Attraction and Retention of Physicians and Nurses in Rural Areas in India
Transcript of Attraction and Retention of Physicians and Nurses in Rural Areas in India
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By
GANGARAM BISWAKARMA
Registration No. 18710176
UNDER THE GUIDANCE OF
DR. DEBA PRASAD PANDA
DEPARTMENT OF MANAGEMENT
SHRI JAGDISH PRASAD JHABARMAL TIBREWALA UNIVERSITY,
VIDYANAGARI, JHUNJHUNU, RAJASTHAN – 333001
2012
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DECLARATION BY THE CANDIDATE
I declare that thesis entitled “AN EXPLORATORY STUDY ON
DISTRIBUTION, ATTRACTION AND RETENTION OF
PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA” is my
own work conducted under the supervision of Dr. Deba Prasad Panda,
Associated Professor of Commerce at Jawaharlal Nehru College,
Pasighat under Rajiv Gandhi University, Itanagar, Arunachal Pradesh.
I have put in more than 200 days of attendance with the supervisor
at the centre.
I further declare that to the best of my knowledge the thesis does
not contain any part of any work which has been submitted for award of
any degree either in this University or any other university/ deemed
university without proper citation.
Signature of Supervisor Signature of candidate
(with stamp)
Signature of the Head/Principal(with stamp)
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CERTIFICATE OF SUPERVISOR
This is to certify that work entitled “AN EXPLORATORY
STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION
OF PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA” is
a piece of research work done by Shri Gangaram Biswakarma, under my
supervision for the degree of Doctor of Philosophy in Management of JJT
University, Jhunjhunu, Rajasthan, India. That the candidate has put
attendance of more than 200 days with me.
To the best of my knowledge and belief the thesis
1. Embodies the work of candidate himself
2. Has duly been completed
3. Fulfills the requirement of ordinance related to Ph.D. degree of the
University and
4. Is upto the standard both in respect of content and language for
being referred to the examiner.
Signature of the Supervisor
(with stamp)
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###
This work is dedicated to my parents:
For their inspiration, support, prayers and
constant encouragement for accomplishing
my academic peak
###
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ACKNOWLEDGEMENT
This is the part in the Thesis that I am very happy to write without any
boundation of pre-requisites, norms etc….. and overall with a very peaceful mind, not
just like writing the chapters in this thesis with tense mind.
First of all I would like to thank ‘GOD- the almighty’ for blessing me and
gave me the patience, tolerance and courage to complete my final ladder of my PhD
studies with this thesis and put me to the 50% part of the people who as per the study
of Kurup and Arora, the total number of students who enroll for a PhD only 50% end
up completing their thesis. I always believe in dream-‘a dream you dream alone is on
a dream, a dream you dream together is a reality’- JOHN LENNON . So, this thesiswould never have been completed without the dream of my father, mother, wife,
brother and my beloved sister and off-course my in-laws and their moral support
altogether.
In research study, as we know, choosing a good mentor/guide is the most
crucial factor in the successful outcome and timely completion of the thesis, on this
front, I made a perfect choice. I would like to express my gratitude to my supervisor
Dr. Deba Prasad Panda, Associate Professor, who was always equally passionate and
has shown amazing patience and diligence in assisting me to produce this thesis.
I would like to sincerely thank my Dad for immense morale support and
encouragement throughout my study period not only to complete my PhD but since
my first step to the school. “Yes DAD, I m proud of being your son”. Sincerely thanks
from core of my health to my younger brother ‘Pradeep’, who went to Qatar to earn
for the family as let me continue my PhD study behind. ‘I m proud to get you my
brother’. My sister ‘Bunu’ and MUM were always a supportive and encouraging
throughout the period of study.
At home, finally I would like to express my deep gratitude to my wife ‘Jun’. I
would never have been able to complete this work without her serenity, her
understanding and tolerance, and her sacrifices during the course of study. “Thank
you Jun, for the countless moments of encouragement and support during my lows in
study period and taking care of our little angle ‘ANWESHA’ in absence of me for
almost one and half year since her birth”. My Love for Anwesha, as she missed the
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needed moments of tender love of a father in her infancy, because I could not be with
her side in period of study.
I would also like to thank all my in-laws especially father-in-law and elder
sister-in-law, who were always in my support throughout the period for my study. I
would also like to thank Kartu and his family to support and care for ANWESHA in
my absence.
This work would not have been possible without the responses I received to
both the questionnaire and the interviews. My thanks go to all the respondents who
contributed to the research especially those who agreed to be interviewed.
I would like to thank Dr. D.D. Agarwal, VC, Dr. Reecha Ranjan Singh & Dr.
Manish Sharma, Management Department from JJT University for their help and
valuable comments time to time to improve the quality of the thesis.
I would also like to thank Lakshminarayan Meena, Narshing Meena, Badri
Meena from Jaipur, Sandeep Agarwal from Noida, Rajita Goswami from Itanagar,
D.K. Dhir from IISASTR, Delhi, Jacob Mays from SPSSvideotutoral.com, Dr. Ali
Nasef from Tripoli University Lybia, Rabiu Ado, Research Scholar from Aberdeen
UK, Library Rajiv Gandhi University Itanagar, Library IBS Hyderabad, Library JJT
University and all DPMs of Arunachal Pradesh for their support and off course other
supporting staffs of JJT University who use to be cordial and always helpful in the
event of need during entire period of my stay in the University.
Though if I forget to note you down here, do not think that I m not thankful to
you, but it’s just a slip of mind. Thank you, thank you all for your constant support.
Gangaram Biswakarma
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LIST OF FIGURES
Figure: 1: Total Physicians and nursing workforce in urban and rural areas- aglobal view
22
Figure: 2: Countries with a critical shortage of health service providers
(doctors, nurses and mid-wives)
23
Figure: 3: Density of health workers. Source: WHO Global Atlas of the
Health Workforce
24
Figure: 4: Different environments and location of decision-makers
associated with attraction and retention in the public sector
40
Figure: 5: Map of India 47
Figure: 6: Map of Arunachal Pradesh 47
Figure: 7: Number of Physicians (doctors), Nurses and Mid-wives in
Arunachal Pradesh
60
Figure: 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives
in Arunachal Pradesh
60
Figure: 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh 60
Figure: 10: District wise numbers of Physicians (doctors/ medical officers) in
Arunachal Pradesh
63
Figure: 11: District wise percentage share of Physicians (doctors/ medical
officers) in Arunachal Pradesh
64
Figure: 12: Graphical mapping of district wise number of Physicians (doctors/
medical officers) in Arunachal Pradesh
64
Figure: 13: District wise numbers of nurses in Arunachal Pradesh 66
Figure: 14: District wise share of nurses in Arunachal Pradesh 66
Figure: 15: Graphical mapping of district wise number of nurses in ArunachalPradesh 66
Figure: 16: District wise numbers of mid-wives in Arunachal Pradesh 68
Figure: 17: District wise share of nurses in Arunachal Pradesh 68
Figure: 18: Graphical mapping of district wise number of nurses in Arunachal
Pradesh
69
Figure: 19: Numbers of Physicians, nurses and mid-wives in rural and remote
areas in Arunachal Pradesh
69
Figure: 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives
in rural and remote area of Arunachal Pradesh
70
Figure: 21: Percentage Share of Nurses and Mid-wives in rural and remote
area in Arunachal Pradesh
70
Figure: 22: District wise numbers of Physicians (doctors/ medical officers) inArunachal Pradesh
72
Figure: 23: District wise percentage share of Physicians (doctors/ medicalofficers) in Arunachal Pradesh
72
Figure: 24: Graphical mapping of district wise number of Physicians (doctors/
medical officers) in Arunachal Pradesh
73
Figure: 25: District wise numbers of nurses in rural and remote area
Arunachal Pradesh
74
Figure: 26: District wise share of nurses in rural and remote area Arunachal
Pradesh
75
Figure: 27: Graphical mapping of district wise number of nurses in rural and 75
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remote area in Arunachal Pradesh
Figure: 28: District wise numbers of mid-wives in rural and remote area in
Arunachal Pradesh
77
Figure: 29: District wise share of mid-wives in rural and remote areaArunachal Pradesh
77
Figure: 30: Graphical mapping of district wise number of mid-wives in ruraland remote area in Arunachal Pradesh
77
Figure: 31: Urban-rural distribution of Physicians (doctors) in comparison to
urban – rural population in Arunachal Pradesh
78
Figure: 32: Urban-rural distribution of Nurses in comparison to urban – rural
population in Arunachal Pradesh
78
Figure: 33: Urban-rural distribution of Mid-wives in comparison to urban –
rural population in Arunachal Pradesh
79
Figure: 34: District wise urban-rural percentage distribution of Physicians
(doctors) in Arunachal Pradesh
80
Figure: 35: Graphical mapping of district wise rate of urban concentration of Physicians (doctors) in Arunachal Pradesh 80
Figure: 36: District wise urban-rural percentage distribution of nurses in
Arunachal Pradesh
81
Figure: 37: Graphical mapping of district wise rate of urban concentration of
nurses in Arunachal Pradesh
81
Figure: 38: District wise urban-rural percentage distribution of mid-wives inArunachal Pradesh
82
Figure: 39: Graphical mapping of district wise rate of urban concentration of
mid-wives in Arunachal Pradesh
82
Figure: 40: Percentage of migrating intention of the physicians, nurses and
mid wives
154
Figure: 41: Percentage of migrating intention of the physicians 155
Figure: 42: Percentage of migrating intention of the nurses 155
Figure: 43: Percentage of migrating intention of the mid-wives 155
Figure: 44: Percentage of migrating intention of the contract workforce
(Physicians, nurses and mid-wives)
156
Figure: 45: Percentage of migrating intention of the Permanent workforce(Physicians, nurses and mid-wives)
156
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LIST OF TABLE:
Table : 1: Global health workforce by density 22
Table : 2: Estimated critical shortage of doctors, nurses and midwives 23
Table : 3: The areas falls under Urban areas in the state for this study 42
Table : 4: Demographic indicators Census 2011 and 2001 of ArunachalPradesh
45
Table : 5: Urban Rural comparison of demographic indicators of Arunachal Pradesh
46
Table : 6: Demographic characteristics of management representatives
respondents
54
Table : 7: Mean age and experience of management representatives
respondents
54
Table : 8: Demographic characteristics of employee respondents 55
Table : 9: Mean age and length of service of the respondents 55
Table : 10: Showing health infrastructure growth in rural areas of thestates
58
Table : 11: Distribution of Public Health Facilities in Arunachal Pradesh 58
Table : 12: Population covered by the health institutions in Arunachal
Pradesh
59
Table : 13: Numbers of Pediatricians, Anesthetist and Gynecologist in
Arunachal Pradesh (District Wise)
61
Table : 14: Numbers of Physicians (Medical Officer) in Arunachal
Pradesh district wise
62
Table : 15: Ranking of Density of Physicians (doctors) in Arunachal
Pradesh (District wise)
62
Table : 16: Numbers of Nurses in Arunachal Pradesh (District Wise) 65
Table : 17: District-wise ranking of density of Nurses in Arunachal
Pradesh
65
Table : 18: Numbers of Mid-Wives (ANM) in Arunachal Pradesh
(District Wise)
67
Table : 19: District-wise ranking of density of Mid-wives in Arunachal
Pradesh
67
Table : 20: District wise number of Physicians (Doctors) in Rural Area in
Arunachal Pradesh
71
Table : 21: District wise Doctor-Population ratio in Arunachal Pradesh 71
Table : 22: District wise number of Nurses in Rural Area in Arunachal
Pradesh
73
Table : 23: District wise Nurses –Population ratio in Rural Area in
Arunachal Pradesh
74
Table : 24: District wise number of Mid-wives in Rural Area in Arunachal
Pradesh
76
Table : 25: District wise number of Mid-wives-population ratio in Rural
Area in Arunachal Pradesh
76
Table : 26: Showing the trend in physicians and nurses in-position in 2005
& 2010
83
Table : 27: District wise requirement and shortfall of ANMS in ArunachalPradesh
84
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Table : 28: District wise requirement and shortfall of Nurses in Arunachal
Pradesh
85
Table : 29: District wise requirement and shortfall of Physicians in
Arunachal Pradesh
85
Table : 30: District wise rural and remote area requirement and shortfall of
ANMs in Arunachal Pradesh
86
Table : 31: District wise rural and remote area requirement and shortfall of
Nurses in Arunachal Pradesh
87
Table : 32: District wise rural and remote area requirement and shortfall of
Physicians (doctors) in Arunachal Pradesh
87
Table : 33: Descriptive Statistics of the factors that attracted or placed the
Physicians, nurses and mid-wives in the current job in the ruraland remote area
90
Table : 34: Percentage selection of factors for attraction or placed by
Physicians, nurses and mid-wives
91
Table : 35: Descriptive Statistics of the factors that attracted or placed the
Physicians in the current job in the rural and remote area
92
Table : 36: Descriptive Statistics of the factors that attracted or placed the
contract Physicians in the current job in the rural and remote
area
93
Table : 37: Descriptive Statistics of the factors that attracted or placed the
permanent Physicians in the current job in the rural and remote
area
94
Table : 38: Percentage selection of factors for Attraction or placed by
Physicians
95
Table : 39: Descriptive Statistics of the factors that attracted or placed the
nurses in the current job in the rural and remote area
96
Table : 40: Descriptive Statistics of the factors that attracted or placed the
permanent nurses in the current job in the rural and remotearea
97
Table : 41: Descriptive Statistics of the factors that attracted or placed the
contract nurses in the current job in the rural and remote area
98
Table : 42: Percentage selection of factors for Attraction or placed by
nurses
98
Table : 43: Descriptive Statistics of the factors that attracted or placed the
mid-wives in the current job in the rural and remote area
99
Table : 44: Descriptive Statistics of the factors that attracted or placed the
contractual mid-wives in the current job in the rural andremote area
100
Table : 45: Descriptive Statistics of the factors that attracted or placed the
permanent mid-wives in the current job in the rural and remote
area
101
Table : 46: Percentage selection of factors for Attraction or placed by mid-
wives
102
Table : 47: Relationship between the factor for attraction or placement
with the demographic attributes of Physicians
106
Table : 48: Relationship between the factor for attraction or placement
with the demographic attributes of nurses
109
Table : 49: Relationship between the factor for attraction or placement 113
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with the demographic attributes of mid-wives
Table : 50: Descriptive Statistics of the factors that may attract the
physicians, nurses and mid-wives in the rural and remote area
115
Table : 51: Percentage of factors that may attract physicians, nurses and
mid-wives in rural and remote areas
116
Table : 52: Descriptive Statistics of the factors that may attract the physicians
118
Table : 53: Percentage of factors that may attract physicians in rural andremote areas
119
Table : 54: Descriptive Statistics of the factors that may attracted thenurses
120
Table : 55: Percentage selection of Factor that may attract nurses 121
Table : 56: Descriptive Statistics of the factors that may attracted the Mid
wives
123
Table : 57: Percentage of factors that may attract mid-wives in rural and
remote areas
124
Table : 58: Analysis of Variance in factor that may attract the physicians,nurses and mid-wives
126
Table : 59: Percentage showing Job Satisfaction of physicians, nurses and
mid-wives in rural and remote area setting
129
Table : 60: Descriptive statistics of Job Satisfaction of Physicians, Nurses
and Mid-wives
130
Table : 61: Analysis of Variance in Job Satisfaction among the Physicians,
nurses and mid-wives
130
Table : 62: Percentage showing Job Satisfaction of contractual and
permanent physicians, nurses and mid-wives in rural and
remote area setting
130
Table : 63: Descriptive statistic of Job Satisfaction of contract and
permanent Physicians, nurses and mid-wives
131
Table : 64: Analysis of Variance (T-Test) of Job Satisfaction amongcontractual and permanent Physicians, nurses and mid-wives
131
Table : 65: Correlation between Job satisfaction and the demographic
attributes of the employees (Physicians, Nurses and Mid-
wives)
132
Table : 66: Descriptive statistic of Job Satisfaction of contract and
permanent Physicians.
133
Table : 67: Analysis of Variance (T-Test) of Job Satisfaction among
contractual and permanent Physicians.
133
Table : 68: Correlation between Job satisfaction and the demographic
attributes of Physicians
134
Table : 69: Descriptive statistic of Job Satisfaction of contract and
permanent nurses.
135
Table : 70: Analysis of Variance (T-Test) of Job Satisfaction amongcontractual and permanent nurses
135
Table : 71: Correlation between Job satisfaction and the demographic
attributes of Nurses
136
Table : 72: Descriptive statistic of Job Satisfaction of contract and
permanent mid-wives.
136
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Table : 73: Analysis of Variance (T-Test) of Job Satisfaction among
contractual and permanent mid-wives
137
Table : 74: Correlation between Job satisfaction and the demographic
attributes of mid-wives
137
Table : 75: Descriptive Statistics of Factors contributed for job satisfaction
of the physicians, nurses and mid-wives
139
Table : 76: Regression Analysis of factors contributed for job satisfactionof the physicians, nurses and mid-wives.
140
Table : 77: Correlation matrix of overall job Satisfaction with factor of
job satisfaction for physicians, nurses and mid-wives
141
Table : 78: Descriptive Statistics on Factors contributed for job
satisfaction of the physicians.
142
Table : 79: Regression Analysis of factors contributed for job satisfaction
of the physicians.
143
Table : 80: Correlation matrix of Overall job Satisfaction with factor of
Job satisfaction of Physicians
143
Table : 81: Descriptive Statistics on Factors contributed for job
satisfaction of the Nurses.
144
Table : 82: Regression Analysis of factors contributed for job satisfaction
of the nurses.
146
Table : 83: T-test results of factors contributed for job satisfaction of the
nurses.
146
Table : 84: Correlation matrix of Overall job Satisfaction with factor of Job satisfaction of Nurses
147
Table : 85: Descriptive Statistics on Factors contributed for job
satisfaction of the Mid-wives.
148
Table : 86: Result of Regression Analysis of factors contributed for job
satisfaction of the mid-wives.
149
Table : 87: Correlation matrix of overall job Satisfaction with factor of job
satisfaction of Mid-wives
149
Table : 88: Descriptive Statistics for factors for job satisfaction of permanent Physicians, nurses and mid-wives
150
Table : 89: Descriptive Statistics for factors for job satisfaction of
contracts Physicians, nurses and mid-wives
151
Table : 90: Analysis of variance in factors of Job satisfaction of
Contractual and Permanent Physicians, nurses and mid-wives
in rural and remote area
152
Table : 91: Percentage showing the intention of migration of the physicians, nurses and mid wives
154
Table : 92: Percentage showing the intention of migration of the contract
and permanent workforce (physicians, nurses and mid wives)
156
Table : 93: Descriptive Statistics of contributing factor of likelihood of
retention of physicians, nurses and mid-wives
159
Table : 94: Descriptive statistics for contributing factor of likelihood of
retention of physicians
161
Table : 95: Descriptive statistics for contributing factor of likelihood of
retention of permanent physicians
162
Table : 96: Descriptive statistics for contributing factor of likelihood of 163
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retention of contract physicians
Table : 97: Descriptive statistics for contributing factor of likelihood of
retention of nurses
164
Table : 98: Descriptive statistics contributing factor of likelihood of
retention of permanent nurses
165
Table : 99: Descriptive statistics for contributing factor of likelihood of retention of contract nurses
166
Table : 100: Descriptive statistics for contributing factor of likelihood of retention of Mid-wives
167
Table : 101: Descriptive statistics for contributing factor of likelihood of retention of Permanent Mid-wives
168
Table : 102: Descriptive statistics for contributing factor of likelihood of
retention of contract Mid-wives
169
Table : 103: Descriptive statistics for contributing push factors for
physicians, nurses and mid-wives
171
Table : 104: Descriptive statistics for contributing push factors for
physicians
172
Table : 105: Descriptive statistics for contributing push factors for
permanent physicians
173
Table : 106: Descriptive statistics for contributing push factors for contract
physicians
174
Table : 107: Descriptive statistics for contributing push factors for nurses 175
Table : 108: Descriptive statistics for contributing push factors for regular
nurses
176
Table : 109: Descriptive statistics for contributing push factors for contract
nurses
177
Table : 110: Descriptive statistics for contributing push factors for mid-wives
178
Table : 111: Descriptive statistics for contributing push factors for
permanent mid-wives
179
Table : 112: Descriptive statistics for contributing push factors for contract
mid-wives
180
Table : 113: Descriptive statistics of push factors for migration of
physicians, nurses and mid-wives to another rural area
181
Table : 114: Descriptive statistics of push factors for migration of
physicians, nurses and mid-wives to rural to urban
183
Table : 115: Descriptive statistics of push factors for migration of
physicians, nurses and mid-wives to other employer or outside
state
184
Table : 116: Relationship of demographic attributes to intention to migrate
in physicians, nurses and mid-wives
185
Table : 117: Relationship of demographic attributes to intention to migrate
in physicians
185
Table : 118: Relationship of demographic attributes to intention to migrate
in nurses
186
Table : 119: Relationship of demographic attributes to intention to migrate
in mid-wives
186
Table : 120: Descriptive statistics of factors that may motivate the physicians, nurses and mid-wives to retain in current job in
188
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rural and remote area
Table : 121: Descriptive statistics of factors that may motivate the
physicians to retain in current job in rural and remote area
189
Table : 122: Descriptive statistics of factors that may motivate the contract
physicians to retain in current job in rural and remote area
190
Table : 123: Descriptive statistics of Factors that may motivate the permanent physicians to retain in current job in rural and
remote area
192
Table : 124: Descriptive statistics of factors that may motivate the nurses to
retain in current job in rural and remote area
193
Table : 125: Descriptive statistics of factors that may motivate the contract
nurses to retain in current job in rural and remote area
194
Table : 126: Descriptive statistics of factors that may motivate the permanent nurses to retain in current job in rural and remote
area
195
Table : 127: Descriptive statistics of Factors that may motivate the Mid-
wives to retain in current job in rural and remote area
196
Table : 128: Descriptive statistics of factors that may motivate the contract
Mid-wives to retain in current job in rural and remote area
198
Table : 129: Factors that may motivate the permanent Mid-wives to retain
in current job in rural and remote area
199
Table : 130: Gist of various training under NRHM for physicians, nurses
and mid-wives
214
Table : 131: Achievement cumulative Training for Maternal and Child
Health (March 2005-2012)
215
Table : 132: Categorization of rural and remote area for incentive scheme
for workforce
216
Table : 133: Information on new Constructions of infrastructure in the stateunder reform process
218
Table : 134: Information on Upgradations of infrastructure in the state
under reform process
218
Table : 135: New Constructions of infrastructure in the state under reform
process
218
Table : 136: Identified District Hospitals where New Residential Quarters
will be constructed
219
Table : 137: Identified List of facilities (PHCs) that are proposed for newconstruction of Residential Quarters:
219
Table : 138: Identified CHCs for Construction of Residential Quarters 219
Table : 139: Descriptive Statistics of views on health sector reform process
on HR by physicians, nurses and mid-wives
227
Table : 140: Descriptive Statistics of views on health sector reform process
on HR by physicians
228
Table : 141: Descriptive Statistics of views on health sector reform process
on HR by nurses
229
Table : 142: Descriptive Statistics of views on health sector reform process
on HR by Mid-wives
230
Table : 143: Analysis of Variance of views on health sector reform process
on HR by physicians, nurses and mid-wives
231
Table : 144: Scale of satisfaction on Policies for planning, placement, 236
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transfer and promotion by position of Respondents
Table : 145: Descriptive statistics on scale of satisfaction on policies for
planning, placement, transfer and promotion by position of
respondents
237
Table : 146: Analysis of Variance for scale of satisfaction on policies for
placement, transfer and promotion among the physicians,nurses and mid-wives among the group of respondents
237
Table : 147: Scale of satisfaction on Recruitment and selection process andPosition of Respondent
241
Table : 148: Descriptive statistics on scale of satisfaction on Recruitment
and selection process by position of respondents
242
Table : 149: Analysis of variance for Scale of satisfaction on Recruitment
and selection process among the group of respondents
242
Table : 150: Scale of satisfaction on fairness in HR Practice for placement,
transfer and promotion and Position of Respondent
243
Table : 151: Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position
of respondents
243
Table : 152: Analysis of Variance for the scale of satisfaction on fairness of
HR Practice for placement, transfer and promotion among the
group of respondents
243
Table : 153: Scale of satisfaction on Magnitude of management favouritism
and political interference in transfer and posting among the
group of respondents
244
Table : 154: Descriptive statistics on scale of satisfaction on magnitude of management favouritism and political interference in transfer
and posting by the position of respondents
244
Table : 155: Analysis of Variance for the scale of satisfaction on Magnitude
of management favouritism and political interference intransfer and posting among the group of respondents
244
Table : 156: Scale of satisfaction on response of
administration/management on your placement, transfer and promotional grievances
245
Table : 157: Descriptive statistics on scale of satisfaction on response of administration/ management on your placement, transfer and
promotional grievances by the position of respondents
245
Table : 158: Analysis of Variance for the scale of satisfaction on Response
of administration/management on your placement, transfer and promotional grievances among the group of respondents
245
Table : 159: Scale of satisfaction on Participation and involvement in the
decision making of your placement and transfer
246
Table : 160: Descriptive statistics on scale of satisfaction on participation
and involvement in the decision making of your placement and
transfer by the position of respondents
246
Table : 161: Analysis of variance for the scale of satisfaction on
Participation and involvement in the decision making of your
placement and transfer among the group of respondents
246
Table : 162: Scale of satisfaction of HR Practice for retentions –FinancialInterventions 247
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Table : 163: Descriptive statistics on scale of satisfaction of HR Practice for
retentions –Financial Interventions by the position of respondents
247
Table : 164: Analysis of variance for the Scale of satisfaction of HR Practice for retentions –Financial Interventions among the
group of respondents
248
Table : 165: Scale of satisfaction of HR Practice for retentions –Non-
Financial Interventions
248
Table : 166: Descriptive statistics on scale of satisfaction of HR Practice for
retentions – Non Financial Interventions by the position of
respondents
248
Table : 167: Analysis of variance of Scale of satisfaction of HR Practice for
retentions – Non Financial Interventions among the workforce
among the group of respondents
248
Table : 168: Scale of Satisfaction of Training and Development 250
Table : 169: Descriptive statistics on scale of satisfaction of HR Practice of Training and Development by position of the respondents 250
Table : 170: Analysis of variance of Scale of Satisfaction of Training and
Development among the group of respondents
251
Table : 171: Level of satisfaction of employees on HR practice of planning,
recruitment and placement in respect of physicians, nurses and
mid-wives in rural and remote area in the state
251
Table : 172: Level of satisfaction of Contractual employees on HR practice
of planning, recruitment and placement in rural and remote
area in the state
251
Table : 173: Level of satisfaction of Permanent employees on HR practice
of planning, recruitment and placement in rural and remotearea in the state
251
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ABBREVIATION
ANM- Auxiliary Nurse-Midwives
AYUSH- Ayurvedic, Yoga, Unani, Sidda, and HomeopathicBEmOC- Basic Emergency Obstetrics CareCEO-Chief Executive Officer
CHC-Community Health CentreCMOs- Chief Medical Officers
DH- District HospitalDMOs- District Medical Officers
DNA- Data Not Available
EmOC- Emergency Obstetrics Care
F-IMNCI- Facility based Integrated Management of Neonatal and Childhood Illness
GDP- Gross Domestic Product
GH- General HospitalGNM- General Nursing and Midwifery
GOAP –Government of Arunachal Pradesh
GoI- Govt. of India
HICs- High-income countries
HIV/AIDS- Human immunodeficiency virus infection / Acquired immunodeficiency
syndromeHQ- Head Quarter
HR- Human ResourcesHRD-Human Resource Development
HRH- Human Resource for Health
HRM- Human Resource ManagementIMNCI- Integrated Management of Neonatal and Childhood Illness
IPHS- Indian Public Health Standard
IUCD- intrauterine contraceptive device
LICs- Low income countries
LR- Labour Room
LSAS- Life Saving Anesthesia Skills
MBBS- Bachelor of Medicine, Bachelor of Surgery
MDG- Millennium Development Goals
MDGPs- Millennium Development Goals ProgrammesMiniLap- Mini Laparoscopic
MO- Medical Officer MoHFW- Ministry of Health and Family Welfare
MTP- Medical Termination of PregnancyMVA- Manual Vacuum Aspiration
NCHRH- National Council for Human Resources in Health
NE- North Eastern
NHP- National Health Policy
NRHM- National Rural Health Mission
NSSK- Navjaat Shishu Suraksha Karyakram
NSV- No Scalpel Vasectomy
PHC-Primary Health CentrePIP- Program Implementation Plan
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PMU- Programme Management UnitRHS- Rural Health Statistics
RRWG- Rural and Remote Working Group.
RTI/STI – Reproductive Tract Infection /Sexually Transmitted Infection
SBA- Skill Birth Attendance
SC- Sub CentreSN- Staff Nurse
SPSS- Statistical package for the social sciences
TFR- Total Fertility Rate
UFWC- Urban Family Welfare Centre
UHC- Urban Health Centre
UN – United Nation
WHO- World Health OrganizationWHR- World Health Report
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ABSTRACT
Background: In adopting the Millennium Declaration in the year 2000, the eight
Millennium Development Goals (MDGs) have been adopted by the international
community. To accomplish the MGDs no. 4, 5 and 6, related to Reduce Child
Mortality, Improve Maternal Health and Combat HIV/AIDS, malaria & other diseases
respectively, calls the strengthening of health care delivery system and improved
health care services. Healthcare is a service sector, depends highly on specially
trained professionals, which needs to produced, attract and retain at all level. Health
worker shortages are one of the main challenges internationally. The most concerning
issues on this is producing, attracting, recruiting, deploying and retaining them in
rural and remote areas. This study aimed at understanding the major HR issues in
distribution, attraction and retention of Physicians, nurses and mid-wives in Public
health care delivery system in rural areas in India with special reference to the state of
Arunachal Pradesh.
Method: The primary data required for the study was collected with the help of
interview schedule, survey questionnaire and observation. The primary data was
collected through questionnaire among 334 nos. (113 nos. of physicians, 98 nos. of
Nurses and 123 nos. of midwives) of physicians, nurses and mid-wives, to understand
their attitude towards working and living in rural areas and accepting the rural posting
and insight on the HR issues in the area of study. One management representatives
each from the 16 districts and one state level management representatives were picked
as a sample of management representatives and conducted the interview. The
interview materials were coded and quantitative data was analyzed with SPSS 19.
Results, discussion and conclusion: Over the last few decades the establishment of
health institutions in rural areas of the state is haphazard and not kept pace with
adhering to the norms and keeping view of the consequences of human resource
requirement. Consequently, many rural communities/areas are deprived of the
primary health care and desperately need the attention. The inequities in the
geographic distribution of Physicians, nurses and mid-wives, itself has meant too
many rural and remote areas with the shortage of Physicians, nurses and mid-wives.
The poor availability of Physicians, nurses and mid-wives co-exists and creating an
imbalance and a problem with debilitating health care delivery system in the regionalong with the absence of adequate training institutes for medical and nursing courses
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results in low numbers of medics and paramedics produced for the state. Mal-
distribution, that is the distribution of health workforce is characterized by urban
concentration and rural deficits, but these imbalances are perhaps most disturbing
from within district perspective also. While 77% of the population lives in rural and
remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives are
serving in rural and remotes areas of the state. This creates urban and rural imbalance
in distribution. The phenomenon of urban skewness and mal-distribution among the
districts are there. In this study it is also found that the information on human resource
is in-consistence among the state and district level, while it is also found that the
inconsistency between the divisions of the health department.
While, the major issue on attraction, the study revealed that the workforces
who are presently working in the rural and remote areas of the state are altogether in
compulsion, either working to finish their minimum rural service tenure or on non-
transferable positions or Management and political pressure or demand. It is found
that 58% of the workforce is service in rural and remote areas in the compulsion.
Moreover, the other HR issues on attraction are –the lack of career development
opportunity, inactive recruitment strategy, lack of hospital infrastructure and resource
availability, poor working condition, lack of other cadres, team work and staff
relationship, the reward and recognition for the performance and achievement is not
there in the system which could attract the physicians, nurses and mid-wives in the
rural area service, poor use of financial means of attraction. The study also reveals a
limited scope of attraction due to training and development opportunities and Poor
supervision and mentoring is a hindrance for attraction.
While the HR issues on retention are in the issue of internal migration to urban
areas. The study reveals that only 19% of them want to continue with their present
rural posting place. 24% wants to shift to another rural health institute, 51% wants to
shift to another urban health institute and 6% wants to shift to another job in some
other State/sector in search of an alternative employer. The Factors that contributed
for migration of the physicians, nurses and mid-wives as a whole, from the present
rural area to other rural area, urban area or to leave the sector have two factors
significant that are the Lack of adequate financial incentives / rural
allowances/performance incentives, poor working condition, lack of Career
development opportunities and poor salary. The other retention measures of financial
and non-financial incentives area absent from the system that could retain the
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workforce in rural and remote areas. It is also revealed that the factors that may
motivate the physicians, nurses and mid-wives to retain themselves in the present
rural area have four factors -financial incentives, improved living condition, career
development and Good reward and achievement recognition system. It is found in this
study that the intention of migration of physicians, nurses and mid-wives from a rural
area health institute to another rural health institute is propelled mainly by the factor
of team work and interpersonal relationship in the present place of work. This study
also revealed that the intention of migration of this workforce is related with the level
of job satisfaction of these groups of health workforce and propel them to migrate. So
forth, in addition to the other issues and concerns, there is a growing dissatisfaction
among the physicians, nurses and mid-wives in presently working in the rural and
remote areas.
While the reform initiatives in the sector are the emphasizing on contractual
employment, emphasizing on development of professional training institutes,
initiatives for comprehensive HR policy, decentralisation of HR activities to district
level, adoption of simplified way of recruitment and selection, emphasized on training
and development, emphasized on career development opportunities, shifting of view
towards the financial incentives, emphasizing of availability of essential equipments
for functionalising a health centre as per IPHS, development of supportive supervision
and emphasizing on infrastructure development initiatives including accommodation
facilities.
It is also found in respect of HR practice under reform process for distribution,
attraction and retention, that in the absence of appropriate and concrete human
resources policies on deployment, there is always a hindrance in managing people at
work as the entire district agreed to this. Along with, there is a major issue of HR
planning, recruitment and selection process, the common minimum tenures are not
followed along with the time bound promotions are not practices for several reasons
to these categories of staff, there is no use of provision of financial and non-financial
incentives for rural and remote area posting and retention, The reward and recognition
for the performance and achievement is also not there in the system, and there is no
random access of training needs, the planning of training and the execution of the
same have a random mismatch in the district and as well as in the state level.
Adequate human resources for health (HRH) are a key requirement for reaching
health goals, the study found that, the shortages of physicians, nurses and mid-wives
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are an ongoing problem in the public health sector in Arunachal Pradesh with uneven
distribution. There is low job satisfaction in the workforce in the current job at rural
and remote areas. It is contributed by many of the factors including financial and non-
financial benefits. Attraction and retention of physicians, nurses and mid-wives in
remote and rural areas are determined by many factors including financial incentive,
career development opportunities, recognition etc. But, the factor of compulsion is the
main factor of stock in rural and remote areas, and rest of the factors have less
contribution, and the financial benefits along with non-financial benefits seems to be
migrating factors. The attraction, deployment and retention of physicians, nurses and
mid-wives in rural and remote areas are a real challenge and a difficult situation, and
affected by several factors ranging from organizational factors to external
environmental factors and to personal factors. However, the personal factors have less
affect on the situation. The massive poor living conditions in the rural and remotes
areas, poor working condition in health institutes, poor career development
opportunities with lack of financial benefits are some of the factors that contribute to
the reluctances of the physicians, nurses and mid-wives to serve the rural and remote
areas in the state. The sector has nothing to offer presently, to attract and retain and to
distribute rationally this workforce, which in result deteriorating the situation in the
rural and remote areas. Moreover, the reform process is doing less for the HRM
perspectives and the HR practices are not effective enough to solve the problems in
the state. it is clear that many factors affect the rational distribution, attraction and
retention of Physicians, nurses and mid-wives in the rural and remote area ranging
from environment issues, organisation issues as well as the personal issues, along with
the production issues, the facilities and basic amenities along with financial incentives
are determinant of manpower in rural areas of the state. It is also known that to solve
these HR issues, no individual interventions are not adequate, it need a pyramid of
interventions to ensure the minimization of the issues.
Moreover, a blend of initiatives is needed to address the problems of distribution,
attraction and retention of manpower in the state, there is a need of continue focus and
commitment on the part of government and as well as the political will to solve the
problem. In conclusion, efforts to strengthen health sector must address the HR issues
and a good Human Resource Management and a far sight in HR requirements are
needed.
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LIST OF THE CONTENTS
Title Page No.
Declaration by the candidate i
Certificate of supervisor ii
Acknowledgement iv-v
List of figures vi-vii
List of table viii-xv
Abbreviation xvi-xvii
Abstract xviii-xxi
List of Contents xxii-xxvi
CHAPTER -1 INTRODUCTION 1-9
1.1. Introduction to research theme 1
1.2. Rationale behind the research 4
1.2.1. Why Physicians, nurses and mid-wives are selected for the study?
5
1.2.2. Why rural and remote areas selected for the study? 6
1.2.3. Why HR Practices (including distribution, attraction and
retention) selected for the study?
6
1.3. Objective of the study 7
1.4. Significance of the study 8
1.5. Outline of the thesis 9
CHAPTER -2 LITERATURE REVIEW 10-422.1. Introduction 11
2.2. Key HR issues in public health sector- in a global
perspective
11
2.3. Distributional issues of Health workforce- in global context
20
2.4. Attraction and retention of physicians and nurses in
rural areas- in a global context
24
2.5. Health Sector reform : the international and Indian
context 33
2.6. Gaps in the literature 34
2.7. Conceptual framework for the study 34
2.7.1. HRM in public health sector– a conceptual framework 34
2.7.2. Attraction and retention of health workers in rural areas
-Conceptual framework
38
2.7.3. Framework of urban area and rural area for this study 41
CHAPTER 3 RESEARCH METHODOLOGY 43-51
3.1. Research Methodology 44
3.1.1. Research Design 44
3.1.2. Objective of the study 44
3.1.3. The Study area 45
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3.1.4. Map of the studied area 47
3.1.5. Data Collection methods and instruments 48
3.1.6. Sampling frame 49
3.1.7. Data Analysis 50
3.2. Limitation of research 503.3. Contribution of the research 51
CHAPTER -4 DATA ANALYSIS AND INTERPRETATION 52-
251
Section-1 Characterstics of respondents 53-55
4.1.1. Introduction 54
4.1.2. Characterstics of respondents 54
Section 2 Analysis of dimension of HR issues in Distribution of
Physicians, Nurses and Mid-wives in rural and
remote areas of the state
56-87
4.2.1. Introduction 574.2.2. Scenario of distribution of Health Institution in
Arunachal Pradesh
57
4.2.3. Scenario of distribution of physicians, nurses & mid-
wives in Arunachal Pradesh
59
4.2.3.1. District-wise Distribution pattern of Physicians
(Medical Officers) & Specialists (Paediatrics,
Anaesthetics and Gynaecologist):
61
4.2.3.2 Distributional pattern of Nurses (Staff Nurses & GNM)
district-wise
64
4.2.3.3. Distribution pattern of Mid-wives (ANM) district-wise 674.2.4. Scenario of distribution of physicians, nurses & mid-
wives in rural and remote areas in Arunachal Pradesh
69
4.2.4.1. Distribution pattern of Physicians (Medical Officers) in
rural & remote areas (district wise)
70
4.2.4.2. Distributional pattern of Nurses (Staff Nurses & GNM)in Rural and Remote area in Arunachal Pradesh district-
wise
73
4.2.4.3. Distributional pattern of Mid-wives (ANM) in Rural and
Remote area in Arunachal Pradesh district-wise
75
4.2.5. Urban-Rural distribution of physicians, nurses and mid-wives 78
4.2.5.1. District wise Urban-Rural distribution of Physicians
(doctors) in Arunachal Pradesh
79
4.2.5.2. District wise Urban-Rural distribution of Nurses in
Arunachal Pradesh
80
4.2.5.3. District wise Urban-Rural distribution of Mid-wives
(ANM) in Arunachal Pradesh
82
4.2.6. Numerical inadequacy of physicians, nurses and mid-wives in Arunachal Pradesh
83
4.2.6.1 Requirement and shortfall of human resources in SCs,
PHCs and CHCs in the state according to IPHS norms.
84
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Section 3 Analysis of the dimension of HR issues in attraction
of Physicians, Nurses and Mid-wives in rural and
remote areas of the state
88-
126
4.3.1. Introduction 89
4.3.2. Factors that attracted or placed the physicians, nurses
and mid-wives in the current job in the rural and remotearea: current determinants of attraction and placements
89
4.3.2.1. Factors that attracted or placed the physicians in present
rural and remote area
92
4.3.2.2. Factors that attracted or placed the nurses in present
rural and remote area
95
4.3.2.3. Factors that attracted or placed the mid-wives in present
rural and remote area
99
4.3.3. Relationship of factors of attraction and demographic
characteristics of physicians, nurses and midwives
102
4.3.3.1. Relationship of factors of attraction and demographiccharacteristics of physicians
103
4.3.3.2. Relationship of factors of attraction with thedemographic characteristics of nurses
107
4.3.3.3. Relationship of factors of attraction with the
demographic characteristics of mid-wives
110
4.3.4. Factors that may attract physicians, nurses and mid-
wives to rural area- choice of current physicians, nurses
and mid-wives
114
4.3.4.1. Factors that may attract physicians to rural area- Choice
of current Physicians
117
4.3.4.2. Analysis of the factors that may attract nurses to ruraland remote area- choice of current nurses
119
4.3.4.3. Analysis of the factors that may attract mid-wives to
rural and remote area- choice of current mid-wives
122
4.3.4.4. Variance in choice of factor that may attract the physicians, nurses and mid-wives
124
Section 4 Analysis of the dimension of HR issues in retention
of Physicians, nurses and mid-wives in Rural and
remote areas of the state
127-
199
4.4.1. Introduction 128
4.4.2. Overall Job satisfaction of Physicians, nurses and mid-wives in Present rural and remote area and relationshipwith other demographic attributes
129
4.4.2.1. Job satisfaction of Physicians in rural and remote area
and relationship with other demographic attributes
132
4.4.2.2. Job satisfaction of Nurses in rural and remote area and
relationship with other demographic attributes
134
4.4.2.3. Job satisfaction of Mid-wives in rural and remote area
and relationship with other demographic attributes
136
4.4.3. Factors of job satisfaction of physicians, nurses and
mid-wives in rural and remote area
138
4.4.3.1. Factors of job satisfaction of physicians in rural and 141
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remote area
4.4.3.2. Factors of job satisfaction of nurses in rural and remotearea
144
4.4.3.3. Factors of job satisfaction of mid-wives in rural and
remote area
147
4.4.3.4. Factors of job satisfaction of contractual and permanent physicians, nurses and mid-wives in rural and remote
area
150
4.4.4. Likelihood of migration of physicians, nurses and mid-
wives- choice to migrate
153
4.4.4.1. Contributing factor of likelihood of retention of
physicians, nurses and mid-wives- Choice to stay
159
4.4.4.2. Push factors of likelihood of migration of physicians,
nurses and mid-wives- Choice to migrate
170
4.4.4.3. Push factors of likelihood to migrate according to the
choice of place
181
4.4.4.4. Relationship of demographic and satisfaction attributes
with the major intention to migrate to urban areas
184
4.4.5. Factors that may motivate the physicians, nurses and
mid-wives to retain in current job in rural and remote
area- What is their choice?
