In the past few days, government of various states across the country, have taken some stringent measures to deal with doctor shortages at PHCs. The state of Karnataka announced notices against 668 doctors, threatening them with license cancellation, while Tamil Nadu threatened them with penalties. Similar action was been announced by different states to make sure that doctors report to their rural duties. On the other hand, many states have expanded “their horizon” to deal with doctor shortages. The latest decision of Maharashtra government to appoint Ayurveda graduates to fill up its allopathy vacancies in the public healthcare centres of the state is one such example, also a decision, that has come under fire. The Government says that it has been forced to take such a decision because of acute shortage of allopathic doctors willing to serve in remote or tribal areas. The doctors of Modern system of medicine think it to be a retrograde step and fear that it will affect the quality of medical care as these doctors will end up prescribing allopathic medicines with no training whatsoever. Moreover it will lead to crosspathy which is otherwise illegal,they say.
While the debate does go on, government should clearly first try to understand- why doctors are not ready to go to PHCs?
In first place, let us accept that recruitment and retention of health care professionals in rural areas is a Global problem and all over world this issue has been addressed by various nations in their own way. But no country has ventured into appointing doctors trained in a different system of medicine in place of MBBS doctors even as a stop gap measure. There is big force of BAMS practitioners that can be posted in rural areas but should be strictly directed to prescribe medicines of their own system only, where their expertise stands. Their strengths may be treated as first point of referral and utilised in participating in all the National Health Programmes including Universal Immunisation Programme.
Let us try to decipher range of concerns which may have led to reluctance of doctors to serve in rural areas which may be:
- A heavy workload, with a large number of patients to see and patients who require more care
- Improper housing and recreation facilities
- Professional isolation and difficulty taking time off
- Few opportunities for continuing education
- Challenges in maintaining professional boundaries
- Security issues in rural areas
- Limited job opportunities for spouses
- Lack of educational institutions for children
- Travel distances to attend school and lack of afterschool programs and daycare
The Government of India has taken various measures to provide monetary and non monetary incentives to attract medical professionals to work in rural areas. These include monetary incentives like “hard area allowance” to doctors serving in rural areas so that they find it “attractive” to serve in rural places.
Other incentives include 50 per cent reservation in Post Graduate Diploma courses for medical officers in the government service who have served for at least three years in remote and difficult areas and incentive at the rate of 10 per cent of marks obtained for each year in service in remote or difficult areas up to a maximum of 30 per cent of the marks obtained in the entrance test for admissions in Post Graduate Medical Courses
These incentives though promising seem to be too little and too late . Their impact may also take decades to show. Moreover, some of the needs of doctors working in rural areas, such as clean housing, infrastructure at clinics, lack of professional development, etc are so basic to human nature, that no amount of force are going to get the work done. These issues need to be addressed, not buried. Therefore, Govt. of India needs to proactively revisit and restrategize the issue of recruitment and retention of medical personnel in rural areas to encourage and not force doctors to serve in rural areas .
In the short run, some of the additional benefits and incentives may be offered:
- Residence Facility with proper security
- Provision of opportunities of quality education of children
- Insurance benefits
- Professional benefits- Coverage of malpractice insurance, Payment for licensure fees, Payment for association dues and payment for continuing education, bonuses
- Other benefits
o Better Retirement packages, Paid time off, Sick leave, better opportunities for research, education, or mission work,
- Other incentives
o Assistance with finding spousal employment, Free daycare /crèche facility
Some of the doctors may on their own choose to serve in rural areas as they may experience a greater sense of mission and accomplishment working in an area of need. Moreover, they may get an opportunity to develop stronger relationship with patients and have a lifestyle that has a slower pace, greater access to the outdoors, and other factors that make rural life an appealing choice.
What is indeed important here is that government should develop an environment of encouragement, not fear/force to motivate doctors and not force them to work in difficult areas.