Retaining Doctors in Rural Bangladesh: A Policy Analysis

Document Type: Original Article

Authors

1 James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh

2 HERD International, Kathmandu, Nepal

3 Centre of Excellence for Health Systems and Universal Health Coverage, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh

4 International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh

5 Health Nutrition and Population, Human Development Network, The World Bank, Washington, DC, USA

Abstract

Background
Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes.

 
Methods
Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n = 11), and stakeholder analysis/position-mapping.

 
Results
In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector).

 
Conclusion
Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.

Keywords

Main Subjects


"Watch the Video Summary"

  1. Dolea C, Stormont L, Braichet J-M. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88:379-385.
  2. World Health Organization. Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention: Global Policy Recommendations. Geneva; WHO; 2010.
  3. Ahmed SM, Hossain MA, Chowdhury AMR, Bhuiya AU. The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution. Hum Resour Health. 2011;9(1):3.
  4. Marc L, Jobayda F, Chowdhury J. Review of national and international experiences with human resources incentive packages. In: Bethesda, MD: review, analysis and assessment of issues related to health care financing and health economics in Bangladesh. Dhaka, Bangladesh: Abt Associates Inc; 2009.
  5. Chen LC, Evans TG, Anand S, et al. Human Resources for Health: Overcoming the crisis. Lancet. 2004;364(9449):1984-1990. doi:10.1016/S0140-6736(04)17482-5
  6. Campbell J, Buchan J, Cometto G, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013;91(11):853-863. doi:10.2471/BLT.13.118729
  7. Anand S, Bärnighausen T. Human resources and health outcomes: cross-country econometric study. Lancet. 2004;364(9445):1603-1609. doi:10.1016/S0140-6736(04)17313-3
  8. Ahmed SM, Evans TG, Standing H, Mahmud S. Harnessing pluralism for better health in Bangladesh. Lancet. 2013;382(9906):1746-1755. doi:10.1016/S0140-6736(13)62147-9
  9. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006;4(1):12. doi:10.1186/1478-4491-4-12
  10. National Institute of Population Research and Training (NIPORT), Associates for Community and Population Research (ACPR), ICF International. Bangladesh Health Facility Survey 2014. Dhaka; 2016. https://dhsprogram.com/pubs/pdf/SPA23/SPA23.pdf.
  11. NIPORT, ACPR, ICF international. Bangladesh Health Facility Survey 2014. http://dhsprogram.com/pubs/pdf/SPA23/SPA23.pdf.
  12. Government of Bangladesh. Health Bulletin. Dhaka; 2016.
  13. Government of Bangladesh. Bangladesh Health Workforce Strategy 2015. Dhaka; 2015.
  14. Government of Bangladesh. Health, Population and Nutrition Sector Development Program (2011-2016): Program Implementation Plan. Dhaka; 2011.
  15. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994;9(4):353-370. doi:10.1093/heapol/9.4.353
  16. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. “Doing” health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-317. doi:10.1093/heapol/czn024
  17. Ahmed SM, Alam BB, Anwar I, et al. Bangladesh Health System Review. Vol 5. (Naheed A, Hort K, eds.). Dhaka: World Health Organization; 2015.
  18. Buse K, Mays N, Walt G. Making Health Policy. 2nd ed. Berkshire: McGraw-Hill International; 2012.
  19. Rawal LB, Joarder T, Islam SMS, Uddin A, Ahmed SM. Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis. Hum Resour Health. 2015;13(1). doi:10.1186/s12960-015-0030-6
