Why Some Doctors Serve in Rural Areas: A Qualitative Assessmentfrom Chhattisgarh State
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- Title
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Why Some Doctors Serve in Rural Areas:
A Qualitative Assessmentfrom Chhattisgarh State - extracted text
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Why Some Doctors Serve in Rural Areas:
A Qualitative Assessment from Chhattisgarh State
REPORT
April 2010
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PHFI - NHSRC - SHRC Chhattisgarh
'Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State'
Conducted by the Indian Institute of Public Health, Delhi (11 PH D), the Public Health Foundation
of India (PHFI), the National Health Systems Resource Centre (NHSRC), and the State Health
Resource Centre (SHRC), Chhattisgarh
Supported by funds from the Alliance for Health Policy & Systems Research, World Health
Organization, Geneva and the State Health Resource Centre, Chhattisgarh
RESEARCH TEAM:
11 PHD/PHFI
NHSRC
Dr Kabir Sheikh (Lead Investigator)
Dr T Sundararaman
Dr Kamlesh Jain
Babita Rajkumari
Dr Garima Gupta
Dr Pratibha Patanwar
SHRC Chhattisgarh
Dr Aruna Bhattacharya
Mahendra Gaware
Dr Krishna D Rao
Dr KR Antony
This report was prepared by Kabir Sheikh with input from Pratibha Patanwar, Garima Gupta and
Babita Rajkumari. The views expressed in this report are solely those of the authors and not of
their institutions. Correspondence may be directed to kabir.sheikh@phfi.org
ACKNOWLEDGEMENTS: This study would not have been possible without the efforts and
assistance of numerous friends and associates in Chhattisgarh and Delhi. Foremost, thanks are
due to the study participants - doctors serving in rural and remote areas of eight districts of
Chhattisgarh - for sparing their valuable time and sharing their remarkable stories, thoughts and
Associates from the NRt
•dy districts
facilitated field visits and accompani
:tude. In
Raipur, thanks are due to colleag
tisgarh,
especially Dr Puni Kokho, Virendra K
aluable
assistance at different stages of 1
of the
interviews enhance the value of th
nee for
insights.
jehnieal
Health Systems and Policy Research
support, as well as the Global Healt
SOCHARA
are grateful to Prof K Srinath Reddy <
Community Health
Library and Information Centre (CLIC)
Centre for Public Health and Equity
No. 27, 1st Floor, 6th Cross, 1st Main,
1st Block, Koramangala, Bengaluru - 34
Tel: 080-41280009
email: clic@sochara.org / cphe@sochara.org
www.sochara.org
ally we
e.
PHFl - NHSRC - SHRC Chhattisgarh
ABSTRACT
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 analysed using the "framework" approach for applied qualitative 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.
workers living in these areas, and their needs.
It also highlights the conditions of health
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.
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PHFI - NHSRC - SHRC Chhattisgarh
TABLE OF CONTENTS
ABSTRACT......................................................................
TABLE OF CONTENTS....................................................
LIST OF FIGURES...........................................................
LIST OF TABLES.............................................................
INTRODUCTION............................................................
Background.......................................................
Conceptual Framework...................................
METHODS......................................................................
Selecting Participants......................................
Fieldwork..........................................................
Analysis.............................................................
Ethical Precautions...........................................
FINDINGS.......................................................................
Field Settings....................................................
Profile of Respondents....................................
Personal and Professional Antecedents..........
Coping With Adversity......................................
Factors Influencing Their Decisions to Remain
What They Need: Improving the Experience ...
SUMMARY OF FINDINGS...............................................
STRATEGIC IMPLICATIONS.............................................
REFERENCES..................................................................
ANNEXURES...................................................................
Topic Guide........................................................
Form for Obtaining Consent.............................
Thematic Framework of Analysis.....................
Timeline of Interviews......................................
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11
11
12
12
13
14
14
17
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26
35
58
69
71
74
75
75
77
78
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PHFI - NHSRC - SHRC Chhattisgarh
LIST OF FIGURES
Figure 1 Districts of Chhattisgarh State.......................
Figure 2 Conceptual Framework.................................
Figure 3 Interviews were conducted in eight districts
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10
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PHFI - NHSRC - SHRC Chhattisgarh
LIST OF TABLES
Table 1 Demographic, socio-economic and health profile of Chhattisgarh
Table 2 Profile of study respondents
Table 3 Profile of all rural doctors in Chhattisgarh
Table 4 Profile of all rural doctors in Chhattisgarh corresponding to study essential criteria '
Table 5. Key findings from the study
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17
17
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PHFl - NHSRC - SHRC Chhattisgarh
INTRODUCTION
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. This study
seeks to understand and elaborate the mix of reasons why qualified health workers 'stay on' why they continue working in underserved areas. In doing so we depart from the convention of
exploring the 'negative' phenomenon of resistance to rural placements and migration away from
rural areas, and instead focus on the 'positive' outcome (in health planning terms) of qualified
We focus on medical
health workers continuing to populate and work in rural areas.
practitioners in this study.
Qualitative research methodology was adopted to address this
objective, involving field-based collection of data through in-depth interviews, and thematic
analysis of the data. The fieldwork was conducted in eight districts of Chhattisgarh, a state with
a significant tribal population of poor economic status and a suboptimal density of qualified
health workers
Background
India's Health Workforce Crisis
A health workforce which is adequate in size, skill mix, quality and able to reach all sections of
the population is necessary for achieving a high and equitable coverage of health services. Indian
census estimates adjusted for educational qualifications reveal that the health worker density
(including doctors, nurses and midwives) is approximately 8 per 10,000 population (PHFI 2008),
well short of the suggested norm of 25 per 10,000 (WHO 2006).
A wide variety of health
workers provide services in allopathic and Indian systems of medicine. Alongside the provision of
allopathic services, physicians trained in Ayurveda, Yoga, Unani, Sidha and Homeopathy,
collectively known as AYUSH, provide health care. Health workers from both systems of
medicine are employed by the government funded public sector and the private sector.
The geographic distribution of India's health workforce is disturbing. Most (60%) health workers
are present in urban areas where 28% of the population resides (PHFI 2008). This rural bias is
consistent across cadres of health workers; 40% of allopathic physicians, nurses and midwifes,
AYUSH practitioners and 20% of dentists are present in rural areas. This is reflected in the low
health worker density of 11(42) per 10,000 population in rural (urban) areas. Across cadres of
health workers the differences are more alarming; the density of doctors per 10,000 population
in rural (urban) India is 3 (13), of nurses 2.4 (11.3), of midwifes 0.68 (1.4), of pharmacists 1.3
(4.4) and AYUSH practitioners 1 (3.4). These differences are even more striking for female health
workers, particularly female doctors. This geographic imbalance in the health workforce
hampers the ability of rural populations to access quality health services.
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PHFI - NHSRC-SHRC Chhattisgarh
The majority of health workers in both the private and public sector are present in urban areas.
The private sector in India dominates the delivery of curative health services. In both urban and
rural areas, the majority (70%) of health workers are employed in the private sector (PHFI 2008).
This is consistent across different health worker cadres. Further, over 80 per cent of the qualified
private provider market is concentrated in urban areas (WHO 2007).
The lack of qualified
medical professionals in rural areas has resulted in the majority of rural households receiving
care from private providers, many of whom are less than fully qualified (WHO 2007).
The public sector has made considerable efforts to place doctors and a variety of other health
workers in rural areas through its vast network of health sub-centres, primary and community
health centres in these areas. However, high levels of vacancies in these health facilities due to
appointed health workers not taking up posts, absenteeism and dual practice have compromised
this effort. This problem is particularly acute for doctors at Primary Health Centres (PHCs) and
for specialist doctors at Community Health Centres (CHCs).
PHCs serve as the first point of
contact for curative services in rural areas and have a critical role in locating basic health services
within communities. One study finds that absenteeism among primary care workers in India is as
high as 40%, making it is highest in the world (World Bank 2008). These problems contribute to
the unreliability of official estimates, and may explain official failures to increase allocations of
facilities and beds where they are needed most.
Many reasons have been documented for why health workers typically choose not to work in
rural areas. Salary emerges as an important factor of a job and strongly affects the willingness to
work in rural areas. (Chomitz 1997; Serneels, Lindelow et al. 2007). In India, starting salaries for
allopathic physicians in the public sector is around Rs. 20,000 per month and about half of that
for nurses. However, there is little additional incentive given for those who are posted in rural
areas. Factors other than salary also play an important role in the preference of urban positions.
For example access to training, health care and education for children, promotion opportunities,
the availability of electricity, water and housing are all reasons that urban jobs are usually
favored (Dussault and Franceschini 2006; Lindelow and Serneels 2006; Serneels, Lindelow et al.
2007). In Pakistan, the absence of equipment and supplies was a major deterrent for accepting a
rural post (Zaidi 1986). A study on rural health worker motivation in Vietnam highlighted the
importance of appreciation and support from managers and colleagues as well as from the
community (Dieleman, Cuong et al. 2003; PHFI & World Bank 2008).
Ch ha ttisgarh Sta te
Chhattisgarh was carved out of the central Indian state of Madhya Pradesh in November 2000.
The State has an area of 1,35,191 sq. km. with a population of 21 million (2001 Census). There
are 16 districts, 146 blocks, and 20,308 villages in the State. 44% of the land is forested and is
home to tribes who constitute one third of the population. The above factors place Chhattisgarh
in a unique position. The physical inability to ensure outreach services to forested areas coupled
with the poor economic status of the tribal majority have constrained efforts to improve health
and health service indicators in the state. Chhattisgarh has a shortage of health workforce;
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PHFI - NHSRC - SHRC Chhattisgarh
according to the Bulletin of Rural Health Statistics in India, 2005 the doctor-to-population ratio is
1:3100.
No.
Item
Chhattisgarh
India
1
Total population (Census 2001) (in million)
20.83
1028.61
2
Total Fertility Rate (SRS 2006)
3.4
2.9
3
Infant Mortality Rate (SRS 2007)
61
57
4
Maternal Mortality Ratio (SRS 2001 - 2003)
379
301
5
Sex Ratio (Census 2001)
989
933
6
Schedule caste population (in million)
2.42
166.64
7
Schedule tribe population (in million)
6.62
84.33
8
Female literacy rate (Census 2001) (%)
51.9
53.7
Table 1 Demographic, socio-economic and health profile of Chhattisgarh1
—
Figure 1 Districts of Chhattisgarh State
1 Source: http://mohfw.nic.in/NRHM/State%20Files/chhattisgarh.htm. Accessed on 10/9/08
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PHFl - NHSRC - SHRC Chhattisgarh
Concepts a 1 Fra me work
Practitioners' decisions to 'stay on' are complex, and influenced variously by personal factors as
well as by their relationships and interactions with the health system, the communities they live
and work in, and their patients.
Health System
/Programme
Health Workers
who
•Stay On"
Patients
Community
Figure 2 Conceptual Framework
A simple model drawing from Porter and colleagues (2002) was proposed as a conceptual
framework to plan the research instruments and for subsequent thematic analysis.
The
framework is constructed of four overlapping domains, with the main subject of research - the
health workers - at the centre. Using this framework, the reasons why practitioners 'stay on'
are examined by studying their own personal characteristics, values and forebears, and also their
respective interfaces with the health system, with communities, and with their patients.
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PHFI - NHSRC - SHRC Chhattisgarh
METHODS
In-depth interviews (Grbich 1999) were conducted with a selection of medical practitioners who
have an established record of service in rural areas.
The data from these interviews and
discussions were analysed using the framework approach for applied qualitative research
(Ritchie & Spencer 1994). The data were sorted into emerging thematic categories representing
practitioners' experiences, reasons for staying on, and their expressed needs, and are presented.
Selecting Partici pants
Essential and desirable criteria for the selection of participants were delineated as follows:
Essential:
Serving in PHC or CHC in a rural area for more than five years
OR
Serving in a PHC or CHC in a remote2 rural area for more than one year
Desirable:
Allopathic training
Presence in remote rural area for more than 5 years (more than 10 years highly desirable)
Serving at primary health centre level (as opposed to block level)
Female
The desirable criteria represented a conscious preference for more highly qualified doctors (their
retention in rural areas being more desirable in planning terms), those working in particularly
remote areas, and with a greater length of time spent in rural areas (so as to access a richer set
of accounts drawn from longer experience), and women doctors.
