Skip to main content

Table 1 Proposed policies to improve rural distribution and retention of doctors in Uttar Pradesh

From: Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India

Policy

Rationale

1. Increase opportunities for students from rural backgrounds to enter medical college in the public sector, through providing state sponsored training for the NEET for students from rural areas. (Production)

• Since 2016, medical college aspirants in India must take the National Eligibility cum Entrance Test (NEET) and score within a specified percentile in order to secure admission.

• However, reports have found the exam to perpetuate inequities in medical college admissions, such as favoring students from wealthier, urban backgrounds [22].

• The success of these students is also driven by their ability to afford private ‘coaching’ for the examination through a pervasive, profit-driven coaching industry [55].

• Research suggests that medical students from rural areas are more likely to return to serve in rural areas [23], thereby raising questions about the challenges of recruiting rural students in the current system of NEET coaching.

• Government sponsored NEET coaching has been announced by the Delhi Government and the National Training Authority, and by the Government of Tamil Nadu [24, 25]. The policy proposes that GoUP similarly create opportunities for students from rural backgrounds to enter medical professions.

2. Modify and enforce a compulsory rural posting policy requiring that all newly hired doctors spend a minimum of 3 years in an underserved community (priority districts/underserved rural facilities) so as to increase the availability of health staff in rural areas, after which they have the option to transfer to another posting. (Recruitment)

• Compulsory service programs have been used to deploy and retain health workforce in rural areas in many countries and have demonstrated varied success [26,27,28].

• GoUP required newly hired doctors to be posted to a Primary Health Center at the discretion of the District’s Chief Medical Officer (CMO). However, key informants indicated that these policies were poorly enforced and subject to informal influence. These factors provided new medical officers the ability to circumvent requirements and be posted to higher level facilities.

• To address these influences, the proposed modification of this policy builds on recent changes which centralize the posting of new recruits by prioritizing rural areas postings with a minimum duration of 3 years. Upon fulfilling these requirements, recruits may transfer to another posting.

3. Allow home district posting for clinical cadres (Retention)

• Home district posting is restricted for a large number of government cadres across Indian states including doctors and staff nurses in UP as a means to reduce conflict of interest with the quasi-judicial and financial powers associated with this category of government posts.

• There is growing consensus that this should not be applied to clinical cadres like doctors and nurses who have limited responsibilities that put them in a position of a conflict of interest, instead, clinical cadres are also likely to be more accountable when serving their own communities.

• Key informants noted that home district posting could further contribute to greater availability of health workers in rural posts given that such students are more likely to go back and serve in their communities [23]. This will also address gaps in recruiting more students from rural backgrounds for medical training.

• Furthermore, several Indian states, including Gujarat, have also relaxed home district posting to address rural shortages [29].

4. Living conditions – Improve staff housing infrastructure and security in rural facilities (Retention)

• In discussions with key informants, appropriate living conditions, including the ability to live with family, emerged as an important motivation for health workers in UP in choosing a posting.

• These factors have also been identified as key in other states in India [20]. For example, graduating medical students in the state of Odishaviewed good housing and adequate facilities as key to attracting more students toward rural service [30].

• While GoUP currently has policies and allocation of funds for infrastructure improvements, including housing for health workers, key informants noted that implementation remains a challenge.

• Group housing for health workers to enable them to live with their families and have access to basic amenities and security while working in far flung areas has been a policy option that states like West Bengal, Uttarakhand and Chhattisgarh have used [28]. GoUP may consider a similar policy to improve living conditions for health workers in rural areas.

5. Working conditions - Increase coordination across health departments and agencies to ensure that health workers have appropriate inputs and supports to do their job including the availability of functioning equipment, electricity, drugs and other supplies. (Retention)

• The conditions in which doctors work – such as supplies, drug and equipment availability, electricity, water and other utilities – are major issues for doctors to contend with upon entering government service, particularly in rural areas [28].

• Studies across multiple Indian states have found working conditions to be an important factor in retaining staff in rural areas [30, 31].

• The UP Directorate of Medical and Health, UP National Health Mission, and the UP Medical Supplies Corporation have policies and resources to ensure adequate working conditions, however, key informants suggested coordination across different agencies and levels was essential yet often neglected.

6. Permit private practice for government doctors and develop a policy that regulates hours and conditions under which private practice can occur and remove the non-private practice allowance. (Retention)

• Dual practice is a widespread phenomenon in LMICs, and is also used as a retention strategy to retain highly-skilled physicians in the public sector [32].

• Negative impacts associated with dual practice include absenteeism or fatigue among health workers, and diversion of patients to private clinics [33].

• In India, dual practice is widely believed to be common, and high rates of absenteeism have also been inferred as indicative of dual practice [34].

• In UP, private practice is not permitted and government doctors receive an NPA (non-practicing allowance), which currently forms 20% of a medical officer’s basic pay, to compensate doctors. However, it is perceived by some key informants that this rule is widely flouted and a majority of government doctors pursue some form of private practice while receiving NPA.

• Several other Indian states have a similar ban on private practice along with an NPA [35]. However, there are exceptions. In the state of Kerala, public doctors can see patients on a ‘private fee-for-service’ basis outside their government work time [34, 35].

7. Support the shifting of tasks from MBBS to AYUSH doctors in rural settings:

i. Assess the clinical competence of AYUSH doctors in the provision of services previously provided by MBBS

ii. Provide additional on-the-job and short-term training to AYUSH doctors

iii. Ensure supportive supervision to AYUSH doctors

iv. Explore further task shifting options for Specialists to MBBS and MBBS to nurses

(Planning, regulation and governance)

• Task-shifting has been used in many countries and in several Indian states to address serious workforce shortages of health workers [36,37,38].

• In some Indian states, AYUSH providers are co-located with allopathic doctors in primary health centers, and in recent years, have been permitted to prescribe a limited range of allopathic medications [36, 37].

• In UP, there has been some movement to broaden task shifting of biomedical services to AYUSH providers in rural PHCs. Qualified nurses have more recently been engaged as Community Health Officers at Health and Wellness Centres.

• Key informants suggested that further training and monitoring of task shifting to AYUSH was required in the UP context.