A cross sectional study of attitudes among Goan Doctors towards rural service.
India has a severe shortage of human resources for health. It has a shortage of qualified health workers and the workforce is concentrated in urban areas. Bringing qualified health workers to rural, remote, and underserved areas is very challenging. (2) There is inequitable distribution of qualified allopathic doctors & specialists. Most doctors prefer to work/practice in urban areas. Therefore, there is a mismatch between the felt needs of the rural community and the actual availability of health care in rural areas of India.
Majority of the students who graduate from medical colleges each year, most tend to cluster in cities, where they have better living conditions, schools for their children, social recognition, higher incomes, promotion opportunities and greater job satisfaction.
For allopathic Doctors at PHC, there was a shortfall of 10.3% of the total requirement. The Community Health Centers provide specialized medical care in the form of facilities of Surgeons, Obstetricians & Gynecologists, Physicians and Pediatricians. The situation is even more serious with respect to specialists at the CHCs. There was a shortfall of 74.9% of Surgeons, 65.1% of Obstetricians & Gynaecologists, 79.6% of Physicians and 79.8% of Paediatricians. Overall, there was a shortfall of 69.7% specialists at the CHCs as compared to the requirement for existing CHCs. (3)
It has been observed through many studies that non-availability of health care providers is a major contributor to the poor health indicators of the rural areas. The situation in Goa is no different than the rest of India. Despite having over 2,500 qualified allopathic doctors registered with the Goa Medical Council, there is a shortfall in availability of medical manpower & in particular, full time specialist doctors, at the 5 Community Health Centers in Rural areas of Goa. Many of the posts of Medical officers are lying vacant in the Directorate of Health services. Few allopathic doctors serve in rural areas of Goa compared to urban areas. This study was therefore undertaken with an objective to assess the attitudes among Goan doctors towards service and medical practice in rural areas of Goa.
METHODS AND MATERIALS: A cross-sectional survey was conducted, using self-administered questionnaires, amongst a total of 100 doctors who recently graduated from Goa Medical College during 2010. Open ended questions were asked regarding the reasons for their reluctance to serve in rural areas of Goa. And amongst those who were willing to serve in rural areas, their reason for such options were also studied.
Statistical Analysis: Proportions.
RESULTS: The study found that the majority of the doctors i.e. 71% are reluctant to serve in the rural areas of Goa. The reasons for their reluctance broadly include various issues affecting their social, professional and family life, if they opt to serve in rural areas. Poor amenities in villages (71%) and poor facilities (71%) at PHC were cited as the major reasons. Lack of professional growth cited by for 64%, while the absence of clinical experience was the reason cited by 61% in the present study.
Poor transportation facility (54%) was also a deterrent. Lack of incentives and promotions (42%) also are a big turn off. Many doctors either own residence or wish to own residence in urban areas (36%) and find it difficult to relocate. 32% said that rural service will yield poor income and another 32% were unwilling because it would compete with quacks and AYUSH.
Poor quality of life/living conditions (29%) and poor schooling standards (25%) were reasons for unwillingness. 25% and 22% reply said that rural service will delay in obtaining Post-Graduation and seeking foreign jobs/higher studies respectively. Working in urban areas will accord higher status as stated by 14% doctors in the present study.
Among the 29 doctors who desired to serve/practice in rural areas, the most common reason for willingness to serve do so was to serve rural poor and underprivileged (80%). 69% respondents wanted to serve in rural area because they would get absorbed in Government jobs subsequently. Rural service helping the doctors to obtain higher preference for Post-Graduation (43%), and giving them time to prepare for Post-Graduation entrance (37%) other reasons cited by the respondent in the present study. 34% had their own residence in rural areas whereas 23% wanted to be a General Practitioner.
Rural service will be less stressful (17%), less competitive (11%), lesser supervised and lesser accountability (6%), lesser workload among patients were among other reasons by the doctors. Financial compulsion (6%) and gain rural experience (6%) were among the least reasons to practice in rural areas.
DISCUSSION: In this study doctors were unwilling to work in rural areas because of numerous reasons. The doctors feel that the available health services are insufficient and under developed infrastructure in rural areas will not give them sufficient professional growth and experience. Poor transportation was also another factor responsible, because most of the doctors reside in urban areas. Rural services will also yield poor income which will affect the quality of life. Such posting will also delay obtaining Post-Graduation or seeking foreign jobs or higher studies.
Some of the doctors were willing to work in rural areas because of the possibility of getting Government jobs, time for preparation for entrance exam because of lesser patient workload and higher preference for Post-Graduation if worked in rural areas. Some reside in rural areas whereas others find it a good experience to become a General Practitioner.
Studies conducted in India showed a similar picture of unwillingness to work in rural areas. A follow up study conducted by Shankar K et al on old students of private medical college Tamil Nadu showed that out of 117 passed students, 43.3% were doing Post-Graduation, 26.5% were working in corporate hospitals, 8.55% were preparing for entrance exam, 5.12% were preparing to go abroad and only 2.6% were a part of Government PHC network in rural areas. (4)
Another study conducted by Gaikwad et al, a study on career preferences and attitude towards the rural health services among the graduating interns of a medical college in rural Bangalore showed that out of total 75 graduating interns were aspiring for post-graduation seats, not a single intern wanted to practice only with MBBS degree. Only 44% would like to serve in rural areas. Only 9.33% interns wanted to settle permanently in rural areas and serve rural people. The attitude of interns towards the rural service is not favorable. All the interns were aspiring for post-graduation seats. (5)
A cross sectional study by Sridhar et al, on attitude of Postgraduate medical student's towards rural health service in Andhra Pradesh suggested that among 100 randomly selected postgraduate medical students of Andhra Medical College, Visakhapatnam, 27% were in-service postgraduates. 52% from urban 46% rural & 2% from tribal areas and 17% of the study population said that health care services were sufficient whereas 83% disagreed, interestingly 56% were interested to work in rural areas provided sufficient infrastructure is present. (6)
Kruk EM et al conducted a discrete experiment to study rural practice preferences among medical students in Ghana. In the study they concluded that improved equipment and supportive management was most strongly associated with job preference, although shorter contracts and salary bonuses were also associated. Discontinuing the provision of basic housing had a large negative influence. Women's preferences were more influenced by supportive management and men's by superior housing. (7)
Hence if government makes rural health service an attractive option in terms of pay, infrastructure, supportive staff as well as career growth, better working environment and living facilities for service and practice in rural areas more doctors would be willing to perform.
