Decentralised clinical training affects retention but not recruitment: a case study in East Nusa Tenggara, Indonesia

Medical education interventions are viewed as a solution to the problem of low doctor recruitment and retention in rural areas. One educational intervention is decentralised clinical training (DCT). This study aims to analyse the influence of DCT duration on rural doctor recruitment and retention using a case study of alumni from the classes of 2008-2017 (graduating between 2014 and 2023) from Universitas Nusa Cendana in Kupang, East Nusa Tenggara, Indonesia.

A retrospective cohort study was conducted using total sampling. DCT duration data were obtained from the alumni database. Meanwhile, data on recruitment status and retention duration in rural areas were collected by online questionnaire. Binary logistic regression was used to analyse recruitment, and linear regression was used to analyse retention. Cohort stratification was performed before analysis to control for confounding.

DCT duration showed an insignificant association with recruitment across the entire cohort (odds ratio 0.750-0.967, p>0.05). However, the influence on retention showed a significant positive effect in the most recent cohort (β=0.054, p<0.05).

The analysis results for DCT duration on recruitment (insignificant) and retention (significant) reveal distinct mechanisms underlying initial intent (for recruitment) and adaptability (for retention). These results suggest that DCT may not serve as a primary magnet to attract doctors, but rather as an anchor that prepares them to stay in rural areas.

Overall, the results of this case study provide empirical evidence that educational intervention strategies like DCT need to be integrated with multifactorial interventions - including regulation, policy, and the recruitment of students from rural origins - as the key to the sustainability of health services in rural and island regions.