Respondents were identified purposefully in each district selected for the study, based on
information from local facilitators and corroborated by inspecting government records. Care
was taken to ensure representation of both sexes, both categories of employment (i.e. regular
and contractual) and all geographical locations within the state (8 districts were identified
2
The criteria for remoteness are drawn from official government classification of PHCs and CHCs, based
on the following conditions:
a. Distance from District HQ.
b. Forested area
Poorly connected by road
d. Extent of habitation
e. Significant security concerns
f. Lack of educational facilities
11
PH Fl - NHSRC - SHRC Chhattisgarh
spread across the Northern, Central and Southern zones of the state) within the state (Silverman
2004).
Practitioners meeting 'desirable' criteria were identified preferentially.
A total of 37
participants were enlisted for interview.
Fieldwork
A research team from PHFI and SHRC conducted the research over a period of two and a half
months from July - September 2009, in eight districts of Chhattisgarh state. Prior to embarking
on fieldwork researchers underwent training in qualitative research methodology, including
interview technique, framework analysis, and ethical considerations in interviewing and handling
data.
Topic guides were designed drawing on the different thematic areas depicted in the
research framework (see Figure 1), and were used to conduct the in-depth interviews.
All
interviews were conducted with the verbal consent of respondents. See Annexure for the topic
guide and standard form for obtaining verbal consent.
Aspects of interview technique emphasized included developing good rapport and comfort, nonprejudicial and non-preemptive style, avoiding directive or leading questions, inviting narratives
of experiences and appropriate probing (Britten 2000). Ethical considerations around taking
consent for interviews, ensuring confidentiality of data, respectful communication, attention to
social and cultural norms, were also given particular consideration while conducting fieldwork.
All 37 respondents identified were interviewed.
Interviews were conducted in Hindi and
recorded on a digital media device with the permission of the respondents. All recordings were
transcribed and translated into English text on a computer word processing programme.
Analysis
Data analysis was conducted side by side with collection of the data. For organizing the textual
data from transcripts of interviews, the "framework" approach for applied qualitative research
was applied (Ritchie & Spencer 1994).
This approach combines inductive and deductive
approaches, in that it permits the combination of pre-determined themes, with those emerging
from a reading of the data. The steps in the framework approach are enlisted as follows:
Familiarization with raw data
Identifying a thematic framework (see annexure), based on pre-determined objectives, and
emerging field level issues
Indexing - by applying the thematic framework systematically to the data.
Charting - rearranging the data into distilled summaries of views and experiences.
Mapping and interpretation - using the charts to locate concepts, phenomena, typologies,
and associations between themes.
There was an emphasis on extracting underlying implications and meanings which respondents
ascribed to their experiences, rather than to overtly stated views and rhetoric. Special attention
was paid to notable variations and divergences in perspectives between different respondents.
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PH Fl - NHSRC - SHRC Chhattisgarh
Two analysts coded the data as per the thematic framework, and their choices in attaching
codes to the text were compared and standardized, to improve the reliability of interpretations
from the data (Mays and Pope 2000).
Thematically categorized findings are presented which incorporate patterning and variations in
responses. We have also extracted remarkable narratives which illustrate specific processes and
life experiences of the respondents.
Ethical Precautions
Prior to interviews, respondents were informed of the objectives of the study and how the
collected information would be used. Respondents were also informed of the purpose of the
study and that the data would be treated in a confidential manner. Verbal consent was obtained
for interviews and for recording the interview. All recordings were stored in a lockable container
with restricted access. All digital data were handled in computer programmes in encrypted
format with restricted access. Care has been taken to ensure anonymity of all individuals cited
in this report, by withholding their names and those of towns, villages and institutions which
may have led to their identification.
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PHFI - NHSRC - SHRC Chhattisgarh
FINDINGS
Field Settings
The study covered 14 CHCs and 23 PHCs located in remote and rural areas across eight districts
in the state of Chhattisgarh. All the healthcare centres selected were distant from the district
headquarters and poorly connected by any form of public transport. While some of the CHCs
were adequately linked by roads, reaching the PHCs was often a problem as they were located
deep in the rural interiors usually with unpaved roads. In many cases, the main means of public
transport were jeeps, overcrowded with people and owned by individuals residing in the area.
Healthcare workers posted in these locations generally rely on their privately owned vehicles
and sometimes ambulances (if there is one in the healthcare centre) for travelling to block or
district healthcare centres when called for meetings or other work related visits.
Sstopur
fijipur
&xt3t
ft
Figure 3 Interviews were conducted in eight districts
Due to poor road linkages in some places, some PHCs are cut off from the rest of the state
during the rainy season causing considerable difficulties for medical supplies, patient referral,
and often impede health workers' weekly or daily commutes. Access to fresh produce is also
severely limited in these times. Many of the healthcare centres visited lacked basic facilities of
water supply, electricity and equipment - this is discussed further in the body of the report. In
places where adequate equipment is available, frequent electricity outages prevent its
utilization. Bar a few instances, living quarters provided by authorities are in dilapidated
condition and in most instances practitioners arrange their own accommodation by renting
private houses. Many of the doctors interviewed live alone, compelled by lack of proper housing
14
PH Fl - NHSRC - SHRC Chhattisgarh
and educational facilities for their children, to send their families to towns and cities. Lack of
avenues for society and entertainment are apparent in many instances, and feelings of social
isolation and loneliness are common. Anxiety and depression were also reported among some
practitioners and health workers, coupled with the attendant problems of alcoholism.
The study team had to travel for long hours to reach these locations, through vast stretches of
fields and sometimes densely forested areas. The team was accompanied by local health officials
or health workers who were well acquainted with the terrain and the location of the healthcare
centres. During the visits, the team frequently came across sections of roads which had been
destroyed (and recently repaired) by landmines reportedly planted by insurgents, an indicator of
the environment of violence and militarization in many parts of the state.
For a number of
doctors and health care workers posted in areas affected by insurgency, personal safety is a
major concern and cause of anxiety.
Respondents and study facilitators reported several
instances of violent clashes between insurgents, security forces and counter insurgents. In one
instance, the team heard of the occurrence of an armed attack resulting in the death of several
police officers, a few days after visiting the location. Paradoxically, many parts most affected by
strife were also of exceptional scenic beauty, with their lush green landscapes and forest and
mountain vistas.
./si-®
bO/.a
. -I
.
Paddy fields in a southern district
15
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PHFI - NHSRC-SHRC Chhattisgarh
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A primary health centre3
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An unpaved road leading to a PHC
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Vista from a community health centre
3 Photographs are not necessarily of locations where interviews took place
16
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PHFI - NHSRC - SHRC Chhattisgarh
Profile of Respondents
Table 2 profiles the 37 respondents in the study, based on different characteristics. Details of
the selection process and parameters, including essential and desirable criteria are described on
page 11.
The eventual selection is weighted by our preferential identification of allopathic
doctors, doctors in remote locations, those with more experience, PHC doctors and women.
Sex4
Employment status
System of Medicine
Qualification (degree)
Years of service
Workplace
Male
33 (89%)
Female
4 (11%)
Regular
25 (68%)
Contractual
12 (32%)
Allopathy
31 (84%)
AYUSH
6 (16%)
Medical graduate
31 (84%)
Medical postgraduate
6 (16%)
1-5
12 (32%)
6-10
9 (24%)
>10
16 (43%)
PNC
23 (62%)
CMC
14 (38%)
Table 2 Profile of study respondents
(N = 37)
After the study was completed, we undertook an
inspection
of government
records.
Chhattisgarh has 1,237 doctors working in rural locations across the state (760 in PHCs and 477
in CHCs). They are profiled in Table 3 below. At the time the interviews were conducted, all
AYUSH doctors in the state were engaged on contractual terms.
Sex
Employment status
System of Medicine
Years of service
Workplace
Male
988 (80%)
Female
249 (20%)
Regular
851 (69%)
Contractual
386 (31%)
Allopathy
968 (78%)
AYUSH
269 (22%)
<1
231 (19%)
1-5
609 (49%)
>5
397 (32%)
PHC
760 (61%)
CMC
477 (39%)
Table 3 Profile of all rural doctors in Chhattisgarh
(N = 1237)
4 The preference for respondents with longer durations of service in remote locations conflicted with and
limited the number of women doctors in the eventual selection, since very few women doctors fell in this
category.
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PHFI - NHSRC - SHRC Chhattisgarh
A closer inspection of the records also revealed that 625 medical practitioners in Chhattisgarh
corresponded to our essential criteria of a minimum of five years service in a rural setting OR one
year's service in a remote setting. These doctors have also been profiled below, in Table 4.
Sex
Employment status
System of Medicine
Years of service
Workplace
Male
Female
526 (84%)
Regular
341 (55%)
Contractual
284 (45%)
99 (16%)
Allopathy
373 (60%)
AYUSH
252 (40%)
1-5
376 (60%)
>5
249 (40%)
PHC
401 (64%)
CHC
224 (36%)
Table 4 Profile of all rural doctors in Chhattisgarh corresponding to study essential criteria 5,6
(N = 625)
At the time of fieldwork, the records revealed that 526 (84%) of these 625 professionals were
male, 341 (55%) were regular employees (with the remainder being contractual employees), and
373 (60%) were qualified in allopathic (Western) medicine.
All 252 AYUSH-trained physicians
were employed on contractual terms, thus forming the majority (89%) of all contractual doctors
in the selection universe. Four hundred (64%) of these doctors were employed in primary health
centres, and the rest in block-level facilities (community health centres).
5 These official figures may not reflect actual ground presence of doctors, since they do not account for
absenteeism
6 The profile of study participants (Table 2) varies from that of this listing, since desirable criteria were also
applied while selecting respondents (see page 7)
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PHFI - NHSRC - SHRC Chhattisgarh
Personal and Professional Antecedents
Upbringiitg a11d fainUy background
A significant majority of the doctors in this study had had a rural upbringing (34/37), and a
number of them cited humble beginnings and hardship:
Family background was nothing great from the beginning... straightaway
from the bottom we have come to the top (Allopathic doctor, contractual,
10 years in rural and remote areas, male)
We have always stayed in villages and financially also we are not like that
that we have been brought up nicely... we have stayed in struggle...
(Allopathic doctor, contractual, 15 years in rural and remote areas, male)
I am from a simple and ordinary family. My father was a patwari (land
records clerk). My education was mostly in remote areas. I did my high
school from (name withheld - town well known as insurgent stronghold)- a
Naxalite area (even) in 1983 (Allopathic doctor and specialist, regular, 7
years in rural and remote areas, male)
At least five respondents identified themselves as being ethnically tribal, and having community
affiliations to tribal groups. Some respondents identified themselves as belonging to immigrant
communities originally from a neighbouring state.
Respondents' parental and ancestral
occupations ranged from farming to various forms of government service, and education.
A few (14/37) were born or brought up in the same district or region of their present habitation,
whereas in other instances, they were from towns and (usually) villages in other districts of
Chhattisgarh (17/37), and occasionally from neighbouring states (6/37). Seventeen of the 37
respondents reported living far away from their parental homes, often able to visit them only
infrequently.
Conjugal life
A majority of respondents were married at the time of interview (34/37), often with children. As
many as 14 of these 34 respondents reported living apart from their conjugal families. In some
of these instances, the spouses and children were located in proximate towns, with
opportunities to visit them on weekends or once a month.
My family is in (a nearby town). My wife is a teacher in the education
department. I have a one and a half year old girl in the house. I stay here
(in the village) from Monday to Saturday. I go out to the family on
Saturday. One day will have to be given to the family. (Allopathic doctor,
regular, 6 years in rural and remote areas, male)
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PHFI - NHSRC - SHRC Chhattisgarh
However some respondents also reported that their spouse and children were located in a
distant part of the state or in another state with limited opportunities to meet. Typical reasons
for separation included the absence of facilities for children's education in places of work, and
employment opportunities for husband and wife in separate locations.
If I keep them here then his (son's) education will be affected. Where they
(wife and son) live is quite far from here. 250-300 km. Sometimes it is 4-5
months before I see them... at times if I get an opportunity then I go more
often... (Allopathic doctor, regular, over 20 years in remote areas, male)
Of the four female respondents in the selection, three were married - each of them living with
their husbands and children - and the fourth was single.
Entering the medical profession
Joining the medical profession emerged as a major life-event for several respondents. The most
critical moment in this process, as recounted by respondents, was of gaining admission to a
medical college.
Entry into a MBBS degree course was widely valued over AYUSH medical
degree courses (BAMS, BHMS and others). Some respondents reported repeated attempts to
gain admission to the MBBS degree course. One BAMS graduate recounted in detail how he had
prepared to commit suicide after failing to achieve the requisite marks for MBBS, but was
prevented by his friends and then persuaded to take up the BAMS course.
