title: Rural retention of doctors graduating from the rural medical education project to increase rural doctors in Thailand: a cohort study.
abstract: BACKGROUND
  In Thailand, the inequitable distribution of doctors between rural and urban areas has a major impact on access to care for those living in rural communities. The rural medical education programme 'Collaborative Project to Increase Rural Doctors (CPIRD)' was implemented in 1994 with the aim of attracting and retaining rural doctors. This study examined the impact of CPIRD in relation to doctor retention in rural areas and public health service.
  
  
  METHODS
  Baseline data consisting of age, sex and date of entry to the Ministry of Health (MoH) service was collected from 7,157 doctors graduating between 2000 and 2007. There were 1,093 graduates from the CPIRD track and 6,064 that graduated through normal channels. Follow-up data, consisting of workplace, number of years spent in rural districts and years within the MoH service, were retrieved from June 2000 to July 2011. The Kaplan-Meier method of survival analysis and Cox proportional hazards ratios were used to interpret the data.
  
  
  RESULTS
  Female subjects slightly outnumbered their male counterparts. Almost half of the normal track (48%) and 33% of the CPIRD doctors eventually left the MoH. The retention rate at rural hospitals was 29% for the CPIRD doctors compared to 18% for those from the normal track. Survival curves indicated a dramatic drop rate after 3 years in service for both groups, but normal track individuals decreased at a faster rate. Multivariate Cox proportional hazards modelling revealed that the normal track doctors had a significantly higher risk of leaving rural areas at about 1.3 times the CPIRD doctors. The predicted median survival time in rural hospitals was 4.2 years for the CPIRD group and 3.4 years for the normal track. The normal track doctors had a significantly higher risk of leaving public service at about 1.5 times the CPIRD doctors.
  
  
  CONCLUSIONS
  The project evaluation results showed a positive impact in that CPIRD doctors were more likely to stay longer in rural areas and in public service than their counterparts. However, turnover has been increasing in recent years for both groups. There is a need for the MoH to review and improve upon the project implementation.
authors.affiliation: Sirindhorn College of Public Health, Khon Kaen, 90/1 Anamai Road, Muang, Khon Kaen, 40000, Thailand. ccnonglak@gmail.com.
authors.forename: Nonglak
authors.initials: N
authors.lastname: Pagaiya
authors.affiliation: National Health Security Office, Muang, Nakhon Ratchasima, 30000, Thailand. lalitayakong@gmail.com.
authors.forename: Lalitaya
authors.initials: L
authors.lastname: Kongkam
authors.affiliation: International Health Policy Program, Ministry of Public Health, Tiwanond Road, Muang, Nonthaburi, 11000, Thailand. sanya@ihpp.thaigov.net.
authors.forename: Sanya
authors.initials: S
authors.lastname: Sriratana
mesh_terms: D002321:Career Choice; D015331:Cohort Studies; D004501:Education, Medical; D005260:Female; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006761:Hospitals; D006801:Humans; D008297:Male; D010563:Personnel Turnover; D010820:Physicians / Q000600:supply & distribution*; D011365:Professional Practice Location; D015397:Program Evaluation; D016016:Proportional Hazards Models; D017150:Public Sector; D019035:Rural Health Services; D012424:Rural Population; D012737:Sex Factors; D013785:Thailand; D000078329:Workforce; D017132:Workplace