Why doctors don’t want to work in rural areas

The government of India is planning to launch a new medical course called B.Sc. Community Health, which will be of three and a half years duration. This new cadre of health personnel will be trained at District Hospitals and will be posted in Sub Centres and Primary Health Centres in the villages. They will be trained on diagnosis and treatment of basic medical cases. The idea the government clarifies is not to produce mini-MBBS doctors but to produce a work force to address scarcity of trained health manpower in the rural areas. The Times of India reports that this is to address the ‘menace of doctors unwilling to serve in rural areas’. Health Minister Ghulam Nabi Azad expressed his disappointment in a similar vein stating that young doctors are unwilling to work in rural areas. He says, ‘As the health minister I can make policies and the state government has to implement... and put some kind of genes in doctors to change them, otherwise I cannot do anything’.

There is truly a huge rural urban gap in availability of health manpower in India. Only 26% of doctors work in rural areas serving 72% of the population. Public Health Foundation of India estimates that in India, health manpower (doctor, nurses, midwives) population ratio is 8/10,000 against WHO recommended ratio of 25/10,000 population. 70% of the health manpower is in the private sector out of which 80% work in urban areas. Doctor population ratio in rural areas is 3/10,000 population while it is 13/10,000 for urban.

The government has tried several times to make doctors go and work in rural areas. One of the most common methods is to plead with the doctors to go and work in rural areas. In Nagaland, whenever doctors have their conference or meeting, they are urged to serve with dedication, theirs being a noble profession, and so on and so forth. Another way is to make it compulsory for fresh doctors to work in rural areas. Policy for rotation of posting place has been tried but failed in implementation. Financial incentives, assurance for regularization of job (for contractual doctors), and additional marks in PG entrance exam are also tried in some places. But through it all, why is it that the government has never tried to ask and understand the simple question, ‘why are our doctors not willing to go and work in rural areas? Not that we don’t have answers to the question. Answers are clear and simple, but we have always simply blamed doctors for ‘not willing’ and we never asked why.

So, why are doctors not willing to work in rural areas? There was a study called ‘Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State’ which was conducted jointly by Indian Institute of Public Health, Delhi; Public Health Foundation of India; National Health Systems Resource Centre; and State Health Resource Centre, Chhattisgarh. Instead of asking why doctors are not willing (the answer which I think seem too obvious), the research topic was ‘Why some doctors serve in rural areas’. They asked what the reasons are that make doctors remain and continue to work in rural and remote areas. The study may have lessons for Nagaland given that it was conducted in rural areas of 8 districts where a third of the population is tribal. Moreover, the low density of health manpower, hard to access geography, and problem of insurgency are common experiences. In-depth interviews were conducted among doctors (contractual and regular, male and female, graduates and specialists) serving in Community Health Centres and Primary Health Centres which are poorly connected to the district headquarters. Though it was not the main research focus, the study highlighted the factors that deter doctors from working in rural areas. They are:

1.      Low salary and little incentive to rural doctors.

2.      Poor access to training and upgrading of knowledge, and erosion of professional skills

3.      Lack of educational facilities for children and job for spouse.

4.      Lack of electricity, water supply and housing.

5.      Lack of equipment and supplies for clinical diagnosis and treatment.

6.      Lack of job security for contractual doctors.

7.      Threat to personal security due to insurgency.

These factors need no elaboration. Respondents reported experiences of social isolation and loneliness besides the material discomforts. There is lack of avenues for society and entertainment and some of them experience anxiety, depression, and alcoholism. Many of them live alone, as spouses and children are sent to towns and cities.

So, what is it that makes them stay on in their places of posting? But before that, how did they come to be where they are? Many answered that going to rural place was not their choice. There is corruption in allocation of posting places and since they do not have personal influence or good contacts in authorities to lobby for them, they were sent to rural areas.  Some of them chose to be where they are because of geographical and ethnic (tribal) affinities. Some of them chose rural posting as an obligation to the government for paying for their medical education. Some others cite religious reason to serve people. In most of the respondents, a combination of the above factors is responsible for their going rural. What makes them stay on? Some of the reasons are:

1.      Geographical affinities: Many of the respondents have a rural upbringing. The villages are not unfamiliar and village life is therefore not very uncomfortable to them.

2.      Personal values of service: Selfless service to the poor is a driving motivation to work in rural areas. Respondents feel that they are needed and their service is of value. This brings a sense of fulfillment and job satisfaction that makes them stay.

3.      Familial values and religiosity: The values that are passed from parents to serve and the villagers treating them as family are also factors which make them stay. One medical officer remarked, ‘it is religious work but you can earn money at the same time’.

4.      There were other factors like distaste for commercial enterprise, availability of work for spouse in the same or adjacent locations, availability of good schools for children, reduce in security threat, good relation with colleagues, etc. A number of them simply get used to the place over time (acclimatized) and stayed on.

When asked what their needs are, some of the replies are:

·         Improved work space arrangements and resources.

·         Better housing

·         Schools for children

·         Need based - training and skills development

·         Assurance of job security (for contractual) and better salaries

 The push and pull factors of doctors moving from rural to urban areas and what can be done to address them, given by WHO, are given in the table below:

Category of retention  intervention	Push factors	Pull factors
Education and regulatory interventions	•     desire for further training •     lack of appropriate skills •     desire to get international experience	•     access to continuing medical education and professional development
Monetary compensation (direct and indirect financial incentives)	•     poor remuneration •     lack of private sector or opportunities for moonlighting	•     better remuneration •     allowances
Management, environment and social support	•     poor working and living conditions •     lack of clear career profiles •     lack of schooling for children and jobs for spouses •     work overload •     lack of management support •     emotional burn-out •     decline of health services •     political conflicts and wars •     social unrest	•     improved standards of living •     improved working conditions •     opportunities for education of children •     better supervision

Dr. S Rajasekaran argues that the reason why doctors are not willing to work in rural areas is not solely due to lack of personal comfort. He says, ‘There is a great misunderstanding amongst the public that doctors are reluctant to go to rural areas for lack of comfort. While this may be partially true, the bigger truth is that there is nothing more frustrating to see a suffering patient in front of you and you cannot do anything good for them even though you have the skill but the facilities are lacking… Lack of drugs and infrastructure are as serious as lack of personnel’.

The Chhattisgarh researchers conclude that not just patients but care-givers need to be cared for. In Nagaland, there are doctors who work sincerely in rural areas, in spite of all the personal discomfort and lack of facilities to optimally practice their skills. Not all of them are Governor’s gold medalists. But they quietly carry out their duties to the best they can. And we no doubt have people who are unwilling to work wherever they may be posted. In the middle are the majority who want decent working conditions with facilities and supplies to enable them to practice their trade. Like any other citizen in a modern society, they have professional dreams and family concerns. If our doctors should be judged, it should be after the basic needs and decent working environment are provided. Some people may willingly sacrifice their aspirations and serve in odd conditions. But in a modern democratic society, one cannot expect all doctors to go out and live heroic lives fighting against all odds and achieving only a fraction of what they are capable of.