Respondents were influenced by their siblings and peers studying for pre-medical examinations,
and by cultures of academic achievement and aspiration in their respective families and
communities.
I got inspired by my seniors (at school. There were 4-5 of them and I also
took the subjects they were doing. I thought that they have also given PMT
(pre-medical test), I will also give. This was the thinking. Initially I had not
thought of being a doctor and serve the people. I got inspired by the
seniors. (Allopathic doctor, regular, 9 years in remote area, male)
During my childhood I did not even know what PMT (pre-medical test) was.
When I passed 11th (standard) my friend was filling the form - I asked him
what is PMT? They told me that you become a doctor by doing this so
even I thought lets fill it up. I had spent some Rs. 10-15 (on the form). And
I gave the exam without any preparation, without studying. We were four
of us who sat in the exam. Of us, the one who made me fill the form and I
cleared it, the other two friends did not. But that friend who cleared PMT
failed his first year. Even now when he meets me in (a nearby town)... poor
fellow is running a grocery store now. (Allopathic doctor, regular, 11 years
in remote areas, male)
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PH Fl - NHSRC - SHRC Chhattisgarh
When I was studying, at that time there was a lot of craze for the "science"
subject in relation to other subjects... whether arts or commerce So in my
personal case, the subject that I chose I chose it blindly, thinking that it has
a lot of craze, and also... we should say it is respected...so going with this
thought I chose science and studied. Straightaway after the first year I was
selected in the PMT. (Allopathic doctor, contractual, 10 years in rural and
remote areas, male)
Parental ambitions for their children were also frequently cited as a determinant for entering
medical studies.
My father wanted me to become an engineer and my mother wanted me
to become a doctor... since we were small so we did not think much about
becoming a doctor or engineer. In the beginning I prepared myself for
engineering only... then my mother said that there is nothing in this....life of
an engineer is not as much as that of a doctor...so then I left it and took
biology (as an optional subject and pre-medical requirement) and studied
and became a doctor (Allopathic doctor, regular, 11 years in remote areas,
male)
In more than one instance, practitioners recounted critical childhood experiences-sometimes
the death or infirmity of a parent from a preventable or treatable cause - which led them to
pursue careers in medicine.
My mother was once bitten here in hand, and once on foot, we tried to get
her healed through jhad-phoonk (witchcraft) but nothing worked... My
father was posted somewhere else. I had to take care of my house, used to
look after my mother, used to cook food at home by myself... there was no
one else at my place, no uncle-aunty no one it was not a joint family. From
that day it came to my mind - I was in class six - that I have to become a
doctor. (Allopathic doctor, regular, 18 years in remote areas, male)
My father expired due to malaria. My father was in the irrigation
department. He had to go to the field. There was a phone from the home
that father is suffering as such. Doctors told me that your father passed
away due to malaria... then also I thought that no one should die of
malaria. It is a preventable disease. This is the reason I came into this.
Otherwise I had chosen administration for myself. (Allopathic doctor,
regular, 6 years in rural and remote areas, male)
In my district there is a village...there was this lady...in Chhattisgarhi they
said that she had some chhoot ki bimari (contagious disease) and she
expired... and nobody was ready to pick her up. I used to be really scared
whenever anyone died, I would not even come out of my house... but there
I picked her up ... this gave me strength.... From then I made a choice for
21
PHFl - NHSRC - SHRC Chhattisgarh
but I felt that since I have taken from the government so I return to the
government also. Also to the community to which I belong - I have taken
from the society so I will have to return it. So to return what I took from
the government and society I joined a government job and I am working in
the tribal area for my people (Allopathic doctor and specialist, regular, 8
years in rural and remote areas, male)
A few respondents indicated that they had joined government jobs in rural areas due to policies
linking conduct of rural service with eligibility for or preferential admission to postgraduate
degree courses.
I shifted here leaving a private practice worth (Rs.) 30,000 - 40,000. My
practice was very good in (a nearby town) and I left that practice to be
here. The reason was that with the kids and taking care of the house I
could not study. So for this reason only I joined government job that if I am
in government then government will get our PG done... this was the
motivation. (AYUSH doctor, contractual, 6 years in remote area, male)
One respondent recounted the advantages of greater autonomy in caring for patients and the
ability to utilize his professional skills better as a reason that motivated him to move from a city
hospital to a village PHC.
I left central service and came here... I was there for 3 years. Over there it
was like you have to do whatever is set by the government... like
paracetamol, brufen (ibuprofen), apart from that you can't do anything
else for anybody you just give them some analgesic and send them off, so
all this I did not enjoy, so that's why I left it. Here - whatever resources you
have, whatever knowledge you have, you can use. You can do a lot for the
patient. For that reason I left it and came. (Allopathic doctor, regular, 18
years in rural and remote areas, male)
One female practitioner recounted how the proximity of the doctor's home and spouse's place
of work, family connections in the health department and her willingness to work in a rural area,
each played a role in her decision to take up a position in a remote outpost.
My proper home is in the colony 25 km from here. After passing the PSC
(public services commission examination), I was given this posting. See, no
one wants to come here. For the PSC also it is a problem (to find someone)
that will come here. The coordinator then, (name of a health official), we
also had family relations with them. When the list came out he knew that
this PHC is 25 km away and if nobody else, then she will join and go there.
If someone else is given then that person will not join. May be they were
thinking this because of which I got it. (Allopathic doctor, regular, 4 years
in remote area, female)
24
PHFI - NHSRC - SHRC Chhattisgarh
This account epitomizes how combinations of factors were frequently responsible for doctors'
initial placement and commencement of work in rural primary health systems.
25
PH Fl - NHSRC - SHRC Chhattisgarh
the patient is really ill, if it is a delivery case, then... (AYUSH doctor,
contractual, 3 years in remote areas, male)
Problems with residential facilities were widely reported, with doctors forced to take up private
accommodations or live in poorly maintained or inadequate government facilities.
I can't get my family here. There are no facilities. Infrastructure is zero, all
other facilities are zero. This is a remote place. It is one's good luck if there
is electricity. There is a lot of problem of water. All water sources like tap,
borewell are a fail. You have to order water for Rs 10 a litre. Nowadays,
because of (a government scheme), since people get rice in Rs 2 per kg, the
person who fetches water is also not available. (Allopathic doctor, regular,
6 years in rural and remote areas, male)
There are no proper quarters here... you can see the situation yourself...
every year I spend at least Rs. 4000 laying polythene (waterproof sheeting
to prevent leakage) (Allopathic doctor, regular, 11 years in remote areas,
male)
There are many of us (doctors) who are living in rented houses... for
bathing they are going outside, going to the river... so all this is not right... If
you are managing a PHC or hospital, you should stay near the hospital you
should have quarters in the premises, a little away from common people
(Allopathic doctor, regular, 18 years in rural and remote areas, male)
TOILING IN OBSCURITY
Doctors' frustrations from the anonymity of working in remote areas and from the lack
of appreciation and recognition of their contributions were expressed eloquently by
this Block Medical Officer from an underdeveloped district:
(Doctors) working in good places like AlIMS and Safdarjung
(hospitals in Delhi), their work gets highlighted. We learn
that some doctor has received Padmashri. I am saying some
bitter things. I am working here; if I die in a blast or my hand
gets fractured then I am not going to get any Padmashri. We
are not getting those garlands, those flowers, or gold medals.
We are only serving the patients. If I am satisfied at that level
then its fine. Otherwise if I am going to tax my brains by being
unsatisfied then nobody is going to lose but me. We
understand everything, experience it but cannot say it. Who
do we say it to? Would I say all this to the poor tribals who
themselves don't understand much. Would I say this to those
corrupt administrators? (Allopathic doctor and specialist,
contractual, 16 years in remote areas, male)
28
PH Fl - NHSRC - SHRC Chhattisgarh
Long separations from families, a common consequence of being located in remote and
inaccessible areas, were often a cause of distress. Problems of separation from families were
reported more frequently by contractual doctors, who had less choice in determining their
locations, and limited permitted leave of absence.
A few doctors indicated disturbances in
spousal relations and estrangements, consequent to the problem of separation.
The situation is such that mother-father are in (a neighbouring state).
Father is 80 years of age and Mother is 75 - we have left them both there
and we are sitting here... that's the way my life has turned out.
(Investigator: do you miss them?) This you will realize when it happens to
you [bitterly]. Day before yesterday my mother fell down [starts crying]
and I couldn't go... at the age of 75 what will happen, she doesn't eat
anything... [cries harder]... we don't get a leave from work. Only to earn a
living, I have left behind my 80 year old father to live in this jungle where
no one will live. We don't get leave... we call them, enquire, they tell us
"son, I fell down", I say "Mother, take this medicine", and we go off to
sleep... so don't ask me about my family [sobs].
(AYUSH doctor,
contractual, 2.5 years in remote area, male)
We are living 600-700 Kms away from our family and
relatives.
Government gives us 18 days casual leave only (in a year). If something
good or bad happens in our family then... if you travel 600 km it will take 3
days to go and 3 days to come. And I will stay for at least 2-3 days. So out
of 18 days, 10 days are gone like this. (AYUSH doctor, contractual, 6 years
in remote area, male)
When sometimes we get a holiday, I go (to visit wife and child in the city) fewer than once a month, and many times even that is not possible.
Because of this yes family relations are a little... they do get a little upset...
(They ask) 'what is there, that you are living there so far away?' From my
side, I like it here... If we had the schools and everything else was better,
then I would have got the family here...but it's like
my parents made me
study and made me a doctor, so our kids should also become something...
that is why I have kept them in (the city) (Allopathic doctor, regular, 11
years in remote areas, male)
Erosion of professional skills and confidence was a commonly reported problem, as often
attributed by respondents to others of their acquaintance, as to themselves. Frequently this was
linked to limitations of resources (clinical facilities and equipment) to practice a high standard of
medicine, and the lack of opportunity for further academic development.
Science is moving forward and we are lagging behind... in some emergency
if there is some critical disease, I don't know, then I ask another doctor. If
he knows then it's OK or else I have to look up books - and books are not
here with us. If we had a library, then we could refer to it. Sometimes we
29
PHFl - NHSRC - SHRC Chhattisgarh
have to train these people nurses and workers on diseases... so whatever is
our knowledge we can only give that much (AYUSH doctor, contractual, 3
years in remote areas, male)
There are no arrangements for X-rays, no arrangement for blood tests.
Because of Jeevan Deep (untied funds scheme), there is a table and chair,
before this even table chair was not there. We have adapted to this
environment -1 have forgotten the method of diagnosis of disease here... If
there is any reorientation course I would like to do it, and get new fruits of
knowledge. But here the situation is such that even what we have done
(studied in medical college) has gone. (AYUSH doctor, controctuol, 6 years
in remote area, mole)
We don't have the basic equipment for routine investigation like urea,
creatinine, such routine investigations are not possible. If I am not able to
properly investigate a patient then how will I be able to give him proper
treatment? Once a 30 bed hospital is made there should be an X-ray
machine, one sonography, one specialist. All these facilities are not here.
We are not able to serve our patients like we want to. (Allopathic doctor
and specialist, contractual, 16 years in remote areas, male)
Doctors coped with the prospect of declining skills in different ways. While some conceded
attrition of knowledge and intellectual fervour, others, conversely, immersed themselves deeply
in studious pursuits and accentuated their medical professional identities, to counter isolation
and lack of academic exposure.
I am a doctor so I believe that whatever I have studied I have to maintain
that and not let it go or forget. (Allopathic doctor, contractual, 18 years in
remote areas, male)
Complicating the doctors' concerns around an eroding knowledge base was the problematic
interface with alternative knowledge systems and perceptions of health that were subscribed
to by local populations.
Many (patients) prefer jhad-phoonk (witchcraft) We tried that this should
stop but it was difficult to do so. So we told them that you do jhad-phoonk
but take our tablet as well. Many people have adapted to that. They
understand that malaria can't be treated with jhad-phoonk only. They keep
our medicines as well. (Allopathic doctor, regular, over 20 years in remote
areas, male)
We keep on calling the meeting of these (traditional healer) people to
make them understand. But did not get any result. But they have a hold on
the community - if they have a say in the community they will not just let
go of it. Also if the people believe in something then they will not just stop
30
PH Fl - NHSRC - SHRC Chhattisgarh
believing in those things all of a sudden. (Allopathic doctor and specialist,
regular, 7 years in rural and remote areas, male)
For AYUSH qualified doctors in contractual positions, the experience of prescribing allopathic
medicines in government clinics was sometimes problematic. Colleagues with allopathic degrees
widely did not perceive their competence to be at par, and did not trust them with all aspects of
medical management. AYUSH doctors did not have opportunities to pursue or enhance their
skills and knowledge in their own systems of medicine.