187
4.4.5.1. Factors that may motivate the physicians to stay 188
4.4.5.2. Factors that may motivate the Nurses to stay 192
4.4.5.3. Factors that may motivate the Mid-wives to stay 196
Section 5 Analysis of the Reform initiatives for distribution,
attraction and retention of physicians, nurses andmid-wives
200-
232
4.5.1. Reform initiatives for recruitment and deployment(Distribution)
201
4.5.2. Reform initiatives for attraction and retention 213
4.5.3. Exploring the views on health sector reform from the perspective of physicians, nurses and mid-wives
220
Section 6 Analysis of the HR policies and practices on
attraction, distribution and retention of physicians,
nurses and mid-wives for rural and remote area in
the state
233-
251
4.6.1. Introduction 234
4.6.2. Policies for HR Planning, recruitment (attracting),
placement, transfer and promotion
234
4.6.3. HR planning, recruitment and selection process 237
4.6.4. HR practice for placement, transfer and promotion 242
4.6.5. HR practice for retention - financial & non-financial
interventions
246
4.6.6. HR practice for retention - training and development 249
CHAPTER- 5 MAJOR FINDINGS, SUGGESTIONS AND
CONCLUSION
252
Section 1 Major HR issues in distribution of physicians, nurses 253-
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and midwives in rural and remote areas 264
5.1.1. Introduction 254
5.1.2. Major HR issues in distribution of physicians, nurses
and midwives
254
Section 2 Major HR issues in attraction of physicians, nurses
and midwives in rural and remote areas
265-277
5.2.1. Major HR issues in attraction of physicians, nurses and
midwives
266
Section 3 Major HR issues in retention of physicians, nurses
and midwives in rural and remote areas
278-
299
5.3.1. Major HR issues in retention of physicians, nurses and
midwives
279
Section 4 Major reform initiatives and issues thereon 300-
308
5.4.1. Major Reform initiatives and issues thereon 301
Section 5 Major issues in HR practice related to attraction,distribution and retention of physicians, nurses and
mid-wives
309-314
5.5.1. Major issues in HR practice for attraction, distribution
and retention of physicians, nurses and mid-wives
310
Section 6 Suggestion 315-323
5.6.1. Introduction 316
5.6.2. Broad suggestions 318
Section 7 Conclusion 324-
3265.7.1. Conclusion 325
Reference 327-
343
Appendix – 1: Manpower Recommended under IPHS 344-346
Appendix 2: Questionnaire for physicians, nurses and
mid-wives
347-
353
Appendix 3: Interview schedule for State and District
management representatives
354-
356
Conference attended 357
Paper Published 358
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Chapter -1
INTRODUCTION
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1.1. INTRODUCTION TO RESEARCH THEME
It is apparent that the human element in an organisation is the most important
element in achieving the organisational goal. Focusing to the management of human
affairs within the organizations is the responsibility of human resources management
(HRM) in an organisation. Traditionally, management of this system has gained more
attention from service organizations than from manufacturing organizations
(Radcliffe, 2005).
The early decades of the 21st century considered as the era of human
resources for health sector. The public health sector is purely a service sector, the
human element is a critical element for it success and achievement of organizational
goals. In the health sector, a strong human infrastructure is fundamental to closingtoday’s gap between health promise and health reality and anticipating the health
challenges of the 21st century (WHO, 2006). The World Health Organization (WHO)
estimates the current HRH workforce at 59 million and its global shortage at 4.3
million. Both developed and developing countries are currently of Health worker
shortages. Such shortages are symptoms of a poorly managed health workforce and
health care system. The causes of the crisis are more complex with insufficient
production capacity, and overall with an inability to keep the workers in the places
where they are needed.
Despite of significant achievements after 64 years (1947-2011) of
Independence, public health sector in India is facing a critical challenge on several
fronts. While the country has made substantial strides in economic growth, its
performance in health has been less impressive. Despite an extensive network of
government funded clinics and hospitals providing low cost care, curative health
services, the country fails to address public health needs of the people. An important
reason for this is the inability of the health system to provide health care for all due to
inadequate infrastructure and human resource. Distortions in the area of human
resources in health sector are one of the significant issues in Indian public health
sector today. The country faces a shortage of qualified health workers with large
geographic variations in the health workforce, across states and rural and urban areas.
These issues are the important challenges in reforming Indian public health sector.
The public sector of the health system has been one of the main targets of the
national initiatives of reform for the public administrations, particularly because of the
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magnitude of their expenses and the number of personnel employed (Roberto & Jose,
2003). Designers and implementers of decentralization and other reform measures
have focused much attention on financial and structural reform measures, but ignored
their human resource implications. Concern is mounting about the impact that the
reallocation of roles and responsibilities has had on the health workforce and its
management. (Kolehmainen-Aitken, 2004).
While to accomplish the ‘Millennium Development Goals’ (MDG) which was
adopted in the Millennium Declaration in the year 2000, the strengthening of health
care delivery system and improved health care services are utmost importance.
Healthcare is a service sector, depends highly on specially trained professionals and
technical human resources. Both developed and developing countries are currently
facing Health worker shortages along with attraction and retention problems.
At the same time, India is also struggling to accomplish the development goals
along with the rest of the developing world. For this, the human resource are needed
to developed and retain at all level. There is a need to respond and address the HR
issues and challenges and to mobilize a motivated human resource in particular the
technical workforce towards the accomplishment of targets of the organization.
In India, health worker shortages are one of the main challenges in achieving
population health goals. Adding more on this challenge the geographical distribution
of heath workforce is always a matter of concern, featured with urban attraction in the
country. More on the issue, the mostly concerned area in health sector are difficulty in
producing, recruiting and retaining health workforce in rural and remote areas.
Thus, the major challenge in the new millennium is the retention of health
workers, not only in poorer countries, but also within any country in remote and rural
areas (Bangdiwala et al., 2011). Therefore, this study aimed at understanding the HR
issues on distribution, attraction and retention of Physicians and Nurses including the
Mid-wives in Public health care delivery system in rural India with special reference
to the State of Arunachal Pradesh. This research process not only generated useful
contributions to the field of research, but that it also provided time for reflection and
learning for other people involved in the process as there is no literature on the topic
as on date in Arunachal Pradesh (as far as this researcher has been able to establish).
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1.2 . RATIONALE BEHIND THE RESEARCH
Geographical mal-distribution of health care providers, especially physicians
and nurses including mid-wives, is a ubiquitous problem, affecting many countries
and reasons (Pong, 2008). While adopting the Millennium Declaration in the year 2000, the international community pledged to “spare no effort to free our fellow men,
women and children from the abject and dehumanizing conditions of extreme
poverty.” We are now more than halfway towards the target date – 2015 – by which
the Millennium Development Goals are to be achieved (MDG, Report 2008, UN).
The MDGs no. 4, 5 and 6 are related to Reduce Child Mortality, Improve Maternal
Health and Combat HIV/AIDS, malaria & other diseases respectively. To accomplish
these MGDs, the strengthening of health care delivery system and improved health
care services are utmost importance. Whereas, the healthcare is a service sector,
depends highly on specially trained professionals and technical human resources.
Both developed and developing countries are currently facing Health worker
shortages especially physicians and nurses along with their attraction and retention
problems. Efforts to overcome physicians and nurses shortage can be divided into two
major categories: attraction/recruitment and retention. Whereas the former is an effort
to get a doctor to set up practice in a community, the latter is an attempt to keep the
doctor there as long as possible (Pong, 2008). The causes of the crisis are complex,
with insufficient production capacity, but also with an inability to keep the workers
that are being produced in the places where they are mostly needed. The availability
of human resource is one of the important components for the efficient functioning of
public healthcare delivery system. Increase in health indicators needs increase in the
availability of health workers through improved health workforce attraction,
distribution and retention. Thus, the causes of the crisis are complex, with insufficient
production capacity, inability to keep the health workers that are being produced in
the places where they are mostly needed.
India is a vast country with a wide network of public health service with
diversified challenges in the achieving health goals, including health worker
shortages. The National Health Policy of India (2001) acknowledges the acute
shortage of healthcare professionals especially in rural areas. Such shortages are the
symptoms of a poorly managed health workforce and health care system. Several
issues which are foremost important are producing, distributing, attracting and their
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retention rural and remote areas. India has about 1.4 million medical practitioners,
74% of whom live in urban areas where they serve only 28% of the population, while
the rural population remains largely underserved. (Sundararaman & Gupta, 2011).
The widespread poverty, illiteracy, malnutrition, absence of safe drinking water and
sanitary living conditions, poor maternal and child health services and ineffective
coverage of national health and nutritional services have been traced out in several
studies as possible contributing factors to dismal health conditions prevailing among
the tribal and rural population in India (Basu, 2000).
1.2.1. WHY PHYSICIANS, NURSES AND MID-WIVES ARE SELECTED
FOR THE STUDY?The rationale behind the selection of the physicians and the nurses from the
pool of professional workforce in the healthcare sector is due to the nature of these
categories of workforce. As, these healthcare categories of professionals require
special consideration, particularly to the availability, acquisition, retention,
development of their competence and meeting their professional needs and
expectations. The main skilled health workers in rural areas work in the public health
sector are these two categories of health workforce.
Moreover, according to the National Health Policy 2000, India is committed to
achieve the reduction in maternal and infant mortality rates set for National
Population Policy-2000. The Maternal Mortality in India continues to remain
unacceptably high, and there is enough evidence globally to demonstrate that an
effective package of obstetric and child health services provided within reach of the
communities and families can successfully reduce maternal and childhood mortality.
So, to operationalization of all Community Health Centers, Primary Health Centers
and Sub Health Centers for providing 24 hours x 7 days obstetric (maternal) and child
health services including the management of common obstetric complications,
emergency care of sick children and referrals round the clock, all seven days of the
week, in the public health setting, the services of Physicians, Nurses and Mid-wives
are the critical components besides the infrastructural development at all level.
Thus, the rationale behind the selection of the physicians and the nurses from
the pool of professional workforce in the healthcare sector is due to the nature of these
categories of workforce, as these healthcare categories of professionals require special
consideration, particularly to the availability, acquisition, retention, development of
their competence and meeting their professional needs and expectations.
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1.2.2. WHY RURAL AND REMOTE AREAS SELECTED FOR THE STUDY?In recent year, major initiatives have been launched to tackle health and
inequalities in access to health. The mal-distribution of personnel has its roots in
longstanding global inequalities. It is in this global context of accelerating inequities
that health-service policy makers and managers are searching for ways to improve the
attraction and retention of staff in remote and rural areas (Lehmann et al, 2008).
Recruiting and retaining highly qualified health workers in remotely located areas
presents an enormous challenge in both developed and developing countries (Chomitz
et al, 1998). In view of these quotes, the remarks are particularly for the rural and
remote areas. To talk of Asia as a whole, according to Chen. L., et al. in Joint
Learning Initiative (2004) Asia which has about half the world's population, has
access to only about thirty percent of the world's health professionals and has
confirmed that global inequities in the distribution of health personnel hit those
countries hardest which can least afford it. India is predominantly a rural area and the
Rural Health Care System forms an integral part of the National Health Care System.
Provision of Primary Health Care is the foundation of the rural health care system.
For developing vast public health infrastructure and human resources of the country,
accelerating the socio-economic development and attaining improved quality of life,
the Primary health care is accepted as one of the main instrument of action.
The studied area- the state of Arunachal Pradesh is a pre-dominantly a rural
and remote area. The rural population constitutes 77.33% whereas; the urban
population consists of only 22.67% of the total population of the state (Census 2011).
Thus, the importance of rural and remote areas argues for the selection.
1.2.3. WHY HR PRACTICES (INCLUDING DISTRIBUTION,
ATTRACTION AND RETENTION) SELECTED FOR THE STUDY?According to Infosys CEO, Narayana Murthy said “My employees seek
challenging opportunities, respect, dignity and opportunities to learn new things. I
keep telling them that my assets are not this building, the business or foreign
contacts, My assets – all 8,000 of them – walk out of the gate every evening and I wait
for them to come back to me the next morning” This is what has made Infosys one of
the best proactive HRD practicing company and also one of the first companies to
adopt an employee stock option and create additional wealth for its employees
(Ramani, 2003).
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The increased attention paid to new HRM practices has been particularly
prevalent in the fields of strategic management, human resource management, and
increasingly, the economics of organization (Laursen & Foss, 2000). There are
significant relationship between human resources practice and organisational success.
This is well known that human beings are the most important resources of an
organisation especially in service sector organisation as they play a crucial role in its
growth and development and achievement of goals.
In the health sector, along with several HR issues, according to Lehmann et al,
2008, one of the most negative effects of severely weakened and under-resourced
health systems is the difficulty they face in producing, recruiting, and retaining health
professionals, particularly in rural and remote areas.
Efforts to overcome physician and nurse shortage can be divided into two
major categories: recruitment/attraction and retention. Whereas the former is an effort
to get a doctor to set up practice in a community, the latter is an attempt to keep the
doctor there as long as possible (Pong, 2008). Resulted in, the main challenges as
experienced to be the recruitment, distribution and retention of health workers.
Thus, keeping the synergies between the research problems, a look on at HR
issues regarding distribution, attraction and retention of physicians and nurses in
rural and remote areas are considered.
The discussion of attraction, distribution/placement and retention factors and
strategies falls within the broad scope Human Resource Management (HRM) as a
strategic and coherent approach to managing staff (with inclusions from Armstrong,
2007). These areas are equally important with a focus on rural and remote areas and
thus the order of discussion does not represent their relative importance.
1.3. OBJECTIVE OF THE STUDYAs the researcher could able to establish, that there is no academic literature
available as on date relating to the research topic in the state of Arunachal Pradesh. In
view of the above, this research study aims at exploring the issues on the distribution,
attraction and retention of Physicians and Nurses in Public health care delivery system
in rural area in the state of Arunachal Pradesh. The study is focused on physicians
(doctors) and nurses (Staff Nurse/GNM, ANM -the Mid-wives) only. The research
question puts for the study are that- What are the major HR issues on distribution,
attraction and retention of physicians and nurses in rural and remote areas in
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Arunachal Pradesh? What are the major reform initiatives under reform process for
major issues on distribution, attraction and retention of physicians and nurses in
rural and remote areas in Arunachal Pradesh?
Rationally, the following objectives are place for the study:-
1. To explore the major HR issues on distribution, attraction and retention of
physicians and nurses in rural and remote areas in Arunachal Pradesh.
2. To explore the major reform initiatives under reform process for major issues on
distribution, attraction and retention of physicians and nurses in rural and remote
areas in Arunachal Pradesh.
3. To suggest some remedial measures to address the major issues.
1.4. SIGNIFICANCE OF THE STUDYThe early decades of the 21st century considered as the era of human
resources for health. This research work has brought out major issues and reform
initiatives of distribution, attract and retention of physicians and nurses in Public
Health sector of Arunachal Pradesh.
Among all factors of production, man is by far the most important. The
importance of human factor in any type of co-operative endeavour cannot be
overemphasized. It is a matter of common knowledge that every businessorganization depends for its effective functioning not so much on its material or
financial resources as on its pool of able and willing human resources. The human
resource becomes even more important in the service industry whose value is
delivered through information, personal interaction or group work (Tripathi, 2009). In
the health sector, a strong human infrastructure is fundamental to closing today’s gap
between health promise and health reality and anticipating the health challenges of
the 21st century (WHO, 2006). The health care sector is both labour-intensive and
labour-reliant, and the delivery of quality health care services is strongly dependent
on having enough well-trained health care workers to meet patient needs and
expectations. There is a growing awareness that human resource issues need to be
prioritized more effectively within reforms in order to secure an adequate health care
workforce to deliver services now and in the future (Lethbridge, 2004). Health
reforms that aims at increasing efficiency, quality and users' satisfaction need to take
into consideration human resource issues, because the health sector is labour intensive
and the performance of health systems depends on qualified and motivated workers
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(Homedes and Ugalde, 2005). Health sector reform often focuses on changes in
financing or organisational structure, but neglects a key resource – ‘the staff’. This
may result in inappropriately skilled staff for new tasks, poorly motivated staff, or
even serious opposition to the reforms (Martineau & Buchan, 2000). There has been
several analysis of the successes and failures of health reforms in general. However,
relatively little attention has been paid to the critical part that human resources (HR),
which will play in determining the success or failure of health reforms(Martineau &
Buchan, 2000). Several studies have pointed out that human resource issues need to
be a primary consideration in reform design, suggesting that reforms can only be
implemented successfully where there is consensual participation on the part of the
workforce (Ssengooba et al, 2007).
Therefore, the importance of this research is due to : - FIRSTLY, the urgency
behind “ Health Care Delivery System Reform” emphasizes by Government of India,
and the human resource is always behind in thinking of Health Sector Reforms.
SECONDLY, Human resources management occupies a unique niche in our system
of health care and the importance of attraction and retention of physicians and nurses
in rural and remote areas in delivering health care services. THIRDLY, the need of
motivated and skilled workforce to deliver better and quality primary health care
services to the rural mass.
The urge about, how this aspect of issues in India, particularly in the state of
Arunachal Pradesh are and can be addressed, motivated the researcher to explore the
subject.
1.5. OUTLINE OF THE THESIS
The first chapter is on Introductory part includes the objective, rationale and
significance of the study. The succeeding chapters are organized as follows: Chapter-
2 is Literature review which summarizes the previous study and other related themes.
Chapter-3 presents the research methodology. Chapter-4 presents the data analysis
and interpretation. Chapter-5 summarizes the Major findings on HR Issues on
distribution, attraction and retention of the Physicians, Nurses and Mid-wives and it
also presents the suggestions and conclusion of the study. Thereafter, followed by the
Bibliography and Appendix.
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Chapter -2
LITERATURE REVIEW
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2.1. INTRODUCTIONIn the field of Human Resource Management, fortunately there is no dearth of
literature. Excellent researchers, academicians and practitioners have been devoting
considerable thought to the different aspects of HRM. However, comprehensive
studies covering HR in Health Sector in India or Arunachal Pradesh is limited. An
attempt is made here to explore the literature addressing issues of distribution,
attraction and retention of physicians and nurses in a global context, along with the
health sector reforms.
This chapter discussed the literature available on the study topic. It includes
key HR issues in public health sector in global context, gaps in literatures and
conceptual framework for the study.
2.2. KEY HR ISSUES IN PUBLIC HEALTH SECTOR- IN A
GLOBAL PERSPECTIVEWhile examining health care systems in a global context, several issues are
highlighted in the literature in context of the general human resources issues. Some of
the issues of greatest relevance in the literature are discussed in subsequent section.
Here in a nutshell, the literatures emphasize the variation of size, distribution and
composition within a county's health care workforce is of great concern. One of the
biggest concerns is critical shortages of Human Resource. The importance of health
workforce provision has gained significance and is now considered one of the most
pressing issues worldwide (Hawthorne and Anderson, 2009). The international
shortage of health care professionals exists in different severities and has different
root causes, depending on the particular health profession and the country of origin.
Health care priorities therefore change between countries: a universal health system
would invariably not provide the required health care efficiently to all those who need
it (Hawthorne and Anderson, 2009). At the global level, many countries are facing
critical HRH challenges including worker shortage, skill-mix imbalance, mal-
distribution, poor work environment, and weak knowledge base (Chen, 2004; Wyss,
2004). Health professionals are insufficiently committed to the present public health
system (Homedes & Ugalde, 2005), and that is of particularly nurses and physicians
(El-Jardali et al; 2007) and especially in critical areas like specialist dentists,
anaesthetists etc, (Ramadoss, 2007). The World Health Organization (WHO)
estimates the current HRH workforce at 59 million and its global shortage at 4.3
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million (WHO, 2006). According to the WHO, there are currently 57 countries with
critical shortages of human resource for health (including India) equivalent to a global
deficit of 2.4 million doctors, nurses and midwives.
The general HR issues are highlighted below:
1. Shortage of skilled health workers: The functioning and growth of health
systems depends on the availability of human resources and on the time, effort and
skill mix provided by the workforce in the execution of its tasks (Ozcan et al, 1995,
Martínez et al, 1998- adapted from Gupta and Dal Poz, 2009). The severe shortage of
health workforce globally, especially in developing countries like African countries,
Pacific and Asian countries is a critical issue that must be addressed as an integral part
of strengthening health systems (Henderson and Tulloch, 2008). Factors that
contribute to the shortage of skilled health workers which was highlighted in the
studies of Henderson and Tulloch, 2008; Hawthorne and Anderson, 2009; Satpathy &
Venkatesh, 2006; Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; El-Jardali et
al, 2007; Kabene et al, 2006; Henderson and Tulloch, 2008; Dubois & McKee, 2006;
Management Science for Health, 2009; Institute for Public Health, 2007; WHO,
World Health Report, 2006; Bach, 2000; McCaffery, 2006; Martinez & Martineau,
1997; Mavalankar, 1999; Dussault and Dubois, 2003; Uneke et al 2008; Liu, et al.,
2006; Joaquin, 2009, Mutizwa, 1998, Mathauer and Imhoff, 2006, Brien and Gostin,
2009). The factors includes a lack of effective planning (Henderson and Tulloch,
2008; Martineau & Buchan, 2000; McCaffery, 2006; Mavalankar, 1999; Martínez &
Martineau , 1998; Uneke et al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al,
2007), limited health budgets (Henderson and Tulloch, 2008; Ssengooba et al, 2007;
Uneke et al 2008), migration of health workers (Henderson and Tulloch, 2008;
Dubois & McKee, 2006; Manafa et al, 2009; Martinez & Martineau, 2002;Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006;
Ssengooba et al, 2007), inadequate numbers of students entering and/or
completing professional training (Henderson and Tulloch, 2008; Dubois & McKee,
2006; Institute for Public Health, 2007; WHO, World Health Report, 2006; Martínez
& Martineau, 2002; Bach, 2000;McCaffery, 2006; Martinez & Martineau, 1997;
Dussault and Dubois, 2003; Kushwah, 2000, Brien and Gostin, 2009), limited
employment opportunities (Henderson and Tulloch, 2008), low Salaries (Homedes
& Ugalde, 2005; Kabene et al, 2006; Martínez & Martineau ,1998; El-Jardali et al,
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2007; Henderson and Tulloch, 2008; Institute for Public Health, 2007; WHO, World
Health Report, 2006; Martínez & Martineau, 2002; Martineau & Buchan, 2000;
Mavalankar, 1999; Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009),
poor working conditions (Homedes & Ugalde, 2005; Chen, 2004 ; Wyss, 2004;
Henderson and Tulloch, 2008; Management Science for Health, 2009; El-Jardali et
al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar, 1999;
Uneke et al 2008; Kolehmainen-Aitken, 2004), weak support and Supervision
(Henderson and Tulloch, 2008; Institute for Public Health, 2007; McCaffery, 2006;
Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008; Dieleman et al, 2009) ,
and limited opportunities for professional Development (Henderson and Tulloch,
2008; Uneke et al 2008; Kolehmainen-Aitken, 2004; Dieleman et al, 2009). The
shortage of workers often results in inappropriate skill mixes in the health sector
(Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; Henderson and Tulloch, 2008;
Dubois & McKee, 2006; McCaffery, 2006; El-Jardali et al, 2007; Bach, 2000;
Martineau & Buchan, 2000; Mavalankar, 1999; Mathauer and Imhoff, 2006), as well
as gaps in the distribution of health workers (WHO, 2006; Homedes & Ugalde,
2005; Chen,2004 ; Wyss, 2004; Kabene et al, 2006 ; Martinez & Martineau, 1997;
El-Jardali et al, 2007; Henderson and Tulloch, 2008; Martinez & Martineau, 2002;
Bach, 2000; McCaffery, 2006; Mavalankar, 1999; Dussault and Dubois, 2003;
Martínez & Martineau , 1998; Kolehmainen-Aitken, 2004; Joaquin, 2009). Overall
staffing ‘shortages’ due to the inability to attract and retain sufficient numbers, or due
to financial constraints that may be externally imposed e.g. as part of structural
adjustment. Yet there may be an over concentration of staff in urban areas at the
expense of poorer, more remote, under-served areas where posts are left vacant
(Ghana, India, Bangladesh and many poor countries) (Martínez & Martineau, 2002).
This is especially so in rural and remote areas where the provision of services is
difficult because of limited health budgets and scattered populations living in isolated
villages or islands (Henderson and Tulloch, 2008). According to Bach, (2000),
shortages of personnel trained in disciplines such as primary health care, health
economics, public health, health communication, health education, nutrition, and
environmental engineering continue to severely limit the possibilities for improving
the quality and efficiency of the health care system, that is we can say deals with
number and the composition of health workforce (Kabene et al, 2006). Almost all
countries suffer from misdistribution characterized by urban concentration and rural
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deficits, but these imbalances are perhaps most disturbing from a regional perspective
(WHO 2006). There is an over-concentration of qualified health personnel in urban
hospitals and urban centers, coupled with shortages in poor neighborhoods and rural
areas (Homedes & Ugalde, 2005). At the global level, many countries are facing mal-
distribution (Chen, 2004; Wyss, 2004; El-Jardali et al, 2007) and human resources
units are not adequately staffed (Homedes & Ugalde, 2005), distribution of health
care workers (Kabene et al, 2006 ) are not equally distributed, especially to manage
change in the health sector. Inequity in rural-urban distribution of human resources
for health (HRH) is a worldwide problem (Lexomboon, 2003). So, it may be
summaries that the regional differences of workforce is the major public health issues
and in the organization and delivery of public health services (Beaglehole and Dal
Poz, 2003).
2. Working conditions: Several researchers highlighted and summed up with
poor working condition for public health workforce in this sector. At the global level,
health workforce in the different countries are facing poor work environment which
was highlighted in the studies of Homedes & Ugalde, 2005; Chen, 2004 ; Wyss,
2004; Henderson and Tulloch, 2008; Management Science for Health, 2009; El-
Jardali et al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar,
1999; Uneke et al 2008; Kolehmainen-Aitken, 2004. After understaffing which was
the most commonly reported HR challenge; poor working conditions and staff
grievances (Management Science for Health, 2009) are the most viewed issues.
3. Compensations issues: The issue of low remuneration or inadequate salary
has attracted many research studies like Homedes & Ugalde, 2005; Kabene et al,
2006; Martínez & Martineau ,1998; El-Jardali et al, 2007; Henderson and Tulloch,
2008; Institute for Public Health, 2007; WHO, World Health Report, 2006;
Martínez & Martineau, 2002; Martineau & Buchan, 2000; Mavalankar, 1999;
Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009, Mathauer and Imhoff,
2006 and their studies concludes that, health workers in developing countries are
underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006). Under
production of health workforce, inability to pay higher salaries and benefits, inability
to sustain are other some of the issues pertaining to this, which is highlighted by
WHO, World Health Report, (2006).
4. Migration of health workforce: Even where there are an appropriate number
and mix of trained health workers, there may not be jobs available for them in their
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country of origin, despite the population experiencing widespread unmet health needs
(Brien and Gostin, 2009). Another issue highlighted in the literatures is the migration
of health workforce from own place of origin to other part of the world in search of
better avenues. Many researchers have come across this key issue while studying on
HR issues. As poor compensation packages may be one of the reasons for the
migration of the health workforce. Silently the education opportunities for their
(workforce) children (Uneke et al 2008), the migration of workers are also there. In
addition to international migration there is also considerable in-country migration
between the public and private health sectors, between urban and rural areas and
between tertiary and primary health care delivery (Manafa et al, 2009). Many
countries lack the human resources needed to deliver essential health interventions
and migration of health workers within and across countries (Henderson and Tulloch,
2008; Dubois & McKee, 2006; Manafa et al, 2009; Martínez & Martineau, 2002;
Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006;
Ssengooba et al, 2007) is one of the main concern.
5. Retention and high attrition: Due to poor working conditions, low
compensation package and migration, it is very difficult for retention of these
workforce in a developing or an underdeveloped countries and make use of their
services in rural areas. Retention and high attrition issues have been highlighted by
many research including- Martínez & Martineau, 2002; McCaffery, 2006;
Mavalankar, 1999; Institute for Public Health, 2007.
6. Aging workforce: It is yet another issue confronting some of the countries
and these aging workforces cannot be utilized fully for health interventions. This is
highlighted in the study of El-Jardali et al; (2007).
7. Professional training and production issues: The issue of inadequate
professional training is in disparity as suggested by several studies. The regulation of
training institutions and conditions of practice is weak (Homedes & Ugalde, 2005).
Insufficient numbers of people trained in primary health care and public health related
fields and the training centers are unable to produce personnel to operate the reformed
health system (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Institute for
Public Health, 2007; WHO, World Health Report, 2006; Javier Martínez & Tim
Martineau, 2002; Bach, 2000; McCaffery, 2006; Martinez & Martineau, 1997;
Dussault and Dubois, 2003; Kushwah, 2000). So, there is a need of educational
reform (Chen- 2004; Wyss, 2004; Mavalankar, 1999; El-Jardali et al, 2007).
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8. In-service-training issues: Besides insufficient numbers of health
professionals are produced, the in service-training of other health workforce is
inadequate. Health workforce education has been a low priority (Brien and Gostin,
2009). The training of health promoters and other auxiliary personnel such as dental
assistants, midwives, laboratory technicians, equipment maintenance and repair
technicians, and pharmacist is poor or non-existent (Homedes & Ugalde, 2005). At
the global level, many countries are facing critical weak knowledge base (Chen, 2004;
Wyss,2004). Workforce training is yet another important issue (Homedes & Ugalde,
2005; Kabene et al, 2006; Chen, 2004; Wyss, 2004; Kabene et al, 2006;
Management Science for Health, 2009; Mavalankar,1999; Martinez &
Martineau, 2002;; McCaffery, 2006; Martínez & Martineau , 1998; Kushwah, 2000;
Joaquin, 2009). It is essential that human resource personnel consider the composition
of the health workforce in terms of both skill categories and training levels. The
prevalence of inadequate training at various levels resulted in Limited opportunities
for professional development (Henderson and Tulloch, 2008; Uneke et al 2008;
Kolehmainen-Aitken, 2004; Dieleman et al, 2009) at the service period, which
adversely affect the professional life of the professional workforce in the health
sector.
9. Motivational issues: Health workers especially in underserved areas usually
have motivational problems at work which may be reflected and resulted in a variety
of circumstances like poor compensation packages, more opportunities for career and
educational advancement and unsatisfactory working conditions as mention above.
More to explore on the issue, Rewards are not linked to performance or the incentives
(Mavalankar, 1999; Martinez & Martineau, 2002; Martineau & Buchan, 2000,
Ssengooba et al, 2007; Martínez & Martineau , 1998; Dieleman et al, 2009), added to
the low morale and motivation of the workforce. Health workers in developing
countries are underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006;
Management Science for Health, 2009; Martinez & Martineau, 2002; McCaffery,
2006; Uneke et al 2008; Kolehmainen-Aitken, 2004). Lack of satisfaction is the most
commonly reported HR challenge, (Management Science for Health, 2009) resulted
from poor working conditions, workers’ health and well-being (Mavalankar, 1999;
McCaffery, 2006; El-Jardali et al, 2007) and staff grievances (Management Science
for Health, 2009). The motivations of health worker also affected by the Job security
(Ssengooba et al, 2007) in a great extend.
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10. Human resource policy: The medical profession strongly dominated the
definition of health sector policies and the regulation of the conditions of practice of
all health professions (Homedes & Ugalde, 2005). Regional differences in the major
public health issues and in the organization and delivery of public health services
contribute to the need for public health human resource policy advice to be context-
specific, sustainable and in tune with the available resources. (Beaglehole and Dal
Poz, 2003). The formulation of national policies and plans in pursuit of health
workforce development objectives requires sound information and evidence. (Dubois
& McKee, 2006, adapted from Gupta and Dal Poz, 2006). Absence of appropriate
human resources policies (Beaglehole and Dal Poz, 2003; Homedes & Ugalde, 2005 ;
Dubois & McKee, 2006; Dussault and Dubois, 2003; Martínez & Martineau , 1998;
Kolehmainen-Aitken, 2004), chronic imbalance with multifaceted effects on the
health workforce: quantitative mismatch, qualitative disparity, unequal distribution
and a lack of coordination between HRM actions and health policy needs are the main
issues in HR in health sector. (Dussault and Dubois, 2003). In the absence of the
human resource policies, personnel decisions (hiring and promotion) were too often
guided by favoritism, political dictates, and nepotism (Homedes & Ugalde, 2005).
Recruitment, hiring and retention are the major problems highlighted in many studies
such as (Homedes & Ugalde, 2005; Bach, 2000; Martineau & Buchan, 2000; El-
Jardali et al, 2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007;
Martínez & Martineau , 1998).
11. Health human resource planning: Planning is most important in every
sectors including health sector especially in manpower recruitment and placing.
Health human resource planning (future needs) (Martineau & Buchan, 2000;
McCaffery, 2006; Mavalankar, 1999; Martínez & Martineau , 1998; Uneke et
al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al, 2007; Henderson and Tulloch,
2008) and human resource management skills generally do not exist at local,
peripheral levels in developing countries ( Kolehmainen-Aitken, 2004).
12. HR information, absence of database: Human resource planning can be
difficult in the absence of database on present human resource in the sector.
Moreover, mentioned earlier that, the formulation of national policies and plans in
pursuit of health workforce development objectives requires sound information and
evidence (Dubois & McKee, 2006). Very limited HR information, absence of
database or accurate information on staffing (Dubois & McKee, 2006; Bach, 2000;
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McCaffery, 2006; Mavalankar, 1999; Martínez & Martineau , 1998; Uneke et al
2008; El-Jardali et al, 2007) is not in the system as suggested by many researchers is
affecting human resource management practices, sufficient attention to HR problem
of shortage, misdistribution, poor staff utilization, appropriate skills, recruitment,
performance management.
13. HRM systems: As a result of this circumstances of no access to tools and
information, Human resources management systems are weak (Homedes & Ugalde,
2005; Kolehmainen-Aitken, 2004; Management Science for Health, 2009; Martínez
& Martineau, 2002; Bach, 2000; Martineau & Buchan, 2000; McCaffery, 2006;
Dussault and Dubois, 2003; Ssengooba et al, 2007; Martínez & Martineau , 1998;
Uneke et al 2008; Joaquin, 2009), largely due to dispersal of accountability
(Homedes & Ugalde, 2005). Lack of management experts, especially experts in
insurance systems and contract managers (Homedes & Ugalde, 2005) is highlighted.
In most countries, managerial positions were traditionally given to physicians with
little or no management training (Homedes & Ugalde, 2005). Human resource
management skills generally do not exist at local, peripheral levels in developing
countries (Kolehmainen-Aitken, 2004). It comes out in light that, the lack of well-
trained human resource managers mirrors the region’s shortage of health care
professionals in general (Management Science for Health, 2009). Low pay and staff
motivation, unequal and inequitable distribution of the health workforce, and poor
staff performance and accountability, qualified staff move more freely among
countries, and even countries that can train and produce large numbers of health
workers are unable to retain them, Failure of existing performance management
systems, effective use of incentives in managing performance, weak HR capacity in
the health sector (Martínez & Martineau, 2002). Health workers with relatively high
professional and material expectations are working in a resource poor environment
with little support or supervision (Ferrinho & Lerberghe, 2000). As mentioned above,
Lack of management experts (Homedes & Ugalde, 2005), resulted in weak
supervision at all levels (Henderson and Tulloch, 2008; Institute for Public Health,
2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008;
Dieleman et al, 2009). Insufficiently/limited resourced and neglected health systems
(Henderson and Tulloch, 2008; Ssengooba et al, 2007; Uneke et al 2008), Centralized
planning (Mavalankar, 1999) often results in above situation in the health sector as
can be figured out of various literature review. Decentralization of HR management
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systems (Martineau & Buchan, 2000; Martínez & Martineau , 1998; Dieleman et al,
2009) and capacity, staff performance management, designing/ implementing new
pay/ career structures, changing skill mix new roles for professions, HR planning in a
decentralized system., establishing new employment systems and conditions of
service, development of new types of incentives to support new ways of working
(Martineau & Buchan, 2000), which is absence in majority of the health sector.
14. Absenteeism: Absenteeism among health care workers is a obstacle to
successful health service deliverance and is caused by a number of factors. As figured
out above paragraphs, there is inadequate training, poor working conditions, low
compensation at various levels, so, resulted in lack of availability and accountability
of the staff (Homedes & Ugalde, 2005; Mavalankar,1999; Javier Martínez & Tim
Martineau, 2002), for example only 52% of the auxilliary nurse-midwives (ANM)
and 57% of the medical officers (MO) stay at their place of posting in India (ICMR,
1997). This system of working has not done much to develop a team spirit and
remains a very hierarchical and bureaucratic (Mavalankar,1999).
15. Performance of the workforce: Performance of the public health system
depends on multiple factors, among which human resources (HR) are one of the most
important components (Djibuti et al; 2008). In Latin America, the need to improve
the performance of the workforce had been pointed out in many health sector
assessments conducted in the 1970s and 1980s by the United States Agency for
International Development (USAID), the World Bank (WB). The training of health
personnel is poor or non-existent (Homedes & Ugalde, 2005), thus their performance
was poor (Homedes & Ugalde, 2005), with low productivity and efficiency (Homedes
& Ugalde, 2005), and resulted in poor utilization of the present workforce (Bach,
2000).
16. Equipment and supplies: Inadequate equipment (Homedes & Ugalde, 2005),
shortages of supplies and drugs (Homedes & Ugalde, 2005), workforce ill-equipped
(Institute for Public Health, 2007; Uneke et al 2008) were also highlighted in
literatures.
17. Duality of roles: Minimal supervision, high attrition rates of employees, Less-
qualified personnel, very low government salaries (Institute for Public Health, 2007),
often resulted in duality of roles, overburden and workload (Management Science for
Health, 2009; McCaffery, 2006; Uneke et al 2008, Martinez & Martineau, 2002) to
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the present health human resources. Thus, there are two reasons for this duality of
roles: First, a shortage of staff, especially in rural areas, results in HRM
responsibilities being added to already over-burdened health care practitioners
(Management Science for Health, 2009).
So to sum up, old and new challenges threaten the human resources (HR)
responsible for health care planning and delivery in public sector funded national
health systems. Among the old challenges, low pay and staff motivation, unequal and
inequitable distribution of the health workforce, and poor staff performance and
accountability remain key obstacles to health sector development. Among the new
challenges, qualified staff move more freely among countries, and even countries that
can train and produce large numbers of health workers are unable to retain them
(Martínez & Martineau, 2002).
2.3. DISTRIBUTIONAL ISSUES OF HEALTH WORKFORCE- IN
GLOBAL CONTEXT Globally the problem of distribution of health workforce is a matter of
concern. The uneven distribution of health workforce is a global phenomenon. World
Health Organisation (WHO) estimates show a shortage of about 4 million health
workers, and this more than any other single factor may lead to failure of attaining the
Millennium Development Goals (MDGs) within the set timelines. It also suggests that
“in absolute terms, the greatest shortage occurs in South-East Asia, dominated by the
needs of Bangladesh, India and Indonesia. The largest relative need exists in Sub
Saharan Africa, where an increase of almost 140% is necessary” (WHO, 2006).
Unbalanced distribution of health personnel between and within countries is a
worldwide, longstanding and serious problem. All countries, rich and poor, report a
higher proportion of health personnel in urban and wealthier areas. (Dussault &
Franceschini, 2006). Shortage and mal-distribution of health workers in rural areas is
a concern in all countries. The central health care issue for many communities across
the nation is the inadequate supply of health care professionals and limited access of
residents to health services (Sultz & Young, 1999; Christianson & Moscovice, 1993).
The mal-distribution of health care professionals has left many areas underserved or
without health care services, while other areas deal with surpluses of health care
specialists and services. (LaSala, 2000). This contributes directly or indirectly to
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increased inequalities of access to basic health care and therefore health outcomes
(Wafula et al, 2011).
Health workers are distributed unevenly across the globe (Speybroeck, et al,
2006). Within regions and countries, access to health workers is also unequal. In India
current ratios for doctors are 1 per 1507 and 1 per 1205 for nurses, the problem of
mal-distribution remains unchanged since independence (Sundararaman & Gupta,
2011). Similar variation prevails globally, Viet Nam averages just over one health
service provider per 1000 people, but the range is wide. 37 of Viet Nam’s 61
provinces fall below this national average, while some province have around four
health service providers per 1000 (Prasad, et al, 2006). In Nicaragua, around 50% of
the health personnel are concentrated in the capital, Managua, which comprises only
one-fifth of the country's population (Nigenda & Machado, 2000). In Mexico, it is
estimated that 15% of all physicians are unemployed, underemployed or inactive. Yet
despite this apparent surplus, rural posts remain unfilled (WHO, 2000). In Bangladesh
the metropolitan areas contain around 15% of the country's population but 35% of
doctors and 30% of nurses, in government positions. Since there are virtually no
doctors or nurses in the private sector outside the metropolitan areas, the geographical
concentration of these providers in the metropolitan areas is even greater (MoHFW,
Bangladesh, 1997). In Brazil in 1995, the number of physicians per 1000 population
by region varied from 0.52 and 0.66 in the poorer regions of the north and the
northeast to 1.75 and 2.05 in the states of São Paulo and Rio de Janeiro, in the richer
southeast region. The average for the whole country was 1.19. This gap in favour of
richer regions is smaller than it was 25 years earlier, thanks to efforts to expand the
coverage of the population by public services. But "the low incomes of the population
have discouraged the settlement of doctors" in the poorer regions(Machado, 1997). In
Ghana in 1997, 1087 of the 1247 (87.2%) general physicians worked in the urban
regions, although 66% of the population lives in the rural areas (WHO, 1997). Health
worker density is higher in urban areas globally (WHO, 2006). The distribution of
health workers is heavily skewed towards urban areas. The imbalanced distribution of
health personnel can contribute to great disparities in health outcomes between the
rural and urban population (Dussault & Franceschini, 2006). Approximately one half
of the global population lives in rural areas, but these areas are served by only 38% of
the total nursing workforce and by less than a quarter of the total physicians’
workforce (figure : 1). The nurse to population/patient ratio is low compared to other
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countries. In 2004, the ratio was 1:2250 in India and 1:100-150 in Europe. This ratio
in African countries, Sri Lanka and Thailand is 1:1400, 1:1100 and 1:850,
respectively. Many States in India face a shortage of nurses and midwives. This
shortage is due to variety of reasons including: migration to well developed countries,
under production of health workforce, inability to pay higher salaries and benefits,
inability to sustain other measures to retain health workers in some countries, illness
and death and other factors that are uncontrollable. Estimates by WHO (2006), the
critical shortage are in 57 (fifty seven) countries, which includes India.
population.
