臺灣博碩士論文加值系統

摘要
背景：蒙古的農村健康設施正面臨著嚴重的醫生短缺問題。即使為了讓醫生居住在農村地區已經有多項的補救措施，但現今仍然發現農村地區在尋找醫生方面還是有困難。因此，本研究的目的主要是在探討個人、經濟和非經濟等因素中，哪一個是最主要影響醫生居留在蒙古農村的因素。
方法論：這項研究使用混合方法的途徑。數據分析使用了定量方法描述性統計，Pearson相關和多元回歸，意義設置在0,05水平進行分析。研究工具以問卷調查方式進行。研究的變項為個人、經濟、非經濟因素和醫生居留在農村地區。定量方法採用了質性內容分析和自填問卷。
結果：這項研究的結果顯示醫生的年齡、婚姻狀況、醫學教育、家鄉、薪水、獎金、偏遠地區補助、家庭支持、房子、銀行貸款支持、退休金福利、繼續教育和職業地位等與蒙古醫生居留在農村地區之間有著顯著的相關。自填問卷的結果強調了經濟問題。
結論：總之，年輕、高學歷、有家庭且在農村地區成長的醫生，
當醫療人力充足時樂意居留在農村。最主要的因素是經濟問題。此外，繼續培訓和升職的機會是影響醫生居留在農村地區的主要非經濟因素。根據這些原因蒙古健康部應該比現在更加加緊發展、告知、建議和發起實施蒙古農村地區獎勵的制度。
關鍵詞：醫生的居留，健康部的人力資源，影響因素，獎勵，農村地區

Abstract
Background: Rural health facilities of Mongolia are facing serious doctors’ shortage. Though there is implemented several policies to improve retention of doctors in rural areas, still today there have been found difficulties to accept physicians in rural posts. Therefore this study aimed to examine the personal, financial and non financial factors that mostly affect physicians’ retention in rural areas of Mongolia.
Methodology: This study used mix method approaches. Data analysis were examined by the quantitative method Descriptive statistic, Pearson’s correlation and Multiple regressions with level of significance set at 0,05. Survey used for quantitative method. The research variables were personal, financial and non financial factors and doctors’ retention in rural areas. And for the qualitative method was used qualitative content analyses and self administered survey.
Result: Results of this study ensured that there are significant correlations between age, marital status, education of physician, hometown, salary, bonus, remote area allowance, family support, housing, support on bank loan, pension benefit, constant training and career advancement of physicians and doctors’ retention in rural areas of Mongolia. The self administered survey result highlighted the financial incentives.
Conclusion: In conclusion, younger higher educated physicians who have family and grew up in rural areas willing to stay in rural areas when support of health workers will become sufficient. And a major important factor was financial incentives. Furthermore constant training and career advancements were the important non financial factors in doctors’ preferences to remain in rural areas. On these accounts Mongolian MOH has to develop and promote implementation of incentive packages much better than today through Mongolian rural areas.
Key words: doctors’ retention, human resource for health, factors affect, incentives, rural area

