PONE-D-20-40985

How to attract and retain health workers in rural areas of a fragile state: findings from a labour market survey in Guinea

PLOS ONE

Dear Dr. Witter,

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Summary of study

This study uses three different nationally representative cross-sectional surveys as well as a discrete choice experiment to examine health workers’ motivations and how they could be incentivized to work in remote rural areas of Guinea. The authors examine differences by cadre of health worker as well as by location They suggest several ways to improve health worker retention in rural areas including offering specializations, recruitment from rural areas and improving working conditions.

Major Comments

1. While I appreciate the authors’ efforts to be thorough and to use different sources of data to examine their research question, I found the paper a little overwhelming. With results from three different surveys, a DCE, a focus on multiple outcomes disaggregated by different cadres and location, it was very difficult to determine what the main findings were of this paper. I suggest the authors simplify and split this up into multiple papers. For example, perhaps they could just focus either on the health worker survey or on the DCE in this paper. At a minimum, I think they should exclude the patient survey and health facility survey as I don’t believe they add substantially to the question of health worker motivation.

2. I think the Methods Section could use a little more detail. For example, how were the questions that are presented in Figure 2-5 asked? Were the respondents presented with responses which they had choose from? What kind of regression models were run for the analyses in Table 1 3 and for the DCE? The results section mentions a composite satisfaction index- how was this created? Similarly, what do the measures of intrinsic/extrinsic motivation consist of? (The authors refer to another paper, but I think a summary here would be useful).

3. It would be useful to have a Table 1 that shows some descriptive statistics for the health workers surveyed; some of these statistics are cited in the text but I could not find this information in the tables.

4. Table 4: It would be helpful if the authors could say a little more about how to interpret the coefficients in this table.

5. The figures could use more labeling so that one can see what they are showing without referring to the text. For example, in Figure 2-5, it’s not clear what the question was. Figures 6 and 7 have no axis titles and, again, it’s not clear what they are showing.

6. If the authors choose to keep both the health worker survey and the DCE in the same paper I think it would be useful to have more discussion of to what extent the results of the health worker survey and the DCE correspond with each other.

Minor Comments

7. Table 1 and 3 are a little overwhelming: it may be helpful to have some kind of headings/categories to help orient the reader.

8. Box 1: Suggest making this into a table so can see all the attributes and levels together.

9. The description of the sampling procedure is quite complicated- perhaps a figure will help the reader?

Reviewer #2: Dear Authors,

Thank you for this paper, conducting a Labor market survey in Guinea. Actually i had already seen an earlier version and presentation of it, shared by Prof. Witter.

My main comments are the following; This is a proper conducted health labour market analysis of the health sector , its incentives , constraints and regulation in Guinea. As a method, amongst others, A DCE has been used. Whilest this has been conducted properly, i miss consinderable 'contextual' information and 'the policy momentum' post-ebola that enabled, but also distored , workforce developments and activities in Guinea. context and health system are 'fragile' in a sense that domestic political, epidemic (Ebola, covid-19, but also new measles and polio outbreaks) as well as international actor involvement have 'shaped' the labour market in several ways. This specific Guinean governance context and momentum (post-ebola workforce investments) should be explained more explicit in introduction and discussion as it impacts specificity, relevance and policy uptake of this analysis.

As 'fragility' is in the title of the article, it must be more explicit explained what this fragility implies for the health and labour sector in Guinea

We wrote partly about it here but several more articles should be available

Kolie, D., Delamou, A., van de Pas, R., Dioubate, N., Bouedouno, P., Beavogui, A. H., ... Van Damme, W. (2019). ‘Never let a crisis go to waste’: post-Ebola agenda-setting for health system strengthening in Guinea. BMJ global health, 4(6), e001925.

Kolie D, van de Pas R, Delamou A, Dioubaté N, Beavogui FT, Kaba A, Beavogui AH, MD, Van De Put W, Van Damme W. Retention of Healthcare Workers one year after recruitment and deployment in rural settings: an experience Post-Ebola in five Health Districts in Guinea. Hum Resour Health. 2021

https://doi.org/10.21203/rs.3.rs-122033/v1

Bests and looking forward to a next version. Remco van de Pas

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Reviewer #1: No

Reviewer #2: Yes: Remco van de Pas

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PONE-D-20-40985R1

How to attract and retain health workers in rural areas of a fragile state: findings from a labour market survey in Guinea

PLOS ONE

Dear Dr. Witter,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The authors have done a good job in addressing the comments of the reviewers, yet there remain a number of points that would need to be addressed prior to consideration for publication.

Please submit your revised manuscript by Sep 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mohamad Alameddine, MPH, Ph.D.

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I appreciate the authors efforts to respond to my comments, I think the paper is improved and easier to follow. A few additional comments/suggestions below:

1. Table 1: For the time-bound contract attribute, could the authors clarify what the different levels were? Were the levels increments of a year up to the maximum of 5/7 years? Or something else?

2. I don’t find Table 2 particularly useful, given that it just shows the geographical distribution of the health workers. Instead (or in addition), I think it would be useful to show the descriptive statistics that are mentioned throughout the paper but aren’t shown anywhere. For example, I think the table could show summary statistics cited in the text on work/career history, workload (hours per week, patients seen), satisfaction scores, remuneration etc by health worker type. I think this would help the reader to be able to quickly see differences between the different health worker types.

3. Are the regressions in Table 3 and Table linear models? If so, it would be good to mention this in the methods section.

4. Table 3: For the satisfaction composite score- is it actually a dissatisfaction score? (it seems like a negative coefficient actually means higher satisfaction, correct?). If so, I think it would be helpful to label it as such.

5. If Table 5 presents the results of a linear model, I think the coefficients should be interpreted in terms of percentage points and not percentages.

6. In Lines 321-322, the authors say that those with higher intrinsic motivation are more likely to want to work in rural areas in the long-term, however it should be noted that this isn’t statistically significant.

Reviewer #2: Amendments properly include suggestions from reviewer 1 and 2. Would encourage authors to be engaged in followup research and processed regarding workforce development in Guinea given needs and development. This labor market analysis is an important basis for continuing work.

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Reviewer #1: No

Reviewer #2: Yes: Remco van de Pas

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

How to attract and retain health workers in rural areas of a fragile state: findings from a labour market survey in Guinea

PONE-D-20-40985R2

Dear Dr. Witter,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Elizabeth S. Mayne, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the changes, I appreciate all the edits and efforts to respond to the comments. My only remaining concern is that I still believe that the coefficients in Table 5 should be reported as percentage points and not percentages if the regression model was a linear regression and the outcome is binary. However, I may have mis-understood the regression model used.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Remco van de Pas