Figure : 1 : Total Physicians and nursing workforce in urban and rural areas- a
global view
A clear-cut distinction between public health and clinical services is not
entirely realistic or practical (Beaglehole and Dal Poz, 2003). WHO estimates the
current full time health workforce to be 59.2 million. Out of this, health service
providers constitute about two third, whilst the remaining portion comprises of
management and supporting staffs (WHO, 2006). Based on the above estimates by
WHO (2006), the critical shortage are in 57 (fifty seven) countries, which includes
India. It is estimated that the deficit is 2.4 millions of doctors, nurses and midwives
globally. Sub-Saharan Africa region has the highest proportional shortfalls, and by
absolute numerical terms it is highest in deficiency in South-East Asian region due to
its vast population size. The global profile shows that there are more than 59 million
health workers in the world, distributed unequally between and within countries. They
are found predominantly in richer areas where health needs are less severe. Their
numbers remain woefully insufficient to meet health needs, with the total shortage
being in the order of 4.3 million workers (WHO, 2006). Table: 1 and 2 along withfigure 2 & 3 presented can highlight more on this situation.
50%
50%
62%
38%
76%
24%
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Table 1 : Global health workforce by density
WHO Region Total Health Worker Health Service
Providers
Health management
and support workers
Number Density
(Per 1,000
population)
Number Percentage
of total
healthworkforce
Number Percentage
of total
healthworkforce
Africa 1640000 2.3 1360000 83 280000 17
Eastern
Mediterranean
2100000 4.0 1580000 75 520000 25
South East
Asia
7040000 4.3 4730000 67 2300000 33
WesternPacific
10070000 5.8 7810000 78 2260000 23
Europe 16630000 18.9 11540000 69 5090000 31
Americas 21740000 24.8 12460000 57 9280000 43
World 59220000 9.3 39470000 67 19750000 33Source: WHO, 2006, Pg- 5
Table 2: Estimated critical shortage of doctors, nurses and midwives
WHO Region Number of countries In countries with shortages
Total With
shortages
Total
Stock
Estimated
Shortage
Percentage
increase
required
Africa 46 36 590198 817992 139
Americas 35 5 93603 37886 40South East Asia 11 6 2332054 1164001 50
Europe 52 0 NA NA NA
Eastern
Mediterranean
21 7 312613 306031 98
Western Pacific 27 3 27260 32560 119
World 192 57 3355728 2358470 70
Source: WHO, 2006, Pg- 13
Figure 2: Countries with a critical shortage of health service providers (doctors,nurses and mid-wives) Source : WHO, 2006, Pg-12.
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Figure 3 : Density of health workers. Source: WHO Global Atlas of the Health
Workforce (created on 4 July 2007) (adapted from Henderson & Tulloch, 2008).
2.4. ATTRACTION AND RETENTION OF PHYSICIANS AND
NURSES IN RURAL AREAS- IN A GLOBAL CONTEXT Attraction and Retention of physicians and nurses in rural areas is a challenge
globally, mostly related to attraction towards urban area and leaving the rural areasunderserved. This section of literature review explores the perspective of attraction
and retention of both physicians and nurses including mid-wives in rural areas, as
these groups of health workforce are the largest and the important workforce to cater
the need of maternal and child health services in the community. Due to the limited
documentation on retention in low-income countries (LICs), literature on high-income
countries (HICs) has also been included to explore whether lessons could be learnt
from experiences in them (Dieleman and Harnmeijer, 2006).
The issue of attraction and retention of rural physicians is a long-standing
problem globally. The hindrance of the countries in achieving the health objectives
and goals are of the reasons that the country’s inadequacy and mal-distribution in
health workforce (Snow et al (2011). Difficulty in production, recruitment and
retention of health professionals issues for severely weakened and under resourced
health sector (Lehmann et al, 2008) is a concern. WHO (2006), also emphasized on
the production issue of enough doctors, nurses and other key health workers. But,
only increase in production is not enough. Recent attempts at trying to solve the
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problem of underserviced areas have resulted in much hostility and little achievement
(Jason & Alison, 1999). While the rural population has continued to grow, the
number of physicians in these areas has steadily declined. Urban areas are more
attractive to health care professionals for their comparative social, cultural and
professional advantages (Lerberghe, et al, 2002). This problem is not exclusive in
underdeveloped or developing counties but it in developed countries also, to name a
few are Canada, USA & Australia.
According to the study by Jason & Alison (1999) for physicians in Canada,
they explore the problem of physician recruitment and retention in rural areas in the
three main areas of physician needs – professional satisfaction, financial
remuneration, and lifestyle. They also emphasized on useful approach in defining the
solution is to examine it at all levels of a rural physician’s training and career. They
concluded that an integrated approach to problem solving requires not only
interventions at the high school, university, medical school, and residency levels, but
also the active participation and co-operation of the physicians, the communities in
which they practice, and the regional and provincial governments.
“Rural physicians' recruitment and retainment has traditionally been a
challenge for hospitals and rural communities (Full, 2001).” Several researches have
been done regarding the attraction/recruitment and retention of physicians and nurses
to stay in rural area service. There are different factors in different country setting that
make a physicians and nurses more likely to attract and retain themselves in rural
services. This section summarises findings of the literature review on factors
impacting on staff attraction and retention, with a focus on remote rural areas
(Lehmann, U. et al, 2008).
Individual factors may depend on a person's personal characteristics, such as
age, gender, marital status, etc. How they impact on an individual's decision-making
is often fluid and may change in a person's life and career cycle (Lehmann, U. et al,
2008). Research suggests that the ability to adapt to rural practice and, especially,
rural life is the key determinant of retention (LaRavia. D., et al., 2002). Health
workers have been reluctant to work in rural and remote areas because of little support
or supervision, a lack of material resources for health, poor working and living
conditions, and isolation from professional colleagues (Henderson & Tulloch, 2008).
Doctors and nurses are reluctant to relocate to remote islands and forest locations that
offer poor communications with the rest of the country and few amenities for health
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professionals and their families (Chomitz, et al., 1998). It has been proposed that the
low numbers of physicians in rural area has more to do with retention than with
recruitment (Oreilly, 1997). Low wages, poor working conditions, lack of
supervision, lack of equipment and infrastructure as well as HIV and AIDS, all
contribute to the flight of health care personnel from remote areas (Lehmann, U. et al,
2008). Preferences of location may also depend on what kind of living conditions
health personnel are used to. The correlation between geographical origin of students
and their future choice of practice, i.e. whether students from under-served areas will
return to under-served areas to practise their profession, is much debated in the
literature. (Lehmann, U. et al, 2008).
Study of Snow et al (2011), an assessment of rural posting preferences by the
senior students of medical was considered. The responses were emphasized in three
orders, which are to provide career development incentives, to provide clear terms of
appointment with reliable endpoints and salary top-ups. Other responses included
were clinical infrastructure, adequate accommodation and provision of schooling of
children.
Witter et al. (2011) in his study suggested the order of importance of the
factors that encourage the doctors to work and stay in rural areas. His order of
importance of the factors are : Salary, working condition, training opportunities,
Allowances, Career development, Living condition, Supervision and management.
According to the study by Lagarde and Blaauw (2009), while they carried out
a literature review using discrete choice experiments to investigate the human
resources issues related to health workers, both in developed and developing
countries. They conclude with the salary variable as an important determinant of job
preferences. Beside salaries, the other attributions which were found are workload in
case of developed country, location characteristics, housing, and opportunity to
benefit for further education and drugs and equipments in the facilities in case of
developing countries.
In the study of Irene. A. A. (1999), following factors are identified of rural
area posting -lack of equipments, non-availability of electricity, safe water,
communication system and isolation. She also emphasized on method of selection of
community nurses, who often have an urban background and family ties and reluctant
to work in rural areas. Advocated on changing the process of selection to enable retain
trained nurses in rural areas.
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Kristiansen & Forde (1992), has also suggested proper education facility for
workforce’s children as one of the priority requirements for rural posting of doctors
and staffs. He also emphasized on work load and suggested the overtime payments.
Navajo Area Indian Health Services (Kim C., 2000) study suggested lack of
housing, lack of health care and lack of schools for children are quoted internationally
as reasons why staff either do not join or leave health services in remote areas, they
were raised in research conducted among health care providers.
The importance of general living conditions, including staff accommodation,
schools and qualified teachers, good drinking water, electricity, roads and transport,
also features very prominently in a study conducted by Mensah, (2002), into factors
affecting retention in rural Ghana. (Lehmann, U. et al, 2008).
According to the study of Dormael et al, (2008), in which retention was
assessed for all 65 trainees between 2003 and 2007. Out of the 65 trained doctors
between 2003 and 2007, 55 were still engaged in rural practice end of 2007,
suggesting high retention for the Malian context. Participants viewed the training as
crucial to face technical and social problems related to rural practice. However, they
concluded that retention can however not be attributed solely to the training
intervention but first, incentives related to living and working conditions, which
influenced rural doctors' attraction, also contribute to retention. Second, other support
mechanisms known to foster retention are provided: mentoring, supervision, and
access to further rurally relevant continuous training sessions. While complementary
bundles of interventions indeed work better than isolated interventions, it is difficult
to disentangle their effects.
According to the recent study by Murthy et al., (2012) in Indian context,
covering a few parts of the country, in which the study examine what doctors expect
in order to work in rural areas. Doctors perceived that the current salaries were not
sufficient. They expected increase in salaries; some expected double the current
salaries or parity with private healthcare sector. Many doctors were demotivated by
the lack of infrastructure. Lack of quality education facilities for children in rural
areas was a big deterrent. Security, living facilities, connectivity and proximity to
family were among the prominent expectations of doctors to work in rural areas.
Better management, well-defined and transparent transfer policy and increased leaves
were seemed as important incentives by doctors to serve in rural areas.
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In the study of Ebuehi & Campbell, (2010) in Nigeria, major rural motivators
included: assurances of better working conditions; effective and efficient support
systems; opportunities for career development; financial incentives; better living
conditions and family support systems. The main de-motivator was poor job
satisfaction resulting from inadequate infrastructure. Rural health workers were
particularly dissatisfied with career advancement opportunities.
Similarly, in a study in Nepal by Nick Simons Institute (2008), the key issues
identified as critical to the retention of Nepali MDGPs in rural areas were:
Career/promotion prospects, Status/recognition, financial incentives, working
conditions, Education for children, Continuing medical education and Political
stability and security.
Yet another study Shankar (2010), which was done for Nepal and wrote that
the recent introduction of mandatory rural service for scholarship students was aimed
to reduce the loss of medical graduates to developed nations. High tuition fees in
private medical schools and low Government wages prevent recent graduates from
taking up rural positions, and those who do face many challenges.
In the study of Glasser. M., (2010) in United States, most rural physicians in
this study decided to practise in rural areas because of family ties. The major reason
for deciding to practise in a rural location was family ties to the community, followed
by a loan or scholarship obligation. With respect to attributes positively impacting
practice satisfaction in the community, the most frequently mentioned was good
partners/call coverage, followed by good revenues/patient volume and
autonomy/freedom in the rural practice setting. Negative attributes of rural
professional practice were varied: the top three mentioned were lack of private paying
patients; hard work/long hours; and distance from specialists and medical testing.
In the study of Awofeso. N., (2010), in Nigeria, highlighted the factors as the
Spartan living standards in rural and remote areas (Open defecation, severely limited
access to electricity, primitive social amenities, chronic poverty, poor quality
educational or communication facilities, fragile health systems and the inadequacy of
potable water), Inadequate numbers of trained health staff and limited employment
capacity in the public sector, Inadequate remuneration, Sub-optimal mix and
distribution of healthcare worker, Burnout of staff (excessive workload, coupled with
relatively poor remuneration, inadequate clinical facilities and limited opportunities
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for professional development, hinder efforts to recruit and retain skilled health staff in
rural and remote areas.
According to the study by Nestman, N. A., ( 1998), factors of retaining
physicians and nurses in rural areas of Canada emphasized on lack of time off and
working hours, frustrated with earnings, not valued by regulatory bodies, medical
schools, and government, reduced availability of acute care services and specialty
services and working conditions.
According to Ballance, D. et al., (2009), while “nature” or rural background is
a common factor in many physicians who choose rural practices, “nurture” or
programs that encourage and maintain rural affinity. Effective recruitment efforts that
highlight the positive aspects of rural life and address work-life balance are also
shown to attract providers and retain them in their rural practices.
In a study of doctors and medical students in Vietnam by Vujicic. M., (2010),
respondents positively value being located in an urban area, having adequate
equipment, higher official income, being offered skills development (short-term
training), long-term education (specialist training), and free housing.
In a cohort study of 145 doctors responded by Pagaiya. N., etal., (2011) under
International Health Policy Program, found in relation of their job preference, 6
attributes found to be statistically significant in the decision to choose a job in a rural
area: hospital size, location, salary, overtime work, specialty training opportunities
and career promotion.
In the study of King. B., (2006) of Health Professions Resource Center, Texas,
the reasons given for not wanting to practice in rural areas in Texas had less to do
with the amenities or social activities associated with urban areas than with the patient
base (large numbers of uninsured or poor people) or the quality of the facilities. They
ranked “competitive salaries” as “very important” to the retention of providers in rural
areas along with facilities in rural areas, long term service to patients, recognition of
efforts and updated equipment.
In the research paper of McDonald. J., (2002), factors that have been
identified as barriers include: professional isolation and lack of organisational
support, inadequate access to hospitals, unreasonable workloads, unsatisfactory levels
of procedural work, and the lack of availability of good social and cultural facilities.
Factors likely to attract medical graduates to rural areas include: childhood experience
of country life, and rural internship.
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A study by Straume & Shaw (2010), the area of study was northern Norway
and they explore the issues of Lack of opportunities for professional development to
be the most common reason for leaving – more common than wage- and workload-
related factors. On the other hand, the enjoyable aspects of rural living and working
conditions were the most important reasons for staying.
According to the study of Kornik & Clark, (undated) on retention of doctors in
rural areas of South Africa, emphasizes on issues of professional isolation, Poor
management at facility and department level, poorly equipped hospitals, erratic salary.
The study of LaSala (2000), it is found that both rural and urban settings,
nursing administrators perceived salaries, lack of full-time positions for nurses, and a
competitive job market as barriers to both recruitment and retention. Rural
administrators also reported the local economy and unmet family needs as barriers.
The administrators in both areas indicated nurse relationships (with other nurses,
administration and physicians) and work related variables (benefits, working
conditions, and workload) were viewed as positive incentives for retention.
Geographic location, housing, and community amenities were not significant factors
in either the rural or urban settings.
Hegney, McCarthy, Rogers-Clark and Gorman (2002) conducted a cross-
sectional survey of 146 registered and enrolled nurses in rural Australia. The survey
asked nurses to rank 91 separate items on level of importance in relation to the
decision to remain in rural practice. The results suggest job satisfaction and being part
of a professional team are the most important predictors of remaining in rural practice
(Cited in Manahan, 2008).
Bilodeau and Leduc (2003), when discussing factors affecting retention of
health personnel in rural and remote areas, define three categories of factors affecting
health personnel's motivation to practise in these locations: personal (age, gender,
education, etc.), professional (specialization, working hours, incentives, etc.), and
contextual/ environmental (community amenities, quality of life, population's
educational level, etc). (Chomitz, et al., 1998).
Lea & Cruickshank (2007), the factor analyzed were-the ward culture,
workload and level of responsibility within rural healthcare facilities were of concern
for new graduates and influenced their retention within the rural nursing workforce.
While in Mullei et al. (2010) , investigated reasons for poor recruitment and
retention in rural areas of 345 nursing trainees in Kenya interviewed. The findings
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were, positive aspects included lower costs of living and more autonomy at work.
Negative issues included poor infrastructure, inadequate education facilities and
opportunities, higher workloads, and inadequate supplies and supervision.
Bushy (2006), suggested to retain a highly skilled rural nursing workforce,
continuing education must be accessible to nurses.
The major inferences drawn from a study of Klaas (2007) is that nurses are
dissatisfied with lack of promotional opportunities, lack of professional support,
facing drastic responsibilities but with less income, tremendous workloads, emotional
demands and unrealistic salary package.
A study by Vujicic M., et al. (2010) of recruitment and retention of nurses and
certified midwives in rural areas of Liberia focused the six key job attributes-location,
total pay, conditions of equipment, availability of transportation, availability of
housing, and workload.
RRWG (2004), Identified the following issues or challenges as priorities
facing rural nursing in Nova Scotia are Quality of Work Life, Limited Work
Opportunities, Continuing Education.
In study of Reardon, (2010), significant differences were identified by
country. The rank ordered items for nurses from Australia and the United States
proved to be different, but emphasized the importance of a positive workplace, good
management, job satisfaction, and job security for nurses. Decisions to leave a rural
facility included, feeling unvalued, workplace morale/culture, and job satisfaction.
The findings indicated non-financial issues rated high as factors nurses considered
when leaving rural employment.
Incentives had a large impact on the willingness (Chomitz, 1998). Taking into
consideration of a study of running financial incentive program in Canada they argued
that only financial incentives cannot solve the rural accessibility of health workforce.
The programme fails to attend the objective of locating physicians in remote rural
areas of Ontario.
Anderson & Rosenberg (1990), emphasized on combination of compulsory
service and incentive, which is being used by various developed and developing
countries.
In Blaauw et al., 2010 study findings in Thailand, Kenya and South Africa,
suggested that financial incentives are very important in persuading health workers to
choose a rural posting, especially in poorer countries, but only if they are fairly large.
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Non-financial strategies are just as important. Improved housing and accelerated
promotion were moderately effective, but preferential access to training and career
development opportunities were very powerful non-financial strategies.
Frehywot et al. (2010), put another dimension of retention of physicians. In
their study, they put emphasize on compulsory service programme for physicians in
rural areas. They found more than 70 (seventy) countries including India with
compulsory service programme as a strategy for physicians in rural areas. However,
the study emphasizes on compulsory service in rural but, opinion on that no
commitment for service could be seen in this circumstances.
According to the study of Matsumoto M, et al., (2010), they write about the
bound medical education program followed by obligatory rural service in Japan for
retention of the physicians in rural Japan. Free medical education in exchange for
obligatory rural service; and close, long-term cooperation of national and local
governments, and the medical school over the period from pre entrance selection to
completion of the nine-year obligation for each student.
Other than those of the factors highlighted, yet another issue is the migration
out of the country of the health workforce. While some countries, such as India,
Indonesia and the Philippines, have specifically trained health professionals for export
to developed countries, the unplanned loss of health workers can be extremely costly
due to their lengthy education programs, the high cost of teaching materials and
techniques, and the need to hire replacements that may lack appropriate skills,
languages or cultural sensitivity (WHO, 2004).
Literatures characterized health sector with shortage and poor availability of
physicians and nurses in rural areas globally. Health workforce is reluctant to be
posted in rural and remote areas. Several factors have been identified from monetary
to non-monetary, which affects the willingness or desire of physicians and nurses for
rural posting. The studies also suggested and encouraged a wide range of mixed
interventions for possibly solve the problem and let physicians and nurses to work for
the rural community by their own will or by compulsion. The international
experience shows that alone the monetary incentives could not change the picture and
blends of interventions are needed.
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2.5. HEALTH SECTOR REFORM : THE INTERNATIONAL AND
INDIAN CONTEXT
Reform means to reorganize, to change the way in which things are being
done or to make something better. Reform in the Health Sector means to reorganize
the manner in which the system is run so that it can become a more efficient entity. It
is with this thought in mind that health policy makers around the world embarked on a
mission to find new and improved ways to make the health sector a vibrant and
productive organization that will meet the needs of its customers. (Gittens-Gilkes, _).
Infante (1999) describes health sector reform as a dynamic process employed by
governments and health authorities to improve efficiency and effectiveness in the
health sector. The goal is to provide equity in health care, increase productivity and
improvement in the general management of health systems.
Health sector reform became a worldwide phenomenon in the 1990s (Alwan
and Horny, 2002). As Kutzin (1995) pointed out, Health Sector Reform is not a new
development. In its broader sense, it has been happening for many years in many
countries. However, in its more recent usage, it is associated with a set of fairly
focused activities and objectives which are being considered or implemented by
countries across the developing world and the political spectrum. These are
particularly addressed to financing, resource allocation and management issues,
although the precise mix and emphasis of HSR policies varies (Standing, 2000).
Health sector reforms have been used as crutches to pretend one is changing the
system, but basically staying the course or even regressing (Bjorkman, 2010).
So, Health system reforms have been a regular occurrence in countries around
the world for several decades (Yepes et al, 2010). Since the late 1980s, many
developing countries have initiated efforts to improve their health systems.
(Dmytraczenko et al, 2003). Both developed and developing are undertaking health
sector reform in their respective countries. Philippines, Thailand, South Korea,
Malaysia, Indonesia, India and Pakistan are some of the developing countries and
underdeveloped countries like Nepal and Bangladesh in Asia-Pacific are taking
initiatives for health sector reform in their respective countries.
Although there are many useful ways to categorize reforms, in practice, many
health sector reforms cannot be grouped under a single heading because of the
complex and inter-related nature of the components of the health system (PAHO,2003). During the 1990s, the pace of reforms accelerated. In some countries, this
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occurred in response to internal political changes, but in many others it was caused by
external pressures from international organizations. A common thread has been the
search for universality and efficiency, with most health reforms of the 1990s being
market-oriented. Decentralization has also been a strategy of many reforms, being
seen as effective in stimulating service delivery, better allocating resources according
to needs, and involving communities in decisions on priorities, so as to reduce
inequities. (Yepes et al, 2010).
The decade of the 1990s is seen as a marker for the beginning of health sector
reform in South Asia. These reforms are premised on four cardinal market principles
of Individual, charities and private organizations should be made responsible for
health care; Public funding must be restricted to health promotion and prevention of
disease; Central government’s role should be restricted to policy formulation and
technical guidance, with delivery of services left to the private sector and local
authorities; Private and non-governmental sector should be supported to become the
key providers of health and social services. It is these principles that guided the
design of health sector reforms across South Asia (South Asia includes India,
Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan) with the active support of
multilateral and bilateral agencies. Most of these countries initiated reforms in the
1990s and has been guided by a similar design for these reforms. (Baru, 2010).
Many other developing countries in the globe adopted Health Sector Reform
like Bolivia, Bamako, China , Chile, Czech Republic, Colombia, Egypt, Ghana,
Hungary, Kyrgyzstan Kenya, Poland, Senegal, South Africa, South Africa , Zambia,
Zimbabwe and other Central and Eastern European nations.
While literatures available on Indian context, though Government initiatives in
public health have recorded some noteworthy success over time, the Indian health
system is ranked 118 among 191 WHO member countries on overall health
performance. Health is a priority goal in its own right, as well as central input into
economic development and poverty reduction. India is well placed now to develop a
uniquely India set of health sector reforms to enable the health system in meeting the
increasing expectation of is users and staff (Ramani et al, 2005).
The health sector reforms in India were started way back in 1970s .The Govt.
of India identifies the need HSR and stated in the eighth five year plan. The Ninth
Five Year Plan (1997-2002) introduce more on health system reforms to enable the
population to obtain optimum care at affordable cost, increase the involvement of
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voluntary, private organizations, self-help groups and Panchayati Raj Institutions
(PRI) in planning and monitoring of health programmes. The Tenth Five Year Plan
(2002-2007) touches upon reforms at primary, secondary and tertiary level.
(www.april24.info)
According to the study of Agarwal (2006), the importance of working on
sector reforms and the important elements of health sector reforms are paramount in
Indian context. India is one of the country which are less developed are reforming
their health systems in an effort to achieve public health goals more affordably and
effectively.
In India, the health sector reforms broadly cover the following areas:
Reorganisation and restructuring of existing government health care system
Involving Community in health service delivery and provision
Health Management Information System
Quality of care
2.6. GAPS IN THE LITERATURE
Although the research specific to rural physicians and nursing including mid-
wives is growing, it is still very limited in the side of academic literature. Research
specific to rural physicians and nurses including mid-wives-distribution, attraction
and retention needs to be replicated and elaborated in terms of remote rural area in
context of Indian scenario especially a state which is sharing international boundary
and predominately a tribal area in sector reform environment, which is scare at this
time of research.
2.7. CONCEPTURAL FRAMEWORK FOR THE STUDY
2.7.1.HRM IN PUBLIC HEALTH SECTOR– A CONCEPTUALFRAMEWORK
Human Resource Management today is not a conceptual revolution but a
revolutionary concept (Sharma, 2000). In general Human Resource Management
refers to the management of people within the organization, not to a specific function.
This is the management of people in an organization. This includes consideration of
the management of people at a strategic level within the organization (Hyde et al,
2006). HRM is the process of acquiring, training, appraising, and compensating
employees, and of attending to their labor relations, health and safety, and fairness
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concerns (Dessler, 2008). HRM is a management function that helps manager recruit,
select, train and develops members for an organisation (Aswathappa, K., 2008).
According to Saiyadain (2009), HRM is a relative recent title for all the aspects of
managing people in an organization. It represents a broad based understanding of the
problems of people and their management in view of the development of behavioral
science knowledge. This is human resource approach; it is concerned with the growth
and development of people towards higher levels of competency, creativity, and
fulfillment, because people are the central resource in any organisation and any
society (Newstrom, 2007).
Conceptually, it may be defined as the art of procuring, developing and
maintaining competent workforce to achieve the goals of an organisation in an
effective and efficient manner.
In coming years there will be great demand for highly developed human
capital. This will require systematic and substantial investment in the development of
employees skills and knowledge. Firms will build portfolio of skills in the employee
base (Kodwani, 2003). To develop firm’s human capital more concerted effort is
necessary from every quarter. Further research by Gallup Organisation (Ramani,
2003); reveals that positive employee attitudes are likely to create 50 per cent more
customer loyalty to a company and are 44 per cent more likely to result in above
average productivity. The study also revealed that positive attitudes have a significant
impact on profits and turnover . The above views are self explanatory to the context of need
and importance of HRM.
The people in the health system carry the knowledge and skill that are the
important determinants of sustainable health in the society (Lexomboon, 2003).
Human resources play a critical role in delivering health services to the population.
Health planners and decision makers have to ensure that the right number of people,
with the right skills, is at the right place at the right time to deliver health services for
the population needs, at an affordable cost (Dreesch et al, 2005). More than any other
type of organization, health organizations are highly dependent on their workforce
(Dussault and Dubois, 2003). The health sector is a major employer in all countries.
The International Labour Organisation reckons that 35 million persons are currently
employed in the health sector worldwide (ILO, 1998). Also, HR account for a high
proportion of budgets assigned to the health sector (Narine L, 2000).
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The performance of the health sector is the sum of the performance of
individual performers and groups of performers in each organization that comprise the
sector. Unlike the physical assets of an institution, human capital which is the
capability of the workforce and its willingness and commitment to work, is an asset
that, with the proper support, can appreciate. Human resources management in the
particular area of management in an organization explicitly charged with people needs
and the priorities of employees in the organization (Johnson, 2000).
Human Resource Management in health sector involves the different functions
involving planning, managing and supporting the professional development of the
health workforce within a health system (Esmail et al, 2007). Good human resource
management (HRM) is essential to retaining staff and maintaining a high overall level
of performance within a health organization and within many health care systems
worldwide, increased attention is being focused.
Human resource management in the health sector has to function with a
unique set of circumstances and characteristics. These include: A large and diverse
workforce; A workforce comprising separate occupations and professions, some with
sector-specific skills and others with more portable ones; Loyalty of those with sector-
specific skills (e.g. doctors and nurses) tends to be first to their profession and patients
rather than to their employer.; Access to health professional training and employment
is controlled by standards and entry requirements in many countries; The health sector
is a major recipient of public expenditure in many countries; Health care delivery is a
politicised process; Health is very labour-intensive and the proportion of the total
budget spent on staff is much greater than in manufacturing and many service
industries. (Buchan 2004).
A refocus on human resources management in health care and more research
are needed to develop new policies (Kabene et al, 2006). The health sector is
considered an atypical customer when it comes to the effective utilization of HRM
interventions and the ability to show sector-specific results or outcomes that can be
directly attributed to those interventions (Adano, 2006). Further, Human resources
management plays a significant role in the distribution of health care workers. With
those in more developed countries offering amenities otherwise unavailable, chances
are that professionals will be more enticed to relocate, thus increasing shortages in all
areas of health care (Kabene et al, 2006). Human resources management also played
an important role in investing in employee development. This case makes obvious the
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important roles that human resources management can play in orchestrating
organizational change.
As discussed above, all health care is ultimately delivered by people, effective
human resources management will play a vital role in the success of health sector.
And a strong understanding of the human resources management issues is required to
ensure the success of any health care program. Here we have found that the
relationship between human resources management and health care is extremely
complex, particularly when selected literature reviews from a global perspective.
2.7.2. ATTRACTION AND RETENTION OF HEALTH WORKERS IN
RURAL AREAS -CONCEPTUAL FRAMEWORK
Health systems employ a large and growing number of medical professionals
(Fujisawa and Lafortune, 2008). Hence, it is important to attract and retain the health
workforce particularly in rural areas for achieving health goals.
The extent to which health workers can be attracted to and retained in rural
and remote areas depends on two interconnected sides: the factors which contribute to
health workers' decisions to accept and the stay in rural and remote areas and the
strategies employed by management to respond to such factors (under its control). It is
highlighted by the literature review above that the factors globally are mainly higher
salaries, better working conditions, better career opportunities or by compulsion. Both
push and pull factors impact on the individual who makes a decision about moving to,
leaving or staying in rural and remote area in many different ways. Attitudes towards
these factors by an individual physicians and nurses will be the result of adequacy of
physicians and nurses in rural and remote areas.
There are several theories supporting the mobility of workforce. One of them
is the Standard location theory has been used to predict and explain choices of
practice location by health professionals (Chomitz, et al., 1998). Location theory is
concerned with the geographic location of economic activity (Wikipedia.org). Such
that, the Neoclassic Wage Theory, suggest that the choice is driven largely by
financial motives (Boyle & Halfacree, 1998) and by the probability of finding
employment (Todaro, 1976). (Lehmann et al, 2008). Behavioural theories, such as
those developed by Maslow and Herzberg, show a more complex decision-making
process regarding the movement of labour with a particular emphasis on the
importance of job satisfaction (Lehmann et al, 2008).
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Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for
turnover in general include dissatisfaction with work. The lower level of job
satisfaction, results in more intention to migrate of this workforce. Performance,
motivation and job satisfaction are closely related to each other: workforce satisfied
with their jobs remains in their posts and performs well (Dieleman and Harnmeijer,
2006). The term, job satisfaction, has been defined by Grieshaber, Parker, and
Deering (1995): “Job satisfaction has been measured in various ways: in terms of the
gratification of needs in the work place, a ratio of perceived inputs and outcomes, as
an emotional response, and more generally as an equivalent to job attitudes.
According to the Hughes et al., (2002), Job satisfaction is defined as “the extent to
which a person likes his or her job” and is related to a person’s attitudes and feelings
towards the tasks, salary, working conditions, training and career opportunities,
supportive working environment, etc. Various studies have demonstrated that there is
a clear link between job satisfaction and staff retention (Dieleman and Harnmeijer,
2006. Therefore, the job satisfaction component is included in the framework.
Riegel (2002) argues that turnover is the consequence of a complicated series
of dynamics, including job satisfaction, organisational commitment, and intent to
leave, that influence employee attitudes and ultimately affect employee behaviour.
Turnover models have been extensively studied, and scholars have provided strong
support for the proposition that behavioural intentions (intention to leave) are the most
immediate determinant of actual behaviour (turnover) (Igharia & Greenhaus, 1992;
Lee & Mowday, 1987). Scholars have recommended using intent to leave attitudes
rather than actual staying or leaving behavior because it is relatively less expensive to
collect data on turnover intentions than actual turnover (Udo etal., 1997). Prior
research also has reported a positive relationship between intention to leave and actual
turnover (Igharia & Greenhaus, 1992; Udo et al., 1997). (cited in – Guchait, 2007).
So, the intention of migration is also included in the framework.
According to Lehmann et al; 2008, there are different types of environment
surrounding the health workforce attraction and retention. The figure 4 is presenting
the different environments.
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Figure 4: Different environments & Location of decision-makers associated with
attraction and retention in the public sector. (Source: Lehmann et al; 2008)
The factors in the international environment are mainly pull factors such as
higher salaries, better working conditions and better career opportunities in other
countries. The national environment comprises both push and pull factors such as the
general political climate, including the degree of political and social stability, war,
crime, etc., as well as general labour relations, the situation of the public service,
salary levels, career opportunities, etc. The local environment is primarily made up of
general living conditions and the social environment. The work environment again
encompass push and pull factors, such as local labour relations, management styles,
existence or lack of leadership, opportunities for continuing education, availability of
infrastructure, equipment and support. Lastly, there are a number of individual factors
which may impact on decisions, such as origin, age, gender and marital status. All
factors will be discussed in more detail below. (Lehmann et al; 2008).
To best suit for this study, analytical framework for exploring the HR Issues
will be two sided exploration, one from the side of Management Representative and
the other from the side of employee perceptions that is Physicians, Nurses & Mid-
wives with above framework of attraction and retention.
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2.7.3. FRAMEWORK OF URBAN AREA AND RURAL AREA FOR THIS
STUDY
The identification of rural and urban area of the state for this study is done
within the framework of these definitions.
Rural settlement : The definition of a rural settlement depends on the country. In
some countries, a rural settlement is any settlement in the areas defined as rural by a
governmental office, e.g., by the national census bureau. This may include even rural
towns. In some others, rural settlements traditionally do not include towns.
(Wikipedia)
Urban Settlement: For the Census of India 2011, the definition of urban area is as
follows (Census, 2011, Data highlights):
1. All places with a municipality, corporation, cantonment board or notified townarea committee, etc.
2. All other places which satisfied the following criteria:
a. A minimum population of 5,000;
b. At least 75 per cent of the male main working population engaged in
non-agricultural pursuits; and
c. A density of population of at least 400 persons per sq. km.
Other criteria: Along with the considerations of above definitions, the inclusion
criteria of presence of a District or General Hospital within the health system structure
in the state are also looked into.
The framework of urban area and rural area for this study:
As highlighted by the above definition and other criteria, the following point
will be considered for filtering the urban area:
1. Presence of District Hospital/General Hospital in the location of town area will be
considered as Urban area
2. Further it will be filtered with population above the minimum criteria of 5000
3. Rest of the towns falls outside the point 1 & 2 will considered as rural town areas
4. Other areas of the above will be inclusively rural area.
5. The areas falls under urban area is tabulated in the table.3
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Table 3: The areas falls under Urban areas in the state for this study
Sl.no.
District District HQ/DistrictHospital
location
Population DistrictHospital/General
Hospital
Consideration asUrban Area for thisstudy
1 Tawang Tawang 8376 1 Qualify as UrbanArea
2 West Kameng Bomdila 6693 1 Qualify as Urban
Area
3 East Kameng Seppa 15002 1 Qualify as UrbanArea
4 Papum Pare
includingCapitalComplex
Yupia
(Rural area)/Itanagar &
Naharlagun
----
35022 &27020
1 Qualify as UrbanArea
5 Lower Subansiri
Ziro 12384 1 Qualify as UrbanArea
6 Kurung Kumey Koloriang 4798 0 Not Qualify asUrban Area
7 Upper Subansiri
Daporijo 15756 1 Qualify as UrbanArea
8 West Siang Along 17033 1 Qualify as UrbanArea
9 East Siang Pasighat 21965 1 Qualify as Urban
Area
10 Upper Siang Yingkiong 5103 1 Qualify as UrbanArea
11 Lower Dibang
Valley
Roing 10107 1 Qualify as Urban
Area12 Dibang Valley Anini 4853 1 Not Qualify asUrban Area
Considered as RuralTown
13 Lohit Tezu 15015 1 Qualify as Urban
Area
14 Anjaw Hawai 3954 0 Not Qualify asUrban Area
15 Changlang Changlang 6469 1 Qualify as Urban
Area
16 Tirap Khonsa 9233 1 Qualify as Urban
Area
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Chapter -3
RESEARCH
METHODOLOGY
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3.1. RESEARCH METHODOLOGY
3.1.1. RESEARCH DESIGNBased on the research objectives, the study is analytical, exploratory and
descriptive on the major HR issues on distribution, attraction and retention of physicians and nurses in rural areas in India with special reference to the state of
Arunachal Pradesh. The study included both quantitative and qualitative data
collection and analyses. This research is primarily based on primary data with
inclusion of secondary data as well. Interview and questionnaire are the major
technique used in this research along with the technique of observation. Data
collection instruments like interview schedule and survey questionnaires were
developed with the help of wide literature review. The data as collected from the
respondents (physicians, nurses and the management representatives was analyzed
and present the findings with description on the topics. Subsequently, the
interpretations and commentaries were put on the line keeping in the view of
sequences of the respective objectives.
3.1.2. OBJECTIVE OF THE STUDY
The research question puts for the study are that- What are the major HR
issues on distribution, attraction and retention of physicians and nurses in rural and
remote areas in Arunachal Pradesh? What are the major reform initiatives under
reform process for major issues on distribution, attraction and retention of physicians
and nurses in rural and remote areas in Arunachal Pradesh?
Rationally, the following objectives are place for the study:-
4. To explore the major HR issues on distribution, attraction and retention of
physicians and nurses in rural and remote areas in Arunachal Pradesh.
5. To explore the major reform initiatives under reform process for major issues on
distribution, attraction and retention of physicians and nurses in rural and remote
areas in Arunachal Pradesh.
6. To suggest some remedial measures to address the major issues.
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3.1.3. THE STUDY AREA For this study, the state of Arunachal Pradesh in India was selected. It is
situated in north-eastern most part of the country, sharing the international border of
1628 km with Bhutan to the West, China to the North and North-East and Myanmar
to the East. The referred state of Arunachal Pradesh is a pre-dominantly a rural and
remote area and one of the most splendid and variegated tribal area of the country. As
the researcher could able to establish, that there is no academic literature available as
on date relating to the research topic in the state of Arunachal Pradesh. This raises the
unexplored issues in context of tribal remote and rural areas and even if it is explored,
it is not in record in form of any literature. The health system in Arunachal Pradesh is
still in a poor state and this is traceable to several factors especially the gross under-
infrastructure of the health system and shortage of skilled medical personnel at the
primary health care level. Despite the vast improvement in the establishment of
primary health infrastructure in the state, several parts of the state continue to suffer
from lack of access to primary care services, particularly those in the poorer hilly
tribal regions in the absence of physicians and nurses to provide maternal and child
health services. Over the last decade, a series of reforms have been undertaken, in the
states. The urge about, how this aspect of issues in the state of Arunachal Pradesh are
and can be addressed, motivated me to explore the subject in this study area.
Demographic and socio economic feature: The state is situated at latitude of
90.360E to 97.30 E and longitude of 26.420 N to 29.300 N covering a total land area of
83,743 sq. km., the largest amongst NE States in India. It has a total population of
1,382,611 with an average population density per square kilometer of 17 persons. Due
to its peculiar topography and difficult terrain, there is widely dispersed settlement
pattern of the population that applies to both rural and urban areas. The rural
population constitutes 77.33% and the urban only 22.67 %.Sex ratio of the state is 920females per 1000 males. The total literacy rate of the state is 66.95% with a male
literacy rate of 73.69 % and female literacy rate of 59.57 %. (Source: Census 2011).
The district wise Population as per census 2011 is presented in table 4.
Table 4: Demographic indicators Census 2011 and 2001 of Arunachal Pradesh
Indicators 2011 (census) 2001 (census)
Population 1,382,611 1,097,968
Male 720,232 579,941
Female 662,379 518,027
Population Growth 25.92% 26.21%
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Percentage of total Population 0.11% 0.11%
Sex Ratio 920 901
Child Sex Ratio 960 798
Density/km2 17 13
Density/mi2 43 34
Area km2 83,743 83,743Area mi2 32,333 32,333
Total Child Population (0-6 Age) 202,759 205,871
Male Population (0-6 Age) 103,430 104,833
Female Population (0-6 Age) 99,329 101,038
Literacy 66.95 % 54.34 %
Male Literacy 73.69 % 65.43 %
Female Literacy 59.57 % 40.23 %
Total Literate 789,943 484,785
Male Literate 454,532 303,281
Female Literate 335,411 181,504
Table 5 : Urban-Rural comparison of demographic indicators of Arunachal
Pradesh
Indicators Rural Urban
Population (%) 77.33 % 22.67 %
Total Population 1,069,165 313,446
Male Population 554,304 165,928
Female Population 514,861 147,518
Population Growth 22.88 % 37.55 %
Sex Ratio 929 889
Child Sex Ratio (0-6) 964 944Child Population (0-6) 164,617 38,142
Child Percentage (0-6) 15.40 % 12.17 %
Literates 557,105 232,838
Average Literacy 61.59 % 84.57 %
Male Literacy 68.79 % 89.45 %
Female Literacy 53.78 % 79.04 %
The administrative set up of Arunachal Pradesh and its changing district
boundaries correspond broadly to natural boundaries of river basin. Even the
boundaries of Sub-Divisions, Community Development Blocks and Administrative
Circles within the districts have also been directly affected by the terrain features.
There are 16 Districts, 37 sub-divisions, 155 circles, 17 towns, 69 blocks and
3862 villages (Source - Census: 2001) constituting an elaborate administrative
structure for diffusing developmental activities in the state.
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3.1.4. MAP OF THE STUDIED AREA
Figure 5: Map of India (Source : www.Stayfinder.com)
Figure 6: Map of Arunachal Pradesh (Source : www.arunachalipr.gov.in)
Focused
Studied
Area
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3.1.5. DATA COLLECTION METHODS AND INSTRUMENTS
PRIMARY DATA: The primary data required for the study was collected
with the help of interview schedule, survey questionnaire and observation. The
primary data was collected through questionnaire among sampled physicians, nurses
and mid-wives to understand their attitude towards working and living in rural areas
and accepting the rural posting and insight on the HR issues in the area of study. A
selected key informants from state and district health official in Arunachal Pradesh
was interviewed with the help of interview schedule. Further, the data required on
distribution pattern was collected with personal visits to department of health and
family welfare, Govt. of Arunachal Pradesh.
The survey questionnaire for physicians and nurses including mid-wives was
developed with literature review and it was done in two stages. Firstly, it was
developed and tested in a pilot survey to ensure that the survey instrument is free from
all errors and all inclusions. For the purpose a field visit was undertaken. The pilot
survey was done in a rural area Primary Health Centre named as Koronu PHC, Iduli
PHC and Parbuk CHC in the Lower Dibang Valley district of Arunachal Pradesh on
dated 7.9.2010 to 10.9.10, along with 3 nos. of Physicians, 1 no. of Nurse and 3 mid-
wives. Copies of the instrument in English was prepared for each of them and handed
to them personally along with the covering letter attached with the instrument. The
filled-in questionnaires were returned to the researcher with some suggestions in
about 20 minutes of time. The suggestions of the participants were well taken and
necessary suggestions were included and reviewed for a final copy of the survey
instrument. The finally developed questionnaire is displayed in Appendix. The
participants in pilot survey were again included in the fresh survey after necessary
corrections of the instrument. The interview schedule is place in Appendix.
SECONDARY DATA: A range of research articles, books and officialdocuments available in soft and hard copies were reviewed which were related to
distribution, attraction and retention of workforce in public health sector in rural areas
in India and specially referring to the study area. The Rural Health Statistics, 2010,
published by Ministry of Health and Family Welfare, Govt. of India was used for
exploring the issues in distribution of physicians and nurses in rural India and
Arunachal Pradesh. For other secondary data, the printed & online policy manuals of
government, printed journals, government publications, articles, research thesisand books was used for collecting relevant secondary information.