Table of contents
Acknowledgement iii
Abstract iv
摘要 v
Table of contents vi
List of tables viii
List of figures ix
Abbreviation x
CHAPTER ONE: INTRODUCTION 1
1.1. Research background and evidence 1
1.2. Problem statement 3
1.3. Research objectives: 4
1.4. Research question 5
1.5. Scope and purpose of this research 5
1.6. Structure of the research 6
1.7. Definitions of the area, physicians and physicians’ levels. 7
CHAPTER TWO: LITERATURE REVIEW 9
2.1. Basic concept of Human Resource for Health 9
2.1.1. Global health workforce 9
2.1.2. Shortage and uneven distribution of globe. 10
2.2. General information about Mongolia 14
2.3. Health situation of human resource in Mongolia: 16
2.3.1. Supply, Distribution and migration of physicians in Mongolia 16
2.3.2. Current situation in rural areas of Mongolia. 17
2.3.3. Policy intervention in Mongolia: 21
2.4. Factors affecting for doctors’ retention: 23
2.4.1. Individual factors 24
2.4.2. Incentives: Financial incentive factors. 27
2.4.3. Non financial incentive factors: 31
2.5. Policy interventions affect: 34
2.6. The conceptual model 35
CHAPTER THREE: RESEARCH METHODOLOGY AND DESIGN 36
3.1. Procedure 36
3.2. Study design 36
3.3. Site description. 37
3.4. Population and Sample 37
3.5. Sampling technique 38
3.6. Questionnaire definition of quantitative method. 38
3.7. Questionnaire definition of qualitative method: 40
3.8. Hypotheses: 40
3.9. Reliability of a scale: 41
3.10. Instrument: 41
3.11. Procedure data collection 43
3.12. Data analysis: 44
3.13. Problems and ethical considerations: 45
CHAPTER FOUR: RESEARCH FINDINGS 46
4.1. Quantitative results: 46
4.1.1. Descriptive analysis. 46
4.1.2. Pearson’s correlation analysis of the factors affecting doctors’ retention 49
4.1.3. Multiple regression analysis of the factors affecting doctors’ retention: 54
4.2. Qualitative analysis: 57
CHAPTER FIVE: DISCUSSION AND CONCLUSIONS 63
5.1. Discussion 63
5.2. Research limitations 67
5.3. Future research recommendations 68
5.4. Policy recommendations 69
5.5. Conclusions 71
REFERENCES 73
Appendix A 79
Appendix B 82
Appendix C 83
Appendix D 84
List of tables
Table 1. Physicians of provinces and capital by region in Mongolia. 17
Table 2. Persons per physician by region and capital in Mongolia. 18
Table 3. Types of incentives. 28
Table 4. Questionnaire definition of quantitative method 38
Table 5. Frequency distribution of the demographic variables. 46
Table 6. Reliability analysis 49
Table 7. Pearson’s correlation between dependent and independent variables. 50
Table 8. Strength of correlation coefficient 51
Table 9. Multiple regression coefficients 54
Table 10. Summary result with regarding tendency to continue to work and to stay 56
Table 11. List of self administered survey by open coding answers 58
Table 12. Factors from self administered survey 61

List of figures
Figure 1. Rural and Urban worldwide distribution of physicians and nurses. 11
Figure 2. Map of Mongolia. 15
Figure 3. Health workers structure of Mongolia 2010. 16
Figure 4. Number of doctors per 10000 populations in local areas in Mongolia. 20
Figure 5. Factors affect in health professionals’ retention 35

REFERENCES
Acosta, M.D., & David, A. (2000). Impact of Rural Training on Physician Work Force: The Role of Postresidency Education. Rural Health, 16 (3), 254-261.

Adams, O. (2000). Pay and non-pay incentives, performance and motivation: Round Table Discussion. Document for the WHO Global Health Workforce Strategy Group, Geneva.

ADB & MOH of Mongolia (2009). Third health sector development project: Inception report.

ADB & MOH of Mongolia (2011). Third health development project: Incentive program assessment of health workforces in Mongolian hospitals. Technical report.

Amoako, P. (2011). Identifying pull and push factors of health workers in rural Ghana. (A case study-Mponor Wassa east district in the western region).

Bayart, B., Erdenetuya, S. & Battulga,Sh. (2009). Human resource development policy of the health sector for 2010-2014. MOH. Health Sector Development Project 3” funded by ADB.

BCMA (British Columbia Medical Association), (1998). Attracting and retaining physicians in rural British Columbia. Report of the BCMA rural issue committee. Vancouver.

Blanche, T.M., & Durrheim, K. (2004). Research in practice: Applied method of the social science. Cape town: UCT press.

Buchan, J., Thompson, M., & O’May, F. (2000). Health workforce incentive and remuneration strategies: A research review, Geneva, WHO. Issues in Health Services Delivery, Discussion Paper 4, Incentive and Remuneration Strategies.

Chaudhury, N., & Hammer, J.S. (2003). Ghost doctors: Absenteeism in Bangladesh health facilities.

Cheney, H., Campbell, S., & Wilson, E. (2003). The 21 st Century General Physicians: recruitment and retention in rural Australia. Discussion Paper

Codjia, L., Jabot, F., & Dubois, H. (2010). Evaluation of the programme to strengthen the medical presence in health subdistricts in rural Mali. Geneva. WHO.

Dambisya, Y.M.( 2007). A review of non-financial incentives for health worker retention in east and southern Africa. ESC A-HC, EQUINET Discission papper #44.

De Vries, E., & Reid, S. (2003). Do South African medical students of rural origin return to rural practice? South African medical journal, 11, 277-284.

Dieleman, M., & Harnmeijer, W. (2006); Lehmann et al 2005. Improving health worker performance: in search of promising practices.