  20. Ritchie J, Lewis J, Elam G. Designing and Selecting Samples. In: Ritchie J, Lewis J, eds. Qualitative Research Practice: A Guide for Social Science Students and Researchers. Thousand Oaks, California: SAGE Publications; 2003:77-108.
  21. Alam SS. Physician leaders gained promotion through presidential mercy (translated from Bangla). Prothom Alo. April 2, 2013.http://archive.prothom-alo.com/detail/news/341630
  22. Shawkat Ali AMM. Civil Service Management in Bangladesh: An Agenda for Policy Reform. The University Press Ltd; 2007.
  23. Jahan F, Shahan AM. Politics−Bureaucracy Relationship in Bangladesh: Consequences for the Public Service Commission. Public Organ Rev. 2008;8(4):307-328. doi:10.1007/s11115-008-0061-8
  24. Government of Bangladesh. Gazette Notification on Transfer and Posting Policy for Officers. Bangladesh; 2008.
  25. Osman FA. Policy Making in Bangladesh: A Study of the Health Policy Process. Dhaka: A.H. Development Publishing House; 2004.
  26. Rahman ATR. Bangladesh in the Mirror: An Outsider Perspective on a Struggling Democracy. The University Press; 2006.
  27. Government of Bangladesh. The Government Servants (Conduct) Rules, 1979. Bangladesh; 1979. http://workspace.unpan.org/sites/internet/Documents/UNPAN038017.pdf.
  28. Majumder AI. Professional physicians in political activities, patients in waiting line (translated from Bengali). Prothom Alo. November 18, 2012. http://archive.prothom-alo.com/detail/date/2012-11-28/news/308848
  29. Moral S. Intelligence report: physicians are continuously committing irregularities (translated from Bangla). Prothom Alo. 2012.
  30. Darkwa EK, Newman MS, Kawkab M, Chowdhury ME. A qualitative study of factors influencing retention of doctors and nurses at rural healthcare facilities in Bangladesh. BMC Health Serv Res. 2015;15(1):1-12. doi:10.1186/s12913-015-1012-z
  31. Chaudhury N, Hammer JS. Ghost Doctors: Absenteeism in Rural Bangladeshi Health Facilities. https://openknowledge.worldbank.org/handle/10986/17167. Published 2004.
  32. Shah SM, Zaidi S, Ahmed J, Rehman SU. Motivation and retention of physicians in primary healthcare facilities: a qualitative study from Abbottabad, Pakistan. Int J Heal Policy Manag. 2016;5(8):467–475. doi:10.15171/ijhpm.2016.38
  33. Malik AA, Yamamoto SS, Souares A, Malik Z, Sauerborn R. Motivational determinants among physicians in Lahore, Pakistan. BMC Health Serv Res. 2010;10:201. doi:10.1186/1472-6963-10-201.
  34. Akbar Zaidi S. Planning in the health sector: For whom, by whom? Soc Sci Med. 1994;39(9):1385-1393. doi:10.1016/0277-9536(94)90369-7
  35. Mostert S, Njuguna F, Olbara G, et al. Corruption in health-care systems and its effect on cancer care in Africa. Lancet Oncol. 2015;16(8):E394-E404.
  36. Bribe for everything: public health sector riddled with corruption, TIB study finds. The Daily Star. March 8, 2015.http://www.thedailystar.net/bribe-for-everything-49143
  37. Scheffer MC, Dal Poz MR. The privatization of medical education in Brazil: trends and challenges. Hum Resour Health. 2015;13(1):96. doi:10.1186/s12960-015-0095-2
  38. Amin Z, Burdick WP, Supe A, Singh T. Relevance of the Flexner Report to Contemporary Medical Education in South Asia. Acad Med. 2010;85(2):333-339. doi:10.1097/ACM.0b013e3181c874cb
  39. Wurie HR, Samai M, Witter S. Retention of health workers in rural Sierra Leone: findings from life histories. Hum Resour Health. 2016;14(1):3. doi:10.1186/s12960-016-0099-6
  40. Roberts MJ, Hsiao W, Berman PA, Reich MR. Getting Health Reform Right: A Guide to Improving Performance and Equity. Oxford: Oxford University Press; 2004.
  41. Roy A, van der Weijden T, de Vries N. Relationships of work characteristics to job satisfaction, turnover intention, and burnout among doctors in the district public-private mixed health system of Bangladesh. BMC Health Serv Res. 2017;17(1):421. doi:10.1186/s12913-017-2369-y