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3.1.6. SAMPLING FRAME
Choosing a study sample is an important step in any research study, since it is
rarely practical, efficient or ethical to study whole population. In this study, the
multistage sampling, convenience sampling and simple random method was used to
frame the sample of physicians and nurses in rural areas in the study area. By
applying the sampling techniques, the total sixteen (16) districts were divided in four
equal zones comprises of four districts in each zone according to their geographical
location. Zone 1: (Tawang, West Kameng, East Kameng and Papumpare); Zone 2:
(Kurung Kumey, Lower Subansiri, Upper Subansiri and West Siang); Zone-3(Upper
Siang, East Siang, Dibang Valley and Lower Dibang Valley); Zone-4: (Lohit, Anjaw,
Changlang and Tirap). The simple random sampling was used to pick the sample of
physicians and nurses from each of the zone from selected health institutions through
convenience sampling.
According to the Rural Health Statistics (2010), there are 200 nos. of
physicians (doctors) and 688 nos. of nurses and mid-wives (395 nos. of mid-wives
and 293 nos. of nurses) in the rural public health system in Arunachal Pradesh.
Therefore, the sample size determined were 132 nos. of physicians and 247
nos. of midwives and nurses. The sample was determined with 95% of confidence
level, 5% margin of error with a response distribution of 50%.
According to the sample size determined, the survey questionnaires were
distributed and total of 353 nos. of questionnaires were returned to the researcher out
of which 334 nos. (113 nos. of physicians, 98 nos. of Nurses and 123 nos. of
midwives) of questionnaires were useable for the study. Henceforth the useable
response rate was 88% in total. Whereas the individual response rate for physicians
was 85% and mid-wives and nurses was 89%. To get the high response rate the use of
reminders (at-least 3 times) and questionnaire survey were used. The distribution of
questionnaire and collection of data was done within the period of 7.9.2010 to
25.03.2012.
One management representatives each from the 16 districts and one state level
management representatives were picked as a sample of management representatives
and conducted the interview.
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3.1.7. DATA ANALYSIS
Possessing relevant information generated from the interviews,
questionnaires and observations are categorizes the interviewees point to the key
themes, into main themes of issues including the observational themes. It
includes analyzing by organizing the text from the individual interview
respondent and grouping the relevant issues and eliminating the answers which
seemed irrelevant to the topic. Once the data are organized, the next step
followed was the description i.e., the researcher described the various pertinent
aspects of the study including the setting, the individual being studied, the
purpose of any activities examined, the viewpoints of the participants, etc. Only
after data have organized and described, the final step of analysis process i.e.,
interpretation and commentary was done, which involves explaining the
findings. Subsequently, the interpretation and commentary was placed according
to the research questionnaire and the study objectives. Findings and results is
presented in the sequence of the research problems.
The information collected from both the primary and secondary sources
was classified, tabulated and subjected to analysis. SPSS software was used for
data entry, validation, cleaning and analysis. The statistical package for the social
sciences (SPSS for windows version 19) and Microsoft Excel 2007 was used to
analyse the quantitative data. The summaries of the data were undertaken which
includes percentage, mean, standard deviations. The statistical analysis used
included reliabilities, correlation, T-Test (one sample & paired), ANOVA, Chi-
square test, multiple & logistic regression etc.
3.2. LIMITATION OF RESEARCH To lineout the limitation of this study, it may not be free from some of the
limitations despite of maximum heed. Although the primary data was collected with
the assumption that it truly represented the character, and the views expressed by the
respondents and the possibility of personal bias of such respondents cannot be ruled
out. Further, analysis includes the researchers own views on the HR Issues and HRM
Practice in the health sector of Arunachal Pradesh, which may include personal
experience and bias. Moreover, to determine the major issues only pertinent to
Physicians and nurses from a wide range of technical professional occupations in
health sector was considered. Other service occupations in health sectors are not
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considered here for the study, as it would have invited a huge area of study which is
not possible to sum up in the constraints of funding and timing.
3.3. CONTRIBUTION OF THE RESEARCH
It is mentioned in earlier sections that there is limited literature of the topic as
on date in Arunachal Pradesh, (so far as this researcher has been able to establish).
This research process would not only generate useful contributions to the field of
research, but that it would also provide time for reflection and learning for other
people involved in this sector. This research work definitely is useful, which has
brought out in the light of Human Resource issues and present HR practice in Public
Health sector in Arunachal Pradesh. That would I believe generate an atmosphere of
enhancing workforce management in the organization creating a WIN-WIN Situation.
It also may act as a resource book for future reference to know the HRM in the Public
Health Sector in Arunachal Pradesh in health organisation and other study purposes
also. In addition, a study such as this one, which focuses on the experiences and
views of healthcare workforce, provides useful information to policy-makers and
those responsible for the implementation and effectiveness of health sector reform
initiative in the state. It also tries to provide ideas for future improvements.
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Chapter -4
DATA ANALYSIS AND
INTERPRETATION
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SECTION-1
CHARACTERSTICS OF
RESPONDENTS
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4.1.1. INTRODUCTION
This chapter is present, the detail data analysis of the questionnaire survey and
the interview followed by interpretation of all findings. The chapter is divided into six
sections and consist of : i) Demographic characteristics of respondents, ii) Dimensionon Distribution, iii) Dimension on attraction, iv) Dimension on retention, v)
Dimension in Reform initiatives and vi) Exploration of HR Practice in Reform
Process.
4.1.2. CHARACTERSTICS OF RESPONDENTS
Characteristics- management representatives: Seventeen (17) nos. of management
representatives were pooled from District (16 nos.) and State level (1 no.) for the
study. 88.2% of the respondents were male and 11.8% were female. The mean age
and management experience of the respondents are 44 years and 8 years (approx.)
respectively. Table 6 and 7 shows the sample descriptive.
Table 6 : Demographic characteristics of management representatives respondents
Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)1 Position Level State Level 1 5.9
District Level 16 94.1
2 Gender Male 15 88.2
Female 2 11.8
3 Age 35-40 2 11.841-45 9 52.9
46-50 6 35.3
4 Years of managementexperience
0-5 3 17.6
6-10 8 47.1
11-15 6 35.3
Table 7 : Mean age and experience of management representatives respondents
Sl. No. Attributes N Mean Std. Dev.
1 Age of the respondents 17 44.29 2.88
2 Management Experience of the respondents 17 7.88 3.47
Characteristics- employees: According to the data of RHS (2010), 200 numbers of
physicians (doctors) and 688 nos. of nurses and mid-wives are in the rural and remote
areas in the state. Among these physicians, nurses and mid-wives, 132 nos. of
physicians and 247 nos. of midwives and nurses were included in the sampling size.
Finally, 334 nos. of responses in completed form were selected and included in the
data analysis. Out of total 334 nos. of respondents, 113 nos. (33.8%) are Physicians,
98 (29.3%) nurses and 123 nos. (36.8%) of mid-wives. Out of the total respondents,
26.3% of the respondents were male and 73.7% were female. In individual groups of
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these three employees 87 nos. (77%) were male and 26 nos. (23%) were female in
group of the Physicians and only 1 no. of male in group of nurses and mid-wives. 230
nos.(68.9%) of respondents had rural family Background and 104 nos. (31.1%) had
urban family background. 215 nos. (64.4%) of the respondents were married and 119
nos. (35.6%) were unmarried. The mean age and length of in-service were 31 years
(approx.) and 7 years (approx.) respectively. Out of the total respondents, 154 nos.
(46.1%) were contractual employees and 180 nos. (53.9%) were permanent
employees. At the time of study, 12 nos. (3.6%), 101 nos. (30.2%), 157 nos. (47.0%)
and 64 nos. (19.2%) of respondents were working in District Hospitals, CHCs, PHCs
and SCs respectively. Table 8 and 9 shows the employee demographic characteristics
in detail.
Table 8: Demographic characteristics of employee respondents
Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)
1 Position Physicians 113 33.8
Nurses 98 29.3
Mid-wives 123 36.8
2 Age 20-30 years 178 53.3
30-40 years 121 36.2
40-50 years 33 9.9
50-60 years 2 0.6
3 Sex Male 88 26.3
Female 246 73.7
4 Family Background Rural 230 68.9
Urban 104 31.1
5 Marital Status Married 215 64.4
Unmarried 119 35.6
6 Length of Service 0-5 years 172 51.5
5-10 years 96 28.7
10-15 years 43 12.9
15-20 years 16 4.8
20-25 years 7 2.1
7 Presently Working in DH 12 3.6
CHC 101 30.2
PHC 157 47.0
SC 64 19.2
8 Nature of Employment Contract 154 46.1
Permanent 180 53.9
Table 9: Mean age and length of service of the respondents
Sl. No. Attributes N Mean Std. Dev.
1 Age of the respondents 334 31.38 6.270
2 Length of service of the respondents 334 6.78 4.781
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SECTION 2
ANALYSIS OF DIMENSION OF
HR ISSUES IN DISTRIBUTION OF
PHYSICIANS, NURSES AND MID-
WIVES IN RURAL AND REMOTE
AREAS OF THE STATE
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4.2.1. INTRODUCTIONThis section of this chapter describes the dimensions of distributional issues of
the Physicians, Nurses and Mid-wives in the study area i.e., the state of Arunachal
Pradesh, focusing on the government health system where the problem is most severe.
The state public health delivery system is based on the three tiers that are in
primary, secondary and tertiary health care system. Public hospitals in Arunachal
Pradesh have to behave and function in accordance with the government's
administrative and financial laws issued by specific Government of India and
Government of Arunachal Pradesh. With the network of the public hospitals in the
state, the State government is responsible for managing and delivering health services,
including some aspects of prescription care, as well as planning, financing, and
evaluating hospital care provision and health care services.
The Public Health Services department that is the Department of Health and
Family Welfare is headed by Secretary H& FW and Director of Health Services and
the directorate has a separate branches headed by a Joint Directors. The planning
department undertakes the planning of new institutions which include creation of
posts for the new institutions as per the Govt. of India and state govt. norms. The
other respective National health programmes are handled by respective programme
officers, under the umbrella of National Rural Health Mission Programme which is
being headed by the Mission Director-NRHM in Directorate level.
4.2.2.SCENARIO OF DISTRIBUTION OF HEALTH
INSTITUTION IN ARUNACHAL PRADESHA widespread establishment of health institutions in the state was done across
the five year plans. According to the RHS, (2010), there is a sharp increase in the
health institutions in rural areas of the state. 55 SCs in sixth plan (1981-85) to 286
SCs in eleventh plan (2007-2012), not a single PHCs to 97 PHCs and not a single
CHCs to 48 CHCs in the region. There are 2 General Hospitals in the state, one at
Pasighat (the district headquarter of East Siang) and other at Naharlagun in the district
of PapumPare (the capital district).
Presently the state is having 468 nos. of sanctioned SCs, out of which only 286
SCs are functional due to one of other reasons of human resource inadequacy or
inadequacy of infrastructure. Above the hierarchy 119 nos. of sanctioned and
functional PHCs are functioning out of which 29 nos. of 24x7 PHCs and rest are non24x7 PHCs. Above that a wide network of sanctioned 49 nos. of CHCs are functional,
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out of which only 1 no. of CHC is functioning as FRU. There are 2 General Hospitals
at Naharlagun and Pasighat, 13 District Hospitals at Tawang, Bomdila, Seppa, Ziro,
Daporijo, Along, Yingkiong, Roing, Anini, Tezu, Changlang, Khonsa and Hawai
(under-construction). The District/General Hospital covers an average of 98,758 nos.
of population. Similarly, Average population for CHC is 28,217 and for PHC is
11,619 and SC is 2,954. Table 11 puts detail lights of the individual districts.
Table 10: Showing health infrastructure growth in rural areas of the states
State
Sub Centres Primary Health Centres Community Health Centres6
th
7
th
8
th
9
th
10
th
11
th
6
th
7th
8
th
9
th
10
th
11
th
6
th
7
th
8
th
9
th
10
th
11
th
Arunachal
Pradesh 55 155 223 273 379 286 0 24 45 65 85 97 0 6 9 20 31 48
Source : RHS, 2010
Table 11: Distribution of Public Health Facilities in Arunachal Pradesh
No. of facilities
T o t a l
Name of the Districts
T a w a n g
W e s t K a m e n g
E a s t K a m e n g
P a p u m p a r e
L o w e r S u b a n s i r i
K u r u n g K u m e y
U p p e r S u b a n s i r i
W e s t S i a n g
E a s t S i a n g
U p p e r s i a n g
L o w e r D i b a n g V a l l e y
D i b a n g V a l l e y
L o h i t
A n j a w
C h a n g l a n g
T i r a p
Total no. of
sanctioned
sub centres
468 14 27 41 42 25 45 46 44 38 13 13 3 24 27 30 36
Total no. of
functional
sub centres
286 7 21 10 30 18 13 25 28 38 11 11 4 20 12 18 22
Total no. of
sanctioned
PHCs
119 6 4 9 8 7 10 11 15 15 2 6 1 8 2 8 7
Total no. of
24x7 PHC29 1 3 1 1 1 3 1 3 4 1 1 1 1 1 4 2
Total no. of
non 24x7
PHCs
90 5 1 8 7 6 7 10 12 11 1 5 0 7 1 4 5
Total no. of CHC
49 1 4 2 4 2 4 4 5 6 4 2 0 3 2 4 3
Total no. of
CHC
(FRUs)
1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0
Total no. of
CHC
which are
non-FRUs
48 1 4 1 4 2 4 4 5 5 4 2 0 3 2 4 3
Total
number of
District
Hospitals/
General
Hospital
14 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1
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Table 12: Population covered by the health institutions in Arunachal PradeshSlNo
Name of District
Population
(Census
2011)
Number
of
DH/
GH
Population of
DH
No.Of
CHC
Population for
CHC*
No.Of
PHC
Population for
PHC
No.Of
HSC
Population
for
HSC
1 Tawang49,950
1 49,950 124,975
68,325
143,568
2 West
Kameng 87,013
1 87,013 4
21,753
4
21,753
27
3,223
3 East
Kameng 78,413
1 78,413 1
39,207
9
8,713
41
1,913
4 Papum
Pare 1,76,385
1 1,76,385 4
44,096
8
22,048
42
4,200
5 Lower
Subansiri 82,839
1 82,839 2
41,420
7
11,834
25
3,314
6 KurungKumey 89,717 0 0 4 22,429 10 8,972 45 1,994
7 Upper Subansiri 83,205
1 83,205 420,801
117,564
461,809
8 West
Siang 1,12,272
1 1,12,272 5
22,454
15
7,485
44
2,552
9 East
Siang 99,019
1 99,019 6
16,503
15
6,601
38
2,606
10 Upper
Siang 35,289
1 35,289 4
8,822
2
17,645
13
2,715
11 L/D/Vall
ey 53,986
1 53,986 2
26,993
6
8,998
13
4,15312 Dibang
Valley 7,948
1 7,948 0
-
1
1,590
3
2,649
13 Lohit
1,45,538
1 1,45,538 3
48,513
8
18,192
24
6,064
14 Anjaw
21,089
0 0 2
10,545
2
10,545
27
781
15 Changlang1,47,951 1 1,47,951 4 36,988 8
18,494
30
4,932
16 Tirap 1,11,997 1 1,11,997 3 37,332 7
16,000
36
3,111
Total 13,82,611 14 98,758 49 28,217 119 11,619 468 2,954
* Population covered by a single Health Institution in the districts are actual population covered by the HI and rest are average
4.2.3. SCENARIO OF DISTRIBUTION OF PHYSICIANS, NURSES
& MID-WIVES IN ARUNACHAL PRADESH
In Arunachal Pradesh, there is scarce on the data availability on distribution,
and trends in human resources in public health care sector has been observed by the
researcher. It is also a barrier to the effective human resource planning in the state.
According to the primary data collection from the field districts and state officials,
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there are 449 nos. of physicians/Medical Officers, 390 nos. of nurses and 542 nos. of
Mid-wives (ANM) distributed across the health institutions in Arunachal Pradesh.
This accounted for 33% of doctors, 28% of nurses and 39% of mid-wives among this
pool of human resource. Among the nursing cadre 58% accounted Mid-Wives (ANM)
and 42 % accounted for Nurses (GNM/SN). The trend may be seen at figure 7, 8 & 9.
Figure 7: Number of Physicians (doctors), Nurses and Mid-wives in Arunachal
Pradesh
Figure 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives in
Arunachal Pradesh
Figure 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh
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4.2.3.1. DISTRICT-WISE DISTRIBUTION PATTERN OF PHYSICIANS
(MEDICAL OFFICERS) & SPECIALISTS (PAEDIATRICS, ANAESTHETICS
AND GYNAECOLOGIST):
The Physicians are synonymously called doctors or Medical Officers in the
field. The distribution of the physicians is skewed and mal-distributed among thedistricts. They are more concentrated to the district which is with good access to
communication. The Specialist cadres, essential for the maternal and child like
Paediatrics, Anaesthetics and Gynaecologist are very scare and concentrated only to
the highest possible level of hospitals in urban area in the state. There are overall 11
nos. of Paediatrician, 13 nos. of Anaesthetist and 15 nos. Gynaecologist in the state.
Only 6 (37%) out of 16 districts have pediatrician. They are distributed as 3 nos. in
Papum Pare district, 2 nos. in Lower Subansiri district, 1 nos. in Upper Subansiri
district, 2 nos. in East Siang district, 2 nos. in Upper Siang and 1 no. in Lohit district.
Only 5 (31%) out of 16 districts have Anesthetist, 4 nos. in Papum Pare, 1 nos. in
Upper Subansiri, 5 nos. in East Siang, 2 nos. in Upper Siang and 1 no. Lohit Districts.
Only 8 out of 16 districts have Gynaecologist, 1 no. in West Kameng, 3 nos. in
Papum Pare, 2 nos. in L/Subansiri, 1 no. in U/Subansiri, 1 no. in West Siang, 4 nos. in
East Siang, 2 nos. in Upper Siang, and 1 no. in Lower Dibang Valley.
Table 13: Numbers of Pediatricians, Anesthetist and Gynecologist in
Arunachal Pradesh (District Wise)Sl. No. Name of District Paediatrician Anaesthetist Gynaecologist
1 Tawang 0 0 0
2 West Kameng 0 0 1
3 East Kameng 0 0 0
4 Papum Pare 3 4 3
5 L/Subansiri 2 0 2
6 Kurung Kumey 0 0 0
7 U/Subansiri 1 1 1
8 West Siang 0 0 1
9 East Siang 2 5 410 Upper Siang 2 2 2
11 L/D/Valley 0 0 1
12 Dibang Valley 0 0 0
13 Lohit 1 1 0
14 Anjaw 0 0 0
15 Changlang 0 0 0
16 Tirap 0 0 0
Total 11 13 15
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There are 449 nos. of physicians/Medical Officers distributed across the health
institutions in Arunachal Pradesh having 1:3079 of doctor-population ratio against a
norm of 1:1000 by WHO, which deviates 68% of the norms. Comparing the
concentration of physicians across the districts the districts of Papum Pare (75), East
Siang (53) and West Siang (40) are three highest districts. These districts are featured
by good communication and other basic amenities in urban areas. The Doctor-
population ratio is good in comparing to other district in Anjaw district (1:1506) to the
worst scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in
Table: 15.
Table 14: Numbers of Physicians (Medical Officer) in Arunachal Pradesh
district wise
Sl. No. Name of District No. of MOs 1 Papum Pare 75
2 East Siang 53
3 West Siang 40
4 Lohit 33
5 L/Subansiri 32
6 Changlang 29
7 West Kameng 26
8 U/Subansiri 24
9 East Kameng 23
10 Upper Siang 23
11 Tirap 22
12 L/D/Valley 21
13 Tawang 19
14 Anjaw 14
15 Kurung Kumey 10
16 Dibang Valley 5
Total 449
Table 15: Ranking of Density of Physicians (doctors) in Arunachal Pradesh
(District wise)
Rank
District Population(2011
census)
No. of Physicians
Density of physicians
Differencefrom the
norm of
WHO
&GOI
%Difference
(norm -
actual)
1 Anjaw 21,089 14 1506 506 34%
2
Upper
Siang
35,289 23 1534
534 35%
3
Dibang
Valley
7,948
5
1590
590 37%
4 East Siang 99,019 53 1868 868 46%
5PapumPare
1,76,385 75 23521352 57%
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6 L/D/Valley 53,986 21 2571 1571 61%
7 L/Subansiri 82,839 32 2589 1589 61%
8 Tawang 49,950 19 2629 1629 62%
9 West Siang 1,12,272 40 2807 1807 64%
10 WestKameng 87,013 26 3347 2347 70%
11
East
Kameng
78,413 23 3409
2409 71%
12 U/Subansiri 83,205 24 3467 2467 71%
13 Lohit 1,45,538 33 4410 3410 77%
14 Tirap 1,11,997 22 5091 4091 80%
15 Changlang 1,47,951 29 5102 4102 80%
16
Kurung
Kumey
89,717 10 8972
7972 89%
Total 13,82,611 449 3079 2079 68%
The distribution of the physicians in Arunachal Pradesh is concentrated to the
districts with good access to communication, semi-urban, rural towns and higher
health institutions. The number of physicians of 75 nos. (17%) is in Papum Pare the
capital district followed by East Siang 53 nos. (12%), West Siang 40 nos. (9%), Lohit
33 nos. (7%), L/Subansiri 32 nos. (7%), Changlang 29 nos.(6%), West Kameng
26nos.(6%), U/Subansiri 24 nos. (5%), Upper Siang 23 nos. (5%), East, Kameng 23
nos. (5%), Tirap 22 nos. (5%), L/D/Valley 21 nos. (5%), Tawang 19 nos. (4%),
Anjaw 14 nos. (3%), Kurung Kumey 10 nos (2%), Dibang Valley 5 nos. (1%). This
trend is presented graphically in figures 10, 11 and 12.
Figure 10: District wise numbers of Physicians (doctors/ medical officers) in
Arunachal Pradesh
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Figure 11: District wise percentage share of Physicians (doctors/ medical officers)in Arunachal Pradesh
Figure 12: Graphical mapping of district wise number of Physicians (doctors/
medical officers) in Arunachal Pradesh
4.2.3.2 DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES &
GNM) DISTRICT-WISE
The Nurses are synonymously called Staff Nurses and GNM in Arunachal
Pradesh. There are 390 nos. of Nurses across the geographical boundary of the state,
covering 3545 average population by a single Nurse against an expected norm of
1:500 by Govt. of India. Comparing the concentration of nurses across the districts the
districts of Papum Pare (90), East Siang (62) and West Siang (35) are three highest
districts. The density of Nurse-population ratio is good in comparison within the
districts in East Siang (1:1597) to the worst scenario in Kurung Kumey district
(1:9802). The district wise ratio is placed in table 17.
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Table 16: Numbers of Nurses in Arunachal Pradesh (District Wise)
Sl.
No.
Name of District No of
Nurses
Sl.
No.
Name of District No of
Nurses
1 Papum Pare 90 9 West Kameng 16
2 East Siang 62 10 Upper Subansiri 14
3 West Siang 35 11 Upper Siang 124 Changlang 31 12 Tawang 11
5 Lohit 27 13 Kurung Kumey 11
6 Lower Subansiri 24 14 East Kameng 8
7 L/D/Valley 20 15 Anjaw 8
8 Tirap 19 16 Dibang Valley 2
Total 390
Table 17: District-wise ranking of density of Nurses in Arunachal Pradesh
Rank Name of District Population
(2011 census)
No of
Nurses
Density of
Nurses1 East Siang 99,019 62 1597
2 Papum Pare 1,76,385 90 1960
3 Anjaw 21,089 8 2636
4 L/D/Valley 53,986 20 2699
5 Upper Siang 35,289 12 2941
6 West Siang 1,12,272 35 3208
7 Lower Subansiri 82,839 24 3452
8 Dibang Valley 7,948 2 3974
9 Tawang 49,950 11 4541
10 Changlang 1,47,951 31 4773
11 Lohit 1,45,538 27 5390
12 West Kameng 87,013 16 5438
13 Tirap 1,11,997 19 5895
14 Upper Subansiri 83,205 14 5943
15 Kurung Kumey 89,717 11 8156
16 East Kameng 78,413 8 9802
Total 13,82,611 390 3545
As per the norms Nurses are placed in higher health institution than Sub-
Centres. The distributional pattern of the nurses in the state is also concentrated to the
districts with good access to communication and higher health institutions. The
number of nurses is concentrated to the districts are Papum Pare 90 nos. (23%), East
Siang 62 nos. (16%),West Siang 35 nos. (9%),Changlang 31 nos.(8%), Lohit 27 nos.
(7%), Lower Subansiri 24 nos. (6%), Lower Dibang Valley 20 nos. (5%), Tirap 19
nos. (5%),West Kameng 16 nos. (4%), Upper Subansiri 14 nos. (4%), Upper Siang
12 nos. (3%), Tawang 11nos. (3%), Kurung Kumey 11 nos. (3%), East Kameng 8
nos. (2%), Anjaw 8 nos. (2%), and Dibang Valley 2 nos. (1%). This trend is presented
graphically in figure 13, 14 and 15.
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Figure 13: District wise numbers of nurses in Arunachal Pradesh
Figure 14: District wise share of nurses in Arunachal Pradesh
Figure 15: Graphical mapping of district wise number of nurses in ArunachalPradesh
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4.2.3.3. DISTRIBUTION PATTERN OF MID-WIVES (ANM) DISTRICT-
WISE
The Mid-wives are synonymously called ANM in Arunachal Pradesh.
Generally as per norms ANMs are posted in Sub-Centre Level and if adequate are
placed in higher institutions as per norms. There are 542 nos. of ANMs are across the
geographical boundary of the state, covering 2551 average population by a single
Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The density of
Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison to other
districts to the worst scenario in Kurung Kumey district (1:4722). The district wise
ratio is placed in Table: 19.
Table 18: Numbers of Mid-Wives (ANM) in Arunachal Pradesh (District Wise)
Sl. No Name of District No of Midwives Sl. no Name of
District
No of
Midwives
1 Papum Pare65 9 Lower
Subansiri35
2 East Siang 55 10 L/D/Valley 32
3 West Siang 47 11 West Kameng 29
4 East Kameng
45 12 Kurung
Kumey
19
5 Changlang 43 13 Tawang 17
6 Upper Subansiri 41 14 Anjaw 16
7 Lohit 38 15 Upper Siang 15
8 Tirap 36 16 Dibang Valley 9Total 542
Table 19: District-wise ranking of density of Mid-wives in Arunachal Pradesh
Rank Name of District Population (2011
census)
No of
Midwives
Density
of Nurses
1 Dibang Valley 7,948 9 883
2 Anjaw 21,089 16 1318
3 Lower Dibang Valley 53,986 32 1687
4 East Kameng 78,413 45 1743
5 East Siang 99,019 55 1800
6 Upper Subansiri 83,205 41 2029
7 Upper Siang 35,289 15 2353
8 Lower Subansiri 82,839 35 2367
9 West Siang 1,12,272 47 2389
10 Papum Pare 1,76,385 65 2714
11 Tawang 49,950 17 2938
12 West Kameng 87,013 29 3000
13 Tirap 1,11,997 36 3111
14 Changlang 1,47,951 43 3441
15 Lohit 1,45,538 38 3830
16 Kurung Kumey 89,717 19 4722Total 13,82,611 542 2551
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The distributional pattern of the ANMs in the state is also concentrated to the
districts with good access to communication and higher health institutions. The
number of mid-wives is concentrated to the districts as Papum Pare 65 nos. (12%),
East Siang 55 nos. (10%), West Siang 47 nos. (9%), East Kameng 45 nos. (8%),
Changlang 43 nos.(8%), Upper Subansiri 41 nos. (8%), Lohit 38 nos. (7%),Tirap 36
nos. (7%), Lower Subansiri 35 nos.(6%), Lower Dibang Valley 32 nos. (6%), West
Kameng 29 nos. (5%), Kurung Kumey 19 nos. (4%), Tawang 17 nos. (3%), Anjaw 16
nos. (3%), Upper Siang 15 nos. (3%) and Dibang Valley 9 nos.(2%). This trend is
presented graphically in figure 16, 17 and 18.
Figure 16: District wise numbers of mid-wives in Arunachal Pradesh
Figure 17: District wise share of nurses in Arunachal Pradesh
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Figure 18: Graphical mapping of district wise number of nurses in Arunachal
Pradesh
4.2.4. SCENARIO OF DISTRIBUTION OF PHYSICIANS,
NURSES & MID-WIVES IN RURAL AND REMOTE AREAS IN
ARUNACHAL PRADESHAccording to the primary data collection, there are 283 nos. of
physicians/medical officers, 210 nos. of nurses and 390 nos. of Mid-wives (ANM)
distributed across the rural and remote health institutions in Arunachal Pradesh. This
accounted for 32% of doctors, 24% of nurses and 44% of mid-wives among this pool
of human resource. Among the nursing cadre 65% accounted Mid-wives (ANM) and
35% accounted for Nurses (GNM/SN). Figure 19, 20 and 21 represent the situation
graphically.
Figure 19: Numbers of Physicians, nurses and mid-wives in rural and remote
areas in Arunachal Pradesh
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Figure 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives in
rural and remote area of Arunachal Pradesh
Figure 21: Percentage Share of Nurses and Mid-wives in rural and remote area
in Arunachal Pradesh
4.2.4.1. DISTRIBUTION PATTERN OF PHYSICIANS (MEDICAL
OFFICERS) IN RURAL & REMOTE AREAS (DISTRICT WISE)
There are 283 nos. of physicians/Medical Officers distributed across the rural
health institutions in Arunachal Pradesh having 1:3797 of doctor-rural population
ratio against a norm of 1:1000 by WHO, which deviates 74%. Comparing the
concentration of physicians across the districts the districts of Papum Pare (36), East
Siang (32) and West Siang (31) are three highest districts. The Doctor-population
ratio is good in comparing to other district in Anjaw district (1:1506) to the worst
scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in Table:
21.
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Table 20: District wise number of Physicians (Doctors) in Rural Area in
Arunachal Pradesh
Sl.
NO
Name of District Physicians
(Doctors) inRural Area
Sl.
NO
Name of
District
Physicians
(Doctors) inRural Area
1 Papum Pare 36 9 Anjaw 14
2 West Siang 32 10 Tirap 13
3 East Siang 31 11 East Kameng 12
4 Changlang 25 12 L/D/Valley 12
5 Lohit 23 13 Tawang 11
6 Lower Subansiri 18 14 Kurung Kumey 10
7 West kameng 16 15 Upper Siang 10
8 Upper Subansiri 15 16 Dibang Valley 5
Total 283
Table 21: District wise Doctor-Population ratio in Arunachal Pradesh Name of
District
Physicians
(Doctors)
in Rural
Area
Rural
Population
(Census
2011)
Doctor
Populatio
n ratio
WHO
norms
Difference
from the
norm of
WHO
&GOI
%
Difference
(norm -
actual)
Anjaw 14 21089 1506 1000 506 34%
Dibang
Valley
5 7948 1590 1000 590 37%
Papum
Pare
36 79500 2208 1000 1208 55%
East Siang 31 71417 2304 1000 1304 57%
West
Siang
32 87311 2728 1000 1728 63%
Upper
Siang
10 28743 2874 1000 1874 65%
L/D/Valley 12 42601 3550 1000 2550 72%
Lower Subansiri
18 70029 3891 1000 2891 74%
Tawang 11 44323 4029 1000 3029 75%
West
Kameng
16 68654 4291 1000 3291 77%
Upper
Subansiri
15 69595 4640 1000 3640 78%
Lohit 23 113700 4943 1000 3943 80%
East
Kameng
12 60156 5013 1000 4013 80%
Changlang 25 128736 5149 1000 4149 81%
Tirap 13 91113 7009 1000 6009 86%
Kurung
Kumey
10 89717 8972 1000 7972 89%
Total 283 1074632 3797 1000 2797 74%
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The distributional pattern of the physicians in rural & remote area in
Arunachal Pradesh is concentrated to the districts with easy to access of rural from the
urban areas. The number of physicians of Papum Pare 36 nos. (13%), West Siang 32
nos. (11%),East Siang 31 nos. (11%), Changlang 25 nos. (9%), Lohit 23 nos. (8%),
Lower Subansiri 18 nos. (6%), West Kameng 16 nos. (6%), Upper Subansiri 15 nos.
(5%), Anjaw 14 nos. (5%), Tirap 13 nos. (5%), L/D/Valley 12 nos. (4%), East
Kameng 12 nos. (4%), Tawang 11 nos. (4%), Upper Siang 10 nos. (4%), Kurung
Kumey 10 nos. (4%) and Dibang Valley 5 nos. (2%). This trend is presented
graphically in figure 22, 23 and 24.
Figure 22: District wise numbers of Physicians (doctors/ medical officers) in
Arunachal Pradesh
Figure 23: District wise percentage share of Physicians (doctors/ medical officers)
in Arunachal Pradesh
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Figure 24 : Graphical mapping of district wise number of Physicians (doctors/
medical officers) in Arunachal Pradesh
4.2.4.2. DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES &
GNM) IN RURAL AND REMOTE AREA IN ARUNACHAL PRADESH
DISTRICT-WISE
There are 210 nos. of Nurses across the geographical boundary of the state,
covering 5117 average population by a single Nurse against an expected norm of
1:500 by Govt. of India. Comparing the concentration of nurses across the districts,
East Siang (33), Changlang (26) and West Siang (24) are three highest districts. The
density of Nurse-population ratio is good in comparison within the districts in East
Siang (1: 2164) to the worst scenario in East Kameng district (1: 15039). The district
wise ratio is placed in Table: 23.
Table 22: District wise number of Nurses in Rural Area in Arunachal Pradesh
Sl.
NO
Name of District Nurses in
Rural Area
Sl.
NO
Name of District Nurses in
Rural Area
1 East Siang 33 9 Upper Subansiri 102 Changlang 26 10 West Kameng 8
3 West Siang 24 11 L/D/Valley 8
4 Papum Pare 19 12 Anjaw 8
5 Lohit 19 13 Upper Siang 6
6 Lower Subansiri 16 14 Tawang 5
7 Kurung Kumey 11 15 East Kameng 4
8 Tirap 11 16 Dibang Valley 2
Total 210
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Table 23: District wise Nurses –Population ratio in Rural Area in Arunachal
Pradesh
Name of
District
Nurses
inRural
Area
Rural
Population(Census
2011)
Nurse
Populationratio
WHO
norms
Difference
from thenorm of
WHO&GOI
ifference(norm -
actual)
East Siang 33 71417 2164 500 1664 77%
Anjaw 8 21089 2636 500 2136 81%
West Siang 24 87311 3638 500 3138 86%
Dibang Valley 2 7948 3974 500 3474 87%
Papum Pare 19 79500 4184 500 3684 88%
Lower Subansiri 16 70029 4377 500 3877 89%
Upper Siang 6 28743 4791 500 4291 90%
Changlang 26 128736 4951 500 4451 90%
L/D/Valley 8 42601 5325 500 4825 91%Lohit 19 113700 5984 500 5484 92%
Upper Subansiri 10 69595 6960 500 6460 93%
Kurung Kumey 11 89717 8156 500 7656 94%
Tirap 11 91113 8283 500 7783 94%
West Kameng 8 68654 8582 500 8082 94%
Tawang 5 44323 8865 500 8365 94%
East Kameng 4 60156 15039 500 14539 97%
Total 210 1074632 5117 500 4617 90%
The number of nurses as concentrated to the districts in ranking are East Siang
33 nos. (16%), Changlang 26 nos. (12%), West Siang 24 nos. (11%), Lohit 19 nos. (9%),
Papum Pare 19 nos. (9%), Lower Subansiri 16 nos. (8%), Tirap 11 nos. (5%), Kurung
Kumey 11 nos. (5%), Upper Subansiri 10 nos. (5%), Anjaw 8 nos. (4%), Lower Dibang
Valley 8 nos. (4%) , West Kameng 8 nos. (4%), Upper Siang 6 nos. (3%), Tawang 5 nos.
(2%), East Kameng 4 nos. (2%), Dibang Valley 2 nos. (1%). This trend is presented
graphically in figure 25, 26 and 27.
Figure 25: District wise numbers of nurses in rural and remote area ArunachalPradesh
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Figure 26: District wise share of nurses in rural and remote area Arunachal
Pradesh
Figure 27: Graphical mapping of district wise number of nurses in rural and
remote area in Arunachal Pradesh
4.2.4.3. DISTRIBUTIONAL PATTERN OF MID-WIVES (ANM) IN RURAL
AND REMOTE AREA IN ARUNACHAL PRADESH DISTRICT-WISE
Generally as per norms ANMs are posted in Sub-Centre Level. There are 390
nos. of ANMs in rural and remote area of the state, covering 2755 average population
by a single Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The
density of Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison
to other districts to the worst scenario in Tawang district (1: 6332). The district wise
ratio is placed in table 25.
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Table 24: District wise number of Mid-wives in Rural Area in Arunachal
Pradesh
Sl.
No.
Name of District Mid-wives
in rural andremote area
Sl.
No.
Name of
District
Mid-wives
in rural andremote area
1 Tawang 7 9 L/D/Valley 262 Dibang Valley 9 10 Tirap 29
3 Upper Siang 14 11 East Kameng 30
4 Anjaw 16 12 Papum Pare 30
5 Kurung Kumey 19 13 Lohit 30
6 Lower Subansiri 23 14 West Siang 35
7 West Kameng 25 15 East Siang 35
8 Upper Subansiri 25 16 Changlang 37
Total 390
Table 25: District wise number of Mid-wives-population ratio in Rural Area
in Arunachal Pradesh Name of District Mid-
wives
in
Rural
Area
RuralPopulation
(Census
2011)
Mid-wives
Population
ratio
WHO
norms
Difference
from the
norm of
WHO
&GOI
%
Difference
(norm -
actual)
Dibang Valley 9 7948 883 500 383 43%
Anjaw 16 21089 1318 500 818 62%
L/D/Valley 26 42601 1639 500 1139 69%
East Kameng 30 60156 2005 500 1505 75%
East Siang 35 71417 2040 500 1540 75%
Upper Siang 14 28743 2053 500 1553 76%
West Siang 35 87311 2495 500 1995 80%
Papum Pare 30 79500 2650 500 2150 81%
West Kameng 25 68654 2746 500 2246 82%
Upper Subansiri 25 69595 2784 500 2284 82%
Lower Subansiri 23 70029 3045 500 2545 84%
Tirap 29 91113 3142 500 2642 84%
Changlang 37 128736 3479 500 2979 86%
Lohit 30 113700 3790 500 3290 87%
Kurung Kumey 19 89717 4722 500 4222 89%
Tawang 7 44323 6332 500 5832 92%Total 390 1074632 2755 500 2255 82%
The distributional pattern of the ANMs in rural & remote areas in the state is
also concentrated to the districts with good access to communication. The number of
nurses is concentrated to the districts are as Tawang 7nos. (2%), Dibang Valley 9 nos.
(2%), Upper Siang 14 nos. (4%), Anjaw 16 nos. (4%), Kurung Kumey 19 nos. (5%),
Lower Subansiri 23 nos. (6%),West Kameng 25 nos. (6%), Upper Subansiri 25 nos.
(6%), L/D/Valley 26 nos. (7%),Tirap 29 nos. (7%), East Kameng 30 nos. (8%),
Papum Pare 30nos. (8%), Lohit 30 nos. (8%), West Siang 35nos. (9%), East Siang 35
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nos. (9%) and Changlang 37 nos. (9%). This trend is presented graphically in Figure
28, 29 and 30.
Figure 28: District wise numbers of mid-wives in rural and remote area
Arunachal Pradesh
Figure 29: District wise share of mid-wives in rural and remote area Arunachal
Pradesh
Figure 30: Graphical mapping of district wise number of mid-wives in rural andremote area in Arunachal Pradesh
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4.2.5.URBAN-RURAL DISTRIBUTION OF PHYSICIANS,
NURSES AND MID-WIVESThe global problem of the unequal distribution of the health workforce
between urban and rural is also found in Arunachal Pradesh. The phenomenon of
workforce mal-distribution can be seen on the data analysed.
The percentage share of Physicians (Doctors) in urban and rural area is 37%
and 63% respectively, share of Nurses in urban and rural area is 46% and 54%
respectively, share of Mid-wives in urban and rural area is 28% and 72% respectively.
In comparison to 23% of the population is urban and 77% population is rural in the
state. Figure 31, 32 and 33 presents the situation graphically.
Figure 31: Urban-rural distribution of Physicians (doctors) in comparison to urban
– rural population in Arunachal Pradesh
Figure 32: Urban-rural distribution of Nurses in comparison to urban – rural
population in Arunachal Pradesh
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Figure 33: Urban-rural distribution of Mid-wives in comparison to urban – rural
population in Arunachal Pradesh
4.2.5.1. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF PHYSICIANS
(DOCTORS) IN ARUNACHAL PRADESHThe percentage share of Physicians (Doctors) in urban and rural area is 37%
and 63% respectively in the state. When it is analysed district wise, the figures are
asymmetrical, Kurung Kumey, Dibang Valley and Anjaw Districts are predominantly
a rural area, the rest are having few numbers of health institute in urban area basically
the district hospital and general hospitals are in urban area. The figures range from
14% of urban concentration in Changlang district to 52% in Papumpare & 57% in
Upper Subansiri districts of physicians concentrated to the urban areas. However, as it
is mentioned only one institute per district are in urban areas, so in comparison it has
higher concentrations. The figures graphically of the entire district are presented in
figures 34 and 35.
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Figure 34: District wise urban-rural percentage distribution of Physicians
(doctors) in Arunachal Pradesh
Figure 35: Graphical mapping of district wise rate of urban concentration of
Physicians (doctors) in Arunachal Pradesh
4.2.5.2. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF NURSES IN
ARUNACHAL PRADESH
The percentage share of Nurses in urban and rural area is 46% and 54%
respectively. When it is analysed district wise, the figures are asymmetrical
throughout the district and maximum of the nurses area concentrated to the urban
areas. It is already mentioned in earlier paragraphs that Kurung Kumey, Dibang
Valley and Anjaw Districts are predominantly a rural area, the rest are having few
numbers of health institute in urban area basically the district hospital and general
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hospitals are in urban area. The figures range from the highest concentration of 79%
of Nurses in Urban area of Papum Pare District which is the capital complex of the
State, 60% of urban concentration in Lower Dibang Valley district to 55% in Tawang
districts. The lowest concentration of urban nurses is of 16% in Changlang district
besides the Kurung Kumey, Dibang Valley and Anjaw Districts. The figures of the
entire districts are presented in figures 36 and 37.
Figure 36: District wise urban-rural percentage distribution of nurses inArunachal Pradesh
Figure 37: Graphical mapping of district wise rate of urban concentration of
nurses in Arunachal Pradesh
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4.2.5.3. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF MID-WIVES
(ANM) IN ARUNACHAL PRADESHThe percentage share of Mid-wives in urban and rural area is 28% and 72%,
which seems to be a good figure, however, Mid-wives are basically the category of
health workforce those are meant for Sub-centres and then to PHCs and CHCs. 54%
of ANM are concentrated in the capital complex urban area health institute in
Papumpare District. 59% in Tawang and the least in Upper Siang district (7%),
besides the predominate rural areas districts of Kurung Kumey, Dibang Valley and
Anjaw Districts. The figures of the entire district are presented in figures 38 and 39.
