Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State- Research Report from PHFI
The global problem of the unequal distribution of the health workforce between cities and villages, with its severe consequences for the availability and quality of health services, and on health outcomes in rural and remote geographical areas, is also marked in India. Research into the phenomenon of workforce maldistribution has typically focused on why health workers choose not to stay in rural locations. In this qualitative research study, conducted in Chhattisgarh state in India, we explore the converse – the reasons why some qualified health workers remain and continue to serve in otherwise underserved rural and remote areas. Thirty-seven in-depth interviews were conducted with medical practitioners serving in rural healthcare facilities in eight districts of Chhattisgarh, between June and August 2009. Data were thematically analyzed using the “framework” approach for applied qualitative n research. We found that practitioners’ initial decisions to join service in rural and remote areas were widely influenced by geographical affinities and familial associations. Once in service, the practitioners confronted complex adverse conditions and circumstances, including poor working and living arrangements, long estrangements from families, and threats to personal security.
Their decisions to remain in rural and remote areas over periods of time were driven by varied combinations of factors including geographical affinities, personal values of service, professional interests and ambitions, strong relationships with colleagues and in the case of contractual doctors, the anticipation of obtaining a regular position. A majority of respondents had had a rural upbringing, and emphasized the importance of familiarity and comfort in village environs. For women doctors, the opportunity for both spouses to work and live in the same location distinctly emerged as a positive factor. Specific areas of need identified by respondents included improved workplace arrangements and resources, better housing and schools for their children, training and skill development in areas which reflected community needs, and – in the case of contractual doctors – assurances of job security and better salaries.
This empirical study identifies key, specific complexes of factors at the individual level which act in favour of retention of providers in rural areas. It also highlights the conditions of health workers living in these areas, and their needs. Planners and health authorities can address critical issues of workforce retention by professional education and recruitment policies that attract candidates more likely to serve in rural areas, by enabling and emphasizing the positive phenomena and factors which underlie practitioners’ decisions to remain, and by addressing their emerging needs through varied policy actions including improvements in specific aspects of health systems performance and design.