Dieleman, M., Cuong, PV., & Martineau, T. (2003). Identifying factors for job motivation of rural health workers in North Viet Nam. Human Resource for Health 1(1),10.

Doescher, M., Ellsbury, K., & Hart, L. (2000). The distribution of rural female generalist physicians in the United States. Journal of Rural Health, 16(2),111-118.

Dovlo, D. (2007). Migration of nurses from Sub-Saharian Africa: A review of issues and challenges.

Dumont, J.C., Zurn, P., & Thi, C.l.(2008). International mobility of health professionals and health workforce management in Canada: Myths and realities. Paris, Organisation for Economic Co-operation and Development, (OECD Health Working Paper no.40).

Dussault,G., & Franceschini, M.C. (2006). Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resource for Health, 4(12),1-16.

Elo, S., & Kingas, H. (2007). The qualitative content analysis process. JAN research mothodology

Ferrinho, P., & Dal Poz, M. (2003). Towards a Global Health Workforce Strategy.

Franco, L.M., Bennett, S,. & Kanfer, R. (2002). Health sector reform and public sector health worker motivation a conceptual framework. Social science and medicine, 54, I255-I266

Fritzen, S.A. (2007). Strategic management of the health workforce in developing countries: What have we learned? Human resource for Health, 5(4).

Gilles, D., & Maria, D.F. (2006). Not enough there, too many here: Understanding geographical imbalance in the distribution of the health workforce. Human Resource for health, 4(12).

Graneheim, U.H., & Lundman, B. (2003). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness

Book, second edition, Jr. in name
Hair, J.F., Bush, R.P., & Ortinau, D.J. (2003). Marketing research: Within a changing information environment (2ded).

Hamilton, K., & Yau, J. (2004). The global tug-of-war for health care workers. Washington, DC, Migration Policy Institute. http://www.migrationinformation.org/feature/display.cfm?ID=271

Henderson, L,N., & Tulloch, J.(2008). Incentives for retaining and motivating health workers in Pacific and Asian countries. Human Resource for Health, 6(18).

Herzberg, F., Mausner, B., & Capwell, D. (1957). Job attitudes: Review of research and opinion. Pittsburgh: Psychological Services of Pittsburgh.

Hsiao, W., & Li, K.T. (1997). Personal communication. Hsiao W & KT Li Professor of Economics, Harvard University School of Public Health.

http://who.int/globalatlas/default.asp
http://www.nyulawglobal.org/globalex/mongolia.htm#_The_Constitution
http://www.medterms.com/script/main/art.asp?articlekey=4887.
http://www.healthpoint.co.nz/default,135777.sm
http://www.studya.com/en/trade/medicine_pharmaceutics/specialized_physician.htm
http://wiki.answers.com/Q/How_did_the_word_'quack'_get_chosen_to_represent_a_dishonest_doctor

ICN (2008), Buchan,J., Thompson,M., and O'May,F. (2000). Incentive system for health care professionals. Copyright by: International Council of Nurses, International Hospital Federation, International Pharmaceutical Federation, World Confederation for Physical Therapy, World Dental Federation, World Medical Association. http://www.whpa.org/PPE_Fact_Incentive_Pro.pdf

IM (2005). Institute of Medicine. Quality Through Collaboration: The Future of Rural Health. Washington, D.C, National Academies Press. http://books.nap.edu/openbook.php?record_id=11140

James, P.S., & Thomas, D. (1998). On the road: Marriage and Mobility in Malaysia. Journal of Human Resources, 33(4), 805-832.

James, T.B Rouke., Filomena, I., & Mary, A. K. (2003). Keeping family physicians in rural practice: Solution favored by rural physicians and family medicine residents. Can Fam Physician 49,1142-1149.

JLI (2004). Human resource for health. Overcoming the crises.

Kabene, S.M., Orchard, C., & Leduc, R. (2006). The importance of human resources management in health care: A global context. Human Resources for Health, 4(20)

Kanfer, R. (1999). ‘Measuring health worker motivation in developing countries.’ Major Applied Research 5, Working Paper 1; Partnerships for Health Reform Project, Abt Associates Inc., Bethesda, MD, USA.

Kirigia, J.M., Gbary, A.R., & Seddoh, A. (2006). ‘The cost of health professionals’ brain drain in Kenya, BMC Health Services Research, 6( 89).

