Indian approaches to retaining skilled health workers in rural areas

Abstract

Problem

The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved.

Approach

The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India’s federal constitution, the states are responsible for implementing the health system with financial support from the national government.

Local setting

The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes.

Relevant changes

Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82 343 skilled health workers to the public health workforce.

Lessons learnt

The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.

Introduction

The problem of lack of professional health service providers in rural areas has been an area of discussion in India since the 1960s. At the time of independence (1947), when there was approximately one doctor per 6300 people and one nurse for 43 000 people, the main focus was on expansion of medical and nursing colleges. However, the distribution of institutions was also very uneven. Recent figures show that 65% of medical and nursing colleges are concentrated in only six states. By 1961, the focus started shifting to the problem of skewed distribution of doctor and nurses. While the overall ratio of doctor to population had reduced to 1 per 4850 and 1 per 14 300 for nurses, only 2.2% of rural villages had allopathic (conventionally trained) doctors.¹ While the current ratios for doctors are 1 per 1507 and 1 per 1205 for nurses, the problem of maldistribution remains unchanged.

The launch of the National Rural Health Mission in 2005 marked a turning point for public health planning in India. One of its key features was the commitment to increase public health expenditure from 0.9% of gross domestic product to at least 3%. It set out public health standards that specify the human resources required for each facility.^2,3 The federal government provided funds for increasing the number of posts sanctioned by state governments to meet Indian public health standard norms. As an immediate measure, states were encouraged to hire, on a contractual basis, an additional auxiliary nurse-midwife for peripheral health subcentres, three nurses and a second doctor for primary health centres; nine nurses and seven doctors including five specialists in the 30-bed community health centres.

Within two years, this led to the appointment of almost 82 343 skilled health workers with medical or nursing qualifications in the public health system.⁴ This includes 39 633 auxiliary nurse-midwives, 22 789 nurses, 9172 allopathic doctors and specialists, 5321 ayurvedic/homeopathic doctors and 5428 other technical staff. Impressive as this addition was, it still left a huge gap. There was also a clear problem in attracting nurses and doctors to more difficult areas, especially in tribal and hilly areas of central India and the north-east.⁵

Retaining workers

The main skilled health workers in rural areas work in the public sector. Before the National Rural Health Mission, state governments covered all human resource costs except for the auxiliary nurse-midwife. About 80% of total health expenditure is borne by the states and, of this, about 70% goes towards salaries. From 2007 onwards, state governments introduced a range of measures with financial support from the federal government to address the problem of retention in rural postings. The information presented in this paper was collected from the review of state programme implementation plans of the National Rural Health Mission and from responses to specific queries sent to state health directorates.

Monetary compensation

Since 2007, monthly financial incentives in addition to salaries have been widely introduced across all the states for doctors, nurses and midwives working in remote areas (Table 1). There is a wide diversity between states in categorizing “difficult” areas. States have used criteria including: distance from urban areas; geographical terrain such as hilly, desert or forest areas; access by roads and public transport; availability of housing; and tribal areas or extremist insurgencies. The incentive amount depends on the cadre of the worker and on the way each state grades difficult areas.

Table 1. Monthly incentives for doctors and nurses in “difficult area” postings in India.

State	Classification of “difficult area”	Incentive amount for Bachelor of Medicine/ Bachelor of Surgery/specialists	Incentive amount for staff nurses/ auxiliary nurse-midwives
Andhra Pradesh	Rural areas	Specialists Rs 7000 (US$ 152) / medical officers Rs 1000 (US$ 22)/female medical officers Rs 1500 (US$ 32)	n/a
	Tribal areas	Rs 2500 (US$ 54)/Rs 2000 (US$ 43)
Andaman & Nicobar Islands	Tribal areas	Gynaecologists Rs 10 000 (US$ 217)/other specialists Rs 3000 (US$ 65)	n/a
	Rural areas	Gynaecologists Rs 7000 (US$ 152)
Bihar		Rs 3000 (US$ 65)	n/a
Haryana	Difficult areas	Rs 25 000 (US$ 543) / Rs 10 000 (US$ 217)	Rs 3000 (US$ 65)
	Rural areas	Rs15 000 (US$ 326)
Himachal Pradesh	Tribal areas	Rs 5000 (US$ 109)	n/a
	Rural areas	Rs 3000 (US$ 65)
Jammu and Kashmir	Most difficult areas	Rs 10 000 (US$ 217)	n/a
	Difficult areas	Rs 3000 (US$ 65)
Jharkhand		Rs 10 000 (US$ $217)/Rs 5000 (US$ 109)	Rs 1000 (US$ 22)
Kerala	Difficult areas	Rs 5000 (US$ 109)	n/a
	Rural areas	Rs 3000 (US$ 65)
Madhya Pradesh		Rs 10 000 (US$ $217)/Rs 5000 (US$ 109)	n/a
Maharashtra	Extremist area	Rs 1500 (US$ 32)	Rs 1500 (US$ 32)
	Tribal area	Rs 1000 (US$ 22)	Rs 1000 (US$ 22)
Orissa	Remote areas	Rs 5000 (US$ 109) for contractual staff/Rs 8000 (US$ 174) for regular staff	n/a
	District headquarters	Rs 4000 (US$ $87) for regular staff
Punjab		Rs 10 000 (US$ 217)/Rs 20 000 (US$ 435)/Rs 5000 (US$ 109)/Rs 10 000 (US$ 217)	n/a
Rajasthan	Hard area	Rs 7000 (US$ 152)	Rs 2500 (US$ 54)
	Rural area	Rs 4000 (US$ 87)	Rs 1500 (US$ 32)
Tripura	Primary health care	Rs 3000 (US$ 65)	Rs 1000 (US$ 22)
	Community health centre	Rs 2000 (US$ 43)	Rs 800 (US$ 17)
	State district hospital	Rs 1000 (US$ 22)	Rs 600 (US$ $13)
Uttrakhand	Upper Himalayas (most difficult)	Rs 5000 (US$ 109) for degree holders/Rs 3000 (US$ 65) for diploma holders	n/a
	Middle Himalayas (more difficult)	Rs 2000 (US$ 43)
	Lower regions (difficult)	Rs 1000 (US$ 22)

