When health professionals flock to big cities for work, rural areas suffer
A much talked-about topic is the absenteeism of doctors in upazila health centres and clinics. Days go by without an attending physician in these centres and people with serious illness go without any medical attention.
This is not shocking news. The fate of rural health centres has not improved in last five decades despite a quantum leap in the number of medical colleges and turnout of qualified medical graduates. The country has now about 90 medical colleges, turning out thousands of doctors every year. Yet, the country suffers from a tremendous shortage of doctors, mostly at the rural level.
According to statistics, there are only 1.1 doctors per 10,000 people in rural areas compared with 18.2 for the similar number in urban areas. And that too on paper only for the rural area, since the doctors appointed in a rural clinic often do not live there.
The problem of doctor absenteeism has not changed from nearly four decades ago, while I was working in the districts. The government had set up a medical centre in every thana and a medical officer to attend it. The thana centre called Thana Training and Development Centre was meant to be a service delivery centre to the local population for everything starting from agriculture, livestock, education, social welfare, family planning, and of course health.
Each office was staffed by government-appointed officials, and in a large number of places, these officials were given free accommodation to ensure that they can live there and be available to the local people. And yet, there would be many instances where the residences would be unoccupied because the tenants preferred to remain away. A typical absentee would be the medical officer.
Our attempts in those days to force a truant medical officer back to his job mostly by threats of job loss would not work, as to start with there were no substitutes. There were not too many medical graduates to fill these jobs. So, the medical centres in thanas continued to remain unattended until some new doctors would surface.
The problem 40 years ago and now essentially remains the same. A recent study by an independent health research group found that 35% of doctors and 30% of the nurses are serving 15% of the total population living in four major cities of Bangladesh -- Dhaka, Chittagong, Rajshahi, and Khulna, whereas less than 20% of health workers serve over 70% people living in rural areas.
And why do they do this? Because cities like Dhaka, Chittagong, and other major urban centres offer the kind of earning opportunities for doctors that a rural area does not.
This lure is also aggravated when the bosses of these young doctors facilitate their departure from duty station to augment their private practice. And this happens even after three decades of a government policy that demands a two-year minimum of rural service before a new medical doctor is confirmed in his job.
Is there a way to stem this absenteeism by doctors in rural areas and help the poor hapless patients in the villages besides pious rhetoric of taking stern action against the unwilling healer?
These rhetorical words have been uttered before, doctors have been suspended, reprimanded, officially taken to task. But they are again put back on the payroll. The doctors make a pretense of showing and then disappear. Cat and mouse game starts all over again.
Last year, the famed International Journal of Health Policy and Management published an article on the problem of retaining doctors in rural Bangladesh. It identified four areas that need attention to alleviate this problem.
These are: Lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. The systems and policies that are in place are poorly designed, and policies are not properly followed or monitored.
A two-year mandatory rural posting for new recruits is often not strictly enforced. This is often done either in collusion with or negligence of senior health bureaucrats. Politicians often intervene to make this happen. The policies to change the current system are interfered with by influential groups such as Medical Associations that may align with the ruling party for their goals.
Rural retention of doctors can happen when there is a commitment from all stakeholders, including doctors association, health bureaucrats and above all, the political hierarchy to work together.
But this policy framework has to be embedded in an incentive structure for the doctors, which pulls them away from the lure of working in big cities. The incentives should be both policy and system driven.
A common explanation for absenteeism among doctors (as well as many other government staff) working in rural areas are poor infrastructure, physical facilities, and a lack of educational opportunities for children. While it may not be possible for the government to attend to improve all of these at a time, the government could and should ensure that accommodations are available to each doctor in the area before they are assigned.
In addition, the government could provide other direct monetary incentives such as remote area allowance, government transports, and paid leave for a month every year.
But these incentives alone may not be able to replace the attraction for a doctor to work in a big city to earn money. These may be aided by a strict stipulation for a minimum period of service in a rural area, with active support of BMA.
But the main motivation for a doctor to work in a rural area has to come from their professional ethics to serve people, from the Hippocratic Oath that they took when passing the medical exams.
We have plenty of doctors, and many will still be turned out each year. But they will not serve our people until they heed their main duty to serve people wherever they are, rural or urban.
Ziauddin Choudhury has worked in the higher civil service of Bangladesh early in his career, and later for the World Bank in the US.