Dear Peter Burgess, I am attaching a review of literature on the matter. The point that we need to budget higher salaries and facilities to attract and retain health workers in underserved areas had been made by many a researchers, we only need will to implement them.
Many countries in middle- and low-income countries today suffer from severe staff shortages and/or mal-distribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure contribute to the flight of health care personnel from remote areas.
Though there is no difference of opinion on whether medical or other staff are needed in rural areas- the debate is on the approach- INCENTIVE V/S COERCION. YOU CAN TAKE A HORSE TO WATER BUT NOT MAKE HIM DRINK...
In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. The *development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries, and which strategies to improve attraction and retention are therefore likely to be successful.* [Lehmann, Marjolein Dieleman, Tim Martineau. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. Uta *BMC Health Services Research* 2008, 8:19]
Rather than simply expecting students to be ethical practitioners we must look at what prevents them from investing a single year of their lives towards rural healthcare delivery. Medical education today:* *For most medical students, the MBBS degree has lost its value because of the way in which medical practice works today, and the pressure to get a postgraduate seat is intense. Entrance examinations for postgraduate programmes are extremely competitive (only one in three students gets into a clinical postgraduate programme). *..*Currently students complete five and a half years of medical college before they acquire an MBBS degree, which will be six and a half years with the one-year rural service rule. They must do up to two years of additional rural service before joining an MD programme. They are awarded a postgraduate degree only after three to three and a half years (depending on the state). *An MD graduate will have spent up to 12 years in medical college, a period most medical students consider too long to cope with, especially when compared to education in other professional courses such as engineering, architecture and management. *[ Kalantri SP (Ed) Getting doctors to the villages: will compulsion work? Indian Journal of Medical Ethics Vol IV No 4 October-December 2007: 152-3]
In Indonesia ..Pay is tied to remoteness, however. Currently, doctors serving in 'ordinary' regions are paid Rp 500,000/mo; in remote regions, Rp 825,000, and those in very remote regions, Rp 1,050,000/mo. Because doctors in ordinary regions have much greater opportunities for supplementary earnings from private practice, total income differentials are much smaller. A doctor working in a 24-hour clinic in Jakarta could probably earn about Rp 1,000,000/month (though this would be illegal if the doctor had not yet completed compulsory service.) Considering the difference in amenities associated with remote postings, the salary incentives are relatively modest. There are several important results: *Incentives had a large impact on the willingness of Java/Bali graduates to volunteer for remote and very remote posts.* Proportion willing to go to Outer Island nonremote posts increased from 5.8% to 8.1%; the proportion willing to go to very remote posts increased from 3.5% to 9.5%. [M. Chomitz,* *WHAT DO DOCTORS WANT? Developing Incentives for Doctors to Serve in Indonesia's Rural and Remote Areas World Bank] *Compulsory medical service programs* for physicians and other health care professionals have been installed in developing countries around the world. The underlying assumption for the creation of these programs is that the *increased presence of physicians will improve the health status of rural populations*which exhibit higher rates of morbidity and mortality compared to urban populations. This assumption, however, *has been challenged by recent evaluative studies of compulsory service programs* [AVENDER A. ALBAN M. Compulsory medical service in Ecuador : The physician's perspective. Social science & medicine 1998, Vol. 47(12):1937-46.]
An imbalance exists between offered medical services and needed health care for the people in rural areas of Pakistan. Many studies have found non-availability, of health care providers as major contributors to the poor health indicators of the rural areas. Methods and Results: An endeavor to attend the issue has been made through a cross-sectional survey of the Medical Officers working in the different health facilities of District Abbottabad. The study found that the doctors are neither trained to work in rural setups nor they are given proper facilities and service structure to work there. They perceive to face disadvantages affecting their social, professional and family life, if they join in rural areas. Recommendations: This study recommends strengthening of Community Oriented Medical Education for motivating doctors towards participation in rural health services. Doctors working in rural health facilities might be given financial and professional incentives and a conducive environment to retain them.[Doctors' Reluctance to work in Rural Areas:Journal of Ayub Medical College; 16(2) Doctors Perception about Staying in or leaving Rural Health Facilities IN DISTRICT ABBOTTABAD Umer Farooq, Abdul Ghaffar***, Iftikhar Ahmed Narru****, Dilawar Khan*, Romana Irshad**]
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Rajesh Sood
mailto:drrksood@gmail.com