n/a, not available; Rs, Indian rupees.

Source: Information as reported by state mission directors in response to written queries and as taken from State Programme Implementation Plans of the National Rural Health Mission.

The use of incentives increased significantly once integrated in the National Rural Health Mission. A national scheme for incentives for difficult areas is also proposed. Are incentives effective? It is still too early to comment. At the time of writing, most of these initiatives had been in place for less than two years. The workers welcome the use of incentives. However, whether they are adequate to increase willingness for rural postings has not yet been evaluated. There is reason to be cautious. Studies from other sources show a limited role of incentives, especially when the incentive amount is modest.⁶ The threat is that if incentives are not found to make a difference, then there is a strong temptation to consider the problem of retention as unsolvable.

Workforce management

Recent experiences from Tamil Nadu and Karnataka states have shown that a major impact on worker morale can be achieved by providing rotational posting in difficult areas, ensuring that everyone spends some years there, after which they could choose to be posted to another area. The National Rural Health Mission is trying to encourage states to adopt workforce management policies that ensure transparent transfer and placement for doctors and nurses and better residential infrastructure for all health personnel. Although this is apparently a simple reform, in practice it often proves to be the most difficult, given its linkages to basic issues of governance.

One key strategy of the National Rural Health Mission is to appoint workers on contracts, usually for one to three years’ duration. There is a perception among health administrators that contractual appointments ensure more accountability, less absenteeism, more appropriate postings and therefore better workforce performance. Since contractual appointment is made to the facility, whereas permanent appointment is to the state public system, they may make it easier to prioritize rural and remote postings. But whether reduced job security from contractual appointments is the key to better performance and accountability is an open question.

Education

Another set of measures is through preferentially drawing students for medical and nursing education from those who are willing to work in underserviced areas. The pioneer programme in this regard is in West Bengal state and, as preliminary reports suggest, it has been quite successful.⁷ The state faced the challenge of adding 10 000 auxiliary nurse-midwives within five years, while simultaneously addressing the problem of keeping the existing ones at their place of work. As a first step, 24 government schools for auxiliary nurse-midwives were revived and another 18 were started in partnerships with private hospitals. Then the local governance body (village panchayats) were given the power to select a woman resident in the village to train as an auxiliary nurse-midwife for that village to be employed by the local government institution. At the time of writing, more than 4000 such auxiliary nurse-midwives had been given appointments, with many more in training.

Another example is the “Swalamban Yojana (self-reliance plan),” launched in Madhya Pradesh state in 2006–07 with the objective of filling the gap of staff nurses. Women with rural backgrounds from under-served districts are selected and sponsored for the nursing courses. They are bonded to serve in the rural areas for 7 years after training or else they have to pay a penalty of 200 000 Indian rupees. The initial responses to this strategy are very encouraging though it is still too early to judge.

Alternative strategies

Almost all states have been addressing specialist shortages by providing doctors with short-term 18–24 week training courses in emergency obstetric care including Caesarean section and anaesthesia. Two states, Assam and Chhattisgarh, have created a cadre of rural medical practitioner with three years’ training, exclusively for working in primary health care in rural areas. Assam has insisted on local selection and conditional licensing to work only in rural areas and in the public sector.

Another form of multiskilling is to train and deploy doctors trained in the indigenous streams of medicine to work as medical officers in primary health centres. This has been used extensively in some states. About 700 000 female community health workers called ASHA (accredited social health activists) are trained to provide basic, first-contact health care and to encourage families to seek pregnancy and child health services.⁸ The pioneering effort for this was the “Mitanin” programme in Chhattisgarh (8). The first evaluations of this programme are promising but they also point to the need for much more investment to be made in this cadre for a greater outcome.^9,10 A summary of the main lessons learnt is given in Box 1.

Box 1. Summary of main lessons learnt.

• Measures to address the shortage of skilled health workers in rural India include: monetary compensation, workforce management, education and continuous professional development and alternative service providers.

• Considerable success has been achieved with education-related innovations, alternative service providers and the community health worker programme.

• Evaluations are needed to generate evidence for designing appropriate packages of retention strategies tailored to each state’s different situation.