations is noteworthy, and the findings appeal to a combined package of incentives.
The Chinese health system is now presented some challenges with reference to maintaining the balance of health workforce at various levels of this system. In fact, overall numbers of health workers are identified to be numerous [
37,
38], whereas their distribution is imbalanced. The Chinese government is already implementing a series of policies to sustain the recruitment and retention of health workers in township hospitals based on the local population and medical needs, and these have been the target of several significant factors highlighted in this study. However, several policy measures just pay attention to singular issues, such as improving infrastructure or increasing special allowances. As shown by the systematic framework of findings, centrally-based policy makers can use them as a manual to revisit policy measures and to design the trials of selected combination of non-monetary and fiscal incentives for replacing singular stimuli that are considered important but not adequate as an isolating incentive for engaging in rural health service, thereby contributing to ensure the sustainability of attracting and retaining health workers in rural health system. In reality, we have to admit that the local and central governments have begun to pursue combined policies, known as “one-two punch,” to improve retention in Chinese rural areas nowadays, such as training allied with promotion, and these are perceived as having conspicuous effectiveness to date [
39]. Furthermore, addressing the intervention strategies bundled together is likely to result in broader market reforms and more purposive governmental regulations [
2,
40]. Further research may be possible to monitor developmental trends and to verify the hypotheses generated.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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