Why doctors are reluctant to work in rural areas
Why doctors are reluctant to work in rural areas
Mohammad Rajja
Urban means territory, population, and housing units located within an urbanised area, which has a population density of about 1,000 people per square mile and overall density of at least 500 people per square mile. Rural means territory, population and housing units located outside an urban area. Resources for health centres and other safety net and ambulatory care providers who are seeking to implement health are missing there.
There is need to highlight the situation of health workers in South Asian countries to gain a better understanding of the contributing factors to health worker motivation, dissatisfaction and migration; examine the regional and global evidence on initiatives to retain a competent and motivated health workforce, especially in rural and remote areas. Economic factors play a significant role in the decisions of workers to remain in the health sector. South Asia’s salaries and benefits, together with working conditions, supervision and management, and education and training opportunities are important. South Asia, facing shortages of health workers, needs to identify the underlying reasons for the shortages, determine what motivates health workers to remain in the health sector, and evaluate the incentives required for maintaining a competent and motivated health workforce.
Determinant factors and responses to financial and non-financial incentives have not been adequately monitored and evaluated in the region. Efforts must be made to build the evidence base so that countries can develop appropriate workforce strategies. Shortage of health workers in South Asia is a critical issue that must be addressed through policy, planning and implementation of innovative strategies such as incentives for retaining and motivating health workers. Health workers are vital to health systems but are often neglected. Factors that contribute to the shortage of skilled health workers include a lack of effective planning, limited health budgets, migration of health workers, inadequate numbers of students entering and completing professional training, limited employment opportunities, low salaries, poor working conditions, weak support and supervision, and limited opportunities for professional development. The shortage of workers often results in inappropriate skill mixes in the health sector as well as gaps in the distribution of health workers. This is especially so in rural and remote areas where the provision of services is difficult because of limited health budgets and scattered populations living in isolated villages.
The magnitude of the shortage can be seen in health worker density rates and workforce vacancy rates. Its impact is reflected in health system performance indicators including maternal and child health indicators, which correlate with health worker density. South Asia is lagging behind other regions in providing a package of essential health interventions to achieve the health-related Millennium Development Goals (MDGs).
Where health workers are scarce, health services suffer. Countries with low ratios of health workers to population are among the countries with high mortality rates for children under five years of age.
The challenges in maintaining an adequate health workforce that meets the needs of a population with social, demographic, epidemiological and political transitions require a sustained effort in addressing workforce planning, development and financing. Further examination and analysis are needed to better understand the factors that contribute to health worker retention in resource constrained settings and the initiatives that have the potential to maintain a competent and motivated health workforce in South Asia.
Skilled health workers are increasingly taking up jobs in the global labour market as the demand for their expertise rises in high income areas. The rural to urban, intraregional and international migration of health workers in South Asian countries inevitably leaves poor, rural and remote areas under serviced and disadvantaged.
Some countries, such as India, Bangladesh and Pakistan have specifically trained health professionals for export to developed countries. The unplanned loss of health workers can be extremely costly due to their lengthy education programmes, and high cost of teaching materials. Their replacements may lack appropriate skills, languages and cultural sensitivity.
Economic factors play a big role in health worker motivation and retention, though they are not the sole reasons for health worker shortages. Health workers leave their positions for numerous reasons. Health workers commonly leave to obtain better salaries, training opportunities and more desirable working conditions; to access education for children, to find political stability, and because of family ties abroad. Health workers who remain in their countries of origin hold more senior positions, receive good salaries and privileges, and work in favoured locations.
The shortage of skilled health workers in many South Asian countries is compounded by the difficulties in training adequate numbers of health workers and balancing the skill mix and distribution in a country. Health workers have been reluctant to work in rural and remote areas because of little support or supervision, a lack of material resources for health, poor working and living conditions, and isolation from professional colleagues. Developing countries often experience urban bias where the political and economic forces support the provision of services and investment in urban areas to the detriment of rural areas. This increases the disparities in health worker distribution, access to services, and health outcomes. In South Asia doctors are generally employed in hospitals in urban areas, while nurses deliver the majority of health services in rural areas. Over half of all nurses work for provincial health services.
In Bangladesh, there is a poor distribution of doctors as well as an acute shortage of midwives outside Dhaka, particularly in remote areas and sparsely populated communities. To attract and retain health workers in rural and remote communities, innovative strategies are required.
Health workers respond to inadequate or intermittent remuneration, poor working conditions and poor supervision with various coping strategies. Health workers may engage in multiple jobs in both the public and private sectors. Though dual practice is condoned in many countries, there is a risk that it can negatively influence the quality of care of the public services as it may encourage health workers to skimp on their public health efforts and to make referrals to their own private practices. In Nepal, health workers with very low and irregularly paid salaries are forced to seek alternative sources of income for their survival.
Although dual practice is not authorised by legislation, the authorities do not object if public health workers open private clinics, laboratories or pharmacies. Many health workers in Nepal maintain a private practice next to the public health facility where they are employed.
Another coping strategy is over-prescribing drugs and diagnostic tests. This has been shown to be a problem in rural India where low utilisation of health services has led to over-prescribing in order to increase income from the regular clients. Other coping strategies include pilfering public goods to sell in private clinics, informal user fees and absenteeism. To minimise the negative effects of coping strategies, the causes of health worker dissatisfaction must be addressed in workforce policy and planning.
Financial incentives have been shown to be an important motivating factor for health workers, especially in South Asia where government salaries and wages are insufficient to meet the basic needs of health workers and their families. A low salary is a major reason for job dissatisfaction and migration among health workers. Improved salaries and benefits are major financial incentives for workers to remain in the health sector. India has encouraged doctors to work in remote and disadvantaged areas by establishing permanent state staff positions with salaries and allowances from the state budget.
This measure has improved the overall numbers of medical doctors working at the rural level in India. However, there is wide variation between provinces. Findings from a survey of Bangladesh government-employed doctors with private practices indicate that doctors in primary health care would give up private practice if paid a higher salary, while doctors in secondary and tertiary care reported a low propensity to give up private practice. It is often difficult to increase salaries. In addition, the structure of public service salaries in some countries is not easily altered because of public expenditure, public service commissions that consider it unfair to raise salaries in one sector alone. There is need to explore the use of incentives to compensate staff for working in remote and isolated conditions. However, this will require total government approach, as staff ceilings and salaries are subject to strict civil servant regulations.
There is need for the government to contain commotion of the health workers by revising the pay-scale, reviewing minimum qualifications, developing fairer rostering, and implementing hardship allowances for nurses in rural areas. Payment reforms for health workers in rural areas should include supplements to specialist doctors combined with compensation for doctors, dentists and pharmacists not in private practice, and additional financial and non-financial incentives. However, increasing the salaries and benefits of priority groups is a complex matter that must be determined carefully by the government, since incentives aimed at one group of professionals may affect the entire system. It is virtually impossible for developing countries to compete with the salaries of the developed nations. Starting from such a low base, even significant improvements in salaries are likely to be only one part of the package of incentives that health workers consider when deciding whether to stay in the domestic workforce. All remuneration strategies must be monitored and adapted over time to ensure that the desired outcomes are achieved.
Many countries have adopted various initiatives to mitigate the low remuneration in the public sector. These include financial allowances to attract and retain health workers such as the rural location allowance, the public sector retention allowance and the accommodation allowance. Additional financial benefits include overtime pay, pension plans, health insurance, contract gratuities, and transportation allowance. In South Asia special hardship allowances are required as incentives for doctors to remain in rural areas.
Dr Mohammad Rajja
Medical Doctor, Birgunj, Nepal