Laven, G., & Wilkinson, D. (2003). Rural doctors and rural backgrounds: How strong is the evidence? A systematic review. Australian journal of rural health, 11,277-284

Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle and low income countries: A literature review of attraction and retention. BMC Health service research, 8(19), 1-10.

Lexomboon, D. (2003). Recruitment and retention of human resources for health in rural areas: A case study of dentists in Thailand.

Locke, E.A. (1969). What is job satisfaction? Organizational Behavior and Human Performance, 4(4), 309-336.

Luoma, M. (2006). Increasing the motivation of health care workers. The Capacity Project. Technical Brief.

Mathauer, I., & Imhoff, I. (2006). Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Human resource for health, 4(26).

Mazibuko, P.A. (2003). Balanced scorecard evaluation of transformation in a company operating within an economy in crisis: The case of Delta Beverages in Zimbabwe. University of Port Elizabeth treatise.

MNALHC (Mongolian new additional law of health care) 2011. http://www.legalinfo.mn/insys/lawmain.php?vlawid=1463

MNSB (2010). Mongolian National Statistic Bulletin.

MOH (2009). Health Partnership Group: Joint annual health review. Human resource for health in Vietnam. Hanoi.

MOH (2011). Third Health Sector Development Project: Evaluation of incentive packages of health care professionals. Technical report. MGL

Mumtaz, Z., Salway, S., & Umer, N. (2003). Gender-based barriers to primary health care provision in Pakistan: the experience of female provinders. Health policy and planning, 18(3),261-269.

Ntuli, A. (2006). Regional evidence and perspectives on migration of health workers: Retention and migration of health personnel in southern Africa.

Patricia, H., Sigrid, D., & Mario, D, P. (2003). Measuring expenditure for the health workforce: Evidence and challenges.
http://www.who.int/nha/docs/Paper%20on%20HR.pdf

PNGPSCAA (2001). Papua New Guinea Public Services Conciliation & Arbitration Act. Memorandum of Agreement Governing the Terms and Conditions of the Nursing Personnel in the Health Service.

PNGPSCAA, (2001). Papua New Guinea Public Services Conciliation & Arbitration Act: Memorandum of Agreement Governing the Terms and Conditions of the Nursing Personnel in the Health Service.

EQUINET (Regional network for equity on health) and HST (Health Systems Trust), (2005). “Equity in the distribution of health personnel in southern Africa: Report of regional meeting”. Johannesburg, South Africa.

Sempowski, I.P.(2004) Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: Systematic review of the literature. Med, 9(2),82-8.

Speybroeck N., Ebener S., & Prasad, A. (2006). Inequality in access to human resources for health: Measurement issues. WHO, Geneva. (Background paper for the world health report).

Travis, P., Bennett, S., & Hyder, A.A. (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet, 364, 900–6.

Ulrich, L., & Altantuya, J. (2002). Mongolian second health sector development project: Report and recommendation for health sector public-private partnership.

Vujicic, M., Zurn, P., & Dal, P.MR. (2004). The role of wages in the migration of health care professionals from developing countries. Human Resource for Health. 2(1),3.

WHO (2011). World Health Statistics.
http://www.who.int/whosis/whostat/2011/en/index.html.

WHO (2004). The migration of skilled health personnel in the Pacific region.

WHO (2006). The World Health Report: Working together for health. Geneva.

WHO (2010). Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendation.

Wibulpolprasert, S., & Pengpaibon, P. (2003). Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human resource and health, 1(1),12.

Wibulpolprasert, S. (2001). Economic uncertainties: future challenges to world health. Lessons learned from Thailand. In Health by the people: a celebration of the life of Ken Newell Liverpool: Liverpool School of Tropical Medicine.

Wilson, N.W., Couper, I. D., & Marais, B.J. (2009). A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote health, 9,1060.

Witter, S., Bui Thi Thu Ha & Vujicic, M. (2011). Understand the ‘four direction of travel’: Qualitative research into the factors affecting recruitement and retention of doctors in rural Vietnam. Human resource for health, 9(20).

Zurn, P., Vujicic, M., & Braichet, J.M. (2011). A technical framework for costing health workforce retention schemes in remote and rural areas

Zurn, P., Dal Poz, MR., & Adams,O.(2004). Imbalance in the health workforce. WHO, Geneva, Switzerland. Human Resource for Health, 2(1),13.

Zurn, P., Dolea,C., & Stilwell,B. (2004). Nurse retention and recruitment: Developing a motivated workforce. Issue Paper 4, WHO: Geneva.