An exploratory study on distribution, attraction and retention of physicians and nurses in rural areas in India

Abstract

Background: In adopting the Millennium Declaration in the year 2000, the eight Millennium Development Goals (MDGs) have been adopted by the international community. To accomplish the MGDs no. 4, 5 and 6, related to Reduce Child Mortality, Improve Maternal Health and Combat HIV/AIDS, malaria & other diseases respectively, calls the strengthening of health care delivery system and improved health care services. Healthcare is a service sector, depends highly on specially trained professionals, which needs to produced, attract and retain at all level. Health worker shortages are one of the main challenges internationally. The most concerning issues on this is producing, attracting, recruiting, deploying and retaining them in rural and remote areas. This study aimed at understanding the major HR issues in distribution, attraction and retention of Physicians, nurses and mid-wives in Public health care delivery system in rural areas in India with special reference to the state of Arunachal Pradesh. Method: The primary data required for the study was collected with the help of interview schedule, survey questionnaire and observation. The primary data was collected through questionnaire among 334 nos. (113 nos. of physicians, 98 nos. of Nurses and 123 nos. of midwives) of physicians, nurses and mid-wives, to understand their attitude towards working and living in rural areas and accepting the rural posting and insight on the HR issues in the area of study. One management representatives each from the 16 districts and one state level management representatives were picked as a sample of management representatives and conducted the interview. The interview materials were coded and quantitative data was analyzed with SPSS 19. Results, discussion and conclusion: Over the last few decades the establishment of health institutions in rural areas of the state is haphazard and not kept pace with adhering to the norms and keeping view of the consequences of human resource requirement. Consequently, many rural communities/areas are deprived of the primary health care and desperately need the attention. The inequities in the geographic distribution of Physicians, nurses and mid-wives, itself has meant too many rural and remote areas with the shortage of Physicians, nurses and mid-wives. The poor availability of Physicians, nurses and mid-wives co-exists and creating an imbalance and a problem with debilitating health care delivery system in the region along with the absence of adequate training institutes for medical and nursing courses results in low numbers of medics and paramedics produced for the state. Mal-distribution, that is the distribution of health workforce is characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from within district perspective also. While 77% of the population lives in rural and remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives are serving in rural and remotes areas of the state. This creates urban and rural imbalance in distribution. The phenomenon of urban skewness and mal-distribution among the districts are there. In this study it is also found that the information on human resource is in-consistence among the state and district level, while it is also found that the inconsistency between the divisions of the health department. While, the major issue on attraction, the study revealed that the workforces who are presently working in the rural and remote areas of the state are altogether in compulsion, either working to finish their minimum rural service tenure or on non-transferable positions or Management and political pressure or demand. It is found that 58% of the workforce is service in rural and remote areas in the compulsion. Moreover, the other HR issues on attraction are –the lack of career development opportunity, inactive recruitment strategy, lack of hospital infrastructure and resource availability, poor working condition, lack of other cadres, team work and staff relationship, the reward and recognition for the performance and achievement is not there in the system which could attract the physicians, nurses and mid-wives in the rural area service, poor use of financial means of attraction. The study also reveals a limited scope of attraction due to training and development opportunities and Poor supervision and mentoring is a hindrance for attraction. While the HR issues on retention are in the issue of internal migration to urban areas. The study reveals that only 19% of them want to continue with their present rural posting place. 24% wants to shift to another rural health institute, 51% wants to shift to another urban health institute and 6% wants to shift to another job in some other State/sector in search of an alternative employer. The Factors that contributed for migration of the physicians, nurses and mid-wives as a whole, from the present rural area to other rural area, urban area or to leave the sector have two factors significant that are the Lack of adequate financial incentives / rural allowances/performance incentives, poor working condition, lack of Career development opportunities and poor salary. The other retention measures of financial and non-financial incentives area absent from the system that could retain the workforce in rural and remote areas. It is also revealed that the factors that may motivate the physicians, nurses and mid-wives to retain themselves in the present rural area have four factors -financial incentives, improved living condition, career development and Good reward and achievement recognition system. It is found in this study that the intention of migration of physicians, nurses and mid-wives from a rural area health institute to another rural health institute is propelled mainly by the factor of team work and interpersonal relationship in the present place of work. This study also revealed that the intention of migration of this workforce is related with the level of job satisfaction of these groups of health workforce and propel them to migrate. So forth, in addition to the other issues and concerns, there is a growing dissatisfaction among the physicians, nurses and mid-wives in presently working in the rural and remote areas. While the reform initiatives in the sector are the emphasizing on contractual employment, emphasizing on development of professional training institutes, initiatives for comprehensive HR policy, decentralisation of HR activities to district level, adoption of simplified way of recruitment and selection, emphasized on training and development, emphasized on career development opportunities, shifting of view towards the financial incentives, emphasizing of availability of essential equipments for functionalising a health centre as per IPHS, development of supportive supervision and emphasizing on infrastructure development initiatives including accommodation facilities. It is also found in respect of HR practice under reform process for distribution, attraction and retention, that in the absence of appropriate and concrete human resources policies on deployment, there is always a hindrance in managing people at work as the entire district agreed to this. Along with, there is a major issue of HR planning, recruitment and selection process, the common minimum tenures are not followed along with the time bound promotions are not practices for several reasons to these categories of staff, there is no use of provision of financial and non-financial incentives for rural and remote area posting and retention, The reward and recognition for the performance and achievement is also not there in the system, and there is no random access of training needs, the planning of training and the execution of the same have a random mismatch in the district and as well as in the state level. Adequate human resources for health (HRH) are a key requirement for reaching health goals, the study found that, the shortages of physicians, nurses and mid-wives are an ongoing problem in the public health sector in Arunachal Pradesh with uneven distribution. There is low job satisfaction in the workforce in the current job at rural and remote areas. It is contributed by many of the factors including financial and non-financial benefits. Attraction and retention of physicians, nurses and mid-wives in remote and rural areas are determined by many factors including financial incentive, career development opportunities, recognition etc. But, the factor of compulsion is the main factor of stock in rural and remote areas, and rest of the factors have less contribution, and the financial benefits along with non-financial benefits seems to be migrating factors. The attraction, deployment and retention of physicians, nurses and mid-wives in rural and remote areas are a real challenge and a difficult situation, and affected by several factors ranging from organizational factors to external environmental factors and to personal factors. However, the personal factors have less affect on the situation. The massive poor living conditions in the rural and remotes areas, poor working condition in health institutes, poor career development opportunities with lack of financial benefits are some of the factors that contribute to the reluctances of the physicians, nurses and mid-wives to serve the rural and remote areas in the state. The sector has nothing to offer presently, to attract and retain and to distribute rationally this workforce, which in result deteriorating the situation in the rural and remote areas. Moreover, the reform process is doing less for the HRM perspectives and the HR practices are not effective enough to solve the problems in the state. it is clear that many factors affect the rational distribution, attraction and retention of Physicians, nurses and mid-wives in the rural and remote area ranging from environment issues, organisation issues as well as the personal issues, along with the production issues, the facilities and basic amenities along with financial incentives are determinant of manpower in rural areas of the state. It is also known that to solve these HR issues, no individual interventions are not adequate, it need a pyramid of interventions to ensure the minimization of the issues. Moreover, a blend of initiatives is needed to address the problems of distribution, attraction and retention of manpower in the state, there is a need of continue focus and commitment on the part of government and as well as the political will to solve the problem. In conclusion, efforts to strengthen health sector must address the HR issues and a good Human Resource Management and a far sight in HR requirements are needed.