CONCLUSION: The study found that the majority of the doctors i.e. 71% are reluctant to serve in the rural areas of Goa. Multiple factors contributed to the unwillingness of doctors towards rural service. The reasons for their reluctance broadly include various issues affecting their social, professional and family life, if they opt to serve in rural areas. Adequate Community-based training in Medical Education to inspire and motivate future doctors towards serving in rural areas of Goa is required. Doctors working in rural health facilities may be given financial and professional incentives and a conducive environment. Opportunities for academic and professional advancement for rural doctors should also be considered.
RECOMMENDATIONS: This study recommends adequate Community-based training in Medical Education to inspire and motivate future doctors towards serving in rural areas of Goa. Doctors working in rural health facilities may be given financial and professional incentives and a conducive environment. The revised Rules of MCI for allocating additional marks corresponding to years of rural service to those aspiring to be Post-Graduate doctors may help to overcome the inequitable distribution of health care in rural areas of Goa.
(1.) World Health Organization. World health report 2006: working together for health. Geneva: WHO; 2006.
(2.) Rao M, Rao K, Kumar S, Chatterjee M, Sundararaman T. Human resources for health in India: The Lancet. Feb 2011; 377: 587-98.
(3.) Bulletin on Rural health Statistics in India 2012. Ministry of Health and Family Welfare (Statistics Division), National Rural Health Mission (NRHM) Management Information System (HMIS) Portal, Government of India. Available at mohfw.nic.in/Write Read Data/1892s/492794502RHS%202012.pdf.
(4.) K Shankar, P Sivaprakasam, Kokila Selvaraj. "Do medical graduates prefer to work in rural areas? - A follow up study of old students of a private Medical college in Tamil Nadu". Journal of Evolution of Medical and Dental Sciences 30 September 2013; 2 (3): 751-17.
(5.) Gaikwad V, Sudeepa D, Suwarna Madhukumar. A study on career preferences and attitude towards the rural health services among the graduating interns of a medical college in Bangalore rural; Int J Biol Med Res. 2012; 3 (2): 1577-80.
(6.) Sridhar Ch, Radhakumari P, Appalanaidu S. Attitude of Postgraduate medical student's towards rural health service in Andhra Pradesh; IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 9 Ver. VIII (Sep. 2014), PP 48-51 www.iosrjournals.org.
(7.) Margaret E Kruk, Jennifer C, Johnson b, Mawuli Gyakobo, Peter Agyei-Baffour, Kwesi-Asabir, S Rani Kotha, Janet Kwansah, Emmanuel Nakua, Rachel C Snowg & Mawuli Dzodzomenyoh. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ 2010; 88:333-41.
Jagadish A. Cacodcar , Sissy Colaco , Annet Oliveira 
[1.] Jagadish A. Cacodcar
[2.] Sissy Colaco
[3.] Annet Oliveira
PARTICULARS OF CONTRIBUTORS:
[1.] Associate Professor, Department of Preventive and Social Medicine, Goa Medical College, Goa, India.
[2.] Insurance Medical Officer, M. B. B. S, DPH, ESIC, Goa.
FINANCIAL OR OTHER COMPETING INTERESTS: None
[3.] District Epidemiologist (IDSP), M. B. B. S, DPH, Directorate of Health Services, Goa.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Annet Oliveira, House. No. 805/B, Santemol, Raja Salcete-403720, Goa.
Date of Submission: 27/07/2015.
Date of Peer Review: 28/07/2015.
Date of Acceptance: 10/08/2015.
Date of Publishing: 14/08/2015.
Table 1: Reasons for willingness to serve in Rural areas of Goa Reasons for willingness No. (%) 1. To do private practice 23 2. To join Government Health Centres 69 3. Own residence in rural area 34 4. Less workload in rural areas 6 5. No strict supervision 6 6. Less stressful work 17 7. Less competition in practice 11 8. Get time to study for PG entrance 37 9. To help rural poor/underprivileged 80 10. Private medical facility offers work 9 11. To obtain preference for higher studies 43 12. Financial compulsions 6 13. Other reasons: Please specify 6 To gain rural experience Table 2: Reasons for reluctance to work in Rural areas of Goa Reasons for unwillingness No. (%) 1. No professional growth 64 2. Limited clinical exposure 61 3. Own residence in urban area 36 4. Delay in Post-graduation 25 5. Seeking employment in foreign country 22 6. Poor quality of life / living conditions 29 7. Poor income 32 8. Poor schooling for children 25 9. High status in urban areas 14 10. Never previously exposed to rural life 42 (lack of incentives/promotions) 11. Poor infrastructure of rural facilities 71 12. Lack of efficient transport mechanism 54 13. Poor facilities in Govt. Health Centres 71 14. Problems of quackery medical practice 32 15. Others: Please specify --
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|Title Annotation:||ORIGINAL ARTICLE; Goan, India|
|Author:||Cacodcar, Jagadish A.; Colaco, Sissy; Oliveira, Annet|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Aug 17, 2015|
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