I thank the authors for their insightful comments1 on my commentary2. They have raised a number of important points which have to be addressed.
The issue of doctors being unwilling and unable to serve in rural areas is a major one. While hard data is lacking, many primary health centers in rural areas lack doctors. Retaining doctors in rural areas remains a major challenge. I agree with the authors that doctors are more likely to remain in rural areas if they can stay with their families. The lack of appropriate housing, food, other facilities and inadequate schooling options for children could also be reasons preventing families from moving to rural areas. One possible solution is a general improvement of the facilities in rural areas; another is providing 'special' facilities for doctors, health workers and their families.
I also agree with the authors that there is no strict definition of a rural area. A survey among nurses in Canada defined community characteristics, geographical location, health human and technical resources and characteristics of nursing practice as key factors determining rurality3. The study quoted by the authors also states there is no universal definition of a rural area4.
In parts of south India, especially the state of Kerala and in Sri Lanka, those in rural areas have almost all the facilities and conveniences available in cities5. Because of this, doctors and health workers in rural areas have access to facilities equivalent to those of their urban counterparts. In addition in this case, the rural population has the ability to pay for services. As a consequence, these areas have fewer problems in attracting and retaining doctors5.
In Kerala, household disposable incomes have been rising steadily and the private sector is increasingly playing an important role in providing health care5. People were and are able to pay for healthcare services and this has been exploited by the private sector. The factors affecting the growth of these health services have been studied, and the growth of education, especially female literacy, has created awareness of health matters. In addition, settlement patterns due to the growth of roads and communications have facilitated access5. The government invests substantially in the health and education sectors and there are a number of agencies that provide funds for the development of health facilities in the private sector.
Other factors influencing retention briefly mentioned by the Comment authors include financial incentives, career development and management issues - all important factors affecting staff motivation6. Recognition is also highly influential in health worker motivation. A study on health worker motivation in Africa showed health workers are strongly motivated by their professional conscience and professional ethos7. Motivation is also described as willingness to exert and maintain an effort towards attaining organizational goals. The work environment, support, supervision and recognition, appreciation by superiors and the community have all been mentioned as motivating factors.
I agree with the Comment authors that other health workers are equally important in healthcare delivery in Nepal. I only briefly touched on this issue towards the end of my Commentary due to the need for brevity, and the fact that my primary focus was on attracting and retaining doctors in rural areas. Non-physician health workers have played an important role in public health in Nepal.
I agree with the authors that the 'pull' factors for health work force migration also need to be considered. Developed nations derive significant benefit from the migration of developing nations' health workers. The policy of not recruiting health workers from developing countries, or of the developed nation compensating the loss of health workers has been discussed. As is rightly mentioned by the Comment authors, developing nations cannot compete in terms of remuneration and facilities. It has recently been suggested that the United States of America (USA) has an important role in genesis and solution of the migration problem8; for, in an attempt to ensure care for its neediest people, a continuous supply of foreign graduate. The USA can produce enough medical graduates to fill all the residency positions. If structural adjustments imposed by the International Monetary Fund (IMF) are a major reason for developing nations reducing internal spending on healthcare, the USA could play an important role in reversing these policies. The issue requires dialogue and cooperation between developed and developing nations.
The Comment authors also mentioned the contribution of bonds for doctors. The issue of compulsory service programs for health workers has recently been examined in detail9. In my original Commentary I quoted this research and concluded that compulsory service programs can only provide a temporary solution. Rural health workforce disparities among countries with and without compulsory programs have not been studied. Such programs may not provide a permanent workforce or a permanent solution for capacity development. The advantage of compulsory programs is that health workers who have completed their period of compulsory service and leave can be replaced by the new batch of health workers. It may also have the benefits of a lower financial outlay, which is important for low and medium income countries.
My Commentary can only serve as an introduction to the complex issue of doctor retention in rural areas of developing countries. It may also, however, provide stimulus for debate and action on this important issue.
P Ravi Shankar, MD
Department of Medical Education
KIST Medical College
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