Figure 38: District wise urban-rural percentage distribution of mid-wives
in Arunachal Pradesh
Figure 39: Graphical mapping of district wise rate of urban concentration of mid-
wives in Arunachal Pradesh
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4.2.6. NUMERICAL INADEQUACY OF PHYSICIANS, NURSES
AND MID-WIVES IN ARUNACHAL PRADESHAccording to RHS, 2010, the number of ANMs at Sub Centres and PHCs has
decreased from 454 in 2005 to 392 in 2010. The numbers of Nurses at PHCs and
CHCs has increased from 105 in 2005 to 293 in 2010. The Doctors at PHCs have
increased from 78 in 2005 to 92 in 2010. The number of Specialist doctors at CHCs
has increased from 0 in 2005 to 1 only in 2010, along with 108 General Duty Medical
Officers (GDMOs) is also available at CHCs.
However, as compared to requirement according to RHS, (2010), there was a
shortfall of 27 nos. of ANM at SCs taking into consideration of 286 SC in RHS, 2010,
whereas, the number of SCs without ANM out of 286 SCs were 56 SCs. There was
140 nos. of shortfall of Nurses in PHC/CHCs. The shortfall Doctors at PHCs were 5
in 2010 with PHCs without doctors were 10 out of 97 PHCs. There was a shortfall of
48 nos. of Obstetricians & Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs.
As per primary data available for this study, there are total no. of sanctioned
sub centres are 468, out of which only 301 have existing infrastructure, 222 No. of
SCs having only one ANM each, only 33 SCs have 2 nos. each ANMs. 22 nos. of
PHCs does not have Medical Officer i.e., the physician. 12 PHCs only have the full
strength of 3 staff nurses or 3 ANMs, none of the CHCs except are having fullcomplement of specialists i.e. Gynaecologist, Anaesthetist and Paediatrician.
It is also came to know from the interview of the management representative
that many of the health posts in the rural area are manned by the less skilled workers
like nursing assistant and other semi-skilled or unskilled fourth grade staffs, this
because of shortages in nurses and mid-wives or rather they are staying at urban areas.
The impact of this mal-distribution on health care delivery in rural areas is profound,
at times resulting in primary health care facilities being staffed mostly by other staffs.
Table 26: Showing the trend in physicians and nurses in-position in 2005 & 2010
State
SCS/PHCs ANM
CHCs/PHCs nurses
Physician
s (MO) inPHCs
Physicians
(MO)in CHCs
Specialistsin CHCs
2005 2010 2005 2010 2005 2010 2005 2010 2005 2010
Arunachal
Pradesh 454 395 105 293 78 92 NA 108 0 1
Source : RHS, 2010
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4.2.6.1 REQUIREMENT AND SHORTFALL OF HUMAN RESOURCES IN
SCS, PHCS AND CHCS IN THE STATE ACCORDING TO IPHS NORMS.The availability of human resource is one of the vital prerequisite for the
competency in Rural Healthcare Delivery System in the state, where 77% population
(2011 census) lives in rural and remote areas.
The Government of India has developed the Indian Public Health Standards
(IPHS) and indicated the human resources requirements for SHC, PHC, CHC as well
as various Hospitals with bed strengths ranging from 31 to 500 beds. The estimation
is based on the HR data of the available health facilities as primarily collected by the
researcher, the requirement and shortfall of Physicians, nurses and mid-wives is
estimated on the basis of Indian Public Health Standards. For the estimation
requirement of physicians, nurse and mid-wives, the norms of IPHS for SHC, PHC,CHC , Hospital norms of 31-50 beds for District hospitals and Hospital norms for
101-200 beds for General Hospital has been adapted. The 31-50 beds norm for
District Hospital has been considered as most of the district hospitals in the state are
yet to attain the full requirement of First Referral Unit norms and lack one of other
infrastructural requirement of 51-100 beds. The detail norms of IPHS are presented in
Appendix.
There is an acute shortage of ANMs, Nurses and Physicians for the existing
health facilities (SHCs, PHCs, CHCs and District hospitals). There is a requirement of
570 more nos. of ANM and percentage of current shortfall is 51%. The requirement of
Nurses is 926 more nos. of nurses and percentage of current shortfall is 70%. The
requirement of Physicians (doctors) is 510 more nos. of nurses and percentage of
current shortfall is 53%. The critical human resources required for the entire health
institutes district wise in the state are as detailed below in table 27, 28 and 29.
Table: 27: District wise requirement and shortfall of ANM in ArunachalPradesh
Sl.
No Districts
ANMs
Requirement Available
Shortfall
(IPHS)
% of
Shortfall
1 Tawang 35 17 18 51%
2 West kameng 62 29 33 53%
3 East Kameng 93 45 48 52%
4 Papum Pare 100 65 35 35%
5 Lower Subansiri 59 35 24 41%
6 Kurung Kumey 104 19 85 82%
7 Upper Subansiri 107 41 66 62%8 West Siang 108 47 61 56%
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9 East Siang 100 55 45 45%
10 Upper Siang 32 15 17 53%
11 L/D/Valley 34 32 2 6%
12 Dibang Valley 7 9 -2 -29%
13 Lohit 59 38 21 36%
14 Anjaw 58 16 42 72%15 Changlang 72 43 29 40%
16 Tirap 82 36 46 56%
Total 1112 542 570 51%
Table 28: District wise requirement and shortfall of Nurses in Arunachal
Pradesh
Sl.
No Districts
Nurses
Requirement Available
Shortfall
(IPHS)
% of
Shortfall
1 Tawang 56 11 45 80%2 West Kameng 67 16 51 76%
3 East Kameng 78 8 70 90%
4 Papum Pare 143 90 53 37%
5 Lower Subansiri 68 24 44 65%
6 Kurung Kumey 78 11 67 86%
7 Upper Subansiri 102 14 88 86%
8 West Siang 129 35 94 73%
9 East Siang 185 62 123 66%
10 Upper Siang 57 12 45 79%
11 L/D/Valley 63 20 43 68%
12 Dibang Valley 24 2 22 92%13 Lohit 80 27 53 66%
14 Anjaw 24 8 16 67%
15 Changlang 87 31 56 64%
16 Tirap 75 19 56 75%
Total 1316 390 926 70%
Table 29: District wise requirement and shortfall of Physicians in Arunachal
Pradesh
Sl. No Districts
Physicians (Doctors)
Requirement AvailableShortfall(IPHS)
% of Shortfall
1 Tawang 40 19 21 53%
2 West kameng 53 26 27 51%
3 East Kameng 59 23 36 61%
4 Papum Pare 76 75 1 1%
5 Lower Subansiri 51 32 19 37%
6 Kurung Kumey 68 10 58 85%
7 Upper Subansiri 81 24 57 70%
8 West Siang 104 40 64 62%
9 East Siang 111 53 58 52%
10 Upper Siang 45 23 22 49%
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11 Lower Dibang Valley 47 21 26 55%
12 Dibang Valley 13 5 8 62%
13 Lohit 62 33 29 47%
14 Anjaw 22 14 8 36%
15 Changlang 69 29 40 58%
16 Tirap 58 22 36 62%Total 959 449 510 53%
There is an acute shortage of ANMs, Nurses and Physicians for the existing
health facilities in rural areas (SHCs, PHCs, CHCs and District hospitals). There is a
requirement of 714 more nos. of ANM and percentage of current shortfall is 65%. The
requirement of Nurses is 747 more nos. of nurses and percentage of current shortfall
is 78%. The requirement of Physicians (doctors) is 545 more nos. of nurses and
percentage of current shortfall is 66%. The critical human resources required for the
entire health institutes in rural and remote area of district wise in the state are as
detailed below in table 30, 31 and 32.
Table 30: District wise rural and remote area requirement and shortfall of
ANMs in Arunachal Pradesh
Sl.
No Districts
ANMs
Requirement Available
Shortfall
(IPHS)
% of
Shortfall
1 Tawang 35 7 28 80%
2 West Kameng 62 25 37 60%3 East Kameng 93 30 63 68%
4 Papum Pare 96 30 66 69%
5 Lower Subansiri 59 23 36 61%
6 Kurung Kumey 104 19 85 82%
7 Upper Subansiri 107 25 82 77%
8 West Siang 108 35 73 68%
9 East Siang 96 35 61 64%
10 Upper Siang 32 14 18 56%
11 L/D/Valley 34 26 8 24%
12 Dibang Valley 7 9 -2 -29%
13 Lohit 59 30 29 49%
14 Anjaw 58 16 42 72%
15 Changlang 72 37 35 49%
16 Tirap 82 29 53 65%
Total 1104 390 714 65%
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Table 31: District wise rural and remote area requirement and shortfall of
Nurses in Arunachal Pradesh
Sl.
No Districts
Nurses
Requirement Available
Shortfall
(IPHS)
% of
Shortfall
1 Tawang 37 5 32 86%
2 West Kameng 48 8 40 83%
3 East Kameng 59 4 55 93%
4 Papum Pare 68 19 49 72%
5 Lower Subansiri 49 16 33 67%
6 Kurung Kumey 78 11 67 86%
7 Upper Subansiri 83 10 73 88%
8 West Siang 110 24 86 78%
9 East Siang 110 33 77 70%
10 Upper Siang 38 6 32 84%
11 L/D/Valley 44 8 36 82%12 Dibang Valley 24 2 22 92%
13 Lohit 61 19 42 69%
14 Anjaw 24 8 16 67%
15 Changlang 68 26 42 62%
16 Tirap 56 11 45 80%
Total 957 210 747 78%
Table 32: District wise rural and remote area requirement and shortfall of
Physicians (doctors) in Arunachal Pradesh
Sl.
No Districts
Physicians (Doctors)
Requirement Available
Shortfall
(IPHS)
% of
Shortfall
1 Tawang 31 11 20 65%
2 West kameng 44 16 28 64%
3 East Kameng 50 12 38 76%
4 Papum Pare 60 36 24 40%
5 Lower Subansiri 42 18 24 57%
6 Kurung Kumey 68 10 58 85%
7 Upper Subansiri 72 15 57 79%
8 West Siang 95 32 63 66%
9 East Siang 95 31 64 67%
10 Upper Siang 36 10 26 72%
11 L/D/Valley 38 12 26 68%
12 Dibang Valley 13 5 8 62%
13 Lohit 53 23 30 57%
14 Anjaw 22 14 8 36%
15 Changlang 60 25 35 58%
16 Tirap 49 13 36 73%
Total 828 283 545 66%
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SECTION 3
ANALYSIS OF THE DIMENSION
OF HR ISSUES IN ATTRACTION
OF PHYSICIANS, NURSES AND
MID-WIVES IN RURAL AND
REMOTE AREAS
OF THE STATE
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4.3.1. INTRODUCTIONThis section of this chapter describes the dimensions of attraction of the
Physicians, nurses and mid-wives to the rural area services. An employee attitude
survey measured the employee attitudes towards the rural and remote area services
covering the factors that attracted them to the rural services. It is also attempted to
explore the factors that may attract them more to work in the rural and remote area.
Side by side this section of the chapter also presents where deem fit the management
perspective on the issue as well. The determination of the factor that majorly
attracted and may attract the physicians, nurses and mid-wives has considered on the
Mean factor which would be statistically significant at Mean Test value of (1.5), that
means the selection was done by the majority (more than half) of the respondents and
have an greater impact at large workforce. This helps in ascertain the most affected
factors for the current attraction and the factor that may attract the workforce.
4.3.2. FACTORS THAT ATTRACTED OR PLACED THE
PHYSICIANS, NURSES AND MID-WIVES IN THE CURRENT
JOB IN THE RURAL AND REMOTE AREA: CURRENT
DETERMINANTS OF ATTRACTION AND PLACEMENTS
Several previous studies have an outlook that the doctors and nurses are
reluctant to relocate to rural and remote areas. These workforces who are presently in
rural and remote areas are only due to compulsion or with their any other attraction
factors contribute to their location. So, in this section it is attempted to explore the
factors contributed regarding physicians, nurses and mid-wives for selection of their
current employment in the rural and remote area. Is the compulsion is only factor
which contributed to their attraction of rural area services, or the other factors do
contribute to it. The exploration is based on the sixteen (16) preset factors which were
included for the same. The determination of the factor that majorly attracted the
physicians, nurses and mid-wives has considered on the Mean factor which would be
statistically significant at Mean value of (1.5), that means the selection was done by
the majority (more than half) of the respondents and have an greater impact at large
workforce. This helps in ascertain the most affected factors presently.
The Reliability analysis was done for the present attraction factors consistency
of responses to items. The Cronbach alpha coefficient indicates the consistency of
responses to items in a measure (Foxcroft & Roodt, 2002). The Cronbach’s alpha
coefficient for the factor items is α =(-0.038) on item 16 and N=334, which is a
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negative alpha and when the factor no 8: Compulsion (minimum rural service tenure
or non-transferable or Management or political pressure) has been dropped and the
Cronbach’s alpha coefficient comes to α =(0.534) on item 15 and N=334, which is
higher than 0.5.
As it can be derived from Table 33, the results indicated the factors of
attraction of the physicians, nurses and mid-wives as : Compulsion (minimum rural
service tenure or non-transferable or Management or political pressure) (1.58), Career
opportunity (1.25), Current health facility is closer to town or Closer to family and
friends (1.20), Continuing education/higher education Opportunities (1.20), Training
and skill development Opportunities (1.19), Flexible working hour with minimal
workload (1.13), Authority, independency and autonomy (1.09), Improved working
condition (1.09), Amenities like housing, conveyance provided (1.07), Availability of
equipment, drugs and supplies (1.05), Availability of good schools for children nearby
town (1.05), Safety at workplace (1.04), Teamwork and Interpersonal staffs
relationship (1.03), Reward and recognition system (1.00), Supportive supervision
and mentoring (1.00) and Financial incentives / Rural allowances/ Performance
incentives (1.00). Whereas the Compulsion (minimum rural service tenure or non-
transferable or Management or political pressure) having mean of 1.58 has the highest
mean and the factor item contributed the employee to be in rural and remote area but
it may resulted in non-commitment towards the service. Compulsion (minimum rural
service tenure or non-transferable or Management or political pressure) is statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)= 2.990 , p=
.003. The Percentage selection of Factor for Attraction or placed is presented in detail
in table 34.
Table 33: Descriptive Statistics of the factors that attracted or placed the
Physicians, nurses and mid-wives in the current job in the rural and remotearea
Factors
N MeanStd.Dev.
Test Value = 1.5
t df
Sig.
(2-tailed)
MeanDiff.
Compulsion 334 1.58 .494 2.990 333 .003 .081
Career development opportunity 334 1.25 .433 -10.620 333 .001 -.251
Current health facility is closer
to town or Closer to family and
friends
334 1.20 .403 -13.433 333 .001 -.296
Continuing education/higher education Opportunities
334 1.20 .401 -13.644 333 .001 -.299
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Training and skill development
Opportunities
334 1.19 .394 -14.298 333 .001 -.308
Flexible working hour with
minimal workload
334 1.13 .332 -20.598 333 .001 -.374
Improved working condition 334 1.09 .291 -25.607 333 .001 -.407
Authority, independency andautonomy
334 1.09 .291 -25.607 333 .001 -.407
Amenities like housing,conveyance provided
334 1.07 .254 -31.070 333 .001 -.431
Availability of equipment,drugs and supplies
334 1.05 .226 -36.052 333 .001 -.446
Availability of good schools
for children nearby town
334 1.05 .214 -38.630 333 .001 -.452
Safety at workplace 334 1.04 .194 -43.503 333 .001 -.461
Teamwork and Interpersonal
staffs relationship
334 1.03 .171 -50.333 333 .001 -.470
Financial incentives / Rural
allowances/ Performance
incentives
334 1.00 .000
- - - -
Supportive supervision and
mentoring
334 1.00 .000- - - -
Reward and recognition system 334 1.00 .000 - - - -
Table 34: Percentage selection of factors for attraction by Physicians, nurses
and mid-wives
Factors n n%
Compulsion 194 58%
Career development opportunity 83 25%
Current health facility is closer to town or Closer to family and friends 68 20%
Continuing education/higher education Opportunities 67 20%
Training and skill development Opportunities 64 19%
Flexible working hour with minimal workload 42 13%
Improved working condition 31 9%
Authority, independency and autonomy 31 9%
Amenities like housing, conveyance provided 23 7%
Availability of equipment, drugs and supplies 18 5%
Availability of good schools for children nearby town 16 5%
Safety at workplace 13 4%
Teamwork and Interpersonal staffs relationship 10 3%
Financial incentives / Rural allowances/ Performance incentives 0 0%
Supportive supervision and mentoring 0 0%
Reward and recognition system 0 0%
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4.3.2.1. FACTORS THAT ATTRACTED OR PLACED THE PHYSICIANS IN
PRESENT RURAL AND REMOTE AREA
As it can be derived from table 35, the factors of attraction of the physicians
in rural and remote area service are basically is Compulsion (minimum rural service
tenure or non-transferable or Management or political pressure) (1.66), beside the
factor of compulsion, the other attraction top five factors are-Continuing
education/higher education Opportunities (1.46), Career development opportunity
(1.23), Current health facility is closer to town or Closer to family and friends (1.20),
Authority, independency and autonomy (1.19) and Training and skill development
Opportunities (1.16). Only one factor that is the Compulsion is statistically significant
at Mean Test Value=1.5, 95%C.I, it is significant at t(113)=3.667 , p= .001. The
Percentage selection of Factor for Attraction or placed is presented in table 38.Table 35: Descriptive Statistics of the factors that attracted or placed the
Physicians in the current job in the rural and remote area
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
taile
d)
Mean
Diff.
Compulsion 113 1.66 .475 3.667 112 .001 .164
Continuing /higher education
Opportunity
113 1.46 .501 -.846 112 .400 -.040
Career development opportunity 113 1.23 .423 -6.787 112 .001 -.270
Current health facility is closer to
town or Closer to family &friends
113 1.20 .404 -7.792 112 .001 -.296
Authority,independency&autonomy 113 1.19 .398 -8.160 112 .001 -.305
Training and skill development
Opportunities
113 1.16 .368 -9.853 112 .001 -.341
Improved working condition 113 1.10 .298 -14.376 112 .001 -.403
Availability of equipment, drugs
and supplies
113 1.08 .272 -16.431 112 .001 -.420
Flexible working hour with
minimal workload
113 1.08 .272 -16.431 112 .001 -.420
Safety at workplace 113 1.08 .272 -16.431 112 .001 -.420
Amenities like housing,
conveyance provided
113 1.07 .258 -17.710 112 .001 -.429
Availability of good schools for
children nearby town
113 1.06 .242 -19.231 112 .001 -.438
Teamwork and Interpersonal staffs
relationship
113 1.04 .186 -26.609 112 .001 -.465
Financial / Rural allowances/
Performance incentives
113 1.00 .000- - - -
Supportive supervision & mentoring 113 1.00 .000 - - - -Reward and recognition system 113 1.00 .000 - - - -
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When the group of physicians is further divided to contractual physicians, two
factors are significant and the factors are the Compulsion (minimum rural service
tenure or non-transferable or Management or political pressure) and Continuing
education/higher education is statistically significant at Mean Test Value=1.5, 95%
C.I, it is significant at t(34)= 3.064 , p= .004 and t(34)= 1.339 , p= .037. The
Percentage selection of Factor for Attraction or placed is presented in table 38.
Table 36: Descriptive Statistics of the factors that attracted or placed the
contract Physicians in the current job in the rural and remote area
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Compulsion 34 1.74 .448 3.064 33 .004 .235
Continuing education/higher
education Opportunities
34 1.58 .500 1.339 33 .037 .029
Career development
opportunity
34 1.38 .493 -1.391 33 .174 -.118
Training and skilldevelopment Opportunities
34 1.21 .410 -4.179 33 .001 -.294
Current health facility is
closer to town or Closer to
family and friends
34 1.12 .327 -6.817 33 .001 -.382
Improved working condition 34 1.06 .239 -10.771 33 .001 -.441
Flexible working hour with
minimal workload
34 1.06 .239 -10.771 33 .001 -.441
Financial incentives / Rural
allowances/ Performance
incentives
34 1.00 .000
- - - -
Availability of equipment,
drugs and supplies
34 1.00 .000- - - -
Authority, independency
and autonomy
34 1.00 .000- - - -
Supportive supervision and
mentoring
34 1.00 .000- - - -
Amenities like housing,
conveyance provided
34 1.00 .000- - - -
Reward and recognition
system
34 1.00 .000- - - -
Teamwork and
Interpersonal staffs
relationship
34 1.00 .000
- - - -
Safety at workplace 34 1.00 .000 - - - -
Availability of good schools
for children nearby town
34 1.00 .000- - - -
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When the group of permanent physicians is analysed separately, the same
factor, that is the Compulsion (minimum rural service tenure or non-transferable or
Management or political pressure) is statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(79)= 2.435 , p=.017. The Percentage selection of Factor
for Attraction or placed is presented in table 38.
Table 37: Descriptive Statistics of the factors that attracted or placed the
permanent Physicians in the current job in the rural and remote area
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.
Compulsion 79 1.63 .485 2.435 78 .017 .133
Continuing
education/higher educationOpportunities
79 1.43 .498 -1.242 78 .218 -.070
Authority, independency
and autonomy
79 1.28 .451 -4.365 78 .001 -.222
Current health facility is
closer to town or Closer tofamily and friends
79 1.24 .430 -5.362 78 .001 -.259
Career development
opportunity
79 1.16 .373 -7.990 78 .001 -.335
Training and skill
development Opportunities
79 1.14 .348 -9.203 78 .001 -.361
Improved working
condition
79 1.11 .320 -10.732 78 .001 -.386
Availability of equipment,
drugs and supplies
79 1.11 .320 -10.732 78 .001 -.386
Safety at workplace 79 1.11 .320 -10.732 78 .001 -.386
Amenities like housing,
conveyance provided
79 1.10 .304 -11.673 78 .001 -.399
Flexible working hour withminimal workload
79 1.09 .286 -12.785 78 .001 -.411
Availability of good schools
for children nearby town
79 1.09 .286 -12.785 78 .001 -.411
Teamwork and
Interpersonal staffs
relationship
79 1.05 .221 -18.102 78 .001 -.449
Financial incentives / Rural
allowances/ Performance
incentives
79 1.00 .000
- - - -
Supportive supervision and
mentoring
79 1.00 .000- - - -
Reward and recognition
system
79 1.00 .000- - - -
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Table 38: Percentage selection of factors for Attraction by Physicians
Factors Physicians
Contract
Physicians
Permanent
Physicians
n n % n n % n n %
Compulsion 75 66% 25 74% 50 63%Continuing /higher education Opportunities 52 46% 18 53% 34 43%
Career development opportunity 26 23% 13 38% 13 16%
Current health facility is closer to town or
Closer to family and friends
23 20% 4 12% 19 24%
Authority, independency and autonomy 22 19% 0 0% 22 28%
Training and skill developmentOpportunities
18 16% 7 21% 11 14%
Improved working condition 11 10% 2 6% 9 11%
Availability of equipment, drugs and
supplies
9 8% 0 0% 9 11%
Flexible working hour with minimal
workload
9 8% 2 6% 7 9%
Safety at workplace 9 8% 0 0% 9 11%
Amenities like housing, conveyance
provided
8 7% 0 0% 8 10%
Availability of good schools for children
nearby town
7 6% 0 0% 7 9%
Teamwork and Interpersonal staffs
relationship
4 4% 0 0% 4 5%
Financial incentives / Rural allowances/
Performance incentives
0 0% 0 0% 0 0%
Supportive supervision and mentoring 0 0% 0 0% 0 0%
Reward and recognition system 0 0% 0 0% 0 0%
4.3.2.2. FACTORS THAT ATTRACTED OR PLACED THE NURSES IN
PRESENT RURAL AND REMOTE AREAThe factors that attracted or placed the nurses can be derived from table 39.
The results indicated the factors of Compulsion (minimum rural service tenure or non-
transferable or Management or political pressure) (1.59) have the highest Mean.
Beside the compulsion for the choice of the rural posting, the other top five factors of attraction for the nurses are- Current health facility is closer to town or Closer to
family and friends (1.26), Training and skill development Opportunities (1.26), Career
development opportunity (1.21), Flexible working hour with minimal workload (1.14)
and Improved working condition (1.08).
Thus, only one factor, that is the Compulsion (minimum rural service tenure or
non-transferable or Management or political pressure) is statistically significant at
Mean Test Value=1.5, 95% C.I, it is significant at t(97)=1.201, p=.041. The
Percentage selection of Factor for Attraction or presented is place in table 42.
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Table 39: Descriptive Statistics of the factors that attracted or placed the
nurses in the current job in the rural and remote area
Factors
N MeanStd.Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mea
nDiff.
Compulsion 98 1.59 .402 1.201 97 .041 .09
Training and skill development
Opportunities
98 1.26 .438 -5.533 97 .001 -.245
Current health facility is closer to
town or Closer to family &
friends
98 1.26 .438 -5.533 97 .001 -.245
Career development opportunity 98 1.21 .412 -6.858 97 .001 -.286
Flexible working hour withminimal workload
98 1.14 .352 -10.052 97 .001 -.357
Improved working condition 98 1.08 .275 -15.049 97 .001 -.418Amenities like housing,
conveyance provided
98 1.07 .259 -16.389 97 .001 -.429
Availability of equipment,
drugs and supplies
98 1.05 .221 -20.096 97 .001 -.449
Availability of good schools for
children nearby town
98 1.04 .199 -22.856 97 .001 -.459
Teamwork and Interpersonal
staffs relationship
98 1.03 .173 -26.836 97 .001 -.469
Safety at workplace 98 1.01 .101 -48.000 97 .001 -.490
Financial incentives / Ruralallowances/ Performance
incentives
98 1.00 .000- - - -
Authority, independency and
autonomy
98 1.00 .000- - - -
Continuing education/higher education Opportunities
98 1.00 .000- - - -
Supportive supervision and
mentoring
98 1.00 .000- - - -
Reward and recognition system 98 1.00 .000 - - - -
When the data is analysed separately in the case of permanent nurses, it isfound that there is the combination of two factors of Compulsion (minimum rural
service tenure or non-transferable or Management or political pressure) and current
health facility is closer to town or to family are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(52)=2.442, p=.018 and t(52)=3.112,
p=.003. The Percentage selection of Factor for Attraction or placed is presented in
table 42.
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Table 40: Descriptive Statistics of the factors that attracted or placed the
permanent nurses in the current job in the rural and remote area
Factor
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.Compulsion 53 1.64 .578 2.442 52 .018 .160
Current health facility is closer
to town or Closer to family andfriends
53 1.60 .563 3.112 52 .003 .198
Training and skill developmentOpportunities
53 1.21 .409 -5.200 52 .001 -.292
Flexible working hour with
minimal workload
53 1.21 .409 -5.200 52 .001 -.292
Amenities like housing,
conveyance provided
53 1.13 .342 -7.836 52 .001 -.368
Career development opportunity 53 1.09 .295 -10.008 52 .001 -.406
Improved working condition 53 1.08 .267 -11.589 52 .001 -.425
Availability of equipment, drugs
and supplies
53 1.06 .233 -13.836 52 .001 -.443
Teamwork and Interpersonal
staffs relationship
53 1.06 .233 -13.836 52 .001 -.443
Availability of good schools for
children nearby town
53 1.06 .233 -13.836 52 .001 -.443
Safety at workplace 53 1.02 .137 -25.500 52 .001 -.481
Financial incentives / Rural
allowances/ Performanceincentives
53 1.00 .000
- - - -
Authority, independency andautonomy
53 1.00 .000- - - -
Continuing education/higher
education Opportunities
53 1.00 .000- - - -
Supportive supervision and
mentoring
53 1.00 .000- - - -
Reward and recognition system 53 1.00 .000 - - - -
While in the case of contract nurses, only one factors of Compulsion
(minimum rural service tenure or non-transferable or Management or political
pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant
at t(44)=3.090, p=.003. The Percentage selection of Factor for Attraction or
presented is place in table 42.
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Table 41 : Descriptive Statistics of the factors that attracted or placed the
contract nurses in the current job in the rural and remote area
Factor
N MeanStd.Dev.
Test Value = 1.5
t df
Sig.
(2-tailed)
MeanDiff.
Compulsion 45 1.71 .458 3.090 44 .003 .211
Career development
opportunity
45 1.36 .484 -2.002 44 .052 -.144
Training and skilldevelopment Opportunities
45 1.31 .468 -2.706 44 .010 -.189
Current health facility is
closer to town or Closer to
family and friends
45 1.16 .367 -6.304 44 .001 -.344
Improved working condition 45 1.09 .288 -9.582 44 .001 -.411
Flexible working hour with
minimal workload
45 1.07 .252 -11.523 44 .001 -.433
Availability of equipment,
drugs and supplies
45 1.04 .208 -14.663 44 .001 -.456
Availability of good schools
for children nearby town
45 1.02 .149 -21.500 44 .001 -.478
Financial incentives / Rural
allowances/ Performanceincentives
45 1.00 .000
- - - -
Authority, independency and
autonomy
45 1.00 .000- - - -
Continuing education/higher
education Opportunities
45 1.00 .000- - - -
Supportive supervision and
mentoring
45 1.00 .000- - - -
Amenities like housing,conveyance provided
45 1.00 .000- - - -
Reward and recognition
system
45 1.00 .000- - - -
Teamwork and Interpersonal
staffs relationship
45 1.00 .000- - - -
Safety at workplace 45 1.00 .000 - - - -
Table 42: Percentage selection of factors for Attraction by nurses
Factors
Nurses
Contract
Nurses
Permanent
Nurses
n n% n n% n n%
Financial incentives / Rural allowances/
Performance incentives
0 0% 0 0% 0 0%
Improved working condition 8 8% 4 9% 4 8%
Availability of equipment, drugs and supplies 5 5% 2 4% 3 6%
Authority, independency and autonomy 0 0% 0 0% 0 0%Career development opportunity 21 21% 16 36% 5 9%
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Continuing education/higher educationOpportunities
0 0% 0 0% 0 0%
Training and skill development Opportunities 25 26% 14 31% 11 21%
Compulsion 48 49% 32 71% 16 30%
Flexible working hour with minimal workload 14 14% 3 7% 11 21%
Supportive supervision and mentoring 0 0% 0 0% 0 0%Amenities like housing, conveyance provided 7 7% 0 0% 7 13%
Reward and recognition system 0 0% 0 0% 0 0%
Teamwork and Interpersonal staffs relationship 3 3% 0 0% 3 6%
Safety at workplace 1 1% 0 0% 1 2%
Availability of good schools for children
nearby town
4 4% 1 2% 3 6%
Current health facility is closer to town or Closer to family and friends
25 26% 7 16% 18 34%
4.3.2.3. FACTORS THAT ATTRACTED OR PLACED THE MID-WIVES INPRESENT RURAL AND REMOTE AREAThe factors that attract or placed the mid-wives towards rural and remote area
has also the factor of Compulsion (minimum rural service tenure or non-transferable
or Management or political pressure) (1.58), which have the highest mean, detail can
be derived from the table 43. Beside the compulsion, the other top five factors of
attraction for the nurses are- Career development opportunity (1.29), Training and
skill development Opportunities (1.17), Current health facility is closer to town or
Closer to family and friends (1.16), Flexible working hour with minimal workload(1.15) and Continuing education/higher education Opportunities (1.12). However,
only one factor that is the Compulsion (minimum rural service tenure or non-
transferable or Management or political pressure) is statistically significant at Mean
Test Value=1.5, 95% C.I, it is significant at t(122)=1.727, p=.047. The Percentage
selection of Factor for Attraction or placed is presented in table 46.
Table 43: Descriptive Statistics of the factors that attracted or placed the
mid-wives in the current job in the rural and remote area
Factors
N MeanStd.Dev.
Test Value = 1.5
t df
Sig.
(2-tailed)
MeanDiff.
Compulsion 123 1.58 .496 1.727 122 .047 .077
Career developmentopportunity
123 1.29 .457 -5.033 122 .001 -.207
Training and skill
development Opportunities
123 1.17 .378 -9.666 122 .001 -.329
Current health facility is
closer to town or Closer tofamily and friends
123 1.16 .371 -10.099 122 .001 -.337
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Flexible working hour with
minimal workload
123 1.15 .363 -10.560 122 .001 -.346
Continuing
education/higher educationOpportunities
123 1.12 .329 -12.761 122 .001 -.378
Improved working condition 123 1.10 .298 -14.981 122 .001 -.402Authority, independency
and autonomy
123 1.07 .261 -18.104 122 .001 -.427
Amenities like housing,conveyance provided
123 1.07 .248 -19.482 122 .001 -.435
Availability of good
schools for children nearby
town
123 1.04 .198 -25.692 122 .001 -.459
Availability of equipment,
drugs and supplies
123 1.03 .178 -29.110 122 .001 -.467
Teamwork andInterpersonal staffs
relationship
123 1.02 .155 -34.055 122 .001 -.476
Safety at workplace 123 1.02 .155 -34.055 122 .001 -.476
Financial incentives / Rural
allowances/ Performance
incentives
123 1.00 .000
- - - -
Supportive supervision andmentoring
123 1.00 .000- - - -
Reward and recognition
system
123 1.00 .000- - - -
When the data for the group of contractual mid-wives are separately analysed,
the same factor of Compulsion (minimum rural service tenure or non-transferable or
Management or political pressure) is statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(74)=5.616, p=.001. The Percentage selection of Factor
for Attraction or placed is presented in table 46.
Table 44: Descriptive Statistics of the factors that attracted or placed the
contractual mid-wives in the current job in the rural and remote area
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.
Compulsion 75 1.77 .421 5.616 74 .001 .273
Career developmentopportunity
75 1.39 .490 -2.002 74 .049 -.113
Training and skilldevelopment Opportunities
75 1.15 .356 -8.592 74 .001 -.353
Current health facility is
closer to town or Closer to
family and friends
75 1.09 .293 -12.026 74 .001 -.407
Improved working condition 75 1.08 .273 -13.318 74 .001 -.420
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Continuing education/higher
education Opportunities
75 1.05 .226 -17.100 74 .001 -.447
Flexible working hour with
minimal workload
75 1.04 .197 -20.193 74 .001 -.460
Availability of equipment,drugs and supplies
75 1.01 .115 -36.500 74 .001 -.487
Authority, independencyand autonomy
75 1.01 .115 -36.500 74 .001 -.487
Availability of good schools
for children nearby town
75 1.01 .115 -36.500 74 .001 -.487
Financial incentives / Rural
allowances/ Performance
incentives
75 1.00 .000
- - - -
Supportive supervision and
mentoring
75 1.00 .000- - - -
Amenities like housing,conveyance provided
75 1.00 .000 - - - -
Reward and recognitionsystem
75 1.00 .000- - - -
Teamwork andInterpersonal staffs
relationship
75 1.00 .000- - - -
Safety at workplace 75 1.00 .000 - - - -
While in the case of permanent mid-wives, it is also found that the same factor
of Compulsion (minimum rural service tenure or non-transferable or Management or
political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is
significant at t(47)=2.424, p=.019. The Percentage selection of Factor for Attraction
or placed is presented in table 46.
Table 45: Descriptive Statistics of the factors that attracted or placed the
permanent mid-wives in the current job in the rural and remote area
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.Compulsion 48 1.63 .576 2.424 47 .019 .167
Flexible working hour with
minimal workload
48 1.27 .449 -3.535 47 .001 -.229
Current health facility is closer
to town or Closer to family and
friends
48 1.27 .449 -3.535 47 .001 -.229
Continuing education/higher
education Opportunities
48 1.23 .425 -4.418 47 .001 -.271
Training & skill development
Opportunities
48 1.21 .410 -4.924 47 .001 -.292
Authority, independency &autonomy
48 1.17 .377 -6.132 47 .001 -.333
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Amenities like housing,
conveyance provided
48 1.17 .377 -6.132 47 .001 -.333
Career development opportunity 48 1.15 .357 -6.880 47 .001 -.354
Improved working condition 48 1.13 .334 -7.774 47 .001 -.375
Availability of good schools
for children nearby town
48 1.08 .279 -10.335 47 .001 -.417
Availability of equipment,
drugs and supplies
48 1.06 .245 -12.391 47 .001 -.438
Teamwork and Interpersonal
staffs relationship
48 1.06 .245 -12.391 47 .001 -.438
Safety at workplace 48 1.06 .245 -12.391 47 .001 -.438
Financial incentives/Rural
allowances/Performance
incentives
48 1.00 .000
- - - -
Supportive supervision&mentori 48 1.00 .000 - - - -
Reward and recognition system 48 1.00 .000 - - - -
Table 46: Percentage selection of factors for Attraction by mid-wives
Factors
Mid-
wives
Contract
mid-
wives
ermanent
id-wives
n n% n n% n n%
Compulsion 71 58% 58 77% 13 27%
Career development opportunity 36 9% 29 9% 7 15%
Training and skill development Opportunities 21 17% 11 15% 10 21%
Current health facility is closer to town or Closer to
family and friends
20 16% 7 9% 13 27%
Flexible working hour with minimal workload 19 15% 3 4% 16 33%
Continuing education/higher education Opportunities 15 12% 4 5% 11 23%
Improved working condition 12 10% 6 8% 6 13%
Authority, independency and autonomy 9 7% 1 1% 8 17%
Amenities like housing, conveyance provided 8 7% 0 0% 8 17%
Availability of good schools for children nearby town 5 4% 1 1% 4 8%
Availability of equipment, drugs and supplies 4 3% 1 1% 3 6%
Teamwork and Interpersonal staffs relationship 3 2% 0 0% 3 6%
Safety at workplace 3 2% 0 0% 3 6%
Financial incentives / Rural allowances/ Performance
incentives
0 0% 0 0% 0 0%
Supportive supervision and mentoring 0 0% 0 0% 0 0%
Reward and recognition system 0 0% 0 0% 0 0%
4.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION AND
DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS,
NURSES AND MIDWIVES
The analysing of the relationship of factors of Attraction and the demographic
characteristics of physicians such as age, sex, family background, marital status,
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length of service, place of work and nature of employment is presented in this
section. The three factors of attraction viz., Financial incentives / Rural allowances/
Performance incentives, Supportive supervision & mentoring and Reward and
recognition system, have at least one of the variables has zero variance and there is
only one variable in the analysis chi-square could not be computed for all pairs of
variables, henceforth it has been dropped from the analysis.
4.3.3.1. RELATIONSHIP OF FACTORS OF ATTRACTION AND
DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS
From the analysis of primary data at table 47, it is found that there is a
relationship between age group of the physicians and attraction factors like
availability of equipment, drugs and supplies { χ 2(3, N = 113) = 13.9, p = 0.003,
Cramer’s V=0.408} the higher age group (more than 30 years) of the physicians has
the tendency to attract by this factor; Authority, independency and autonomy { χ 2(3, N
= 113) = 34.43, p = 0.001, Cramer’s V=0.545} the higher age group (more than 30
years) of the physicians has the tendency to attract by this factor; Amenities like
housing & conveyance provided { χ 2(3, N = 113) = 8.79, p = 0.03, Cramer’s
V=0.267 } the higher age group (more than 30-50 years) of the physicians has the
tendency to attract by this factor; Safety at workplace { χ 2(3, N = 113) = 13.9, p =
0.003, Cramer’s V=0.408} the higher age group (more than 30-50 years) of the
physicians has the tendency to attract by this factor; and Current health facility is
closer to town or closer to family and friends { χ 2(3, N = 113) = 9.746, p = 0.021,
Cramer’s V=0.268} the higher age group (more than 30-50 years) of the physicians
has the tendency to attract by this factor.
It is also found that the Marital Status of the physicians has relationship with
Authority independency and autonomy { χ 2(1, N = 113) = 16.16, p = 0.001, Cramer’s
V=0.378, 31% of married physicians against non of the unmarried physicians are
attracted by this reason; amenities like housing & conveyance provided { χ 2(1, N =
113) = 5.093, p = 0.024, Cramer’s V=0.212}, this factor has contributed as a factor
to 11.3% of married physicians against none of the unmarried; safety at workplace
{ χ 2(1, N = 113) = 5.785, p = 0.016, Cramer’s V=0.226 }, 12% of the married
physicians were attracted as one of the factor for attraction against none of the
unmarried physicians has attract due to this factor; and availability of good schools
for children nearby town { χ 2
(1, N = 113) = 4.414, p = 0.036, Cramer’s V=0.198}, it
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is obvious that the married physicians were attracted of this reason, only 9.9% of
married physicians were attracted of this reason.
While, there is a relationship between Length of service of the physicians and
attraction from the availability of equipment, drugs and supplies { χ 2(4, N = 113) =
13.937, p = 0.007, Cramer’s V=0.351} the higher service length physicians 52% of
more than 10-20 years of service length of the physicians has shown the tendency to
attract by this factor; Authority, independency and autonomy { χ 2(4, N = 113) =
26.762, p = 0.001, Cramer’s V=0.487 } the higher age group (more than 10-25 years-
19% of 5-10 years, 43% of 10-15 years, 66% of 15-20 years and 100% of 20-25
years) of the physicians has shown the tendency to attract by this factor; Compulsion
(minimum rural service tenure or non-transferable or Management or political
pressure) { χ 2(4, N = 113) = 10.251, p = 0.036, Cramer’s V=0.301}, the physicians
with lower service length are serving in the rural area, 52% out of the service length
of 0-5 years and 33% out of the service length of 5-10 years are serving in
compulsion; Amenities like housing & conveyance provided{ χ 2(4, N = 113) =
16.454, p = 0.002, Cramer’s V=0.382} the physicians with medium and higher
service length are attracted by this factor, 6.3% out of the service length of 5-10
years, 24% out of the service length of 10-15 years and 33% of 15-20 years services
length are attracted of this; Teamwork and Interpersonal staffs relationship{ χ 2(4, N =
113) = 18.167, p = 0.001, Cramer’s V=0.401} only the 19% of physicians who have
10-15 years service length have considered this factor; Availability of good schools
for children nearby town { χ 2(4, N = 113) = 10.489, p = 0.033, Cramer’s V=0.305},
only 28% physicians with service length of 5-15 years has considered that this factor
has contributed to the attraction to rural areas, and Current health facility is closer to
town or closer to family and friends { χ 2(4, N = 113) = 14.217, p = 0.007, Cramer’s
V=0.355}, this factor has attracted almost all the physicians from 12% to 50% of
individual service length group, it is observed the attraction tendency is increasing as
the length of the services increases.
Similarly, it is found that there is a relationship between Nature of
Employment of physicians and attraction factors like Availability of equipment,
drugs and supplies { χ 2(3, N = 113) = 4.209, p = 0.04, Cramer’s V=0.193}, 12% of
the permanent physicians are more attracted of this factor than that of the contract
physicians but more of the both category were not agreed to this factor; Authority,
independency and autonomy { χ 2(3, N = 113) = 11.757, p = 0.001, Cramer’s
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V=0.323} have 28% of the permanent physicians agreed that they were attracted but
more of the both category has not agreed to it; Career development opportunity { χ 2(3,
N = 113) = 6.365, p = 0.012, Cramer’s V=0.237 }-39% of contract and 16% of
permanent physicians are attracted of this factor; and Amenities like housing,
conveyance provided{ χ 2(3, N = 113) = 3.705, p = 0.05, Cramer’s V=0.181} have
more of the permanent physicians in comparison to contract employees attracted of
this factor.
