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Physicians working in rural areas

Why do some rural health workers stay when others choose to leave? This paper speaks to health workers in rural areas of India who choose to remain.
© UNICEF/UN0157899/Singh

Are we asking the right questions about rural health worker retention?

The existing health inequalities between rural and urban populations are made worse by the unequal distribution of health professionals in many countries. Such “maldistribution” of health workers across rural and urban areas is found in both high income and low/middle income countries, and is often difficult to correct through policies and schemes. Policies that attempt to get more health workers to rural areas have included: enforcement of rural postings, financial incentives for rural health workers to remain there, hiring health workers locally on contract, and engaging less qualified workers in tasks associated with more qualified cadres (task shifting).

Previous research has found many factors associated with qualified health workers’ preferences for urban areas, including good schools, employment for spouses, family and social ties, and professional aspirations. Frequently, policy strategies for rural retention in different settings globally have tended to try to address or compensate for these factors, with variable success.

The paper in the link below (see related links) reports findings from a study of the experiences of physicians who remain in rural areas in India. Unusually, this study looked for reasons for doctors’ decisions to remain in rural area service, rather than to prefer urban areas. The study found there was complexity of motivations behind their reasons.

Some of the major reasons for doctors to stay in rural areas include:

  • links to the region,
  • their own rural upbringing,
  • ethnic (tribal) links to the area,
  • good schools,
  • values of service,
  • professional interest in rural practice,
  • relationships with colleagues,
  • expectations of getting regular government jobs, and
  • opportunities for both spouses to work and live in the same location.

The authors engage with several key debates about health workforce policies in low and middle-income countries.

Looking in the right direction

Firstly, they balance the usual preoccupation with compensating for urban preference, with an alternative focus on understanding the motivations of those doctors that stay on, and supporting them. This choice of focus reflects some underlying values. Study participants’ narratives highlighted the fact that their labours and services are often poorly recognised. Research and policies tend to mimic this neglect of these practitioners who are providing valuable services where they are needed most.

This approach also highlights diversity of health worker characteristics. Factors associated with location preference can be both intrinsic (ie driven by personal values and preferences that can vary) and extrinsic (contextual and environmental), and policies can target both sets of factors.

Targeted strategies or holistic reform

Second, the study highlights that different factors associated with location preferences of the doctors do not operate separately, but interact with each other. The authors emphasise

“…the value of multidimensional strategies for retaining doctors. Strategies based on targeting providers with specific attributes may preclude the need for broader system reforms, including creating positive practice environments, better infrastructure, financial and non-financial incentives, and better accountability to employees.” (Sheikh et al., 2012, p.198).
For example, a selective placement and contracting strategy that is not strong on employee welfare may not succeed.

Is there a difference in how high income countries (HICs) and low- and middle-income countries (LMICs) should tackle workforce maldistribution?

Health worker maldistribution is a global issue affecting both rich and poor countries. While acknowledging this, the authors argue that, for poorer countries with high social inequity and diminished accountability of health systems to citizens, the issue of workforce retention cannot be separated from the much larger issues of community empowerment and strengthening the public sector. They conclude the paper by stating that
“…Strategies to engage with rural communities and empower them to demand quality essential services may, in the long term, be the key to creating a more equitable balance of human resources for health.” (Sheikh et al., 2012, p.198).

The policies and strategies aimed at retention of health workers in under-served locations reveal quite a lot about health planners’ assumptions regarding the reasons health workers make the choices they do. What strategies are you aware of in your health system to improve staffing levels in under-served areas? Do you think these are addressing the key concerns of health workers? Are they effective? Reflect on this as we move to the next step.

Sheikh, K, Rajkumari, B, Jain, K, Rao, K, Patanwar, P, Gupta, G, Antony, KR and Sundararaman, T, 2012. ‘Location and vocation: why some government doctors stay on in rural Chhattisgarh, India’, International health, vol. 4, no. 3, pp. 192-199.
© Nossal Institute for Global Health at the University of Melbourne
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