Since we are in the (Ayurvedic) profession, we always feel good to give
pure Ayurvedic treatment.
♦
But you see, in Ayurveda, you do not have
medicines for immediate results. The medicines have not been improved.
It has happened but not that much. But in Allopathy it is improving rapidly.
And we have to (give allopathic treatment) since we have been posted in
government facilities. (AYUSH doctor, contractual, 3 years in remote areas,
female)
The threat of civil strife is pervasive in many parts of interior Chhattisgarh. Insurgent groups
were widely feared - they were typically referred to in hushed tones as those "from inside"
(Hindi: "andar wale", a reference to their dwelling in camps deep inside the forests which cover
large tracts of rural Chhattisgarh). However there is also a strong presence of counter-insurgent
groups and armed forces of the government in these regions - and these, along with insurgency,
represent a collective context of military presence and strife in the lives of villagers, and the
insecurities experienced by health personnel.
-
■'
-
&
-*^5.
„ „
nunsm
A bridge destroyed by insurgents7
7 Photographs are not necessarily of locations where interviews took place
31
PH Fl - NHSRC - SHRC Chhattisgarh
If I think about the children, we have a joint family and their grandparents
are there. My children are staying with the grandparents comfortably. I
leave them there often.
They also study in (the village where the
grandparents live). (Allopathic doctor, regular, 4 years in remote area,
female)
I had opportunities - I was getting a well-paying job in Delhi, but I did not
go. Because I have been staying away from my home, and my folks were
saying: 'how many years will you stay away?' So I thought to opt for a
nearby place. (I thought) will stay within 100-200 km - at least there will be
frequent visits to my place. There are some family problems also so I prefer
not to be too far away. (Allopathic doctor, regular, 2.5 years in rural and
remote areas, male)
Other respondents who did not specifically have forebears in the locations in which they were
posted but had had a rural upbringing also cited a preference for rural jobs. Rural upbringing,
familiarity with village life and with associated values of simplicity and fortitude were the key
factors cited in these accounts.
People from middle class, who are from cities - they don't like it here. We
have always stayed in villages and financially also it's not that we have
been brought up nicely - we have stayed in struggle. We like it in struggle,
there is no problem in that. (Allopathic doctor, contractual, 15 years in
rural and remote areas, male)
Why do we want to go to a city? (Because) we feel that there are good
facilities, good money and if money is there everything is there. But in
village there is no money, but still you can get peace... if you are working
for people in villages they will thank you and give you regards from their
heart.
They will give you more respect. If the person get respect his
efficiency and energy increases. (Allopathic doctor and specialist, regular, 7
years in rural and remote areas, male)
My personal feeling is that if you have been born in a village you will not
take time in settling down here. But if there is someone born and raised in
a city and if asked to live a village then they might not be able to. Those
who come from outside, after looking at the environment here, they not be
able to adjust. (Allopathic doctor, contractual, 18 years in remote areas,
male)
It was already in my heart that I will live in a small place only and work.
Because my background was not such, that I would have adjusted in a big
place. In very big cities, what they say, the lifestyle, I wouldn't be able to
adjust in it. This place was familiar to me, so I felt that it is suitable for me.
44
PHFI - NHSRC-SHRC Chhattisgarh
And since then (laughingly) it has continued here. (Allopathic doctor,
contractual, 10 years in rural and remote areas, male)
My house is 1 kilometer away... and as far as staying in the village is
concerned, I am from a village, I have been born and brought up in the
village, and so I do not face a problem. (Allopathic doctor, regular, 16 years
in rural and remote areas, male)
Some respondents specifically referred to an ethnic (usually tribal) identity as being a
determinant in their decisions to remain and serve particular communities.
In my tribal region no other person wants to work so I will only work for my
people. People run away from this place - it is a very tribal area, there are
a lot of forests. But I am myself a tribal, so (I thought) who will work in our
area? We only will-have to work in our area (Allopathic doctor and
specialist, regular, 8 years in rural and remote areas, male)
I am also an ST (Scheduled Tribe) and I am serving the ST people here, so I
find it good (AYUSH doctor, contractual, 3 years in remote area, male)
From the beginning I belong to such a family....now because I am a tribal so
I find it fine to work in a tribal area. (Allopathic doctor, regular, 8 years in
remote area, male)
Ethnic affinities were not only restricted to tribal or caste identity. In at least one instance, a
respondent with Bengali parentage indicated that he had preferentially chosen a location which
had large Bengali-speaking settlements. In other instances, doctors may not have originally have
had a rural upbringing or previous community links in their place of work, but had developed
close links and relationships with the local communities over time. This sense of belonging to
local communities was cited by some as a reason for staying on.
I liked the place; here it's not like the city life, no fighting and all. Peaceful
people live here and if you do a little for them, they treat you like family.
They trust you and if they have any problem they come to you saying that
you are our elders. (Allopathic doctor, regular, 11 years in remote areas,
male)
Once I was transferred, everyone went on a strike, they surrounded the
minister, caused a problem.
Because the thing is that in remote areas
doctors don't want to stay. Now length of my service is getting over. I have
settled here. I have spent so many years in this district that now it is
difficult for me to go to a different district. In a new place we might know
people but who will know us. But in an old place, over here, everybody
knows me. Even if a politician goes by more people will know me (laugh)
because we are the ones who go for (field work) campaigns - whether it is
45
PHFI - NHSRC - SHRC Chhattisgarh
The Workplace and the 'System'
The extent of satisfaction from work was variable among the doctors. On the one hand,
justifiably, most respondents were not entirely satisfied with the support and facilities available
to them. Conversely, there was also a widespread expression of being inspired by the unique
challenges and ability to influence health outcomes.
"I am satisfied 75%, and 25% I am not
satisfied because of the facilities, the limitations..." said one contractual doctor. A number of
other respondents expressed a strong sense of personal fulfilment from their daily work.
There was a case of delivery, they had nobody in their home... we send our
jeep to her home and got her admitted to hospital and then we referred
her, our jeep only took her there... so this happens, then in your heart you
get a different kind of satisfaction and peace which you cannot get from
any other thing (Allopathic doctor and specialist, regular, 8 years in rural
and remote areas, male)
I go with a fully positive attitude. If I take it to be a headache then my work
will not happen. I am fond of my work also - I like explaining, talking to the
people (Allopathic doctor, regular, 5 years in rural and remote areas,
female)
People are happy with my services and I also stay motivated with their
response. I have been here for two years now. (Allopathic doctor, regular, 9
years in remote area, male)
Interest in the scientific and professional aspects of their work was commonly expressed by
respondents (see also boxed item below).
One contractual doctor described work in a
particularly strife-affected and remote area as being "beautiful and challenging".
Many also
took an interest in undertaking outreach work, and in implementing national public health
programmes in the community.
Others claimed particular interests and skills (eye care,
infectious diseases, surgery, obstetrics, health administration, etc.) which they wished to
develop further by means of training and higher education.
If you take an interest then the one in front of you will also take interest. I
am a doctor so I believe that whatever I have studied I have to maintain
that and not let it go or forget... if I keep treating the people and share my
medical experiences, whatever I have studied I will remember. I will not
forget that topic then. And then when the patient benefits from those
medicines then he would be able to develop trust in me as well the medical
science that this doctor is good and useful. This is what I think and this is
what I had been doing all this time... Prove it to him (the patient) by doing
it - that 'you have fever and I am giving you medicine, till evening you will
have fever, sleep under a blanket and then you'll feel better'. And then
when she (the patient) gets better then she will accept you. If today one
48
PHFl - NHSRC - SHRC Chhattisgarh
(patient) believes in you, tomorrow there will be 10 and the day after there
will be 100. (Allopathic doctor, contractual, 18 years in remote areas, male)
The government appointed me, so I stayed here. I stayed and served the
people. I went and talked to the people and said that I have been
appointed here as doctor. But people said no, we know that there is no
treatment, any two tablets are given and we are sent back. So I went door
to door in village and I told them 'I am a new doctor - you will get glucose
and injections if you need, and you will get admitted in hospital', so this
way I convinced the people. A patient welfare association was formed - I
worked there with nominal charges of Rs. 2 only and within six months the
funds increased several-fold. (AYUSH doctor, contractual, 6 years in remote
area, male)
I first started health camps in the villages - like till 1, you work in the
hospital, then at 2 we leave for the villages. We used to make a plan -
when we will go in which village, section wise. In hilly areas my target was
more where there was more poor people - so this way, 3 days in week 3-4
times we started doing camps. And during diseases (outbreak) time - extra
efforts. Also we used to encourage people to come to the hospital that
come you will get medicines and we will give bottle (i.v. fluid) also or
whatever things they need, so when we kept doing this, people started
having trust. It took a lot of time to do all this (Allopathic doctor, regular,
18 years in rural and remote areas, male)
Yes I did camps for cataract - there were more than 100 cases once so I
took arranged that the village society would make everything free of cost.
We did all the rest - getting the patients, arranging for vehicles, taking care
of the patients and all that. (Allopathic doctor, regular, 24 years in rural and
remote areas, male)
I have treated something like 500 to 700 cases of leprosy. If we get (the
patient) in the early stages, it is fine, we treat them, and if he has come to
us really late then - if somebody does not have a finger, or a limb - then we
donate clothes, shoes, through the Leprosy Mission. So they (the patients)
really like us, and say that we are serving them. Those patients remember
that if Doctor Sahab was not there we would not have got all this. Earlier
doctors have come and gone but we were the ones to pay so much
attention to leprosy cases. (Allopathic doctor, contractual, 18 years in
remote areas, male)
49
PHFI - NHSRC - SHRC Chhattisgarh
PROFESSIONAL FULFILMENT
While doctors did complain about the erosion of their knowledge and the lack of
educational opportunities, yet, scientific interest and professional fulfilment was
marked among several of the respondents. The frequently critical nature of illness
in poor and underserved areas, and the opportunities to achieve significant
medical outcomes was cherished.
The life-saving that we have done, like almost when the
person was dying - at the brink of death, we have saved
them. Many of them - some bike accident cases, malaria,
snake bite - you get more satisfaction after giving such
service. Basically I am a doctor; I like doctors' work only.
(Allopathic doctor, regular, 28 years in rural and remote
areas, male)
Like a super specialist is saving life by removing brain
tumours, I am working at the same level by treating
cerebral malaria, meningitis patients. There is no
difference in the work. It would only be my mentality that
I am not a super specialist placed in some big place -so I
don't have cars and other facilities. Otherwise my motive
of serving is being fulfilled here. If there is a patient of
diarrhoea and dysentery and the patient is in mortal
state, if his life is saved then it has the some value as
those in some big place. This is what I believe. (Allopathic
doctor and specialist, contractual, 16 years in remote
areas, male)
Among selected respondents, the ambition to progress to higher positions in the government
public health systems was a motivating factor.
By God's grace if I will do my PG. after that according to the State policy, a
government doctor can decide if he wants to go in the administrative field
or otherwise - medical. I feel that I will be able to give better service in the
administrative team. Either BMO or CMO - one should have knowledge
about the programme. The number of national programmes that are
running, the epidemics, one should have detailed knowledge. I think I
should go in for a BMO in future after I am promoted. I can give a good
result as a BMO. (Allopathic doctor, regular, 6 years in rural and remote
areas, male)
For many doctors, particularly those in the more remote areas, there was no obvious separation
between work and home life. Workplaces were also avenues for support and social interaction,
and they sharing living quarters, pastimes and preoccupations with co-workers, often adjusting
50
PHFI - NHSRC - SHRC Chhattisgarh
with equanimity. While there were instances of interpersonal differences, good personal and
working relationships with colleagues were a source of strength and sustenance.
I have good relations with all staff members... see if we are good then our
staff is good. If I am wrong my staff members will also be wrong. This is
such a place that apart from them there is no family - so we share our
happiness and sorrows and they share theirs with us. I scold them also if
they do something wrong, but I do not scold them in front of the patients.
But when patient goes I tell them that they should not have done this.
(AYUSH doctor, contractual, 6 years in remote area, male)
I have kept the hospital staff like a family, so whatever work I give to them,
they do it. For instance, if I give some other work to the Sister (nurse), she
generally does it for me because all of us have to do the work together.