Similarly, it is found that there is a significant relationship between the choice
of Place of work (rural health institution) by the physicians and Authority,
independency and autonomy at the place of posting { χ 2(3, N = 113) = 7.61, p = 0.05,
Cramer’s V=0.245} have physicians have more tendency to choice PHCs and CHCs
of this factor. Wherein, we did not found any relationship between the factors and sex
of the physicians and family background of the physicians has no relationship with
any other factors of attraction.
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Table 47: Relationship between the factor for attraction or placement with the demographic attributes of Physicians
Factor of Attraction or
placement
With Age group With Sex With FamilyBackground
With MaritalStatus
With Length of service (group)
With Place of work
With nature of Employment
(χ 2) p
CV
(χ 2) p
CV (χ 2) p
CV (χ 2) p
CV
(χ 2) p
CV (χ 2) p
CV
(χ 2) p
CV
Improved working
condition
1.84
6
0.60
5
0.121 0.61 0.6
89
0.038 0.61
7
0.43
2
0.074 0.51
1
0.47
5
0.06
7
1.065 0.9 0.09
7
6.86
6
0.07
6
0.274 0 .821 0.365 0.085
Availability of equipment, drugs and
supplies
13.9 0.003
0.408 2.922 0.087
0.161 1.253
0.263
0.105 2.843
0.092
0.159
13.937 0.007 0.351
2.989
0.393
0.166 4.209 0.04 0.193
Authority,
independency andautonomy
34.4
3
0.00
1
0.545 0.359 0.5
49
0.056 0.87
1
0.35
1
0.088 16.1
6
0.00
1
0.37
8
26.762 0.001 0.48
7
7.61 0.05 0.245 11.75
7
0.001 0.323
Career development
opportunity
3.26
4
0.35
3
0.166 0.272 0.6
02
0.049 5.29
2
0.22
1
0.216 2.38
1
0.12
3
0.14
5
4.603 0.331 0.20
2
4.77
8
0.18
9
0.204 6 .365 0.012 0.237
Continuing
education/higher
education
Opportunities
1.97
6
0.57
7
0.119 1.853 0.1
73
0.128 0.09
2
0.76
1
0.029 0.01
6
0.89
8
0.01
2
5.653 0.227 0.22
4
1.16
1
0.76
2
0.101 0 .938 0.333 0.091
Training and skill
development
Opportunities
3.44
3
0.32
8
0.178 0.275 0.6 0.049 4.95
8
0.42
6
0.209 0.02
7
0.86
9
0.01
5
2.535 0.638 0.15 0.48
4
0.92
2
0.054 0 .788 0.375 0.084
Compulsion 3.17
1
0.42
4
0.157 0.353 0.5
52
0.056 0.3 0.58
4
0.052 0.13 0.71
8
0.03
4
10.251 0.036 0.30
1
1.16
5
0.83
6
0.087 1 .116 0.291 0.099
Flexible working hour
with minimal
workload
3.91
4
0.27
1
0.21 0.588 0.4
43
0.072 0.12
1
0.72
8
0.033 0.22
2
0.63
8
0.04
4
5.01 0.286 0.21
1
1.13 0.77 0.076 0.288 0.592 0.05
Amenities like
housing, conveyance
provided
8.79 0.03 0.267 0.537 0.4
64
0.069 0.35
8
0.55 0.056 5.09
3
0.02
4
0.21
2
16.454 0.002 0.38
2
2.16 0.54 0.147 3.705 0.05 0.181
Teamwork and
Interpersonal staffs
relationship
5.75
2
0.12
4
0.244 1.239 0.2
66
0.105 0.96 0.32
7
0.092 2.45
3
0.11
7
0.14
7
18.167 0.001 0.40
1
8.11
7
0.04
4
0.268 1 .785 0.182 0.126
Safety at workplace 13.9
9
0.00
3
0.408 0.588 0.4
43
0.072 0.12
1
0.72
8
0.033 5.78
5
0.01
6
0.22
6
6.844 0.144 0.29
9
2.22
2
0.52
8
0.128 4.209 0.08 0.193
Availability of good
schools for children
nearby town
6.02
3
0.11
1
0.185 2.23 0.1
35
0.14 6.83
2
0.10
9
0.046 4.41
4
0.03
6
0.19
8
10.489 0.033 0.30
5
7.99
6
0.04
6
0.265 3 .212 0.073 0.169
Current health facility
is closer to town or
Closer to family and
friends
9.74
6
0.02
1
0.268 0.154 0.6
94
0.037 1.66
3
0.19
7
0.121 0.56
1
0.45
4
0.07 14.217 0.007 0.35
5
3.47
4
0.32
4
0.173 2.213 0.137 0.14
CV= Cramer’s V
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4.3.3.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE
DEMOGRAPHIC CHARACTERISTICS OF NURSES
While analysing the relationship of factors of Attraction and the demographic
characteristics of the respondents such as age, family background, marital status,
length of service, place of work and nature of employment, wherein the sex
characteristic has been dropped as only one case of differentiation is there in the data.
The three factors of attraction viz., Financial incentives / Rural allowances/
Performance incentives, Supportive supervision & mentoring and Reward and
recognition system, have at least one of the variables has zero variance and there is
only one variable in the analysis chi-square could not be computed for all pairs of
variables, henceforth it has been dropped from the analysis.
According to the table 48, it is found that there is a relationship between agegroup of the nurses and Career development opportunity { χ 2(3, N = 98) = 2.443, p =
0.03, Cramer’s V=0.151} as lower age group nurses (20-30 yrs) has attraction of this
factor, Training and skill development Opportunities { χ 2(3, N = 98) = 3.928, p =
0.039, Cramer’s V=0.204} as lower age group nurses (20-40 yrs) has attraction of
this, and Compulsion (minimum rural service tenure or non-transferable or
Management or political pressure) { χ 2(3, N = 98) = 19.43, p = 0.001, Cramer’s
V=0.43} as lower age group nurses (20-40 yrs) has attraction of this.
Whereas, no association has been found of marital status and other attraction
factors, except the Compulsion has a relationship { χ 2(3, N = 98) = 4.665, p = 0.031,
Cramer’s V=0.218}, 62.5% married nurses has agreed that they are in rural services
on compulsion.
Similarly, the length of services (group) has the relationship to Career
development opportunity { χ 2(4, N = 98) = 9.288, p = 0.05, Cramer’s V=0.289} as
more of the lower group of the service length of 0-5 yrs has attracted for this reason,
Compulsion { χ 2(4, N = 98) = 24.473, p = 0.001, Cramer’s V=0.471} as more of the
lower group of the service length of 0-10 yrs has attracted for this reason, Amenities
like housing & conveyance provided { χ 2(4, N = 98) = 11.919, p = 0.018, Cramer’s
V=0.314}in which the group of 5-15 yrs of service length attracted due to this factor
and current health facility is closer to town or closer to family and friends { χ 2(4, N =
98) = 10.048, p = 0.040, Cramer’s V=0.331} as more of the higher group of the
service length of 10-20 yrs has attracted for this reason.
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It is also found that the nature of employment has relationship with Career
development opportunity { χ 2(1, N = 98) = 9.863, p = 0.002, Cramer’s V=0.317 }
35.6% contract nurses has attracted in comparison to 9.4% permanent nurses attracted
of this factor; compulsion { χ 2(1, N = 98) = 16.309, p = 0.001, Cramer’s V=0.408}
have 66.7% contract nurses out of the total nurses opted for compulsion in
comparison to the permanent nurses; Flexible working hour with minimal workload
{ χ 2(1, N = 98) = 3.945, p = 0.047, Cramer’s V=0.201} as the permanent nurses are
more attracted, 78.6% permanent nurses opted for this against the 21.4% contract
nurses; Amenities like housing & conveyance provided { χ 2(1, N = 98) = 6.401, p =
0.011, Cramer’s V=0.256 } 13.2% of permanent nurses were attracted for this factor
to the rural services and non of the contract nurses; and Current health facility is
closer to town or closer to family and friends { χ 2(1, N = 98) = 4.339, p = 0.037,
Cramer’s V=0.210} this factor has attracted 34% of permanent nurses against 15% of
contract nurses.
However, we found no association between Place of work and other attraction
factors other than the Availability of equipment, drugs and supplies { χ 2(3, N = 98) =
4.665, p = 0.031, Cramer’s V=0.218}.
Wherein, we did not found any relationship between the family backgrounds
of the nurses with any other factors of attraction.
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Table 48: Relationship between the factor for attraction or placement with the demographic attributes of nurses
Factor of Attraction
With Age group With Family Background With Marital Status With Length of service
(group)
With Place of work With nature of
Employment
(2) p CV (2) p CV (2) p CV (2) p CV (2) p CV (2) p CV
Improved working
condition
0.704 0.872 0.081 1.609 0.205 0.128 0.432 0.511 0.066 2.127 0.712 0.148 3.144 0.208 0.234 0.058 0.809 0.024
Availability of equipment,
drugs and supplies
0.342 0.958 0.056 0.384 0.536 0.063 0.151 0.698 0.03 9 3.853 0.505 0.184 10.509 0.005 0.366 0.074 0.785 0.028
Career development
opportunity
2.443 0.03 0.151 4 .731 0 .486 0.22 3.137 0.077 0.179 9.288 0.05 0.289 4.205 0.122 0.206 9.863 0.002 0.317
Training and skill
development
Opportunities
3.928 0.039 0.204 2 .443 0 .118 0.158 1.2 0.273 0.111 3.723 0.445 0.19 0.689 0.709 0.089 1.374 0.241 0.118
Compulsion 19.43 0.001 0.43 1.005 0.316 0.101 4.665 0.031 0.218 24.473 0.001 0.471 0.197 0.906 0.045 16.30
9
0.001 0.408
Flexible working hour
with minimal workload
6.128 0.106 0.249 2.235 0.135 0.151 1.44 0.23 0.121 8.479 0.076 0.316 1.583 0.453 0.151 3.945 0.047 0.201
Amenities like housing,
conveyance provided
4.245 0.236 0.201 0.057 0.811 0.024 0.665 0.415 0.08 2 11.919 0.018 0.314 0.934 0.627 0.091 6.401 0.011 0.256
Teamwork and
Interpersonal staffs
relationship
6.468 0.091 0.289 1.62 8 0.202 0.129 1.177 0.278 0.11 7.148 0.128 321 0.24 0.88 7 0.043 2.628 0.105 0.164
Safety at workplace 4.109 0.25 0.26 0.49 0.484 0.071 0.384 0.535 0.063 6.661 0.155 0.4 92 1.757 0.415 0.12 0.858 0.354 0.094
Availability of goodschools for children
nearby town
1.133 0.769 0.106 0.111 0.739 0.034 1.586 0.208 0.127 7.261 0.123 0.281 0.736 0.692 0.08 0.735 0.391 0.087
Current health facility is
closer to town or Closer to
family and friends
5.743 0.125 0.244 2.443 0.118 0.158 2.243 0.134 0.151 10.048 0.04 0.331 1.577 0.455 0.106 4.339 0.037 0.21
CV= Cramer’s V
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4.3.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE
DEMOGRAPHIC CHARACTERISTICS OF MID-WIVES
While analysing the relationship of factors of Attraction and the demographic
characteristics of the respondents such as age, family background, marital status,
length of service, place of work and nature of employment, wherein the sex
characteristic has been dropped as no case of differentiation is there in the data. The
three factors of attraction viz., Financial incentives / Rural allowances/ Performance
incentives, Supportive supervision & mentoring and Reward and recognition system,
have at least one of the variables has zero variance and there is only one variable in
the analysis chi-square could not be computed for all pairs of variables, henceforth it
has been dropped from the analysis.
According to the table 49, it is found that there is a relationship between age
group of the nurses and Improved working condition { χ 2(2, N = 123) = 9.745, p =
0.008, Cramer’s V=0.300}(the lower age group of 20-30 years of the mid-wives has
attracted, 75% of the agreed nurses are of this category); Availability of equipment,
drugs and supplies{ χ 2(2, N = 123) = 7.688, p = 0.021, Cramer’s V=0.359}(about 25-
50% of the age group which has agreed upon it); Training and skill development
Opportunities { χ 2(2, N = 123) = 1.788, p = 0.049, Cramer’s V=0..127 }(about 66%
of age group of 20-30 years attracted due to this factor); Compulsion { χ
2
(2, N = 123)= 26.462, p = 0.001, Cramer’s V=0.455} (57% of mid-wives being placed of this);
Flexible working hour with minimal workload { χ 2(2, N = 123) = 14.072, p = 0.001,
Cramer’s V=0.375} (the higher age group of 57% agreed on this factor); Amenities
like housing & conveyance provided { χ 2(2, N = 123) = 17.693, p = 0.001, Cramer’s
V=0.448} (as the age group of higher mid-wives) and Teamwork and Interpersonal
staffs relationship { χ 2(2, N = 123) = 11.696, p = 0.003, Cramer’s V=0.431}(the
higher age group has attraction due to this factor).
Similarly, we found relationship between Marital status of Mid-wives and
Amenities like housing & conveyance provided { χ 2(1, N = 123) = 5.861, p = 0.015,
Cramer’s V=0.218} (more married mid-wives are attracted of this factor);
Availability of good schools for children nearby town { χ 2(1, N = 123) = 3.570, p =
0.050, Cramer’s V=0.170} (more married mid-wives are attracted of this factor); and
Current health facility is closer to town or Closer to family and friends { χ 2(1, N =
123) = 4.222, p = 0.040, Cramer’s V=0.185} (28% of married mid-wives and 12% of
unmarried Mid-wives attracted due to this factor); while the Compulsion { χ 2(1, N =
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123) = 7.036, p = 0.008, Cramer’s V=0.239}(72% of unmarried and 48% of married
mid-wives are in the rural health institute in compulsion).
It is also found that the length of service has a relationship with factor of
Availability of equipment, drugs and supplies{ χ 2(4, N = 123) = 9.724, p = 0.045,
Cramer’s V=0.358}(18-25% of 10-15 and 15-20 years of service years mid-wives
were attracted); Continuing education/higher education Opportunities { χ 2(4, N =
123) = 13.940, p = 0.007, Cramer’s V=0.368}(5% to 45% of 0-15 years of service
length mid-wives have attracted); Training and skill development Opportunities { χ 2(4,
N = 123) = 6.601, p = 0.050, Cramer’s V=0.236 }(11% to 36% of 0-20 years of
service length has attracted); Flexible working hour with minimal workload { χ 2(4, N
= 123) = 23.991, p = 0.001, Cramer’s V=0.464}(25% to 100% of mid-wives who
have service length of 5-25 years attracted to this factor); Amenities like housing,
conveyance provided { χ 2(4, N = 123) = 9.527, p = 0.049, Cramer’s V=0.285}(12%
to 25% of 5-20 years of service length mid-wives have attracted by this factor);
Availability of good schools for children nearby town { χ 2(4, N = 123) = 11.478, p =
0.022, Cramer’s V=0.303}(about 20% of 5-15 years of service length has been
attracted from this factor); Current health facility is closer to town or closer to family
and friends { χ 2(4, N = 123) = 14.758, p = 0.005, Cramer’s V=0.360} (27% to 100%
of the higher age groups were attracted to this factor); besides these Compulsion
{ χ 2(4, N = 123) = 28.792, p = 0.001, Cramer’s V=0.474} also have the relationship.
Meanwhile, it is also found that the Place of work and the factors of attraction
of Authority, independency and autonomy { χ 2(3, N = 123) = 12.719, p = 0.005,
Cramer’s V=0.274}(15% of mid-wives presently posted in SCs have agreed to the
point); Amenities like housing & conveyance provided { χ 2(3, N = 123) = 23.766, p =
0.001, Cramer’s V=0.536 }; Teamwork and Interpersonal staffs relationship { χ 2(3, N
= 123) = 10.417, p = 0.015, Cramer’s V=0.304} (10% to 20% of the mid-wives in
CHCs and DHs have agreed that this factor also contributed), Current health facility is
closer to town or closer to family and friends { χ 2(3, N = 123) = 7.515, p = 0.050,
Cramer’s V=0.240} (20%-40% of mid-wives at CHCs and DHs have agreed on this
factor); and besides these the Compulsion { χ 2(3, N = 123) = 13.904, p = 0.003,
Cramer’s V=0.332} is the factor of placement in rural areas.
Meanwhile, it is also found that the nature of employment also have
relationship with the factors of attraction like Authority, independency and autonomy
{ χ 2(1, N = 123) = 10.147, p = 0.001, Cramer’s V=0.287 } (17% permanent mid-wives
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are more attracted of this factor); Career development opportunity { χ 2(1, N = 123) =
8.200, p = 0.004, Cramer’s V=0.258} (contract mid-wives (40%) to 14% of
permanent mid-wives have attracted); Continuing education/higher education
opportunities { χ 2(1, N = 123) = 8.451, p = 0.004, Cramer’s V=0.262}(23% of
permanent mid-wives, while 5% of contract mid-wives has attracted); Flexible
working hour with minimal workload { χ 2(1, N = 123) = 19.282, p = 0.001, Cramer’s
V=0.396 }(33% of permanent mid-wives and 4% contract mid-wives); Amenities like
housing, conveyance provided { χ 2(1, N = 123) = 13.370, p = 0.001, Cramer’s
V=0.330}(17% of permanent mid-wives were attracted due to this factor); Teamwork
and Interpersonal staffs relationship { χ 2(1, N = 123) = 4.085, p = 0.028, Cramer’s
V=0.198}(7% of permanent mid-wives were attracted due to this factor); Current
health facility is closer to town or closer to family and friends { χ 2(1, N = 123) =
6.772, p = 0.009, Cramer’s V=0.235}(27% of permanent and 9% contract mid-
wives); besides the above factor Compulsion { χ 2(1, N = 123) = 30.284, p = 0.001,
Cramer’s V=0.496 } also contribute to factor relationship.
However, we found no association between Family Background and other
attraction factors.
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Table 49: Relationship between the factor for attraction or placement with the demographic attributes of mid-wives
Factor of Attraction
With Age group With FamilyBackground
With Marital Status With Length of service(group)
With Place of work With nature of Employment
(2) p CV (2) p CV (2) p CV (2) p CV (2) p CV (2) p CV
Improved working condition 9.745 0.008 0.3 0.507 0.476 0.064 0.295 0.587 0.049 6.59 0.159 0.304 3.636 0.304 0.186 0.673 0.412 0.074
Availability of equipment, drugs andsupplies
7.688 0.021 0.359 0.107 0.744 0.029 0.42 0.517 0.058 9.724 0.045 0.358 6.788 0.079 0.211 2.2249 0.134 0.135
Authority, independency and
autonomy
4.707 0.06 0.214 0.629 0.428 0.072 6.651 0.11 0.233 3.888 0.421 0.19 12.719 0.005 0.274 10.147 0.001 0.287
Career development opportunity 5.204 0.074 0.163 1.312 0.252 0.103 0.911 0.34 0.086 3.78 0.437 0.175 0.528 0.913 0.065 8.2 0.004 0.258
Continuing education/higher education Opportunities
8.124 0.017 0.284 0.267 0.606 0.047 5.284 0.122 0.207 13.94 0.007 0.368 3.324 0.344 0.164 8.451 0.004 0.262
Training and skill developmentOpportunities
1.788 0.049 0.127 3.837 0.059 0.177 2.977 0.084 0.156 6.601 0.05 0.236 1.405 0.704 0.104 0.411 0.522 0.08
Compulsion (minimum rural servicetenure or non-transferable or Management or political pressure)
26.462 0.001 0.455 0.544 0.457 0.067 7.036 0.008 0.239 28.792 0.001 0.474 13.904 0.003 0.332 30.284 0.001 0.496
Flexible working hour with minimalworkload
14.072 0.001 0.375 0.394 0.53 0.057 3.577 0.059 0.171 23.991 0.001 0.464 0.872 0.832 0.085 19.282 0.001 0.396
Amenities like housing, conveyance provided
17.693 0.001 0.448 0.097 0.756 0.028 5.861 0.015 0.218 9.527 0.049 0.285 23.766 0.001 0.536 13.37 0.001 0.33
Teamwork and Interpersonal staffsrelationship
11.696 0.003 0.431 0.001 0.976 0.003 2.106 0.147 0.131 8.746 0.068 0.321 10.417 0.015 0.304 4.085 0.028 0.198
Safety at workplace 3.254 0.196 0.207 0.001 0.976 0.003 2.106 0.147 0.131 8 .877 0.064 0.332 7.555 0.056 0.246 4.805 0.128 0.198
Availability of good schools for children nearby town
1.846 0.397 0.124 0.372 0.542 0.055 3.57 0.05 0.17 11.478 0.022 0.303 2.251 0.522 0.103 3.677 0.055 0.173
Current health facility is closer to
town or Closer to family and friends
5.458 0.047 0.223 0.616 0.433 0.071 4.222 0.04 0.185 14.758 0.005 0.36 7.515 0.05 0.24 6.772 0.009 0.235
CV= Carmer’s V
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4.3.4. FACTORS THAT MAY ATTRACT PHYSICIANS, NURSES
AND MID-WIVES TO RURAL AREA- CHOICE OF CURRENT
PHYSICIANS, NURSES AND MID-WIVES
This part of the section has attempted to explore the factors that may attract
physicians, nurses and mid-wives to rural area. Eighteen (18) factors were included
for the same. The determination of the factor that may majorly attract the physicians,
nurses and mid-wives has considered on the Mean factor which would be statistically
significant at Mean test value of (1.5), that means the selection was done by the
majority (more than half) of the respondents and have an greater impact at large
workforce. This helps in ascertaining the factors that may attract the larger part of the
workforce.
The Reliability analysis was done for the attraction factors consistency of
responses to items. The Cronbach’s alpha coefficient for the factor items is
α =(0.542) on item 18 and N=334.
The top 10 factor that may attract the physicians, nurses and mid-wives can be
derived from Table 50 are: 1) Higher Salary package in compare to urban posting
(1.80), 2) Conducive working condition (1.74), 3) Training and skill development
Opportunities (1.74), 4) Access to amenities like housing & conveyance (1.69), 5)
Financial incentives / Rural allowances/ Performance incentives (1.68), 6) Safety atworkplace (1.61), 7) Rotational Posting after completing minimum rural service
tenure (1.59), 8) Career development opportunities (1.58), 9) Availability of good
schools for children (1.40), 10) Good reward and recognition system (1.40).
The lowest mean factors are: Current health facility is closer to town or
Closer to family and friends (1.01), Flexible working hours with minimal workload
(1.07), Opportunity for authority, independency and autonomy (1.07), Supportive
supervision and mentoring (1.25) and Availability of equipment, drugs and
supplies (1.28).
The factors that may attract physicians, nurses and mid-wives for rural and
remote services has the following percentage of selection from these health
workforces: Higher Salary package in compare to urban posting-268 (80%);
Conducive working condition -247 (74%); Training and skill development
Opportunities-246 (74%); Access to amenities like housing & conveyance-231
(69%); The Financial incentives / Rural allowances/ Performance incentives-227
(68%); Safety at workplace -204 (61%); Rotational Posting after completing
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minimum rural service tenure -196 (59%) and Career development opportunities -195
(58%); Availability of good schools for children -135 (40%); Good reward and
recognition system -134 (40%); Continuing education/higher education Opportunities
-131 (39%); Better teamwork and good interpersonal staffs relationship -128 (38%);
Job security-120 (36%); Availability of equipment, drugs and supplies -92 (28%);
Supportive supervision and mentoring -84 (25%);Opportunity for authority,
independency and autonomy-25 (7%); Flexible working hours with minimal
workload -24 (7%); Current health facility is closer to town or Closer to family and
friends -5 (1%). The detail percentage comparison is presented in table 51.
While the Mean Test value reveals the following factors statistically
significant- Higher Salary package in compare to urban posting, Conducive working
condition, Training and skill development opportunities, Access to amenities like
housing & conveyance, Financial incentives / Rural allowances/ Performance
incentives, Safety at workplace, Rotational Posting after completing minimum rural
service tenure and Career development opportunities. These factors are statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)=13.858, p=
.001, t(333)=9.959, p= .001, t(333)=9.798, p= .001, t(333)=7.571, p= .001,
t(333)=7.025, p= .001, t(333)=4.146, p= .001, t(333)=3.218, p= .001 and
t(333)=3.104, p= .002 respectively.
Table 50: Descriptive Statistics of the factors that may attract the physicians,
nurses and mid-wives in the rural and remote area
Factor
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Higher Salary package in
compare to urban posting
334 1.80 .399 13.858 333 .001 .302
Conducive working conditio 334 1.74 .440 9.959 333 .001 .240Training and skill
development Opportunities
334 1.74 .441 9.798 333 .001 .237
Access to amenities like
housing & conveyance
334 1.69 .463 7.571 333 .001 .192
Financial incentives / Rural
allowances/ Performance
incentives
334 1.68 .467 7.025 333 .001 .180
Safety at workplace 334 1.61 .488 4.146 333 .001 .111
Rotational Posting after completing minimum rural
service tenure
334 1.59 .493 3.218 333 .001 .087
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Career development
opportunities
334 1.58 .494 3.104 333 .002 .084
Availability of good
schools for children
334 1.40 .491 -3.563 333 .001 -.096
Good reward and
recognition system
334 1.40 .491 -3.678 333 .001 -.099
Continuing
education/higher education
Opportunities
334 1.39 .489 -4.028 333 .001 -.108
Better teamwork and good
interpersonal staffs
relationship
334 1.38 .487 -4.383 333 .001 -.117
Job security 334 1.36 .481 -5.352 333 .001 -.141
Availability of equipment,
drugs and supplies
334 1.28 .447 -9.172 333 .001 -.225
Supportive supervision andmentoring 334 1.25 .435 -10.452 333 .001 -.249
Opportunity for authority,independency and
autonomy
334 1.07 .264 -29.482 333 .001 -.425
Flexible working hours
with minimal workload
334 1.07 .259 -30.253 333 .001 -.428
Current health facility is
closer to town or Closer to
family and friends
334 1.01 .122 -72.888 333 .001 -.485
Table 51: Percentage of factors that may attract physicians, nurses and mid-wives in rural and remote areas
Factors n [n(%)]
Higher Salary package in compare to urban posting 268 (80%)
Conducive working condition 247 (74%)
Training and skill development Opportunities 246 (74%)
Access to amenities like housing & conveyance 231 (69%)
Financial incentives / Rural allowances/ Performance incentives 227 (68%)
Safety at workplace 204 (61%)
Rotational Posting after completing minimum rural service tenure 196 (59%)
Career development opportunities 195 (58%)Availability of good schools for children 135 (40%)
Good reward and recognition system 134 (40%)
Continuing education/higher education Opportunities 131 (39%)
Better teamwork and good interpersonal staffs relationship 128 (38%)
Job security 120 (36%)
Availability of equipment, drugs and supplies 92 (28%)
Supportive supervision and mentoring 84 (25%)
Opportunity for authority, independency and autonomy 25 (7%)
Flexible working hours with minimal workload 24 (7%)
Current health facility is closer to town or Closer to family & friends 5 (1%)
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4.3.4.1. FACTORS THAT MAY ATTRACT PHYSICIANS TO RURAL AREA-CHOICE OF CURRENT PHYSICIANS
As it can be derived from Table 52, the results indicated the top 10 factors
that may attract the physicians are: 1) Training and skill development opportunities
(1.81), 2) Access to amenities like housing & conveyance (1.78), 3) Career
development opportunities (1.72), 4) Financial incentives / Rural allowances/
Performance incentives (1.71), 5) Rotational Posting after completing minimum rural
service tenure (1.69), 6) Conducive working condition, (1.65), 7) Good reward and
recognition system (1.64), 8) Higher Salary package in compare to urban posting
(1.63), 9) Continuing education/higher education Opportunities (1.51) and 10) Safety
at workplace (1.50).
The lowest mean factors are: 1) Current health facility is closer to town or
Closer to family and friends (1.03), 2) Flexible working hours with minimal
workload (1.13), 3) Opportunity for authority, independency and autonomy (1.14),
4) Job security (1.21), 5) Availability of equipment, drugs and supplies (1.30), 6)
Supportive supervision and mentoring (1.34), 7) Availability of good schools for
children (1.35) and 8) Better teamwork and good interpersonal staffs relationship
(1.38).
While the Mean Test value reveals the following factors significant- Trainingand skill development Opportunities, Access to amenities like housing & conveyance,
Career development opportunities, Financial incentives / Rural allowances/
Performance incentives, Rotational Posting after completing minimum rural service
tenure, Conducive working condition, Good reward and recognition system, Higher
Salary package in compare to urban posting and Continuing education/higher
education opportunities. These factors are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(112)=8.547, p=.001, t(112)=7.107, p= .001,
t(112)=5.093, p= .001, t(112)=4.840, p= .001, t(112)=4.355, p= .001, t(112)=3.447,
p= .001, t(112)=3.019, p= .003, t(112)=2.810, p= .006 and t(112)=1.281, p= .009
respectively. The Percentage selection of Factor is presented in table 53.
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Table 52: Descriptive Statistics of the factors that may attract the physicians
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
taile
d)
Mean
Diff.
Training and skill development
Opportunities
113 1.81 .391 8.547 112 .001 .314
Access to amenities like
housing & conveyance
113 1.78 .417 7.107 112 .001 .279
Career development opportunity 113 1.72 .453 5.093 112 .001 .217
Financial incentives / Rural
allowances/Performance incentive
113 1.71 .457 4.840 112 .001 .208
Rotational Posting after
completing minimum rural
service tenure
113 1.69 .464 4.355 112 .001 .190
Conducive working condition 113 1.65 .478 3.447 112 .001 .155
Good reward and recognition
system
113 1.64 .483 3.019 112 .003 .137
Higher Salary package in
compare to urban posting
113 1.63 .485 2.810 112 .006 .128
Continuing education/higher
education Opportunities
113 1.61 .479 1.281 112 .009 .113
Safety at workplace 113 1.50 .502 .094 112 .926 .004
Better teamwork and goodinterpersonal staffs relationship
113 1.38 .488 -2.604 112 .010 -.119
Availability of good schoolsfor children
113 1.35 .480 -3.231 112 .002 -.146
Supportive supervision and
mentoring
113 1.34 .475 -3.667 112 .001 -.164
Availability of equipment,
drugs and supplies
113 1.30 .461 -4.595 112 .001 -.199
Job security 113 1.21 .411 -7.442 112 .001 -.288
Opportunity for authority,
independency and autonomy
113 1.14 .350 -10.880 112 .001 -.358
Flexible working hours with
minimal workload
113 1.13 .341 -11.455 112 .001 -.367
Current health facility is closer
to town or Closer to family andfriends
113 1.03 .161 -31.168 112 .001 -.473
The factor that may attract physicians for rural and remote services has the
following percentage of selection from the physicians: Training and skill
development Opportunities (81%), Access to amenities like housing & conveyance
(78%), Career development opportunities (72%), Financial incentives / Rural
allowances/ Performance incentives (71%), Rotational Posting after completing
minimum rural service tenure (69%), Conducive working condition (65%), Good
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reward and recognition system (64%), Higher Salary package in compare to urban
posting (63%), Continuing education/higher education Opportunities (51%), Safety at
workplace (50%), Better teamwork and good interpersonal staffs relationship (38%),
Availability of good schools for children (35%), Supportive supervision and
mentoring (34%), Availability of equipment, drugs and supplies (30%), Job security
(21%), Opportunity for authority, independency and autonomy (14%), Flexible
working hours with minimal workload (13%), Current health facility is closer to town
or Closer to family and friends (3%).
Table 53: Percentage of factors that may attract physicians in rural and remote
areas
Factors may attract
Physicians
n n%Training and skill development Opportunities 92 81%
Access to amenities like housing & conveyance 88 78%
Career development opportunities 81 72%
Financial incentives / Rural allowances/ Performance incentives 80 71%
Rotational Posting after completing minimum rural service tenure 78 69%
Conducive working condition 74 65%
Good reward and recognition system 72 64%
Higher Salary package in compare to urban posting 71 63%
Continuing education/higher education Opportunities 58 51%
Safety at workplace 57 50%Better teamwork and good interpersonal staffs relationship 43 38%
Availability of good schools for children 40 35%
Supportive supervision and mentoring 38 34%
Availability of equipment, drugs and supplies 34 30%
Job security 24 21%
Opportunity for authority, independency and autonomy 16 14%
Flexible working hours with minimal workload 15 13%
Current health facility is closer to town or Closer to family and friends 3 3%
4.3.4.2. ANALYSIS OF THE FACTORS THAT MAY ATTRACT NURSES TORURAL AND REMOTE AREA- CHOICE OF CURRENT NURSES
In this section, it is attempted to explore the factors that may attract nurses to
rural area. The sixteen (18) point factors were included for the same.
As it can be derived from table 54, the results indicated the top 10 factors that
may attraction the nurses are: Higher Salary package in compare to urban posting
(1.89), Conducive working condition (1.82), Access to amenities like housing &
conveyance (1.79), Training and skill development Opportunities (1.74), Financial
incentives / Rural allowances/ Performance incentives (1.69), Good reward and
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recognition system (1.63), Safety at workplace (1.56), Career development
opportunities (1.46), Rotational Posting after completing minimum rural service
tenure (1.40) and Better teamwork and good interpersonal staffs relationship (1.40).
The lowest mean factors are: Availability of good schools for children (1.37),
Job security (1.35), Continuing education/higher education Opportunities (1.32),
Availability of equipment, drugs and supplies (1.26), Supportive supervision and
mentoring (1.20), Flexible working hours with minimal workload (1.08), opportunity
for authority, independency and autonomy (1.04), Current health facility is closer to
town or Closer to family and friends (1.01).
It is found that the combination of seven factors are having statistically
significant at Mean Test Value=1.5, 95% C.I, and the factors : Higher Salary package
in compare to urban posting, Conducive working condition Access to amenities like
housing & conveyance, Training and skill development Opportunities, Financial
incentives / rural allowances/ Performance incentives, Good reward and recognition
system and Safety at workplace. These factors are significant at t(97)=12.098, p=
.001, t(97)=8.046, p= .001, t(97)=6.858, p= .001, t(97)=5.533, p= .001, t(97)=4.143,
p= .001, t(97)=2.710, p= .008 and t(97)=1.201, p= .041 respectively. The Percentage
selection of factor for Attraction or placed is place in table 55.
Table 54 : Descriptive Statistics of the factors that may attracted the nurses
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.
Higher Salary package in
compare to urban posting
98 1.89 .317 12.098 97 .001 .388
Conducive working condition 98 1.82 .389 8.046 97 .001 .316
Access to amenities like
housing & conveyance
98 1.79 .412 6.858 97 .001 .286
Training and skill development
Opportunities
98 1.74 .438 5.533 97 .001 .245
Financial incentives / Rural
allowances/ Performance
incentives
98 1.69 .463 4.143 97 .001 .194
Good reward and recognition
system
98 1.63 .485 2.710 97 .008 .133
Safety at workplace 98 1.56 .478 1.201 97 .041 .006
Career development opportunity 98 1.46 .501 -.807 97 .422 -.041
Rotational Posting after
completing minimum ruralservice tenure
98 1.40 .492 -2.053 97 .043 -.102
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Better teamwork and good
interpersonal staffs relationship
98 1.40 .492 -2.053 97 .043 -.102
Availability of good schools for
children
98 1.37 .485 -2.710 97 .008 -.133
Job security 98 1.35 .478 -3.167 97 .002 -.153
Continuing education/higher education Opportunities
98 1.32 .467 -3.890 97 .001 -.184
Availability of equipment,drugs and supplies
98 1.26 .438 -5.533 97 .001 -.245
Supportive supervision andmentoring
98 1.20 .405 -7.231 97 .001 -.296
Flexible working hours with
minimal workload
98 1.08 .275 -15.049 97 .001 -.418
Opportunity for authority,
independency and autonomy
98 1.04 .199 -22.856 97 .001 -.459
Current health facility is closer to
town or Closer to family & friend
98 1.01 .101 -48.000 97 .001 -.490
The factor that may attract nurses for rural and remote services has the
following percentage of selection: Higher Salary package in compare to urban
posting (89%), Conducive working condition (82%), Access to amenities like
housing & conveyance (74%), Training and skill development Opportunities (79%),
Financial incentives / Rural allowances/ Performance incentives (63%), Good reward
and recognition system (69%), Safety at workplace (46%), Career development
opportunities (51%), Rotational Posting after completing minimum rural service
tenure (40%), Better teamwork and good interpersonal staffs relationship (35%),
Availability of good schools for children (32%), Job security (40%), Continuing
education/higher education Opportunities (37%), Availability of equipment, drugs
and supplies (26%), Supportive supervision and mentoring (20%), Flexible
working hours with minimal workload (4%), Opportunity for authority,
independency and autonomy (8%) and Current health facility is closer to town or
Closer to family and friends (1%)
Table 55: Percentage selection of Factor that may attract nurses
Factors may attract
Nurses
n n%
Higher Salary package in compare to urban posting 87 89%
Conducive working condition 80 82%
Access to amenities like housing & conveyance 73 74%
Training and skill development Opportunities 77 79%
Financial incentives / Rural allowances/ Performance incentives 62 63%
Good reward and recognition system 68 69%Safety at workplace 45 46%
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Career development opportunities 50 51%
Rotational Posting after completing minimum rural service tenure 39 40%
Better teamwork and good interpersonal staffs relationship 34 35%
Availability of good schools for children 31 32%
Job security 39 40%
Continuing education/higher education Opportunities 36 37%Availability of equipment, drugs and supplies 25 26%
Supportive supervision and mentoring 20 20%
Flexible working hours with minimal workload 4 4%
Opportunity for authority, independency and autonomy 8 8%
Current health facility is closer to town or Closer to family and friends 1 1%
4.3.4.3. ANALYSIS OF THE FACTORS THAT MAY ATTRACT MID-WIVESTO RURAL AND REMOTE AREA- CHOICE OF CURRENT MID-WIVES
When the group of mid-wives is analysed, it is found that the top 10 factors
can be derived from table 56 are: Higher Salary package in compare to urban posting
(1.81), Access to amenities like housing & conveyance (1.78), Conducive working
condition (1.72), Training and skill development Opportunities (1.71), Good
reward and recognition system (1.69), Rotational Posting after completing
minimum rural service tenure (1.65), Financial incentives / Rural allowances/
Performance incentives (1.64), Continuing education/higher education Opportunities
(1.63), Career development opportunities (1.61), Safety at workplace (1.60).
The lowest mean factors are: Better teamwork and good interpersonal staffs
relationship (1.38), Availability of good schools for children (1.35), Supportive
supervision and mentoring (1.34), Availability of equipment, drugs and supplies
(1.30), Job security (1.21), Opportunity for authority, independency and autonomy
(1.14), Flexible working hours with minimal workload (1.13) and Current health
facility is closer to town or Closer to family and friends (1.03).
While the combination of ten factors are having statistically significant at
Mean Test Value=1.5, 95% C.I, and they are : Higher Salary package in compare to
urban posting, Access to amenities like housing & conveyance, Conducive working
condition, Training and skill development Opportunities, Good reward and
recognition system, Rotational Posting after completing minimum rural service
tenure, Financial incentives / Rural allowances/ Performance incentives, Continuing
education/higher education Opportunities, Career development opportunities and
Safety at workplace. These factors are significant at t(112)=8.547, p=.001,
t(112)=7.107, p= .001, t(112)=5.093, p= .001, t(112)=4.840, p=.001, t(112)=4.355,
p= .001, t(112)=3.447, p=.001, t(112)=3.019, p=.003, t(112)=2.810, p=.006,
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t(112)=1.281, p=.009 and t(112)=1.094, p=.026 respectively. The Percentage
selection of Factor for Attraction or placed is presented in table 57.
Table 56: Descriptive Statistics of the factors that may attracted the Mid-
wives
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.
Higher Salary package in
compare to urban posting
113 1.81 .391 8.547 112 .001 .314
Access to amenities like
housing & conveyance
113 1.78 .417 7.107 112 .001 .279
Conducive working condition 113 1.72 .453 5.093 112 .001 .217
Training and skill
development Opportunities
113 1.71 .457 4.840 112 .001 .208
Good reward and
recognition system
113 1.69 .464 4.355 112 .001 .190
Rotational Posting after completing minimum rural
service tenure
113 1.65 .478 3.447 112 .001 .155
Financial incentives / Rural
allowances/Performance
incentives
113 1.64 .483 3.019 112 .003 .137
Continuing education/higher
education Opportunities
113 1.63 .485 2.810 112 .006 .128
Career development opportun 113 1.61 .479 1.281 112 .009 .113
Safety at workplace 113 1.60 .475 1.094 112 .026 .010
Better teamwork and good
interpersonal staffs
relationship
113 1.38 .488 -2.604 112 .010 -.119
Availability of good schools
for children
113 1.35 .480 -3.231 112 .002 -.146
Supportive supervision and
mentoring
113 1.34 .475 -3.667 112 .001 -.164
Availability of equipment,
drugs and supplies
113 1.30 .461 -4.595 112 .001 -.199
Job security 113 1.21 .411 -7.442 112 .001 -.288
Opportunity for authority,
independency and autonomy
113 1.14 .350 -10.880 112 .001 -.358
Flexible working hours with
minimal workload
113 1.13 .341 -11.455 112 .001 -.367
Current health facility is
closer to town or Closer to
family and friends
113 1.03 .161 -31.168 112 .001 -.473
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The factor that may attract mid-wives for rural and remote services has the
following percentage of selection: Higher Salary package in compare to urban posting
(82%), Access to amenities like housing & conveyance (76%), Conducive working
condition (66%), Training and skill development Opportunities (67%), Good reward
and recognition system (63%), Rotational Posting after completing minimum rural
service tenure (64%), Financial incentives / Rural allowances/ Performance incentives
(59%), Continuing education/higher education Opportunities (52%), Career
development opportunities (46%), Safety at workplace (23%), Better teamwork and
good interpersonal staffs relationship (34%), Availability of good schools for children
(37%), Supportive supervision and mentoring (49%), Availability of equipment, drugs
and supplies (27%), Job security (21%), Opportunity for authority, independency and
autonomy (4%), Flexible working hours with minimal workload (1%) and Current
health facility is closer to town or Closer to family and friends (1%).
Table 57: Percentage of factors that may attract mid-wives in rural and remote
areas
Factors may attract
Mid-wives
n n%
Higher Salary package in compare to urban posting 101 82%
Access to amenities like housing & conveyance 93 76%
Conducive working condition 81 66%
Training and skill development Opportunities 83 67%Good reward and recognition system 77 63%
Rotational Posting after completing minimum rural service tenure 79 64%
Financial incentives / Rural allowances/ Performance incentives 73 59%
Continuing education/higher education Opportunities 64 52%
Career development opportunities 56 46%
Safety at workplace 28 23%
Better teamwork and good interpersonal staffs relationship 42 34%
Availability of good schools for children 46 37%
Supportive supervision and mentoring 60 49%
Availability of equipment, drugs and supplies 33 27%Job security 26 21%
Opportunity for authority, independency and autonomy 5 4%
Flexible working hours with minimal workload 1 1%
Current health facility is closer to town or Closer to family and friends 1 1%
4.3.4.4. VARIANCE IN CHOICE OF FACTOR THAT MAY ATTRACT THE
PHYSICIANS, NURSES AND MID-WIVES
While analysing the variance in the choice of the factors that may attract the
physicians, nurses and mid-wives, it is found that there is difference in the groups in
the view of factors that may attract to the rural and rural areas services. It is found
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that the physicians may be attracted to the rural and remote when they found there is
scope of training and skill development, a good working environment,
accommodation facilities, incentives and recognition system with a competitive
salary that is more than that of urban areas. It meant that the physicians first look at
self development by training and development, living condition and to the monetary
factors. While, the nurses and mid-wives have attraction of higher salary first, good
work environment, accommodation training and development, recognition and
Safety at workplace. It meant that the group of nurses and mid-wives are more
attracted to financial benefits and then they look after the work and living condition
and off-course to the Safety at workplace. Thus, it meant that the preference is not in
the same order and the factor cannot be generalised for all the three groups.