Then there are days when I don't have much help, then I do the dressing, I
run the OPD, look after the patients as well - I do all work alone... I have
told the entire staff that they should work. Everybody do what they are
responsible for. Come on time, go on time. I don't say that I am your
senior, I am your junior. I am doing my work, you do yours. Everyone works
cordially. (AYUSH doctor, contractual, 2.5 years in remote area, male)
There is a (member of) staff who is finishing on 20th of this month. So we
are all feeling bad that he is going. You see it is like a family - just 5 staff
are there - 2 doctors, RMA, pharmacist and ward boy, so family-style we
are attached to each other.
We feel like someone from our home is
leaving. We are all feeling very bad (AYUSH doctor, contractual, 3 years in
remote areas, male)
My working cooperation is fine with all. There are a few who are drinkers there are always 1-2 people like that. They may not behave very well at
times. They do not work without a scolding. Then he works fine. Rest, all is
fine. They do whatever I ask them. (Allopathic doctor, regular, 6 years in
rural and remote areas, male)
The role of supportive supervisors and peers was also cited by some in creating a positive
working environment at facility level.
The other senior doctors who are here - they are here from before us - so
we keep on discussing with them and take suggestions from them, keep
getting support... if in some decision, we are facing some problem with any
disease we can consult with the senior doctor. Also for the other things
also like we need this or that we keep on consulting... They are helpful, the
BMO and CMO cooperate with us fully. (Allopathic doctor, regular, 2.5
years in rural and remote areas, male)
51
- 100
PIO
PH Fl - NHSRC - SHRC Chhattisgarh
Our BMO is the best - he supports for everything. We immediately call
BMO Sahab that Sir this is the problem - so if it is in his hands then he helps
immediately...if not then we call the CMO or we contact the sarpanch and
rest of the people in the village 30
Our BMO Sahab is a very nice man...its only because of him that I working
or else I would have ran away long back (AYUSH doctor, contractual, 3
years in remote area, male)
Security and prestige afforded by a government job was reported to be important by some of
the respondents, although by some accounts, the prestige associated with govt jobs had waned
in recent years.
This is a government job, so tension, financial tension is less.
In private
(practice) we had to take tension - the whole day we had to roam about you had to give door to door service. (AYUSH doctor, contractual, 3 years in
remote areas, male)
It is government service, so you have stability in life. In a (private) nursing
home you cannot have this (AYUSH doctor, contractual, 3 years in remote
areas, female)
In government we also get other benefits - like we get training for higher
studies.
We get knowledge, we meet a lot of big doctors - there are
benefits (AYUSH doctor, contractual, 3 years in remote areas, male)
They (family) are very happy that I am a doctor - if there is some work in
which I can help they do come to me, and I feel happy about it. It feels
good when somebody in the family is in a high post. (Allopathic doctor,
regular, 11 years in remote areas, male)
In our time, in 1990, that time there was no such craze for private jobs.
Then, government job was considered the best. I had a postgraduate
degree, and I got a government job (Allopathic doctor and specialist,
regular, 20 years in rural and remote areas, male)
Clearly regular jobs were sought after by contractual employees, with these factors in mind, and
the anticipation of obtaining a regular job if they continued in service emerged as a significant
motivating factor for contractual doctors.
My Mrs. stays outside, children and all live outside so I think leave it, why
bother just for 15000 rupees - this much I can earn there (in private
practice in town) also. But because I see some possibilities, so I think that
in a year or two I might get regular, then I can get my Mrs here only. We
have got assurance - we went on strike and they said "in 2-3 months we
52
PH Fl - NHSRC - SHRC Chhattisgarh
will do something about you people" Assurance have been given by the CM
- he said "close the strike and work" because they were compelled - the
rainy season had started and diseases had started to spread (AYUSH
doctor, contractual, 3 years in remote area, male)
It was an unfortunate observation however that delays and irregularities in placements and
transfers may also have been an important factor for doctors' continuing to work in their
present locations. A number of doctors were dissatisfied with their respective postings, and had
sought transfers elsewhere. However they remained where they were, due to unresponsiveness
to their requests and their own financial compulsions which prevented them from risking
seeking new avenues of work.
Since you are asking, I will tell that when I had come here I had thought
that I will stay for 2 years and then will find something near my house. I
had sent in the request last year but they had given me a place further
away near (another district). I did not take that and thought that will apply
again next year. (Allopathic doctor, regular, 9 years in remote area, male)
After post graduation, twice I have almost left. You could say that I could
not leave when I tried to go out but failed... from the past 6 years, 5 years,
7 years I have had a lack of confidence. (Allopathic doctor and specialist,
regular, 25 years in rural and remote areas, male)
I thought of taking a transfer earlier. But if a reliever (replacement) will not
come then you will not be relieved - that's what they said.
And in 2001 I
did a transfer - but at that time also they did not get a reliever, so they
were not ready to let me go. 2-3 times I gave an application saying relieve
me but they did not do so. Then I did not try again. (Allopathic doctor,
regular, 19 years in rural and remote areas, male)
I tried, I got a transfer also. But later there was some problem with the
reliever, so I did not get relieved from here. He did not come to relieve me,
saying that its a backward area. (Allopathic doctor, regular, 24 years in
rural and remote areas, male)
I try every year for a change of posting. Here nobody wants to come. They
say, get a reliever. A reliever - from where do I get one? (Allopathic doctor,
regular, 18 years in rural and remote areas, male)
The CMO said that in a few months he will bring me to (a nearby city) but
then he retired. Then I stopped trying.
Now for how many more days
would I want to stay here? I have spent 7 years here. At the most I want to
stay another year here. (Allopathic doctor and specialist, regular, 7 years in
rural and remote areas, male)
53
PHFI - NHSRC - SHRC Chhattisgarh
SUMMARY: THE WORKPLACE AND THE 'SYSTEM'
Work satisfaction was variable among the respondents, with some reporting high levels of
personal satisfaction from providing day to day care, and also from advancing public health
programmes and strengthening existing services.
A number of doctors also pointed to the
opportunity for professional growth and fulfilment, in under-resourced areas, in the context of
the frequent need for services of a critical and high impact nature. In the absence of other social
avenues and separations from families and communities for doctors in remote areas, the strong
relations developed with co-workers, peers and supervisors, were important in improving the
experience. Notably, since most contractual doctors are placed in remote areas, this finding was
more common among them. The security of regular government jobs was a notable motivating
factor for contractual doctors.
Unresponsive administrative systems also played a role in
doctors not being able to achieve transfers to other locations.
54
PHFI - NHSRC - SHRC Chhattisgarh
Reid tions with Pa tien ts
While most of the doctors reported good relations with local communities, there were also
instances of close and extended relationships with particular patients.
I would like to share my experience with one patient. They showed their
child in district hospital - the doctor wrote the medicine 3 days - 4 days, he
did not get well, then he brought the child to me. I gave symptomatic
medicine to him and the child got fine. He says that district hospital was
not able to cure and Doctor Sahab did it. Today also he gets the child to me
only.
He says Doctor Sahab I will show only to you. So the emotional
connection is there (Allopathic doctor, regular, 4 years in rural and remote
areas, male)
In leprosy if we got (the patient) in the early stages, it is fine...and if it has
come to us really late then...if somebody does not have a finger, or a limb,
then we donate clothes, shoes, through the Leprosy Mission. So they (the
patients) really like us, and say that we are serving them. Those patients
remember that if Doctor 'sahab' was not there 'we would not have got all
this'. Earlier doctors have come and gone, but we were the ones to pay so
much attention to leprosy cases. So they remember us and after they are
cured they respect us. Like even for TB, through the medium of DOTS I
have treated a lot of cases. So like even for them there treatment
continues from 9 to 12 months. They come and go and keep meeting, and
greet us 'namaste'- so a relationship is formed (Allopathic doctor,
contractual, 18 years in remote areas, male)
Yes there are many such, they come to me only. If I am not there then they
wait for me that when will doctor sahab come... I have been here for 21
years. There was a child with nephrotic syndrome - the kid must be 8-10
years old.
Its a very painful life.
I saw and diagnosed him.
I gave
treatment and he used to get OK, and he kept coming to me... now after
11 years he is OK, he has grown into a young man. His father also comes -
they take my name, and they refer other people to me also (Allopathic
doctor, regular, 28 years in rural and remote areas, male)
There is a woman who was not having menses for a long time, so I
prescribed a medicine and now she is having her menses. She is very happy
now. Whenever she would have her periods she would come and tell me
that "Sir, this month I had my menses". Sometimes she leaves mangoes at
my home for the children. So there are such cases - a relationship is
established. (AYUSH doctor, contractual, 2.5 years in remote area, male)
55
PHFI - NHSRC - SHRC Chhattisgarh
, . .1
■
I
I
v-1
I
r?
A community health centre9
IK kJ
Some respondents spoke of the importance of adaptability to the different needs of patients in
remote areas.
They don't understand anything so it is our job to make them understand.
Now if we explain to them according to their own understanding, only then
its OK, if we explain like you would in Raipur then they will not understand
anything. So we have to shape ourselves according to their environment.
(Allopathic doctor, regular, 11 years in remote areas, male)
People want that if they have come to a doctor so then they don't have the
need to go anywhere else... they don't see how much he knows, they want
the behaviour of the doctor should be good. If your behaviour is good they
give a lot of love... My experience has been very good (Allopathic doctor,
regular, 11 years in remote areas, male)
It's a small place.
Few people stay here and there is just one doctor -
obviously all the patients come here only. Like pregnancy cases - if they
have any other ailment they still come to me only. With such patients you
form a relationship above the normal 'patient and doctor' (Allopathic
doctor and specialist, regular, 4 years in rural area, female)
9 Photographs are not necessarily of locations where interviews took place
56
PHFI - NHSRC- SHRC Chhattisgarh
SUMMARY: RELATIONSHIPS WITH PATIENTS
A number of doctors spoke of strong relationships with their patients, but there was little
indication that these impacted directly on their decisions to remain in rural areas.
57
PHFI - NHSRC - SHRC Chhattisgarh
What They Need: Improving the Experience
Among contractual doctors, higher pay-scales were a frequently expressed need, with a
majority of them claiming that their compensation and the terms of their contracts were
prohibitive. A number of respondents reported how their salaries had not been increased to
match the rising prices of commodities and services.
They are giving me 15,000 per month which is nothing. When I joined here,
rice was Rs 11 per kg. Now, how can you manage in 15,000? When we
used to go to Raipur the fare was Rs 50, today it is Rs 350 and our salary is
the same. Our economic condition has been disturbed badly - today if our
children fall ill what will we do in Rs 15,000? Salary is not good. (AYUSH
doctor, contractual, 6 years in remote area, male)
After Chhattisgarh was formed - from Rs. 8000, it straightaway became Rs.
15,000. When it became Rs. 15000/-1 was relieved that a good enough pay
scale has come. So what if I am on contract basis, it's ok. My work will run
smoothly. But as time is passing by, today's position is such that a primary
school teacher is earning above 15,000 and we are still working for the
same. So now for the family or to maintain the lifestyle, where will you get
the money from? So you will have to (do private) practice. But the contract
says that no kind of private practice is allowed (laughs). (Allopathic doctor,
contractual, 10 years in rural and remote areas, male)
When we started here, we were getting 8000, but now it is 15000. After
so many years it is still 15000. In 8000, living was difficult - then it got
15000 and it felt a little good. But with the economic situation now, 15000
is looking equal to that 8000 - it seems there is no difference. And people
below us have superseded us - like a worker is getting 20000. So we are
feeling a little let down. (AYUSH doctor, contractual, 3 years in remote
areas, male)
Remarkably few regular doctors (2/25) expressed dissatisfaction with their current salaries.
However, a number of respondents voiced the opinion that greater compensation for doctors
working in remote areas would assist in their retention doctors in remote areas.
Doctors who are working in these remote areas - they are actually doing a
favour. We say that "you are a government servant you are not doing any
favour" but it's not really like that - if they are living 70 kms inside the
jungle then the doctor is very valuable to the people living there - he is
doing a favour to the system. And as incentive, if a doctor is living 70 kms
away from any place then what can you give? Money - What else can you
give? (Allopathic doctor and specialist, regular, 8 years in rural and remote
areas, male)
58
PHFl - NHSRC - SHRC Chhattisgarh
Give the doctors some incentive so that at least they stay here because of
the lure. If you do not give that, and say that you have to go to villages why will that person go? (Allopathic doctor, regular, 2.5 years in rural and
remote areas, male)
Salary should be increased according to the village location. Totally interior
- salary should be 1 lakh; less interior - 50, 000; city - 30,000. This is very
important. (Allopathic doctor and specialist, regular, 20 years in rural and
remote areas, male)
The security of a regular job was also a widely and strongly expressed need among contractual
doctors. Many of them had joined their current contractual positions; based on assurances or
expectations of conversion to a regular position after a period of time. The uncertainties of
contract employment were magnified in the case of AYUSH doctors, since there are no regular
jobs earmarked for non-allopathic practitioners.
I want to see myself progressing but because it is in the hands of God so I
don't know if it will happen or not. I feel there can be some progress if we
stick here but here, it might also happen that we leave and go. My Mrs
stays outside, children and all live outside, so sometimes I think "leave it,
just for 15000 rupees..." but because I see some possibilities so I think that
in a year or two I might get regular then I can bring my Mrs here. (AYUSH
doctor, contractual, 3 years in remote area, male)
I am in an ad hoc job. When I go to the bank for a loan they say you will be
turned out after one year so how will you pay back the loan. If you will
leave the job and go where will we search for you? By this ad hoc job the
government is getting its work done, but our position is getting poorer.
(AYUSH doctor, contractual, 6 years in remote area, male)
The foremost thing is that our job is not secure. The sword is hanging that is the type of job we have.
We are under contract and when the
allopathic doctors will come then we we will find that we are not needed.
So we have no certainty here. Allopathic doctors have a regular post here
so it's fine for them (AYUSH doctor, contractual, 3 years in remote areas,
female)
In contract service you can't think much - November will come now, then
we will come to know if this service will remain or not.
If there is a
permanent service then a person thinks about the future also - what will
one do or not do. But in a contract job - I have one daughter - you can't
plan whether you will have a service or not, or will be able to afford a
second child or not.
You never know what the future holds. (AYUSH
doctor, contractual, 2.5 years in remote area, male)
59
PHFI - NHSRC - SHRC Chhattisgarh
"ISSUE A SIMPLE LETTER"
Some contractual doctors reported having served on contract for an inordinate
period of time, reportedly due to loopholes and technicalities which could be have
been readily rectified by the exercise of political will by administrators.
When I joined on contract, oil of MP was one state. The
division of Chhattisgarh happened later in 2002, and my
position is still contractual. We are giving so much,
staying in villages - the government should at least think
so much that they make us regular. I have been working
for 12 years. (Allopathic doctor, contractual, 15 years in
rural and remote areas, male)
I have wished it (getting a regular position) but what can
we do about it? It is in the hands of the government.
When I joined service I was two years over-age. And now
ten years later when another round of selections for
regular service is taking place, I am over-age again. So
now I have stopped hoping. (Allopathic doctor,
contractual, 10 years in remote areas, male)
We joined here when Chhattisgarh was not formed - then
this was in Madhya Pradesh. So the Health minister at
that time, for (two underdeveloped districts) he
introduced a special workforce category. And that is still
the case - so we have been here for more than 15 years,
but on our record it is written that we are ad hoc. Think
about what are going through. On one hand you expect
us to serve you and when official loopholes come up then
you can't even issue a simple letter. (Allopathic doctor
and specialist, contractual, 16 years in remote areas,
male)
The need for more transparent and rational procedures for promotion and transfer were
highlighted by several respondents.
I have been working since 20 years, and so far I have had no promotions at
all - I just keep sitting around. Not a single promotion, no increment, no
timeline- it's been 20 years. Those who have just finished probation
periods have received increments. There are many such cases - there is one
who is my 24 years senior, even he has not received any promotion. There
is this doctor in (another district) who is 10 years my junior - he has been
promoted. Here it has nothing to do with junior or senior. There is no
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PH Fl - NHSRC - SHRC Chhattisgarh
representation of such grievances - I do it on my own but it's not heard.
The review was done last year by the directorate but till date the
(administrator) has not been able to get the paper. From here, whatever
paper goes to the (administrator) keeps lying in the trash at the
directorate. The (administrator) says that he did not receive any such paper
and (senior administrator) says that he does not know anything. (Allopathic
doctor and specialist, regular, 20 years in rural and remote areas, male)
Request the government to make a mechanism for promotion. When I
have given service at this level for so long then you should also give
opportunity at upper level - at district level (Allopathic doctor, regular, 28
years in rural and remote areas, male)
The Government, no matter how many rules it makes, (it) cannot follow.
They should say "it's been so many years since his post graduation so he
should be settled in district". But they don't do that. I am a specialist for so
many years, but still here. I have stayed on here, willy-nilly. (Allopathic
doctor and specialist, regular, 25 years in rural and remote areas, male)
If a doctor gets posted in a remote area then there is no such policy that
that poor person would get transferred after 5-10 years. The poor guy
keeps aging and continues to stay in the village. Nobody wants to stay
there forever. It is like when a boy (young doctor) comes for a job his
children are small or he is not married. Then by the time his kids are 4-5
years old he should get transferred because of the children's education. If ’
he is unmarried he can stay anywhere. But when he needs schools and all
around then one needs a change of place. The government should have a
clear policy. (Allopathic doctor and specialist, regular, 20 years in rural and
remote areas, male)
I have been working here for 16 years. If we go by government norms then
after 5 years of duty in a tribal area I should have been transferred to
another less remote place - but all these things are not possible. I don't
want to blame the government but this is a fact that without making a lot
of personal efforts, there will be no transfer. (Allopathic doctor and
specialist, contractual, 16 years in remote areas, male)
Deficient human resources, apart from the problems they create from a planner's perspective,
have their most immediate impact on the working lives of the providers who continue to work in
underserved areas. The need for addressing shortages in personnel by filling existing vacancies
was voiced by a majority (32/37) of respondents.
See, I should admit her (a patient standing nearby) - she has malaria. She
has been treated twice previously.
Now if I admit her in the hospital, I
might learn that there is a camp or that I have to run to one of the PHCs
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PHFI - NHSRC - SHRC Chhattisgarh
(where there are no other allopathic doctors).
And there is no staff
(nurses) here. This is why I don't admit patients. I keep them in OPD for 2-
3 hours when I am sitting, then I ask the patient to come again the next day
or day after next, but I can't ask them to stay overnight. (Allopathic doctor,
regular, 11 years in remote areas, male)
There is X-Ray but the technician is not there so it is not operational... The
workload has also increased, with me and (a colleague) what has happened
that I have to look after a entire PHC and a CHC. (The colleague) has two
PHCs - (names of PHCs). Because of the workload I feel unsure. I think that
if I get one helping hand then I will be able to do it. (Allopathic doctor,
regular, 4 years in remote area, female)
There is one nurse and a ward boy, so its very difficult to manage with just
2 people. I am one doctor and I am looking after 2 PHCs when there should
be 4 (doctors looking after 2 PHCs). I had sent a written request but there
has been no posting till now.
I have sent it twice...
(Allopathic doctor,
regular, 8 years in remote area, male)
Cleaners are the biggest problem for the hospital - we only had one
sweeper. Then from Jeevan Deep Samiti we took a part time sweeper.
Even that was not enough - so we have kept him full time now (Allopathic
doctor, regular, 18 years in rural and remote areas, male)
SHORT-STAFFED AND OVERBURDENED
Existing personnel are overburdened and stand to benefit greatly if vacancies are filled
For a population of 70,000 we are just two MB88 doctors. We
have to do post mortems, MLCs, OPD, surgery and official
work also. We also have to take care of the orders from
Delhi, Raipur and (district headquarters). How we manage all
these things is something only we can understand. For the
sake of humanity - even we are humans - we also have family
obligations. We are not able to fulfil our official
responsibilities, and our family life is facing difficulties too.
(Allopathic doctor and specialist, contractual, 16 years in
remote areas, male)
The need for improving the quality and regularity of medical supplies and provision of better
workplace infrastructure was also stated widely, to improve working conditions and enhance
professional satisfaction.
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PH Fl - NHSRC - SHRC Chhattisgarh
There is shortage of materials, and it is of very bad quality. We get only
l/10th of the required materials for everything. IV fluid - whether I talk to
the CMO, the collector, or give in writing - whatever fluid comes lasts only
a week.
For Janani Suraksha Yojana - it is not as important to increase
institutional deliveries as it is to provide facilities in the institution.
We
need at least 500-600 syringes for 150 deliveries. 200 antibiotics. Ladies
come and lie down in labour room - the rubber sheet is never changed. 50
deliveries take place on the same sheet. For the past 20 years I keep
hearing this - there is no delivery table, no syringe, no stand or drip, no
pads or cotton. If we use one suction tube for one child we should not be
using the same for all the delivered babies. If someone is dying of pain we
should not use used syringes. They give 50 gloves for the month, that too
unsterilized, and one has to wash it every time and then use it. There are
no blood banks. There is just one in the district which has 4 bottles of
blood. If we don't give blood then patients die every day. At CMC level if
blood is not given, then many patients will die. Do write all of this down if something will happen by your writing it, then do write it. (Allopathic
doctor and specialist, regular, 20 years in rural and remote areas, male)
OT is not functional, because there is no sterilization apparatus and oxygen
cylinders. Secondly there is a problem of electricity here. Without
electricity it is difficult to do surgery.
If the suction machine does not
function, and if there is no proper sterilization, how can we run it?
(Allopathic doctor and specialist, regular, 7 years in rural and remote areas,
male)
When we are doing caesarean section, most of the things we have to
arrange on our own.
As such government is not able to supply all the
things to the peripheries like the drugs and equipment - there are many
things which we have to order personally. (Allopathic doctor and specialist,
regular, 4 years in rural area, female)
In 21 places there is no sub centre - so what should the Sister (ANM) do?
Should she open the subcentre at somebody's place? Fix one room for
deliveries, with plastic on top? (Allopathic doctor and specialist, regular, 25
years in rural and remote areas, male)
Being a BMO I should be getting a vehicle to work on field only then will I
be able to cover whole field of 70,000 people - vehicle, diesel, driver, these
are petty things that should not need to be said. But, even to do that I have
to make lots of efforts and despite those I haven't received them. I have to
use my own vehicle and spend on my own petrol and diesel to do field
work (Allopathic doctor and specialist, contractual, 16 years in remote
areas, male)
63
PHFI - NHSRC - SHRC Chhattisgarh
While many had attempted to raise issues of personnel and material shortages with their
supervisors, with varying success, some regarded it to be a futile exercise.
It is unlikely that someone will join. People come, see the place and go... if I
discuss all these things (shortages of staff and materials) with him (the
CMO) then it's a waste of time for me as well as him. Therefore I do not do
it. The OPD is too heavy for me, I want another doctor, but he himself does
not have one, how will he give for me? (Allopathic doctor, regular, 4 years
in remote area, female)
Now here we need medicine but don't have it... I did discuss this CMO
sahib and he is 'yes, yes, yes', but then later nothing. I mean, you are giving
computers everywhere....and there are facilities of mobile phones - if you
want to do so much then why don't you give it to me? Medicines don't go
waste at my OPD. So there is a problem that I don't have medicines and
then what should I say to the patient? (Allopathic doctor, contractual, 18
years in remote areas, male)
Greater opportunity for training and skill development was another explicitly expressed need
of a number of respondents.
If the government can get the doctors who are posted in the peripheries to
polish their skills once in a year or so... A refresher course - we must be
given a chance to do something like that. So that even we are benefited
and we do not forget whatever we have studied. (Allopathic doctor and
specialist, regular, 4 years in rural area, female)
I have to refer out many cases. We should be given a refresher course at
least every 2 years, and we should also be given MD (postgraduate degree)
training, or at least a diploma.
Because we live in remote areas, if they
make us into specialists and get us to do MD then the people will be
benefit. Cases that we end up referring would then be taken care of.
(Allopathic doctor, regular, 11 years in remote areas, male)
Yes, if they train me in orthopedics, (I) will definitely go. They should
organize trainings twice a month! (laughs) Also for burn cases - we are not
able to manage such cases well. The third is maternal health. We are all
male doctors. Initially they do not prefer us - there are some reservations
in the community, but when there is a lot of problem then they do not
think male or female doctor - this would be most beneficial. (Allopathic
doctor, contractual, 18 years in remote areas, mole)
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PHFI - NHSRC - SHRC Chhattisgarh
'MY PATIENTS SHOULD COME TO ME FIRST'
There was a particular demand for needs-specific clinical skills development
among respondents, in areas which reflected their field experiences, and which
would enhance their response to community needs.