However, it is statistically found that the three groups differ in their choices in the
following factors:- Higher Salary package in compare to urban posting at F(2,
331)=3.210 , p= .042, Financial / rural/ Performance incentives at F(2, 331)=5.706 ,
p= .004, Improved working condition at F(2, 331)=3.740 , p= .025, Opportunity for
authority, independency & autonomy at F(2, 331)=5.629 , p= .004, Career
development opportunities at F(2, 331)=6.409 , p= .002, Continuing
education/higher education Opportunities at F(2, 331)=5.448 , p= .005, Training and
skill development Opportunities at F(2, 331) = 3.750 , p= .025, Rotational Posting at
F(2, 331)=5.952 , p= .003, Job security at F(2, 331)=10.231 , p= .001, Flexible
working hours with minimal workload at F(2, 331)=7.193 , p= .001, Supportive
supervision & mentoring at F(2, 331)=3.304 , p= .038, Access to amenities like
housing & conveyance at F(2, 331)=3.914 , p= .021, Safety at workplace at F(2,
331)=4.445 , p= .012, Good reward & recognition system at F(2, 331)=24.334 , p=
.001. Detail analysis of variance is presented in table 58.
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Table 58 : Analysis of Variance in factor that may attract the physicians, nurses
and mid-wives
Factors df F Sig.
Higher Salary package in compare to urban
posting
Between Groups 2 3.210 .042
Within Groups 331
Financial incentives / Rural allowances/Performance incentives
Between Groups 2 5.706 .004Within Groups 331
Improved working condition Between Groups 2 3.740 .025
Within Groups 331
Availability of equipment, drugs and
supplies
Between Groups 2 .298 .742
Within Groups 331
Opportunity for authority, independency
and autonomy
Between Groups 2 5.629 .004
Within Groups 331
Career development opportunities Between Groups 2 6.409 .002
Within Groups 331
Continuing education/higher educationOpportunities Between Groups 2 5.448 .005Within Groups 331
Training and skill development
Opportunities
Between Groups 2 3.750 .025
Within Groups 331
Rotational Posting after completing
minimum rural service tenure
Between Groups 2 5.952 .003
Within Groups 331
Job security Between Groups 2 10.231 .001
Within Groups 331
Flexible working hours with minimal
workload
Between Groups 2 7.193 .001
Within Groups 331
Supportive supervision and mentoring Between Groups 2 3.304 .038
Within Groups 331
Access to amenities like housing &conveyance
Between Groups 2 3.914 .021
Within Groups 331
Better teamwork and good interpersonal
staffs relationship
Between Groups 2 .068 .934
Within Groups 331
Safety at workplace Between Groups 2 4.445 .012
Within Groups 331
Good reward and recognition system Between Groups 2 24.334 .001
Within Groups 331
Availability of good schools for children Between Groups 2 1.264 .284
Within Groups 331Current health facility is closer to town or
Closer to family and friends
Between Groups 2 .781 .459
Within Groups 331
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SECTION 4
ANALYSIS OF THE DIMENSION
OF HR ISSUES IN RETENTION OF
PHYSICIANS, NURSES AND MID-
WIVES IN RURAL AND REMOTE
AREAS OF THE STATE
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4.4.1. INTRODUCTION
This part of the chapter describes the dimensions of retention of the
Physicians, Nurses and Mid-wives in the rural and remote areas. An employee attitude
survey measured the employee attitudes towards their job satisfaction, intention to
migrate and what would motivate them to stand back in present rural and remote
place. There are two propositions concerning the satisfaction and performance
relationship. The first proposition which is based on the traditional view is that,
satisfaction caused performance. The second proposition is that satisfaction is the
effect rather than the cause of performance. This proposition says that effort in a job
leads to rewards, which result in a certain level of satisfaction. In another proposition,
both satisfaction and performance are considered to be functions of rewards (Sharma,
2000). Job satisfaction therefore is a function of satisfaction with different aspects of
the job, such as, nature of job, promotional avenues, supervisors, co-workers role etc.
and the particular importance one attaches to these respective components and it
affects the retention and performance.
Therefore, the exploration of the issues in retention of Physicians, Nurses and
Mid-wives from the perspective of employees itself are presented in five sub-parts of:
i) level of job satisfaction of current job in rural and remote area with individual
contributing factors of level of satisfaction, ii) the intention to continue the present
rural area service for at least another 3-5 years, iii) retention factors for continuing the
rural service, iv) contributing push factors and iv) factors that may motivate them to
retain the current job in rural and remote area.
The determination of the factor that majorly attracted the physicians, nurses
and mid-wives has considered on the Mean factor which would be statistically
significant at Mean Test value of (1.5), that means the selection was done by the
majority (more than half) of the respondents and have an greater impact at large
workforce. This helps in ascertain the most relevant factors for the issue.
Along with the employee perspectives, the management perspective is also
presented in the following section.
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4.4.2. OVERALL JOB SATISFACTION OF PHYSICIANS,
NURSES AND MID-WIVES IN PRESENT RURAL AND REMOTE
AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC
ATTRIBUTES
Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for turnover in general include dissatisfaction with work. The job satisfaction of the
Physicians, Nurses and Mid-wives was measured on a scale of 1 to 5 with their
present job in rural and remote area. The scale denotes 1 (one) as the highly
dissatisfied to 5 (five) as highly satisfied.
The mean of overall scale of job satisfaction of these employees is 2.26
(N=334), which shows an average lower scale of satisfaction. In the group
comparison, the Physicians (2.53, N=113), Nurses (2.32, N=98) and Mid-wives (1.98, N=123) means respectively. The analysis shows that the groups of Mid-wives have
the lowest scale of job satisfaction, followed by the group of nurses and the
physicians.
21.2% of physicians are satisfied against 1.8% of them is highly satisfied and
3.5% have high dissatisfaction along with 64.6% of dissatisfied. In the counterpart the
nurses have 16.3% satisfied and 64.3% are dissatisfied along with 10.2% highly
dissatisfied. While, Mid-wives have 5.7% of satisfied group, 14.6% highly
dissatisfied and 78.9% has dissatisfied. It seems that most of the groups are
dissatisfied with the present job in rural and remote area.
Table 59: Percentage showing Job Satisfaction of physicians, nurses and mid-wives in rural and remote area setting
Category of
Respondents
Scale of overall job satisfaction
Total
H i g h l y
D i s s a t i s f i e d
D i s s a t i s f i e d
N e
i t h e r
S a t i s f i e d N o r
D i s s a t i s f i e d
S a t i s f i e d
H i g h l y
S a t i s f i e d
Physician 4 (3.5%) 73 (64.6%) 10 (8.8%) 24 (21.2%) 2 (1.8%) 113
Nurse 10 (10.2%) 63 (64.3%) 9 (9.2%) 16 (16.%) 0 (0%) 98
Mid-Wife 18 (14.6%) 97 (78.9%) 1 (0.8%) 7 (5.70%) 0 (0%) 123
Total 32 (9.6%) 233 (69.8%) 20 (6%) 47 (14.1%) 2 (0.6%) 334
While the analysis of variance shows that there is difference in the scale of job
satisfaction among the three groups, the values of F(2, 331)=14.197 , p =.001.
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Table 60: Descriptive statistics of Job Satisfaction of Physicians, Nurses and
Mid-wives
Category of Respondents N Mean
Std.
Deviation
Std.
Error Min Max
Physician 113 2.53 .927 .087 1 5
Nurse 98 2.32 .869 .088 1 4Mid-Wife 123 1.98 .620 .056 1 4
Total 334 2.26 .840 .046 1 5
Table 61: Analysis of Variance in Job Satisfaction among the Physicians,
nurses and mid-wives
Sum of Squares df Mean Square F Sig.
Between Groups 18.552 2 9.276 14.197 .001
Within Groups 216.262 331 .653
Total 234.814 333
In the group comparison as per the Nature of Employment, the means of contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. This
interprets as the contractual employees have lower job satisfaction in comparison to
the permanent employees.
If we analysed the situation in categorizing the workforce in nature of
employment, we found that contract workforce are more dissatisfied than the
permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2%
are satisfied in the group of the contracts. Whereas, the permanent employees have9.6% are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only
0.6% are highly satisfied.
Table 62: Percentage showing Job Satisfaction of contractual and permanentphysicians, nurses and mid-wives in rural and remote area setting
Nature of
Employment
Scale of overall job satisfaction
T o t a l
H i g h
l y
D i s s a t i s f i e d
D i s s a t i s f i e d
N e i t h e r S
a t i s f i e d
N o r D i s s a t i s f i e d
S a t i s f i e d
H i g h l y S a t i s f i e d
Contract 27(17.5%) 110 (71.4%) 9 (5.8%) 8 (5.2%) 0(0.0%) 154
Permanent 5 (2.8%) 123 (68.3%) 11 (6.1%) 39 (21.7%) 2(1.1%) 180
Total 32 (9.6%) 233 (69.8%) 20 (6.0%) 47 (14.1%) 2(0.6%) 334
Two sample T-Test shows that it is statistical significant, the values are: t(332)
= -5.835, p=.001. There is a difference in the job satisfaction between the groups. The
mean difference is -.513 between the contractual and permanent employees.
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Table 63: Descriptive statistic of Job Satisfaction of contract and permanent
Physicians, nurses and mid-wives
Nature of Employment N Mean Std. Deviation
Std. Error
Mean
Contract 154 1.99 .667 .054
Permanent 180 2.50 .900 .067
The Medical professions like doctor and nurses has been long among the most
attractive and satisfied profession in the society, but when it is analysed in the context
of rural and remote area services, the results suggests that these group of employees
are increasingly getting dissatisfied with their jobs in rural and remote areas.
The next topic of analysis and interpretation is on how the demographicattributes effect the job satisfaction of these groups in rural and remote area service
setting.
It is well known that the job satisfaction is effected by the demographic
attributes of the employees. To explore the relationship of the Job satisfaction of
Physicians, nurses and mid-wives in rural and remote area services with other
demographic attributes like age, family background, marital status, length of service,
place of posting and nature of employment, the statistical analysis has been done and
interpreted. The variable, (sex) has been drooped from analysing for the relationship
because there are male and female classification is only in the Physicians group,
where as the nurses and mid-wives does not have the classification of male and
female, except 1 (one) no. of male in the nurse group of employee.
Correlation (Pearson’s ratio or Spearman Correlation), paired sample T-Test
were used to identify the attributes significantly related with job satisfaction. The p-
values of 0.05 were used as the level of significance.
Table 64: Analysis of Variance of Job Satisfaction among contractual and
permanent Physicians, nurses and mid-wivesLevene's Testfor Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig.
MeanDifference
Std. Error Difference
(2-tailed)
Equal variances
assumed
54.929 .001 -5.835 332 0 -0.513 0.088
Equal variances
not assumed
-5.969 325.5
41
0 -0.513 0.086
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It is statistically significant that there is a positive relationship of job
satisfaction with the age r(334)=.282, p=.001, length of service r(334)=.224,
p=.001, place of posting r(334)=.053, p=.004 and nature of employment
r(334) = .305, p=.001. However, the relationship is not strong between the variables
because the association is under minimum values. Thus, it signifies that as higher
age employee has higher job satisfaction, higher length of service has higher job
satisfaction, employee posted at the higher level of health institute has higher job
satisfaction and permanent employees have the higher job satisfaction than the
contractual employees.
There is negative relationship and statistically significant as well between the
variables. The correlation between the marital status and job satisfaction is
r(334)=(-).159, p=.004. Thus, in marital status it signifies that married employees
has less job satisfaction. Wherein, it signifies that the more married employees the
less satisfaction level in rural setting.
There is no relationship between family background and job satisfaction of
employees in rural setting. The correlation between the variables is not statistically
significant r(334)=.028, p=.613. Thus, there is no effect of family background on
job satisfaction of the employees.
To sum up, statistically it seems that age, length of service, place of posting
and nature of employment have the positive impact on job satisfaction in the rural
setting.
Table 65: Correlation between Job satisfaction and the demographic attributes
of the employees (Physicians, Nurses and Mid-wives)
4.4.2.1. JOB SATISFACTION OF PHYSICIANS IN RURAL AND REMOTE
AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC
ATTRIBUTESThe job satisfaction of the physicians has been measured on a scale of 1 to 5
with their present job in rural and remote area. The scale denotes 1 (one) as the highly
dissatisfied to 5 (five) as highly satisfied.
Sl. No. Attributes Correlation coefficient P-Value
1. Age 0.282 0.001
2. Family Background 0.028 0.613
3. Marital Status -0.159 0.004
4. Length of Service 0.224 0.001
5. Nature of Employment 0.305 0.001
6. Place of Posting 0.053 0.004
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The mean of overall scale of job satisfaction of physician is (2.53, N=113),
which shows an average low scale of satisfaction. In the group comparison, the
contractual physicians (2.24, N=34), permanent physicians (2.66, N=79).
The analysis shows that the contractual physicians have the lowest scale of job
satisfaction in comparison to the permanent physicians.
Two sample T-Test (Paired) shows that it is statistical significant, the values
are: t(111) = -2.266, p =0.025. It signifies that there is a difference in the job
satisfaction between the groups. The mean difference is -.423 between the contractual
and permanent physicians.
Table 66 : Descriptive statistic of Job Satisfaction of contract and permanent
Physicians.
Category N Mean Std. Dev. Std. Error Min MaxContract 34 2.24 .741 .127 1 4
Permanent 79 2.66 .973 .109 1 5
Total 113 2.53 .927 .087 1 5
Table 67: Analysis of Variance of Job Satisfaction among contractual and
permanent Physicians.Levene's Test
for Equalityof Variances t-test for Equality of Means
F Sig. t df Sig.
(2-tailed)
Mean
Diff.
Std.
Error Diff.
Equal variances assumed 14.522 .001 -2.266 111 0.025 -0.423 0.187
Equal variances not assume -2.522 81.191 0.014 -0.423 0.168
To explore the relationship of the Job satisfaction of Physicians in rural and
remote area services with other demographic attributes like age, sex, family
background, marital status, length of service and nature of employment, the
statistical analysis has been done and interpreted. The variable place of posting is
not considered for the aforesaid test, because the variable has fewer cases of
different groups.
Correlation (Pearson’s) or paired sample T-Test was used to identify the
attributes significantly related with job satisfaction. The p-values of 0.05 were used
as the level of significance.
It is statistically significant that there is a positive relationship of job
satisfaction with the age r(113)=.213, p=.024, length of service r(113)=.223,
p=.018, and nature of employment r(113) = .210, p = .025. However, therelationship is not strong between the variables because the association is under
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minimum positive values. Thus, it signifies that as higher age employee has higher
job satisfaction, higher length of service has higher job satisfaction and permanent
employees have the higher job satisfaction than the contractual employees.
There is negative relationship and statistically significant as well between the
variables. The correlation between the sex and job satisfaction is negative
r(113)=(-).178, p=.05 and the marital status is r(113)=(-).185, p=.05. Thus, it
signifies that males (77%) out-numbered the female (23%) employees and the job
satisfaction diminishes as the male employees goes up and male physicians have less
job satisfaction in rural setting. Moreover, the negative relationship in marital
signifies that married employees has less job satisfaction and it is statistically
signifies. The married physicians (63%) are out-numbered the unmarried physicians
(37%), and as the married physicians out-numbered, the satisfaction level will go
down in rural setting.
It is found that, there is no relationship between family background and job
satisfaction of employees in rural setting. The correlation between the variables is
not statistically significant r(113)=.042, p=.656. Thus, there is no effect of family
background on job satisfaction of the employees.
To sum up, statistically it seems that age, length of service and nature of
employment have positive relationship with the job satisfaction of the Physicians.
Table 68 : Correlation between Job satisfaction and the demographic attributes
of Physicians
4.4.2.2. JOB SATISFACTION OF NURSES IN RURAL AND REMOTE AREA
AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTESThe job satisfaction of the Nurses has been measured on a scale of 1 to 5 with
their present job in rural and remote area. The scale denotes 1 (one) as the highly
dissatisfied to 5 (five) as highly satisfied.
The mean of overall scale of job satisfaction of Nurses is (2.32, N=98), which
shows an average lower scale of satisfaction. In the group comparison, the contractual
nurses (2.02, N=45), permanent nurses (2.57, N=53).
Sl. No. Attributes Correlation coefficient P-Value
1. Age 0.213 0.024
2. Sex -0.178 0.050
3. Family Background 0.042 0.656
4. Marital Status -0.185 0.050
5. Length of Service 0.223 0.018
6. Nature of Employment 0.210 0.025
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The analysis shows that the contractual nurses have the lowest scale of job
satisfaction in comparison to the permanent nurses.
Two sample T-Test (Paired) shows that it is statistical significant, the values
are: t(96) = -3.236, p =0.002. It signifies that there is a difference in the job
satisfaction between the groups. The mean difference is -.544 between the contractual
and permanent nurses.
Table 69: Descriptive statistic of Job Satisfaction of contract and permanent
nurses.
N Mean Std. Dev. Std. Error Min Max
Contract 45 2.02 .723 .108 1 4
Permanent 53 2.57 .910 .125 1 4
Total 98 2.32 .869 .088 1 4
Table 70 : Analysis of Variance of Job Satisfaction among contractual and
permanent nursesLevene's Testfor Equality of
Variances t-test for Equality of Means
F Sig. t df Sig. (2-tailed)
MeanDiff.
Std. Error Diff.
Equal variances assumed 13.959 .001 -3.236 96 .002 -.544 .168
Equal variances not assum -3.297 95.608 .001 -.544 .165
To explore the relationship of the Job satisfaction of Nurses in rural and
remote area services with other demographic attributes like age, family background,
marital status, length of service and nature of employment, the statistical analysis has
been done and interpreted. The variable place of posting and sex is not considered
for the aforesaid test, because the variable has fewer cases of different groups.
Correlation (Pearson’s) or paired sample T-Test was used to identify the
attributes significantly related with job satisfaction. The p-values of 0.05 were used
as the level of significance.
It is statistically significant that there is a positive relationship of job
satisfaction with the age r(98)=.225, p=.026 , length of service r(98)=.227, p=.025,
and nature of employment r(98) = .314, p = .002.
However, the relationship is not strong between the variables because the
association is under minimum positive values. Thus, it signifies that as higher age
nurses has higher job satisfaction, higher length of service has higher job satisfaction
and permanent nurses have the higher job satisfaction than the contractual nurses.
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The correlation between the marital status and job satisfaction is negative and
statistically not significant r(98)=(-).173, p=.089. Also, there is no relationship
between family background and job satisfaction of nurses in rural setting
r(98)=.0.047, p=.644. Thus, there is no relationship of Marital Status and family
background and Job Satisfaction in Nurses.
To sum up, statistically it seems that age, length of service and nature of
employment have positive effect on the job satisfaction of the Nurses.
4.4.2.3. JOB SATISFACTION OF MID-WIVES IN RURAL AND REMOTE
AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC
ATTRIBUTESThe job satisfaction of the Mid-wives has been measured on a scale of 1 to 5
with their present job in rural and remote area. The scale denotes 1 (one) as the highly
dissatisfied to 5 (five) as highly satisfied.
The mean of overall scale of job satisfaction of Nurses is (1.98, N=123),
which shows a lower scale of satisfaction. In the group comparison, the contractual
nurses (1.85, N=75), permanent nurses (2.17, N=48).
The analysis shows that the contractual mid-wives have the lowest scale of job
satisfaction in comparison to the permanent mid-wives.
Two sample T-Test (Paired) shows that it is statistical significant, the values
are: t(121) = -2.809, p= .006. It signifies that there is a difference in the job
satisfaction between the groups. The mean difference is -.313 between the contractual
and permanent mid-wives.
Table 72: Descriptive statistic of Job Satisfaction of contract and permanent
mid-wives.
Category N Mean Std. Deviation Std. Error Min Max
Contract 75 1.85 .562 .065 1 4
Permanent 48 2.17 .663 .096 1 4
Total 123 1.98 .620 .056 1 4
Table 71: Correlation between Job satisfaction and the demographic
attributes of Nurses
Sl. No. Attributes Correlation coefficient P-Value
1. Age 0.225 0.026
2. Family Background 0.047 0.644
3. Marital Status -0.173 0.0894. Length of Service 0.227 0.025
5. Nature of Employment 0.314 0.002
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Table 73: Analysis of Variance of Job Satisfaction among contractual and
permanent mid-wives Levene's
Test t-test for Equality of Means
F Sig. t df Sig. (2-tailed) MeanDiff.
Std.
Error Diff.
Equal variances assumed .042 .839 -2.809 121 .006 -.313 .112
Equal variances not assumed -2.709 88.315 .008 -.313 .116
To explore the relationship of the Job satisfaction of Mid-wives in rural and
remote area services with other demographic attributes like age, family background,
marital status, length of service and nature of employment, the statistical analysis has
been done and interpreted. The variable place of posting and sex is not considered
for the aforesaid test, because the variable has fewer cases of different groups.Correlation (Pearson’s) or paired sample T-Test was used to identify the
attributes significantly related with job satisfaction. The p-values of 0.05 were used
as the level of significance.
It is statistically significant that there is a positive relationship of job
satisfaction with the age r(123)=.183, p=.043 and nature of employment r(123) =
.247, p = .006
However, the relationship is not strong between the variables because the
association is under minimum positive values. Thus, it signifies that as higher age
mid-wives has higher job satisfaction and permanent mid-wives have the higher job
satisfaction than the contractual mid-wives.
The correlation between the length of service r(123)=.158, p=.081, marital
status r(123)=(-).101, p=.265 and family background r(123)=.0.140, p=.123 with
job satisfaction is statistically not significant, thus there is no relationship between
these separate variables and job satisfaction of mid-wives in rural setting.
To sum up, statistically it seems that age and nature of employment have
positive effect on the job satisfaction of the Mid-wives.
Table 74 : Correlation between Job satisfaction and the demographic attributes
of mid-wives
Sl. No. Attributes Correlation coefficient P-Value
1. Age 0.183 0.043
2. Family Background 0.140 0.123
3. Marital Status -0.101 0.265
4. Length of Service 0.158 0.081
5. Nature of Employment 0.247 0.006
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4.4.3. FACTORS OF JOB SATISFACTION OF PHYSICIANS,
NURSES AND MID-WIVES IN RURAL AND REMOTE AREAMany managers subscribe to the belief that a satisfied worker is necessarily a
good worker. In other words, if management could keep all the workers “happy”,
good performance would automatically follow. Job satisfaction in relation to workers
and organisation has been a fascinating area of scientific enduring right from the day
of Taylor and his pessimistic philosophy that the workers are essentially “stupid and
phlegmatic” and satisfied only with more economic return to a more realistic and
complex approach to job satisfaction. It has come a long way. The studies of Hoppock
(1935) and Samantray (1997) to mention some of the studies have added new
dimensions of knowledge on job satisfaction. The studies in the Indian context
between 1951 to 1983 as reviewed by Sayadain (2009) reveal that the economic
factors play a significant role in job satisfaction of Indian workers followed by job
security, fringe benefits and relationship with boss in that order. So, it is attempted to
explore the dimension of factors of job satisfaction in this study. As it is mentioned
job satisfaction is a composite of several variables that contributed to the overall
satisfaction from the job. These variables contribute to the job satisfaction in different
manner. One aspect or the variable can contribute to the job satisfaction and other
may not be. So, the analysis of factors of job satisfaction is necessities here.In this study, job satisfaction among physicians, nurses and mid-wives is
found to be at lower scale of satisfaction. Specifically in overall the mid-wives has the
lowest satisfaction level and the contractual physicians, nurses and mid-wives have
the lowest satisfaction level than the permanent employees of the same category.
Therefore, in this section of the study, it is attempted to explore the factors
contributed for job satisfaction of the physicians, nurses and mid-wives. The factors
of job satisfaction of the physicians, nurses and mid-wives have been measured on 18
items related to the current job in the rural area setting. The items attempted to
explore the contributing factors for job satisfaction of physicians, nurses and mid-
wives from the current job in rural and remote area setting.
The Cronbach’s alpha coefficient for this factor items is α =0.556 on item 18
and N=334, which is higher than 0.5.
The analysed results indicated in table 75 shows that the factor means at - a)
Social recognition and opportunities of public services/ care to patients (1.80) and b)
Better Job Prospects in future (1.80), which is the highest with mean among the factor
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list that contributed for job satisfaction of the physicians, nurses and mid-wives. The
top 10 listed factor according to the compared mean out of the 18 point factors of job
satisfaction are: i) Social recognition and opportunities of public services/ care to
patients, ii) Better Job Prospects in future, iii) Training and skill development
Opportunities, iv) Matching of skills and tasks, v) Support, supervision, management
and mentoring, vi) Job security, vii) Teamwork and Interpersonal staffs relationship
viii) Salary, ix) Appropriate Work load and x) Career development opportunities.
The lowest mean factors are : Financial incentives linked to rural posting
(1.00), Reward system and recognition (1.00), Non-financial benefits/allowances
linked to rural posting (1.08), Safety at the workplace from external environment
(1.10), Work environment (1.19), Access to free accommodation (Housing) (1.20),
Adequacy of equipment, drugs and supplies (1.20), Opportunities of continuing
education/higher education (1.25), Career development opportunities (1.26),
Appropriate Work load (1.43)
Table 75: Descriptive Statistics of Factors contributed for job satisfaction of the
physicians, nurses and mid-wives
Factors
N Mean
Std.
Dev.
Better Job Prospects in future 334 1.8 0.403
Social recognition and opportunities of public services/ care
to patients
334 1.8 0.399
Training and skill development Opportunities 334 1.74 0.44
Matching of skills and tasks 334 1.73 0.444
Support, supervision, management and mentoring 334 1.66 0.473
Job security 334 1.59 0.493
Teamwork and Interpersonal staffs relationship 334 1.55 0.498
Salary 334 1.52 0.5
Appropriate Work load 334 1.43 0.496
Career development opportunities 334 1.26 0.441
Opportunities of continuing education/higher education 334 1.25 0.433Adequacy of equipment, drugs and supplies 334 1.2 0.399
Access to free accommodation (Housing) 334 1.2 0.399
Work environment 334 1.19 0.396
Safety at the workplace from external environment 334 1.1 0.295
Non-financial benefits/allowances linked to rural posting 334 1.08 0.273
A simultaneous multiple linear regression analysis was conducted to find
significant predictor at current time for the job satisfaction of physicians, nurses and
mid-wives altogether in rural and remote area setting. The factor variables of job
satisfaction explained about 17% of the variance in job satisfaction, F(16, 317)=
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4.95; p < .05. As in table 76 shows, the factor model included 18 factors. The
following variables are constants or have missing correlations, financial incentives
linked to rural posting, Reward system and recognition, thus, they were deleted for
the analysis.
An examination of the T-Value indicates that Salary and Training & Skill
development opportunities are the main contributors to Job satisfaction in current
time of physicians, nurses and mid-wives altogether in rural and remote area setting.
Salary found to be significant at (b=.324, t=4.508; p= .001) and Training and skill
development opportunities found to be significant at (b=.108, t=2.017; p= .004).
Table 76: Result of Regression Analysis of factors contributed for job
satisfaction of the physicians, nurses and mid-wives.
Factors b t p-
value
(Constant) .419 .675
Salary .324 4.508 .001
Better Job Prospects in future -.033 -.639 .523
Job security .018 .278 .781
Career development opportunities .059 1.054 .293
Opportunities of continuing education/higher education -.035 -.595 .552
Training and skill development Opportunities .108 2.017 .044
Work environment .053 .970 .333Adequacy of equipment, drugs and supplies .065 1.199 .231
Non-financial benefits/allowances linked to rural posting .023 .434 .665
Appropriate Work load -.081 -1.435 .152
Matching of skills and tasks .060 1.092 .276
Support, supervision, management and mentoring .014 .263 .793
Social recognition and opportunities of public services/ care
to patients
.086 1.629 .104
Teamwork and Interpersonal staffs relationship -.010 -.154 .878
Safety at the workplace from external environment .017 .320 .749
Access to free accommodation (Housing) .050 .919 .359
R R SquareAdjusted R
SquareStd. Error of the Estimate
.415 .172 .131 .783
The correlation matrix at table 77, indicates a positive relationship between
Overall job satisfaction with Salary, Job security, Career development opportunities,
Opportunities of continuing education/higher education, Training and skill
development Opportunities, Matching of skills and tasks, Social recognition and
opportunities of public services/ care to patients, Teamwork and Interpersonal staffs
relationship, Access to free accommodation (Housing).
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Table 77: Correlation matrix of overall job Satisfaction with factor of job
satisfaction for physicians, nurses and mid-wives
Correlation p-value
Salary .350 .001
Better Job Prospects in future -.018 .737
Job security .213 .001Career development opportunities .169 .002
Opportunities of continuing education/higher education .133 .015
Training and skill development Opportunities .089** .005
Work environment .089 .104
Adequacy of equipment, drugs and supplies .086 .116
Financial incentives linked to rural posting .a -
Non-financial benefits/allowances linked to rural posting .090 .100
Appropriate Work load -.028 .605
Matching of skills and tasks .126 .021
Support, supervision, management and mentoring -.011 .837Reward system and recognition .a .
Social recognition and opportunities of public services/ care to
patients
.129 .018
Teamwork and Interpersonal staffs relationship .212 .001
Safety at the workplace from external environment .043 .430
Access to free accommodation (Housing) .158 .004(**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). a. Cannot be
computed because at least one of the variables is constant.)
4.4.3.1. FACTORS OF JOB SATISFACTION OF PHYSICIANS IN RURAL
AND REMOTE AREAWhen we look into separately the factors that impact on job satisfaction of
physicians at table 78, the 1) Social recognition and opportunities of public services/
care to patients (1.89) is the highest mean factor and Financial incentives linked to
rural posting (1.00) is the lowest mean factor. The top 10 factors area : 1) Social
recognition and opportunities of public services/ care to patients (1.89), 2) Better Job
Prospects in future (1.81), 3)Training and skill development Opportunities (1.77), 4)
Job security (1.75), 5) Matching of skills and tasks (1.72), 6) Salary (1.69), 7)
Teamwork and Interpersonal staffs relationship (1.66), 8) Support, supervision,
management and mentoring (1.65), 9) Opportunities of continuing education/higher
education (1.50), 10) Career development opportunities (1.39), and the lowest mean
factors are Financial incentives linked to rural posting (1.00), Reward system and
recognition (1.00), Non-financial benefits/allowances linked to rural posting (1.14),
Safety at the workplace from external environment (1.14), Work environment (1.22),
Adequacy of equipment, drugs and supplies (1.23), Access to free accommodation
(Housing) (1.23), Appropriate Work load (1.24).
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Table 78: Descriptive Statistics on Factors contributed for job satisfaction of
the physicians. Sl.
No.Factors
N Min Max MeanStd.Dev.
1 Social recognition and opportunities of public
services/ care to patients
113 1 2 1.89 .309
2 Better Job Prospects in future 113 1 2 1.81 .398
3 Training and skill development Opportunities 113 1 2 1.77 .423
4 Job security 113 1 2 1.75 .434
5 Matching of skills and tasks 113 1 2 1.72 .453
6 Salary 113 1 2 1.69 .464
7 Teamwork and Interpersonal staffs
relationship
113 1 2 1.66 .475
8 Support, supervision, management and
mentoring
113 1 2 1.65 .478
9 Opportunities of continuing education/higher education
113 1 2 1.50 .502
10 Career development opportunities 113 1 2 1.39 .490
11 Appropriate Work load 113 1 2 1.24 .428
12 Access to free accommodation (Housing) 113 1 2 1.23 .423
13 Adequacy of equipment, drugs and supplies 113 1 2 1.23 .423
14 Work environment 113 1 2 1.22 .417
15 Safety at the workplace from external
environment
113 1 2 1.14 .350
16 Non-financial benefits/allowances linked to
rural posting
113 1 2 1.14 .350
17 Reward system and recognition 113 1 1 1.00 .00018 Financial incentives linked to rural posting 113 1 1 1.00 .000
A simultaneous multiple linear regression analysis was conducted to find
significant predictor at current time for the job satisfaction of physicians in rural and
remote area setting. The factor variables of job satisfaction explained about 22% of
the variance in physicians job satisfaction, F(16, 96)= 1.726; p < .05. As in table 79,
the 18 factors were included. The following variables are constants or have missing
correlations, financial incentives linked to rural posting, Reward system and
recognition, thus, they were deleted for the analysis. An examination of the T-Value
indicates that Salary, Training & skill development Opportunities and Safety at the
workplace from external environment are the main contributors to the prediction of
Job satisfaction in current time of physicians in rural and remote area setting. Salary
found to be significant at (b=.364, t=2.839; p=.006), Training and skill development
opportunities found to be significant at (b=.186, t=1.926; p=.05) and Safety at the
workplace from external environment found to be significant at (b=.232, t=2.441; p=
.016)
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Table 79: Result of Regression Analysis of factors contributed for job
satisfaction of the physicians.
Factors b t P
(Constant) -.340 .734
Salary .364 2.839 .006
Better Job Prospects in future .004 .038 .970Job security -.032 -.319 .751
Career development opportunities .024 .237 .813
Opportunities of continuing education/higher education -.105 -.969 .335
Training and skill development Opportunities .186 1.926 .05
Work environment .143 1.383 .170
Adequacy of equipment, drugs and supplies .101 .961 .339
Non-financial benefits/allowances linked to rural posting -.065 -.700 .486
Appropriate Work load -.166 -1.647 .103
Matching of skills and tasks .001 .012 .991
Support, supervision, management and mentoring .042 .439 .662Social recognition & opportunities of public services .069 .706 .482
Teamwork and Interpersonal staffs relationship -.006 -.053 .958
Safety at the workplace from external environment .232 2.441 .016
Access to free accommodation (Housing) .016 .158 .874
R R Square
Adjusted R
Square
Std. Error of
the Estimate
.473 .223 .094 .882
The correlation matrix at table 80, indicates a positive and strong relationship
between Overall job satisfaction with Salary (r=.282), Training and skill development
Opportunities (r=.110) and Safety at the workplace from external environment
(r= .262).
Table 80: Correlation matrix of overall job Satisfaction with factor of Job
satisfaction of Physicians
Factors r p
Salary .282 .002
Better Job Prospects in future .041 .668
Job security .019 .839
Career development opportunities .111 .242
Opportunities of continuing education/higher education .091 .339Training and skill development Opportunities .110* .048
Work environment .132 .162
Adequacy of equipment, drugs and supplies .141 .136
Non-financial benefits/allowances linked to rural posting -.041 .665
Appropriate Work load -.030 .752
Matching of skills and tasks .106 .263
Support, supervision, management and mentoring .055 .565
Social recognition and opportunities of public services/ care to patients .043 .653
Teamwork and Interpersonal staffs relationship .125 .186
Safety at the workplace from external environment .262 .005
Access to free accommodation (Housing) .118 .212**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).
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4.4.3.2. FACTORS OF JOB SATISFACTION OF NURSES IN RURAL AND
REMOTE AREA
The factors that impact on job satisfaction of nurses can be seen at table 81,
such that- 1) Social recognition and opportunities of public services/ care to patients
(1.89) is the highest mean factor and Financial incentives linked to rural posting
(1.00) is the lowest mean factor.
The top 10 factors are: Social recognition and opportunities of public
services/ care to patients (1.91), Matching of skills and tasks (1.89), Better Job
Prospects in future (1.82), Training and skill development Opportunities (1.72),
Appropriate Work load (1.69), Support, supervision, management and mentoring
(1.65), Teamwork and Interpersonal staffs relationship (1.61), Job security (1.60)
Salary (1.53) and Career development opportunities (1.24).
Work environment (1.23), Access to free accommodation (Housing) (1.21),
Adequacy of equipment, drugs and supplies (1.17), Opportunities of continuing
education/higher education (1.06), Non-financial benefits/allowances linked to rural
posting (1.05), Safety at the workplace from external environment (1.04), Reward
system and recognition (1.00) and Financial incentives linked to rural posting (1.00)
are the main factors which have the lowest scores and contributes to the less job
satisfaction of the nurses.
Table 81: Descriptive Statistics on factors contributed for job satisfaction of
the Nurses.
Sl.
No.Factors
N Min Max Mean
Std.
Dev.
1 Social recognition and opportunities of public
services/ care to patients
98 1 2 1.91 .290
2 Matching of skills and tasks 98 1 2 1.89 .317
3 Better Job Prospects in future 98 1 2 1.82 .389
4 Training and skill development Opportunities 98 1 2 1.72 .449
5 Appropriate Work load 98 1 2 1.69 .4636 Support, supervision, management and mentoring 98 1 2 1.65 .478
7 Teamwork and Interpersonal staffs relationship 98 1 2 1.61 .490
8 Job security 98 1 2 1.60 .492
9 Salary 98 1 2 1.53 .502
10 Career development opportunities 98 1 2 1.24 .432
11 Work environment 98 1 2 1.23 .426
12 Access to free accommodation (Housing) 98 1 2 1.21 .412
13 Adequacy of equipment, drugs and supplies 98 1 2 1.17 .381
14 Opportunities of continuing education/higher
education
98 1 2 1.06 .241
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15 Non-financial benefits/allowances linked to rural
posting
98 1 2 1.05 .221
16 Safety at the workplace from external
environment
98 1 2 1.04 .199
17 Reward system and recognition 98 1 1 1.00 .000
18 Financial incentives linked to rural posting 98 1 1 1.00 .000
A simultaneous multiple linear regression analysis was conducted to find
significant predictor at current time for the job satisfaction of nurses in rural and
remote area setting. The factor variables of job satisfaction explained about 21% of
the variance in nurses job satisfaction, F(16, 81)= 1.403; p > .05. However, it is
statistically not significant, the p value is 0.161.
As table 82 shows, the factor included 18 factors. The following variables are
constants or have missing correlations, financial incentives linked to rural posting,
Reward system and recognition, thus, they were deleted for the analysis. An
examination of the T-Value indicates that no factors contribute to the prediction of
Job satisfaction in current time of nurses in rural and remote area setting. None of the
value found to be statistically significant.
However, the one sample T-test at table 83 shows that the following factors
have the Mean more than 1.5 and statistically significant in selection of factor of
satisfaction according to the responses. Social recognition and opportunities of public
services/ care to patients [t(97) = 13.920 p= .001], Matching of skills and tasks
[t(97) = 12.098 p= .001], Better Job Prospects in future [t(97) = 8.046 p= .001],
Training and skill development Opportunities t(97) = 4.949 p= .001,
Appropriate Work load [t(97) = 4.143 p= .001], Support, supervision, management
and mentoring [t(97) = 3.167 p=.002], Teamwork and Interpersonal staffs
relationship [t(97) = 2.269 p= .025] and Job security [t(97) = 2.053 p= .043]
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Table 82: Regression Analysis of factors contributed for job satisfaction of the
nurses.
Factors b t Sig.
(Constant) 1.378 .172
Salary .209 1.354 .179
Better Job Prospects in future -.130 -1.228 .223Job security -.004 -.031 .975
Career development opportunities -.024 -.203 .840
Opportunities of continuing education/higher education -.066 -.645 .521
Training and skill development Opportunities -.008 -.075 .941
Work environment -.031 -.281 .780
Adequacy of equipment, drugs and supplies .087 .780 .438
Non-financial benefits/allowances linked to rural posting .162 1.489 .140
Appropriate Work load -.097 -.862 .391
Matching of skills and tasks .045 .423 .674
Support, supervision, management and mentoring .051 .474 .637
Social recognition and opportunities of public services/ careto patients
-.016 -.148 .883
Teamwork and Interpersonal staffs relationship .085 .635 .527
Safety at the workplace from external environment -.155 -1.445 .152
Access to free accommodation (Housing) .101 .879 .382
R R Square
Adjusted R
Square
Std. Error of
the Estimate
.466 .217 .062 .841
Table 83: T-test results of factors contributed for job satisfaction of the nurses.
Factors Test Value = 1.5
t df Sig.(2-
tailed)
Mean
Diff.
Salary 0.604 97 0.547 0.031
Better Job Prospects in future 8.046 97 0.001 0.316
Job security 2.053 97 0.043 0.102
Career development opportunities -5.843 97 0.001 -0.255
Opportunities of continuing/higher education -18.025 97 0.001 -0.439
Training & skill development Opportunities 4.949 97 0.001 0.224
Work environment -6.165 97 0.001 -0.265
Adequacy of equipment, drugs and supplies -8.493 97 0.001 -0.327 Non-financial benefits/allowances linked to rural
posting
-20.096 97 0.001 -0.449
Appropriate Work load 4.143 97 0.001 0.194
Matching of skills and tasks 12.098 97 0.001 0.388
Support, supervision, management and mentoring 3.167 97 0.002 0.153
Social recognition and opportunities of public
services/ care to patients
13.92 97 0.001 0.408
Teamwork and Interpersonal staffs relationship 2.269 97 0.025 0.112
Safety at the workplace from external environment -22.856 97 0.001 -0.459
Access to free accommodation (Housing) -6.858 97 0.001 -0.286
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The correlation matrix at table 84, indicates a positive and strong relationship
between overall job satisfaction with Salary (r= .321), Teamwork and Interpersonal
staffs relationship (r=.267) and Access to free accommodation (Housing) (r= .240),
while the weakest relationship was found between Training and skill development
Opportunities (r=.012).
Table 84: Correlation matrix of overall job Satisfaction with factor of Job
satisfaction of Nurses
Factors
Correlation
with job
satisfaction
P
Salary .321 .001
Better Job Prospects in future -.131 .197
Job security .177 .081
Career development opportunities .148 .144
Opportunities of continuing education/higher education -.044 .665
Training and skill development Opportunities .012** .006
Work environment .036 .728
Adequacy of equipment, drugs and supplies .082 .423
Financial incentives linked to rural posting .a .
Non-financial benefits/allowances linked to rural posting .183 .071
Appropriate Work load -.064 .529
Matching of skills and tasks .018 .861
Support, supervision, management and mentoring .044 .670
Reward system and recognition .a .Social recognition and opportunities of public services/ care to
patients
.047 .645
Teamwork and Interpersonal staffs relationship .267 .008
Safety at the workplace from external environment .255 .011
Access to free accommodation (Housing) .240 .017**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one
of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).
4.4.3.3. FACTORS OF JOB SATISFACTION OF MID-WIVES IN RURAL
AND REMOTE AREA
The factors that have impact on job satisfaction of mid-wives have the highest
mean of the factors like- Training and skill development Opportunities (1.72),
Support, supervision and management mentoring (1.68) and Better Job Prospects in
future (1.64) which may be seen at table 85.
The top 10 factors are: Training and skill development Opportunities (1.72),
Support, supervision and management mentoring (1.68), Better Job Prospects in
future (1.64), Social recognition and opportunities of public services/ care to patients
(1.63), Matching of skills and tasks (1.62), Job security (1.42), Appropriate Work
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load (1.40), Teamwork and Interpersonal staffs relationship (1.40), Salary (1.37) and
Adequacy of equipment drugs and supplies (1.19).