If I am given more training in handling TB then I will like it
because I have seen cases very closely, I have seen
patients dying so I feel like I want to be able to do
something about it.
The biggest thing is that patients
don't come here often - they go to (a nearby block
headquarters with private doctors). So it hurts - I feel
that when I am sitting here then my patients should come
to me at least the first time. And I feel that if I was able to
tell people more about DOTS and TB care then maybe the
condition would not have been such. (AYUSH doctor,
contractual, 2.5 years in remote area, male)
Many a time we are in the field and the condition is such
that we feel we don't have enough skills.
Especially in
surgery and obstetrics - we want to treat, but we don't
have the authorization. So it would be good to get some
training.
From the beginning I have had an interest in
surgery, but even if we want to do we are unable to - so
this is the only thing left (Allopathic doctor, regular, 18
years in rural and remote areas, male)
The need for better living and housing arrangements was commonly reported across all
categories of respondents. Costs of repairs in dilapidated housing were often borne personally,
and sharing of living quarters was commonplace.
Some respondents complained about the
indignity of living accommodations which they felt did not befit their professional status.
Give a few amenities to the doctors. They should make quarters for
doctors, not like a primary school master - there are many who are living in
rented houses - to bathe, they are going outside to the river. So all this is
not right. If you are constructing a PHC somewhere then along with that
you should make quarters - a little away from the common people. All
these accommodations are not so good - repairs are often needed, and we
have to do it ourselves. The government only provides the wall and the
roof - if anything has to be improved, we have to do it. (Allopathic doctor,
regular, 18 years in rural and remote areas, male)
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PH Fl - NHSRC - SHRC Chhattisgarh
The second doctor who is here is staying with me, in my quarters. Some
work has been done in my quarter, but in his part, nothing much has been
done10 - so he is staying with me only. (Allopathic doctor, regular, 19 years
in rural and remote areas, male)
Doctors do not want to come to the village, but why? First thing is that
accommodations here are inadequate. For the past 2 1
/2 years, I was staying
in rented quarters - my quarters have just been constructed. If a MBBS
doctor is joining here and he sees that if there is no facility for him to live,
then how will he feel? I did not have a room to stay in for 3 years. But not
everybody would have the same attitude. Because I am raised in a village
we do not take time to adjust but if someone from the metros or good city
then how will he adjust? (Allopathic doctor, regular, 2.5 years in rural and
remote areas, mole)
So we have to stay together, have to share. I took this room in the hospital
(facility) building only. It is actually a sub-centre building - one room and
kitchen. So 3 people live in one room - 2 doctors and one pharmacist. For
staying, some better arrangements should definitely be made. (AYUSH
doctor, contractual, 3 years in remote areas, male)
The need for quality education for their children was widely and emphatically cited by
respondents (27/37), across all groups and categories. A number of doctors in very remote
reported that they were happy to remain primarily because there were good schools in the
vicinity. In other instances, those who were otherwise content with rural work reported that
better schools were the only reason which would have led them to migrate to cities.
I want to give my children a good education, so in my circumstances I have
to keep them in Raipur. I don't know how many years it will take for a good
school to open here. (Allopathic doctor, regular, 11 years in remote areas,
male)
It is the main reason - if a doctor joins here then there is no facility for
water and electricity, there are no doctors7 quarters, but the biggest
problem is that that they can't give their children even primary education.
So according to the times, his children will lag behind. So because of this
nobody wants to join here. At block level at least there should be a school
for children - from there, doctors can go daily to their PHCs. This way there
will be more doctors for rural service. (Allopathic doctor and specialist,
regular, 8 years in rural and remote areas, male)
10 The second doctor's allocated room was in a state of partial destruction, with two walls and part of the
roof missing
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PHFl - NHSRC - SHRC Chhattisgarh
There are no schools here - there are government schools but no teachers.
Schools are in a bad condition - there is a high school but there is only one
teacher - can you imagine from primary to high school only one teacher!
(AYUSH doctor, contractual, 3 years in remote area, male)
Because I am a PG in medicine, even I have a desire that, like those children
who are going to good schools and have good places to go to from there,
similarly our children would also attain a good position. But we are not
even able to give our children good education, the most basic thing.
(Allopathic doctor and specialist, contractual, 16 years in remote areas,
male)
Now for our children education is not possible here.
The government
should make such a plan where our children can study in a modern school.
If they did that, then we would have been tension-free today. And the
service we are doing for the government would be done with interest.
(AYUSH doctor, contractual, 6 years in remote area, male)
Growing concerns in the wake of increasing civil violence and insurgency are summed up in this
female doctor's account. The need for assurance of personal security is clearly important for
doctors in certain violence-afflicted areas.
Staying here has really become difficult. Day by day, the condition is
deteriorating. The Naxalite problem has increased. When I had initially
come here it was not ’that bad. But in last 5-6 months it has got worse.
Although they do not trouble us a lot but you never know what trouble we
may land up in. That is why I feel that it is better to go from here. They
recently burnt a truck near the ANM's house. It is not very safe in the
village. We feel afraid. (Allopathic doctor, regular, 4 years in remote area,
female)
The posting is fine here. There is no problem as such, there is no real
problem from Naxals here, but still if there is a sound of a gunshot, then
mind does get disturbed. Especially at night if it seems that there is
something happening and someone is approaching, it makes me anxious.
(Allopathic doctor, regular, 16 years in rural and remote areas, male)
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PHFI - NHSRC - SHRC Chhattisgarh
SUMMARY: WHAT THEY NEED
The respondents' expressions of their needs - reflecting perceptions of changes which would
improve their experiences of working in rural and remote areas - encompassed a range of
reforms and improvements.
Better salaries and job security were emphatically stated by
contractual doctors, while the entire cross section of doctors emphasized the importance of
more rational transfer and promotion procedures, filling of health worker vacancies, and
improvements in materials and facilities. More opportunity for needs-based skills training and
better housing also found significant mention. Social needs voiced included (most prominently)
better schooling for their children, and assurance of personal security.
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PH Fl - NHSRC - SHRC Chhattisgarh
SUMMARY OF FINDINGS
A synopsis of key observations is presented in Table 5 below.
Reasons for
Joining
Factors
Favouring
Staying On
Needs
Expressed
________________ MAJOR 11____________
______________ MINOR12
- Geographical and ethnic (tribal) affinities
- Personal values of service
- Financial compulsions________________
- Geographical affinities
- Rural upbringing
- Ethnic (tribal) affinities
- Availability of good schools in the region
- Personal values of service
- Professional interest and ambition
- Strong relationships with colleagues
- Anticipation of security of regular job (C)
- Opportunity for both spouses to work
and live in the same location (F)
- Inducements of preferential
admission to higher education
- Assurance of job security (C)
- Improved workplace arrangements and
resources
- Good schools for children
- Better housing
- Needs-specific training and skill
development
- Spiritual and religious leanings
- Disinclination for private practice
- Financial compulsions
- Getting accustomed to rural life
- Closeness to parents and family
- Familiarity / familiarization with
village life
- Good relations with local
communities
- Satisfaction and fulfilment
- Good relations with supervisors
- Better salaries (C)
- More rational promotions and
transfers
- Assurance of personal security
Table 5. Key findings from the study
(C: specific to contractual doctors, F = specific to female doctors)
Practitioners7 initial decisions to join service in rural and remote areas were often influenced by
prior familial and community linkages with the place (district or region) in question. In other
instances the decision to join was often automatic or unmeditated - they were simply posted
there by the state health administration.
Once in service, doctors not only faced adverse external circumstances but also struggle with
magnifications of the generic problems of government health systems. These conditions evoke
a mix of responses among doctors, some revelling in the experience and finding opportunities in
the challenge of adversity, and others confronting an eroding knowledge base and decline in
professional confidence and capabilities.
The doctors' decisions to remain in rural and remote areas over periods of time were driven by a
more complex set of factors reflecting personal qualities, community linkages and systemic
factors and influences. Critically combinations of reasons were as important as discrete factors
in influencing the decisions of the practitioners to remain. Life processes, professional interests
11 Prominent themes - elicited widely and/or emphatically expressed
12 Less prominent themes - elicited among or expressed by fewer respondents
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PH Fl - NHSRC - SHRC Chhattisgarh
and ambitions and relationships built over periods of time influenced the doctors' decisions to
stay on.
Respondents' views were also canvassed on what they needed to improve their experiences of
working and living in remote and rural areas, which covered a spectrum of potential reforms and
improvements around institutional procedures, redressing resource gaps, and job safety.
The professional insecurities of contractual doctors set them apart in some respects - both of
factors favouring staying on and their stated needs.
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PH Fl - NHSRC - SHRC Chhattisgarh
STRATEGIC IMPLICATIONS
Of all facets of an effective health service, the presence of health workers is the most
fundamental requirement. The successful implementation of health care plans requires close
attention, not just to the needs of end-users of care but also to frontline providers of health
care, their antecedents, the circumstances in which they live and discharge their duties, the web
of interactions which define their roles in health systems and societies, and their interests,
aspirations and needs (Sheikh and George 2010).
This qualitative research study explores a phenomenon which should in ideal terms be a fait
accompli - the presence of health workers in health care facilities - but which in the unfortunate
reality of rural health systems, is often rarer than their absence. In its exploration of the work
and lives of qualified practitioners who continue to remain in service in remote rural locations of
Chhattisgarh state, the study yields findings which are of strategic relevance in Chhattisgarh and
Indian health policy contexts, and also contain important global lessons for strategies to retain
qualified health workers in rural and remote areas.
Geographical and ethnic affinities, and a rural upbringing, appear to be dominant factors
favouring doctors' decisions to join and also to remain in service in rural locations. This finding
supports the deployment of policies such as affirmative action for entry into medical education
for doctors originating from underserved areas, and also potentially for candidates with tribal
ethnicity. Another potential strategic direction suggested by this finding is the decentralization
of medical training: the institution of medical colleges in rural and remote areas, to enable
medical aspirants with a rural upbringing to train and join work in their preferred places of
residence. Acclimatization to rural life also emerged as an important factor favouring doctors'
decisions to remain, which also underscores the importance of rural medical education.
While the need for an absolute increase in pay-scales did not emerge as a strong theme among
this selection of respondents, this should not be interpreted to mean that the issue of economic
returns is insignificant. The importance of regular remuneration and of attendant benefits to
government servants such as better housing and educational opportunities for children cannot
be overstated.
Furthermore, a graded salary scale based on remoteness and difficulty of
terrain, and greater benefits (pensions, housing, free education for children) to doctors serving
in difficult areas could be of particular utility, particularly in the context of the war-like
circumstances in parts of the state, the implicit risks to personal security and social isolation.
Special efforts can be undertaken by the state to assist doctors' spouses in finding employment
in the same areas, and in facilitating admission to high quality schools with boarding
arrangements for their children. Voluntarily implemented rotation policies, with the option of
limiting the time spent in a particularly difficult area, may also help to improve uptake of remote
postings.
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PHFI - NHSRC - SHRC Chhattisgarh
The strong personal values and professional interests evinced by a number of respondents belie
the popular myths that doctors remain in rural areas only out of compulsion, and that
government service is widely considered inferior to private practice.
In spite of significant
concerns over the quality of working environments, regular government service was widely
regarded by respondents as a stable career option, and a positive opportunity to contribute to
the broader social good.
Substantive interventions aimed at building on these positive
conceptions by raising the acceptability of employment in rural health services, as well as the
image of government health services among rural communities may well serve to attract more
new recruits and aid in retention of more qualified workers.
First and foremost, the profile of government health care can be enhanced by providing better
working conditions for health workers - including better infrastructure, materials and, ironically,
more manpower. The presence of adequate numbers of staff in health facilities improves the
working experience for those already in station, creating a positive cycle: more manpower
improves working conditions which in turn attracts more manpower / aids in retention.
Nurturance of doctors' professional interests and ambitions, and stemming the erosion of
professional skills is another critical step in raising the social profile of government services.
Opportunities to enhance skills and academic exposure in areas which reflect community
needs act to further doctors' professional interests and can reduce problems of intellectual
attrition and isolation - doctors particularly emphasised the need for refresher clinical skills
training in areas such as emergency and accident care, obstetrics and maternal health,
tuberculosis and malaria care. Electronic communication on medical subjects with peers and
specialists through video and teleconferencing interfaces has become possible, and could help in
countering the professional isolation and skill attrition experienced by rural doctors. The
introduction of postgraduate specialist degrees in rural medicine and primary care is another
intervention that can act to enhance the acceptability and status of rural practice.
Also very significantly, doctors seek accountability and respect from their employers. Rational
and transparent procedures for placement, transfer, promotion and upgradation from
contractual to regular services can all play a role in making rural government service a more
attractive proposition. Lastly, cosmetic gestures are not without their pragmatic importance. It
is an unfortunate commentary that in some circles, rural postings were regarded as 'punishment
postings' or as last resorts for those without the personal connections or entrepreneurial
initiative to find work in cities. Far-removed from this image of the unsuccessful outcast, some
doctors asserted their own self-perceptions as heroes and frontier soldiers in defence of those
most in need. The goal of greater retention may well be served if authorities were to share and
promote this perception, and commence to accord formal recognition and reward for services
under difficult conditions to health workers with appropriate credentials and histories of rural
service.
Authorities can also assist in building positive and enabling working environments
through context specific packages of activities - including supportive supervision, tour
programmes, and scientific events. Organized forums and occasions for intermingling with social
and professional peers and with local communities can also engender stronger perceptions of
appreciation and recognition.
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PHFI - NHSRC - SHRC Chhattisgarh
The findings of this study, emerging through a systematic, rigorous, reflexive and well-validated
research process, are nevertheless of a subjective nature. While the authors believe that they
have significant value in informing strategic directions, they are not intended to represent an
immediate blueprint for policy change, (which is necessarily context-specific, subject to the
prevailing balance of health sector priorities and to considerations of operational feasibility,
political viability and cost). How these findings can serve is 1) as an inferential basis for strategic
directions which deserve to be field-tested for impact and appropriateness, and 2) to highlight
specific systemic enhancements which may aid in improved retention of the qualified public
health workforce, locally, nationally and globally. Key potential strategic implications which can
be inferred from this study are summarised as follows:
Establishment of more medical training institutes in rural and remote areas
Strategies promoting affirmative action for entry into medical education for doctors
from underserved areas, and of tribal ethnicity
Enhanced and assured government employee benefits, notably quality housing and
children's education
Introduction of graded salary scales based on remoteness and difficulty of terrain, and
enhanced packages of benefits to doctors serving in difficult areas
Introduction and implementation of voluntary rotation policies, with the option to limit
the amount of time spent in particularly difficult areas
Stringent implementation of standards for working conditions - including adequacy of
infrastructure, materials and manpower
Augmenting in-service training opportunities to closely reflect community and trainee
needs
Measures to enhance rationality and transparency of procedures for placement, transfer
and promotion
Institution of formal recognition and rewards for services under difficult conditions
Summary: strategic implications
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PHFI - NHSRC - SHRC Chhattisgarh
REFERENCES
1.
Britten, N., 2000. Qualitative Interviews. In C. Pope & N. Mays, eds. Qualitative Research in
Health Care. Blackwell Publishing Ltd., pp. 12-21.
2.
Chomitz, K. M. (1997). "What do doctors want? Developing Incentives for Doctors to Serve in
Indonesia's Rural and Remote Areas."
3.
Dieleman, M., P. Cuong, et al. (2003). "Identifying factors for job motivation of rural health
workers in North Viet Nam." Hum Resource Health 1(1): 10-10.
4.
Dussault, G. and M. C. Franceschini (2006). "Not enough there, too many here: understanding
geographical imbalances in the distribution of the health workforce." Hum Resource Health 4:
12-12.
5.
Grbich, C., 1999. Qualitative research in health: an introduction, London: Sage.
6.
Lindelow, M. and P. Serneels (2006). "The performance of health workers in Ethiopia: results
from qualitative research." SocSci Med 62(9): 2225-2235.
7.
Mays, N. & Pope, C., 1999. Quality in qualitative research. In C. Pope & N. Mays, eds. Qualitative
Research in Health Care. London: BMJ books, pp. 82-102.
8.
PHFI & World Bank (2008). Career Preferences of Medical and Nursing Students in Uttar Pradesh
- A Qualitative Analysis, Public Health Foundation of India & The World Bank, New Delhi.
9.
PHFI (2008). The Size, Composition and Distribution of India's Health Workforce, Public Health
Foundation of India.
10. Pope, C. & Mays, N., 2000. Qualitative methods in health research. In Qualitative research in
health care. London: BMJ Publishing Group.
11. Porter, J.D.H. et al., 2002. Lessons in integration - operations research in an Indian leprosy NGO.
Leprosy Review, 73(2), 147-59.
12. Ritchie, J. & Spencer, L, 1994. Qualitative Data Analysis for Applied Policy Research. In A.
Bryman & R. Burgess, eds. Analyzing Qualitative Data, London; New York: Routledge, pp. 17394.
13. Serneels, P., M. Lindelow, et al. (2007). "For public service or money: understanding
geographical imbalances in the health workforce." Health Policy Plan. 22(3): 128-138.
14. Sheikh, K. & George, A., 2010; India's health providers - diverse frontiers, disparate fortunes. In
K. Sheikh & A. George, eds. Health Providers in India: On the Frontlines of Change, New Delhi:
Routledge, pp. 1-14
15. Silverman, D., 2004. Qualitative Research: Theory, Method and Practice, Sage Publications Inc.
16. WHO (2006). Working together for health. The World Health Report. Geneva, The World Health
Organization.
17. WHO (2007). Not Enough Here... Too Many There - Health Workforce in India. New Delhi, World
Health Organization, Country Office for India.
18. World Bank (2008). Global Monitoring Report 2008 - MGDs and the Environment. Washington
DC, The World Bank.
19. Zaidi, S. A. (1986). "Why medical students will not practice in rural areas: evidence from a
survey." Soc Sci Med 22(5): 527-533.
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PHFl - NHSRC - SHRC Chhattisgarh
ANNEXURES
Topic Guide
TOPIC GUIDE
Introduce self and engage respondent
Provide information on the study and objectives, confidentiality and further information as
detailed in the consent form
Take informed consent for interview and for recording the interview
Switch on recorder
Commence the interview
TOPICS
1.
2.
3.
4.
5.
6.
Educational, professional and social history
Context of joining their respective profession
Experiences of working in their present location
Experiences of working in other locations, if any
Social goals and ambitions
Professional goals and ambitions
7.
8.
9.
Remit of medical duties and activities
Types of patients - medical profiles
Types of patients - social and economic profiles
10. Interactions with patients, remarkable or long-standing associations if any
11. Familial bonds, experience of geographical distancing from family, if so
12. Community bonds, experience of geographical distancing from community, if so
13. Interactions with community leaders, social movements, political actors
14.
15.
16.
17.
18.
19.
Experiences of working arrangements
Experiences of remuneration arrangements
Interactions with co-workers, supervisors, referral units, other health system actors
Experiences of opportunities for personal development / capacity-building
Experience of changes and reforms in working arrangements or remuneration, if any
Experiences of competing opportunities elsewhere
Obtain / reconfirm the following details
Full name of respondent
Designation of respondent
Full qualifications
Total duration of experience
Duration of experience in rural / remote rural area
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PHFI - NHSRC - SHRC Chhattisgarh
Points to remember while conducting interview:
Take time to build rapport and comfort
Cover all the topics carefully, as the interview proceeds although not necessarily in sequential order
Encourage detailed narratives of experiences, probe carefully to encourage - not interrupt - narratives
Focus on experiences of specific events and phenomena, not on hypothetical or abstract examples
Encourage respondents to provide explanations of their experiences, rather than opinions which are not linked
to specific experiences
Probe appropriately, introduce new topics naturally in the course of conversation
Avoid leading questions, do not pre-empt responses
Always be respectful, adopt a neutral tone and consciously avoid expressing judgment, even if you do not agree
with the respondent
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PH Fl - NHSRC - SHRC Chhattisgarh
Foi'm for Obtaining Consent.
Consent Process and Form
Information to be conveyed to the health worker prior to obtaining consent:
We are doing a research study exploring the experiences and circumstances of qualified health workers
who have worked for a long time in rural and remote areas.
This study is being conducted by the Public Health Foundation of India, National Health Systems Resource
Center of the Ministry of Health and Family Welfare, Government of India and Chhattisgarh State Health
Systems Resource Center, Government of Chhattisgarh.
We are hoping to talk with you for about 30 minutes to one hour. Please talk to us freely and frankly and
let us know if there are any issues we bring up that you do not want to discuss. At any time, you may
terminate an interview or request that interview data be removed from the study.
Your participation in this study, and all records about your participation, remain confidential. All data will be
stored in secure locations and available only to study personnel. None of the information obtained will be
identified with you, or your place of work.
If you have any questions now I will answer them, and if you have questions later you can contact us
Statement of person administering consent
I have fully explained to
the context, purpose, procedures and risks that
are involved in the above-described study. I have taken free and informed consent from him/her to
participate in the interview, without suggestion or coercion. I have answered all questions to the best of my
ability.
Date
Signature (Person Administering Consent)
Name
Witnessed by:
Name
Signature (Witness)
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PHFI - NHSRC - SHRC Chhattisgarh
Thematic Framework ofAna lysis
Superfamily
| Code Family
BACKGROUND
Personal antecedents
______________ B_FAM
| Codename
B COM
B_LOC
Personal family history
History of community affinity (ethnic / linguistic /
religious)_________________________________________
Place of upbringing or education
B-EDU
Personal history of education and qualifications
B_PROF
BJDTHWK
Circumstances of entering medical profession_________
BJOIN
FACTORS
| Definition: Segment of text which describes:
Previous work experience other than in present location
Circumstances of joining work in present location
Factors favouring staying on - personal___________________________________________
F_PERVAL
Personal values with bearing on experience of staying on
F ACCUST
Process of getting accustomed to living and working in
present location___________________________________
F_FAMREL
Relationships with family with bearing on experience of
staying on
F_RELIG
Religious inclinations with bearing on experience of
staying on________________________________________
F_SPOUSE
Spouse-related factors with bearing on experience of
staying on
F PP
Opportunity for private practice in present location
Factors favouring staying on - community_____________ ___________________________
F_ETH
Ethnic affinities with bearing on experience of staying on
F_GEOG
Geographical affinities with bearing on experience of
staying on________________________________________
F_GOVREL
Relationships with government actors (local self-govt,
dist administration, other) with bearing on experience of
staying on
Relationships with political movements or actors
(including insurgent and counterinsurgent groups) with
bearing on experience of staying on__________________
F_POLREL
F_COMMREL
Relationships with local communities with bearing on
experience of staying on
Factors favouring staying on - health system_______________________________________
F_COLREL
F_SUPREL
Relationships with workplace colleagues with bearing on
experience of staying on____________________________
Relationships with supervisors or superiors with bearing
on experience of staying on_________________________
FJOBSEC
Job security as a factor bearing on experience of staying
on_______________________________________________
F_WORKVAL
Valuation of work: enjoyment, satisfaction and challenge
of work, ideals of professional service or professional
identity
Compulsion to remain in present location_____________
F_CQMPUL
F_PREST
Prestige (of government job, among peers and
colleagues, etc.) as a factor bearing on experience of
staying on
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PH Fl - NHSRC - SHRC Chhattisgarh
Factors favouring staying on - patients_____________________________________________
F_PATREL
Relationships with patients with bearing on experience of
staying on
NEEDS
Needs which would enhance experience of staying on________________________________
N_SALUP
Significance of increase in salary_____________________
N CHILDED
N ACAD
Significance of educational opportunities for children
N_PEER
Significance of opportunities for peer interactions______
Significance of better personal security_______________
N_PERSEC
NJOBSEC
N_PROM
N TRANS
N STAFF
N MAT
N_HOUS
N ACK
N_SUPER
N SOC
NARRATIVES
Experiential narratives
NAR CRITEX
NAR COP
Significance of opportunities for academic exposure and
development
Significance of job stability and security (mainly for
contractual employees)_____________________________
Significance of more rational procedures and policies for
promotion________________________________________
Significance of more rational procedures and policies for
transfer and placement_____________________________
Significance of correcting shortages of support staff or
colleagues________________________________________
Significance of correcting shortages of equipment and
materials and improving working conditions
Significance of better residential arrangements________
Significance of better acknowledgement and recognition
of contribution____________________________________
Significance of better supervisory support and guidance
Significance of improved social life and leisure facilities
Critical experiences which provide an insight into the •
individual experience of living and working in__________
Experience and mechanisms of coping with personal and
circumstantial problems of living and working in the
present location
<^jealth Awaren,
Scanned
Date:
5^—
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