Career development opportunities (1.16), Opportunities of continuing
education/higher education (1.16), Access to free accommodation (Housing) (1.15),
Work environment (1.14), Safety at the workplace from external environment
(1.10), Non-financial benefits/allowances linked to rural posting (1.05), Reward
system and recognition (1.00), and Financial incentives linked to rural posting (1.00)
have the lowest scores.
Table 85: Descriptive Statistics on factors contributed for job satisfaction of
the Mid-wives.
Factors N Min Max Mean
Std.
Dev.
Training and skill development Opportunities 123 1 2 1.72 .449
Support, supervision and management mentoring 123 1 2 1.68 .467
Better Job Prospects in future 123 1 2 1.64 .483
Social recognition and opportunities of public
services/ care to patients
123 1 2 1.63 .484
Matching of skills and tasks 123 1 2 1.62 .488
Job security 123 1 2 1.42 .496
Appropriate Work load 123 1 2 1.40 .492
Teamwork and Interpersonal staffs relationship 123 1 2 1.40 .492
Salary 123 1 2 1.37 .484
Adequacy of equipment, drugs and supplies 123 1 2 1.19 .391Career development opportunities 123 1 2 1.16 .371
Opportunities of continuing education/higher education123 1 2 1.16 .371
Access to free accommodation (Housing) 123 1 2 1.15 .363
Work environment 123 1 2 1.14 .347
Safety at the workplace from external environment 123 1 2 1.10 .298
Non-financial benefits linked to rural posting 123 1 2 1.05 .216
Reward system and recognition 123 1 1 1.00 .000
Financial incentives linked to rural posting 123 1 1 1.00 .000
A simultaneous multiple linear regression analysis was conducted to find
significant predictor at current time for the job satisfaction of nurses in rural and
remote area setting. The factor variables of job satisfaction explained about 24% of
the variance in mid-wives job satisfaction, F(16, 106)= 2.1; p < .05. It is statistically
significant, the p value is 0.013. As in table 86 shows, this included 18 factors. The
following variables are constants or have missing correlations, financial incentives
linked to rural posting, Reward system and recognition, thus, they were deleted for
the analysis. An examination of the T-Value indicates that Salary and Training &
skill development Opportunities and Safety at the workplace from external
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environment are the main contributors to the prediction of Job satisfaction in current
time of mid-wives in rural and remote area setting. Salary found to be significant at
(b=.245, t=2.040; p= .044) and Training and skill development opportunities found to
be significant at (b=.230, t=2.508; p= .014).
Table 86: Regression Analysis of factors contributed for job satisfaction of the
mid-wives.
Factors b t Sig.
(Constant) 2.464 .015
Salary .245 2.040 .044
Better Job Prospects in future -.055 -.620 .537
Job security .241 1.973 .051
Career development opportunities .019 .204 .838
Opportunities of continuing education/higher education -.066 -.643 .522
Training and skill development Opportunities .230 2.508 .014
Work environment .113 1.187 .238
Adequacy of equipment, drugs and supplies -.049 -.551 .583
Non-financial benefits/allowances linked to rural posting .083 .884 .379
Appropriate Work load .013 .127 .899
Matching of skills and tasks .033 .312 .755
Support, supervision, management and mentoring -.172 -1.766 .080
Social recognition and opportunities of public services/ care
to patients
.097 1.110 .269
Teamwork and Interpersonal staffs relationship -.160 -1.395 .166
Safety at the workplace from external environment -.182 -1.910 .059
Access to free accommodation (Housing) -.096 -1.017 .311
R R Square
Adjusted R
Square
Std. Error of
the Estimate
.491a
.241 .126 .580
The correlation matrix at table 87, indicates a positive and strong relationship
between overall job satisfaction with Salary (r=.303), Job security (r=.274) and while
the weakest relationship was found between Access to free accommodation (Housing)
(r= .053) and current job satisfaction.
Table 87: Correlation matrix of overall job Satisfaction with factor of job
satisfaction of Mid-wives
Factors r p
Salary .303 .001
Better Job Prospects in future -.021 .814
Job security .274 .002
Career development opportunities .089 .329
Opportunities of continuing education/higher education .089 .329
Training and skill development Opportunities .152 .093
Work environment .092 .311
Adequacy of equipment, drugs and supplies -.015 .871Financial incentives linked to rural posting .
a.
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Non-financial benefits/allowances linked to rural posting .131 .148
Appropriate Work load .086 .345
Matching of skills and tasks .159 .080
Support, supervision, management and mentoring -.140 .122
Reward system and recognition .a .
Social recognition & opportunities of public services/ care to patients .134 .140Teamwork and Interpersonal staffs relationship .086 .345
Safety at the workplace from external environment -.120 .186
Access to free accommodation (Housing) .053* .048**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant.
*. Correlation is significant at the 0.05 level (2-tailed).
4.4.3.4. FACTORS OF JOB SATISFACTION OF CONTRACTUAL AND
PERMANENT PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND
REMOTE AREA
The past one decade has seen a growing tendency of contractual employment
in the public health sector in the country and as well in the state, toward a
fundamental restructuring for addressing the inadequacy issue. This section of the
chapter explores the factors of job satisfaction of contractual and permanent
physicians, nurses and mid-wives. A comparison of contractual and permanent job
satisfaction factors significantly shows a difference in between the two groups of
employees. As it is explored above that the contractual and permanent physicians,
nurses and mid-wives have different level of job satisfaction, in which contractual
have less job satisfaction level than that of the permanent physicians, nurses and mid-
wives. In the group comparison as per the Nature of Employment, the means of
contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. T-
Test shows that it is statistical significant, the values are: t(332) = -5.835, p =.001.
There is a difference in the job satisfaction between the groups. The mean difference
is -.513 between the contractual and permanent employees.
While exploring to the factors of job satisfaction in between the contractual
and permanent physicians, nurses and mid-wives, it is found as per table 88 and 89,
with Salary (1.92), Job security (1.88), Social recognition and opportunities of public
services/ care to patients (1.86), Teamwork and Interpersonal staffs relationship
(1.84) and Better Job Prospects in future (1.80) are the five most influential factors
for job satisfaction of permanent physicians, nurses and mid-wives. Whereas the
factors like Training and skill development Opportunities (1.80), Better Job Prospects
in future (1.79), Social recognition and opportunities of public services/ care to
patients (1.73), Matching of skills and tasks (1.69), and Support, supervision,management mentoring (1.66) are for the contractual.
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Table 88 : Descriptive Statistics for factors for job satisfaction of permanent
Physicians, nurses and mid-wives
Factors N in Max Mea
Std.
Dev.
Salary 180 1 2 1.92 .277
Job security 180 1 2 1.88 .322Social recognition and opportunities of public services/
care to patients
180 1 2 1.86 .347
Teamwork and Interpersonal staffs relationship 180 1 2 1.84 .369
Better Job Prospects in future 180 1 2 1.80 .401
Matching of skills and tasks 180 1 2 1.79 .409
Training and skill development Opportunities 180 1 2 1.69 .464
Support, supervision, management and mentoring 180 1 2 1.64 .480
Appropriate Work load 180 1 2 1.44 .498
Opportunities of continuing education/higher education 180 1 2 1.42 .495
Career development opportunities 180 1 2 1.39 .490Access to free accommodation (Housing) 180 1 2 1.31 .462
Adequacy of equipment, drugs and supplies 180 1 2 1.22 .413
Work environment 180 1 2 1.21 .409
Non-financial benefits/allowances linked to rural posting 180 1 2 1.12 .322
Safety at the workplace from external environment 180 1 2 1.11 .308
Reward system and recognition 180 1 1 1.00 .000
Financial incentives linked to rural posting 180 1 1 1.00 .000
Table 89: Descriptive Statistics for factors for job satisfaction of contracts
Physicians, nurses and mid-wives
Factors N Min Max Mean
Std.Dev.
Training and skill development Opportunities 154 1 2 1.80 .402
Better Job Prospects in future 154 1 2 1.79 .407
Social recognition and opportunities of public
services/ care to patients
154 1 2 1.73 .443
Matching of skills and tasks 154 1 2 1.69 .465
Support, supervision, management and mentoring 154 1 2 1.66 .474
Appropriate Work load 154 1 2 1.42 .496
Job security 154 1 2 1.24 .429
Teamwork and Interpersonal staffs relationship 154 1 2 1.21 .412Adequacy of equipment, drugs and supplies 154 1 2 1.18 .381
Work environment 154 1 2 1.18 .381
Career development opportunities 154 1 2 1.11 .314
Safety at the workplace from external environment 154 1 2 1.08 .279
Access to free accommodation (Housing) 154 1 2 1.07 .258
Salary 154 1 2 1.06 .247
Opportunities of continuing /higher education 154 1 2 1.05 .209
Non-financial allowances linked to rural posting 154 1 2 1.04 .194
Reward system and recognition 154 1 1 1.00 .000
Financial incentives linked to rural posting 154 1 1 1.00 .000
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While exploring to the variance of factors of job satisfaction in between the
contractual and permanent physicians, nurses and mid-wives, it is observed in table
90, that the following have statistically significant difference between the two groups
of employees: Salary t(332) = -29.416, p= .001, Job security t(332) = -15.627, p=
.001, Career development opportunities t(332) = -6.185, p= .001, Opportunities of
continuing education/higher education t(332) = -8.793, p= .001, Training and skill
development Opportunities t(332) = 2.290, p= .023, Non-financial
benefits/allowances linked to rural posting t(332) = -2.616, p= .009, Matching of
skills and tasks t(332) = -2.617, p= .009, Social recognition and opportunities of
public services/ care to patients t(332) = -2.942, p= .003, Teamwork and
Interpersonal staffs relationship t(332) = -14.625, p= .001 and Access to free
accommodation (Housing) t(332) = -5.586, p= .001. However, it is found that there
is no significant difference of the following factors between the two groups: Better
Job Prospects in future, t(332)= -.176 p= .861, Work environment t(332)= -.822 p=
.412, Adequacy of equipment, drugs and supplies t(332)= -.944 p= .346, Appropriate
Work load t(332)= -.308 p=.758, Support, supervision, management and mentoring
t(332)=.845 p= .399,and Safety at the workplace from external environment t(332)=
-.653 p= .514.
Table 90: Analysis of variance in factors of Job satisfaction of Contractual and
Permanent Physicians, nurses and mid-wives in rural and remote area
Factors
t-test for Equality of Means
t df
Sig.(2-
tailed)
Mean
Diff.
Std.Error
Diff.
Salary -29.416 332 .001 -.852 .029
Better Job Prospects in future -.176 332 .861 -.008 .044
Job security -15.627 332 .001 -.643 .041
Career development opportunities -6.185 332 .001 -.284 .046
Opportunities of continuingeducation/higher education
-8.793 332 .001 -.377 .043
Training and skill development
Opportunities
2.290 332 .023 .110 .048
Work environment -.822 332 .412 -.036 .044
Adequacy of equipment, drugs and supplies -.944 332 .346 -.041 .044
Non-financial benefits/allowances linked to
rural posting
-2.616 332 .009 -.078 .030
Appropriate Work load -.308 332 .758 -.017 .055
Matching of skills and tasks -2.617 332 .009 -.127 .048
Support, supervision, management andmentoring
.845 332 .399 .044 .052
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Social recognition and opportunities of
public services/ care to patients
-2.942 332 .003 -.127 .043
Teamwork and Interpersonal staffs
relationship
-14.625 332 .001 -.625 .043
Safety at the workplace from external
environment
-.653 332 .514 -.021 .032
Access to free accommodation (Housing) -5.586 332 .001 -.234 .042
4.4.4. LIKELIHOOD OF MIGRATION OF PHYSICIANS, NURSES
AND MID-WIVES- CHOICE TO MIGRATE
Employees are the most valuable assets of organizations. Organisations need
to retain them, as it would benefit them in many ways. Employees who serve the
longest are best bets to win prizes for being the most productive and most reliable.
Long service employees are often the ones that carry the company and account for adisproportionate share of its success. No doubt, turnover arising because of super-
annuation and fusion of fresh blood in organizations is unavoidable and welcomed.
But constant change and flux in the labour force is wasteful. (Raju, 2003).
Therefore the intention of the physicians, nurses and the mid-wives to leave
the current job place or the job was explored with keeping the pay (salary) component
at constant. The dimension of migration was preset - to continue for atleast 3-5 years
in the present rural area posting or to shift to another rural health institute or to shift to
another urban health institute or to shift to another job in some other State/sector.
As per the position of the employees, the descriptive analysis in table 91,
shows that 41.6% of Physicians willing to shift to urban area, 24.8% physicians
willing to shift to other rural area health institute and only 26.5% wants to retain in
the present health institution in rural area, while 7.1% Physicians wants to leave the
public health service of the state. While, 50% of nurses willing to shift to urban area,
19.4% nurses willing to shift to other rural area health institute and only 25.5% wants
to retain in the present health institution in rural area and 5.1% nurses wants to leave
the public health service of the state. Similarly, 59.3% of mid-wives willing to shift to
urban area, 27.6% mid-wives willing to shift to other rural area health institute and
only 6.5% wants to retain in the present health institution in rural area and 6.5%
nurses wants to leave the public health service of the state. Thus, we can interpret that
more mid-wives are willing to shift to urban areas followed by nurses and physicians.
Figure 40 and 43 represent the situation graphically.
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Management represenatatives have the concensus that there is lack of supply
of equipments, drugs and other supplies at the health institutes and the working
conditions are not conducive in the absence of adequate funding at all level. With
minimun resource the planning is very difficult and almost as doing nothing with plan
and the execution.
“For planning we need brain, discussion and laptop with a printer, but for
execution of plan we need money the fund, which is not adequate; funding is
needed for equipments, drugs and other supplies and infrastructure
development at the rural and remote areas in the districts. Contributing factors
are more, nothing is in its place, all mashed up. The workforce are not getting
conducive environment to work on, and overall personal factors are also there
which affects the turnover from the rural areas”.-A management representative
from the district. “the enviorment is good in urban areas, wiith schools, good
market and career development oppurtunites are there, on need the growth inthe professional life, not just dumping itself in the rural areas, this reasoncould be the out flux of the physicians, nurses and mid-wives.”-A management
representative from the district.
Table 91: Percentage showing the intention of migration of the physicians,
nurses and mid wives
Migrating Destination
Position of Respondent Total
Physician Nurse Mid-Wife
N N % N N % N N % N N %
To continue at least 3-5 years more in
the present rural area posting
30 26.5% 25 25.5% 8 6.5% 63 19%
To shift to another rural health institute 28 24.8% 19 19.4% 34 27.6% 81 24%
To shift to another urban health
institute
47 41.6% 49 50.0% 73 59.3% 169 51%
To shift to another job in some other
State/sector
8 7.1% 5 5.1% 8 6.5% 21 6%
Figure 40: Percentage of migrating intention of the physicians, nurses and midwives
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Figure 41: Percentage of migrating intention of the physicians
Figure 42: Percentage of migrating intention of the nurses
Figure 43: Percentage of migrating intention of the mid-wives
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Table 92: Percentage showing the intention of migration of the contract and
permanent workforce (physicians, nurses and mid wives)
Migrating Destination Nature of Employment
Contract Permanent
N N % N N %
To continue at least 3-5 years more in the present rural 16 10.4% 47 26.1%To shift to another rural health institute 38 24.7% 43 23.9%
To shift to another urban health institute 79 51.3% 90 50.0%
To shift to another job in some other State/sector 21 13.6% 0 .0%
Similarly in table 92, 51.3% of contract physicians, nurses and mid-wives are
willing to migrate to another urban health institution, whereas, only 50% of the
permanent physicians, nurses and mid-wives have the intention to leave for urban
area. More of the permanent employees are willing to continue the rural service in the
same posting place rather than the contract counterpart. While none of the permanent
employee are willing to shift to another job than that of 13.6% of contracts. Figure 44
and 45 represent the situation graphically.
Figure 44: Percentage of migrating intention of the contract workforce
(Physicians, nurses and mid-wives)
Figure 45: Percentage of migrating intention of the Permanent workforce(Physicians, nurses and mid-wives)
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It is the job satisfaction of the employees which propel them to migrate. While
analysed, it is known that the job satisfaction has impact on the migration decision of
the employees.
Job satisfaction and decision to stay: With Logistic regression analysis it is tried to
explore the impact of job satisfaction as a predictor for stay at present posting rural
area. The variable job satisfaction significant at p<.001, has an impact and predictive
power for the decision of employees to stay at the present rural place of posting. By
measuring job satisfaction we can predict with 97.6% accuracy of the decision of
employees to stay at the present rural place of posting. A test of the full model against
a constant was statistically significant, indicating that a set reliably distinguished
between, in our case model chi square has 1 degrees of freedom, a value of 254.046and a probability of p<0.001. Thus, the indication is that the predictors do have a
significant effect. Here it is indicating that 53.3% of the variation in the decision to
stay is explained by the logistic model. Nagelkerke R Square is .859, so, it is
indicating a moderately strong relationship of 85.9% between the job satisfaction and
the choice to stay. While, The Wald criterion demonstrated it has 1 degrees of
freedom, a value of 56.505 and a probability of p<0.001 and signifies that job
satisfaction contributed significantly to the prediction of decision of stay at the present
job in rural and remote area of posting. EXP(B) value associated with Job satisfaction
is 79.527. Hence when job satisfaction is raised by one scale the odds ratio is 79 times
as large and therefore employees are 79 more times likely to stay.
Job satisfaction and shift to another rural area: With Logistic regression analysis
it is tried to explore the impact of job satisfaction as a predictor for employee shifting
to another rural area from presently posted rural area. As the variable is not
statistically significant, the p>.05, and if included would not have the predictive
power and not able to contribute to the prediction. Hence, it is statistically proved that
there is no significant relationship of job satisfaction and shifting of employee from
one rural area to another rural area.
Job satisfaction and shift to urban area: With Logistic regression analysis it is tried
to explore the impact of job satisfaction as a predictor for employee shifting to urban
area from presently posted rural area. The variable job satisfaction significant at
p<.001, has an impact and predictive power for the decision of employees to urban
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migration. By measuring job satisfaction we can predict with 71% accuracy of the
decision of employees to migrate to urban area. A test of the full model against a
constant was statistically significant, in our case model chi square has 1 degrees of
freedom, a value of 75.551 and a probability of p<0.001. Thus, the indication is that
the predictors do have a significant effect. Here it is indicating that 20.2% of the
variation in the decision to migrate to urban area is explained by the logistic model.
Nagelkerke R Square is .270, so, it is indicating a low relationship of 27% between
the job satisfactions and migrates to urban area. While, The Wald criterion
demonstrated it has 1 degrees of freedom, a value of 41.434 and a probability of
p<0.001 and signifies that job satisfaction contributed significantly to the prediction
of decision. EXP(B) value associated with Job satisfaction is .221. Hence when the
figure is less that 1, any increase in the job satisfaction will leads to a drop in outcome
occurring that migration to urban area.
Job satisfaction and shift to other sector or state: With Logistic regression analysis
it is tried to explore the impact of job satisfaction as a predictor for employee shifting
out of the sector or the state. The variable job satisfaction significant at p<.001, has an
impact and predictive power for the decision of employees to out sector or state
migration. By measuring job satisfaction we can predict with 93.1% accuracy of the
decision of employees to this migration. A test of the full model against a constant
was statistically significant, in our case model chi square has 1 degrees of freedom, a
value of 50.076 and a probability of p<0.001. Thus, the indication is that the
predictors do have a significant effect. Here it is indicating that 13.9% of the variation
in the decision to migrate to other sector or state is explained by the logistic model.
Nagelkerke R Square is .172, so, it is indicating a low relationship of 17% between
the job satisfactions and migrates to other sector or state. While, The Wald criterion
demonstrated it has 1 degrees of freedom, a value of 38.758 and a probability of
p<0.001 and signifies that job satisfaction contributed significantly to the prediction
of decision. EXP(B) value associated with Job satisfaction is .039. Hence when job
satisfaction is raised by one scale, employees are more times stopped migrating to
other sector or state. However, migrating to other state or sector has low relationship
of 17% only.
Thus, the level of job satisfaction has a relationship and act as a predictor for
pushing the physicians, nurses and mid-wives from rural areas to urban and to other
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sector. Whereas, it is not statically found that there is any association of job
satisfaction and rural to rural migration. However, the other pushing factors also act
as contributor for retention and migration of the workplace that too have an effect on
job satisfaction. So, coming section explores the factor for retention and migration of
this workforce.
4.4.4.1. CONTRIBUTING FACTOR OF LIKELIHOOD OF RETENTION OFPHYSICIANS, NURSES AND MID-WIVES- CHOICE TO STAY
In this section, it is attempted to explore the factors that contributed for the
decision of this workforce to stay back in same health institution at the rural area. The
eighteen (18) preset factors were included for the same.
The Cronbach’s alpha coefficient for the factor items is α =(0.559) on item 18
and N=63.
Factor of likelihood of retention of Physicians, nurses and mid-wives: The factor
that contributed to stay at the place of posting for more 3-5 years for both contract and
permanent physicians, nurses and mid-wives for rural and remote services has the
following top 10 selections: 1) Scope for training and skill development (1.71), 2)
Career development opportunities (1.56), 3) Job Security (1.40),4) Improved working
condition (1.33), 5) Satisfied with salary (1.32), 6) Scope for continuing
education/higher education (1.29), 7) Anticipation of obtaining a regular position after
contractual position (1.25), 8) More autonomy in current place of posting (1.24), 9)
Adequate drugs/equipment at the rural health centre (1.22) and 10) Improved support,
supervision and mentoring (1.17). Out of which, only one factor that is the Scope for
training and skill development is statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(62)= 3.735 , p=.001. However, the selection is made
only by 19% of the employee who wants to stay at the present posting place.Table 93: Descriptive Statistics of contributing factor of likelihood of retention
of physicians, nurses and mid-wives
Factors
N Mean
Test Value = 1.5
t df
Sig.
(2-
tailed
)
Mean
Diff.
Scope for training and skill development 63 1.71 3.735 62 .001 .214
Career development opportunities 63 1.56 .880 62 .382 .056
Job Security 63 1.35 -2.491 62 .015 -.151Improved working condition 63 1.33 -2.784 62 .007 -.167
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Satisfied with salary 63 1.32 -3.088 62 .003 -.183
Scope for continuing /higher education 63 1.29 -3.735 62 .001 -.214
Anticipation of obtaining a regular position
after contractual position
63 1.25 -4.451 62 .001 -.246
More autonomy in current place of posting 63 1.24 -4.842 62 .001 -.262
Adequate drugs/equipment at the ruralhealth centre
63 1.22 -5.261 62 .001 -.278
Improved support, supervision and
mentoring
63 1.17 -6.749 62 .001 -.325
Adequate living conditions 63 1.13 -8.821 62 .001 -.373
Good schools for children/ education
prospects of children
63 1.13 -8.821 62 .001 -.373
Strong Teamwork and interpersonal
relationship
63 1.08 -12.253 62 .001 -.421
Flexible working hours with minimalworkload
63 1.06 -14.095 62 .001 -.437
Geographical affinities(Hometown near)andfamilial associations
63 1.06 -14.095 62 .001 -.437
Opportunity for both spouses to work and
live in the same location
63 1.05 -16.726 62 .001 -.452
Getting adequate financial incentives/ Rural
allowances/performance incentives
63 1.02 -30.500 62 .001 -.484
Physicians: While, analysing the factors to stay at the place of posting for more 3-5
years by the categories of employee i.e., Physicians, nurses and mid-wives. The
following 10 top factors for retention have been found for Physicians: 1)Scope for
training and skill development (1.83), 2) Career development opportunities (1.60),
3)Satisfied with salary (1.53), 4) Scope for continuing education/higher education
(1.43), 5) Improved working condition (1.40), 6) Job Security (1.40), 7) More
autonomy in current place of posting (1.40), 8) Adequate living conditions (access to
amenities like housing, water, electricity, conveyance and communication) (1.27), 9)
Opportunity for both spouses to work and live in the same location (1.20), and 10)
Anticipation of obtaining a regular position after contractual position (1.17). Out of
which, only one factor that is the Scope for training and skill development is
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(29)=
4.817 , p=.001.
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Table 94: Descriptive statistics for contributing factor of likelihood of
retention of physicians
Factors
NMea
nStd.Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mea
nDiff.
Scope for training and skilldevelopment
30 1.83 .379 4.817 29 .001 .333
Career development opportunities 30 1.60 .498 1.099 29 .281 .100
Satisfied with salary 30 1.53 .507 .360 29 .722 .033
Scope for continuing
education/higher education
30 1.43 .504 -.724 29 .475 -.067
Improved working condition 30 1.40 .498 -1.099 29 .281 -.100
Job Security 30 1.40 .498 -1.099 29 .281 -.100
More autonomy in current placeof posting 30 1.40 .498 -1.099 29 .281 -.100
Adequate drugs/equipment at the
rural health centre
30 1.27 .450 -2.841 29 .008 -.233
Adequate living conditions 30 1.20 .407 -4.039 29 .001 -.300
Anticipation of obtaining a
regular position after contractual
position
30 1.17 .379 -4.817 29 .001 -.333
Improved support, supervision
and mentoring
30 1.13 .346 -5.809 29 .001 -.367
Good schools for children/
education prospects of children
30 1.13 .346 -5.809 29 .001 -.367
Geographical
affinities(Hometown near)and
familial associations
30 1.10 .305 -7.180 29 .001 -.400
Opportunity for both spouses to
work and live in the same
location
30 1.10 .305 -7.180 29 .001 -.400
Flexible working hours with
minimal workload
30 1.07 .254 -9.355 29 .001 -.433
Strong Teamwork and
interpersonal relationship
30 1.07 .254 -9.355 29 .001 -.433
Getting adequate financial
incentives/ Rural
allowances/performance
incentives
30 1.00 .000 - - - -
Achievement is recognized and
rewarded
30 1.00 .000 - - - -
Permanent physicians: While, the permanent physicians have the following top 10
factors for retention: 1) Scope for training and skill development (1.80), 2) Satisfied
with salary (1.64), 3) Career development opportunities (1.52), 4) Improved working
condition (1.48), 5) More autonomy in current place of posting (1.44), 6) Scope for
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continuing education/higher education (1.32), 7) Job Security (1.32), 8) Adequate
drugs/equipment at the rural health centre (1.32), 9) Adequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.24). Out of which, only one factor that is the Scope for training and skill
development is statistically significant at Mean Test Value=1.5, 95% C.I, it is
significant at t(24)= 3.674 , p=.001.
Table 95: Descriptive statistics for contributing factor of likelihood of
retention of permanent physicians
Factors
N Mea
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mea
n
Diff.
Scope for training & skill development 25 1.80 .408 3.674 24 .001 .300
Satisfied with salary 25 1.64 .490 1.429 24 .166 .140
Career development opportunities 25 1.52 .510 .196 24 .846 .020
Improved working condition 25 1.48 .510 -.196 24 .846 -.020
More autonomy in current place of
posting
25 1.44 .507 -.592 24 .559 -.060
Adequate drugs/equipment at the
rural health centre
25 1.32 .476 -1.890 24 .071 -.180
Scope for continuing /higher education 25 1.32 .476 -1.890 24 .071 -.180
Job Security 25 1.32 .476 -1.890 24 .071 -.180
Adequate living conditions 25 1.24 .436 -2.982 24 .006 -.260
Geographical affinities(Hometownnear)and familial associations
25 1.12 .332 -5.729 24 .001 -.380
Good schools for children/ education
prospects of children
25 1.12 .332 -5.729 24 .001 -.380
Opportunity for both spouses to work
and live in the same location
25 1.12 .332 -5.729 24 .001 -.380
Flexible working hours with minimal
workload
25 1.08 .277 -7.584 24 .001 -.420
Improved support, supervision and
mentoring
25 1.08 .277 -7.584 24 .001 -.420
Strong Teamwork and interpersonal
relationship
25 1.08 .277 -7.584 24 .001 -.420
Getting adequate financial / Ruralallowances/performance incentives
25 1.00 .000 - - - -
Anticipation of obtaining a regular
position after contractual position
25 1.00 .000 - - - -
Achievement is recognized &rewarded 25 1.00 .000 - - - -
Contract physicians: Likewise, the contract physicians have the following 8 factors
found to relevant for retention: 1) Scope for training and skill development (2.00), 2)
Anticipation of obtaining a regular position after contractual position (1.95), 3) Scope
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for continuing education/higher education (1.86), 4) Career development
opportunities (1.81), 5) Improved support, supervision and mentoring (1.80), 6)
More autonomy in current place of posting (1.40), 7) Job Security (1.20), and 8)
Good schools for children/ education prospects of children (1.20). Out of which, only
two factors that is the Scope for training and skill development and Anticipation of
obtaining permanent post is statistically significant at Mean Test Value=1.5, 95% C.I,
it is significant at t(4)= 4.568 , p=.001 and t(4)= 2.500 , p= .001.
Table 96: Descriptive statistics for contributing factor of likelihood of
retention of contract physicians
Factors
Mean
Std.Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
MeanDiff.
Scope for training and skill development 5 2.00 .000 4.568 4 .001 .500
Anticipation of obtaining a regular
position after contractual position
5 1.95 .218 2.500 4 .001 .452
Scope for continuing /higher education 5 1.86 .359 1.564 4 .100 .357
Career development opportunities 5 1.81 .402 1.525 4 .102 .310
Job Security 5 1.80 .447 1.500 4 .208 .300
Improved support, supervision and
mentoring
5 1.40 .548 -.408 4 .704 -.100
Good schools for children/ education
prospects of children
5 1.20 .447 -1.500 4 .208 -.300
More autonomy in current place of postin 5 1.20 .447 -1.500 4 .208 -.300
Satisfied with salary 5 1.00 .000 - - - -
Getting adequate financial/ Rural
allowances/performance incentives
5 1.00 .000 - - - -
Improved working condition 5 1.00 .000 - - - -
Adequate drugs/equipment at the rural
health centre
5 1.00 .000 - - - -
Flexible working hours with minimalworkload
5 1.00 .000 - - - -
Strong Teamwork and interpersonalrelationship
5 1.00 .000 - - - -
Adequate living conditions 5 1.00 .000 - - - -
Achievement is recognized &rewarded 5 1.00 .000 - - - -
Geographical affinities(Hometown
near)and familial associations
5 1.00 .000 - - - -
Opportunity for both spouses to work
and live in the same location
5 1.00 .000 - - - -
Nurses: While, analysing the factors to stay at the place of posting for more 3-5 years
of the nurses. The following 10 top factors for retention have been found: 1) Scope
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for training and skill development (1.64), 2) Career development opportunities
(1.48), 3) Anticipation of obtaining a regular position after contractual position
(1.32), 4) Job Security (1.32), 5) Improved working condition (1.28), 6) Improved
support, supervision and mentoring (1.20), 7) Adequate drugs/equipment at the rural
health centre (1.16), 8) Strong Teamwork and interpersonal relationship (1.12),
Satisfied with salary (1.12) and 9) Good schools for children/ education prospects
of children (1.12). Out of which, only one factor that is the Scope for training and
skill development and Anticipation of obtaining permanent post is statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(24)= 1.429 ,
p=.006.
Table 97: Descriptive statistics for contributing factor of likelihood of retention
of nurses
Factors
N ean
Std.
Dev.
Test Value = 1.5
t df Sig.
(2-tailed)
Mean
Diff.
Scope for training and skill development 25 1.64 .490 1.429 24 .006 .140
Career development opportunities 25 1.48 .510 -.196 24 .846 -.020
Job Security 25 1.32 .476 -1.890 24 .071 -.180
Anticipation of obtaining a regular
position after contractual position
25 1.32 .476 -1.890 24 .071 -.180
Improved working condition 25 1.28 .458 -2.400 24 .024 -.220
Improved support,supervision &mentorin 25 1.20 .408 -3.674 24 .001 -.300Adequate drugs/equipment at the rural
health centre
25 1.16 .374 -4.543 24 .001 -.340
Satisfied with salary 25 1.12 .332 -5.729 24 .001 -.380
Strong Teamwork and interpersonal
relationship
25 1.12 .332 -5.729 24 .001 -.380
Good schools for children/ education
prospects of children
25 1.12 .332 -5.729 24 .001 -.380
Scope for continuing education/higher
education
25 1.08 .277 -7.584 24 .001 -.420
Flexible working hours with minimal
workload
25 1.08 .277 -7.584 24 .001 -.420
Adequate living conditions 25 1.08 .277 -7.584 24 .001 -.420
Geographical affinities(Hometown
near)and familial associations
25 1.04 .200 -11.50 24 .001 -.460
Getting adequate financial incentives/
Rural allowances/performance incentives
25 1.00 .000 - - - -
Achievement is recognized & rewarded 25 1.00 .000
Opportunity for both spouses to work and live in the same location
25 1.00 .000 - - - -
More autonomy in current place of
posting
25 1.00 .000 - - - -
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Permanent Nurses: While, analysing the factors to stay at the present place of
posting, the following 10 top factors for retention have been found in case of
permanent nurses: 1) Scope for training and skill development (1.53), 2) Career
development opportunities (1.29), 3) Improved working condition (1.24),
4) Adequate drugs/equipment at the rural health centre (1.18), 5) Satisfied with salary
(1.18), 6) Adequate living conditions (access to amenities like housing, water,
electricity, conveyance and communication) (1.12), 7) Strong Teamwork and
interpersonal relationship (1.12), 8) Job Security (1.12), 9) Geographical
affinities(Hometown near)and familial associations (1.06) and 10) Scope for
continuing education/higher education (1.06). Out of which, only one factor that is
the Scope for training and skill development is statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(16)=1 .236 , p= .017.
Table 98: Descriptive statistics contributing factor of likelihood of retention of
permanent nurses- Choice to stay in present rural area
Factors
NMean
Std.Dev.
Test Value = 1.5
t df Sig.
(2-tailed
MeanDiff.
Scope for training & skill development 17 1.53 .514 1.236 16 .017 .029
Career development opportunities 17 1.29 .470 -1.807 16 .090 -.206
Improved working condition 17 1.24 .437 -2.496 16 .024 -.265
Satisfied with salary 17 1.18 .393 -3.395 16 .004 -.324Adequate drugs/equipment at the rural
health centre
17 1.18 .393 -3.395 16 .004 -.324
Job Security 17 1.12 .332 -4.747 16 .001 -.382
Strong Teamwork and interpersonal
relationship
17 1.12 .332 -4.747 16 .001 -.382
Adequate living conditions 17 1.12 .332 -4.747 16 .001 -.382
Scope for continuing /higher education 17 1.06 .243 -7.500 16 .001 -.441
Flexible working hours with minimal
workload
17 1.06 .243 -7.500 16 .001 -.441
Improved support,supervision &mentori 17 1.06 .243 -7.500 16 .001 -.441
Geographical affinities(Hometownnear)and familial associations
17 1.06 .243 -7.500 16 .001 -.441
Good schools for children/ education
prospects of children
17 1.06 .243 -7.500 16 .001 -.441
Getting adequate financial / Rural
allowances/performance incentives
17 1.00 .000 - - - -
Anticipation of obtaining a regular
position after contractual position
17 1.00 .000 - - - -
Achievement is recognized& rewarded 17 1.00 .000 - - - -
Opportunity for both spouses to work
and live in the same location
17 1.00 .000 - - - -
More autonomy in current placeof postin 17 1.00 .000 - - - -
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Contract nurses: While, analysing the factors to stay at the present place of posting
for more 3-5 years, the following 10 top factors for retention have been found in case
of contract nurses: 1) Anticipation of obtaining a regular position after contractual
position (2.00), 2) Scope for training and skill development (1.88), 3) Career
development opportunities (1.88), 4) Improved support, supervision and mentoring
(1.75), 5) Improved working condition (1.50), 6) Good schools for children/
education prospects of children (1.38), 7) Strong Teamwork and interpersonal
relationship (1.25), 8) Flexible working hours with minimal workload (1.13), 9)
Scope for continuing education/higher education (1.13) and 10) Adequate
drugs/equipment at the rural health centre (1.13). Out of which, three factors that is
the Scope for training and skill development, Anticipation of obtaining permanent
post and Career development opportunities are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(7)=5.342, p=.001. t(7)=3.000, p=.020 and
t(7)=3.000, p=.020 respectively.
Table 99: Descriptive statistics for contributing factor of likelihood of retention
of contract nurses
Factors
N
Mea
n
Std.
Dev
.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.Anticipation of obtaining a regular
position after contractual position
8 2.00 .000 5.342 7 .001 .500
Scope for training and skill development 8 1.88 .354 3.000 7 .020 .375
Career development opportunities 8 1.88 .354 3.000 7 .020 .375
Job Security 8 1.75 .463 1.528 7 .170 .250
Improved support, supervision and
mentoring
8 1.50 .535 .000 7 1.000 .000
Improved working condition 8 1.38 .518 -.683 7 .516 -.125
Good schools for children/ education
prospects of children
8 1.25 .463 -1.528 7 .170 -.250
Adequate drugs/equipment at the ruralhealth centre
8 1.13 .354 -3.000 7 .020 -.375
Scope for continuing /higher education 8 1.13 .354 -3.000 7 .020 -.375
Flexible working hours with minimal
workload
8 1.13 .354 -3.000 7 .020 -.375
Strong Teamwork and interpersonalrelationship
8 1.13 .354 -3.000 7 .020 -.375
Satisfied with salary 8 1.00 .000 - - - -
Getting adequate financial incentives/
Rural allowances/performance
incentives
8 1.00 .000 - - - -
Adequate living conditions 8 1.00 .000 - - - -
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Achievement is recognized andrewarded
8 1.00 .000 - - - -
Geographical affinities(Hometown
near)and familial associations
8 1.00 .000 - - - -
Opportunity for both spouses to work
and live in the same location
8 1.00 .000 - - - -
More autonomy in current place of
posting
8 1.00 .000 - - - -
Mid-wives: While, analysing the factors to stay at the present place of posting for
more 3-5 years, the following 10 top factors for retention have been found in case of
nurses: Scope for training and skill development (1.63), Anticipation of obtaining a
regular position after contractual position (1.61), Scope for continuing
education/higher education (1.38), Career development opportunities (1.38),
More autonomy in current place of posting (1.38), Improved working condition
(1.25), Adequate drugs/equipment at the rural health centre (1.25), Job Security
(1.25), Improved support, supervision and mentoring (1.25), Satisfied with salary
(1.13). Out of which, two factors that is the Scope for training and skill development,
Anticipation of obtaining permanent post are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(7)=.683, p=.016 and t(7)=.100, p=.043
respectively.
Table 100: Descriptive statistics for contributing factor of likelihood of
retention of Mid-wives
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
ig. (2
ailed)
Mean
Diff.
Scope for training & skill development 8 1.63 .518 .683 7 .016 .125
Anticipation of obtaining a regular position after contractual position
8 1.61 .535 .100 7 .043 .11
Scope for continuing /higher
education
8 1.38 .518 -.683 7 .516 -.125
Career development opportunities 8 1.38 .518 -.683 7 .516 -.125
More autonomy in current place of
posting
8 1.38 .518 -.683 7 .516 -.125
Improved working condition 8 1.25 .463 -1.528 7 .170 -.250
Adequate drugs/equipment at the rural
health centre
8 1.25 .463 -1.528 7 .170 -.250
Job Security 8 1.25 .463 -1.528 7 .170 -.250
Improved support, supervision and
mentoring
8 1.25 .463 - - - -
Satisfied with salary 8 1.13 .354 -3.000 7 .020 -.375
Getting adequate financial /Ruralallowances/performance incentives
8 1.13 .354 -3.000 7 .020 -.375
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Good schools for children/ education prospects of children
8 1.13 .354 -3.000 7 .020 -.375
Flexible working hours with minimal
workload
8 1.00 .000 -1.528 7 .170 -.250
Strong Teamwork and interpersonal
relationship
8 1.00 .000 - - - -
Adequate living conditions 8 1.00 .000 - - - -
Achievement is recognized &rewarded 8 1.00 .000 - - - -
Geographical affinities(Hometown
near)and familial associations
8 1.00 .000 - - - -
Opportunity for both spouses to work
and live in the same location
8 1.00 .000 - - - -
Permanent Mid-wives: While, analysing the factors to stay at the present place of
posting for more 3-5 years, the following 10 top factors for retention have been
found in case of permanent mid-wives: 1) Scope for training and skill development
(1.60), 2)Career development opportunities (1.40), 3) Job Security (1.40), 4) More
autonomy in current place of posting (1.40), 5) Improved working condition (1.40),
6) Scope for continuing education/higher education (1.20), 7) Good schools for
children/ education prospects of children (1.20), 8) Improved support, supervision
and mentoring (1.20), 9) Adequate drugs/equipment at the rural health centre (1.20)
and 10) Opportunity for both spouses to work and live in the same location (1.20).
Out of which, only one factor that is the Scope for training and skill development, is
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at
t(4)=1.408, p= .004.
Table 101: Descriptive statistics for contributing factor of likelihood of retention
of Permanent Mid-wives
Factors
ean
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mean
Diff.
Scope for training and skilldevelopment
5 1.60 .548 1.408 4 .004 .100
Career development opportunities 5 1.40 .548 -.408 4 .704 -.100
Job Security 5 1.40 .548 -.408 4 .704 -.100
More autonomy in current place of
posting
5 1.40 .548 -.408 4 .704 -.100
Satisfied with salary 5 1.20 .447 -1.500 4 .208 -.300
Getting adequate financial incentives/
Rural allowances/performanceincentives
5 1.20 .447 -1.500 4 .208 -.300
Adequate drugs/equipment at the ruralhealth centre
5 1.20 .447 -1.500 4 .208 -.300
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Scope for continuing education/higher education
5 1.20 .447 -1.500 4 .208 -.300
Improved working condition 5 1.20 .447 -1.500 4 .208 -.300
Improved support, supervision andmentoring
5 1.20 .447 -1.500 4 .208 -.300
Good schools for children/ education prospects of children
5 1.20 .447 -1.500 4 .208 -.300
Flexible working hours with minimal
workload
5 1.00 .000 - - - -
Strong Teamwork and interpersonal
relationship
5 1.00 .000 - - - -
Anticipation of obtaining a regular position after contractual position
5 1.00 .000 - - - -
Adequate living 5 1.00 .000 - - - -
Achievement is recognized andrewarded
5 1.00 .000 - - - -
Geographical affinities(Hometown
near)and familial associations
5 1.00 .000 - - - -
Opportunity for both spouses to work
and live in the same location
5 1.00 .000 - - - -
Contract Mid-wives: While, analysing the factors to stay at the present place of
posting for more 3-5 years, the following 7 factors for retention have been found
relevant mean in case of contract mid-wives: 1) Anticipation of obtaining a regular
position after contractual position (2.00), 2) Scope for training and skill development
(2.00), 3) Career development opportunities (2.00), 4) Scope for continuing
education/higher education (1.67), 5) More autonomy in current place of posting
(1.33), 6) Improved support, supervision and mentoring (1.33) and 7) Adequate
drugs/equipment at the rural health centre (1.33). Out of which, only two factors that
is the Anticipation of obtaining a regular position after contractual position and
Scope for training and skill development, are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(2)=.386, p=.001 and t(2)=.386, p=.001
respectively.
Table 102: Descriptive statistics for contributing factor of likelihood of
retention of contract Mid-wives
Factors
N Mean
Std.
Dev
.
Test Value = 1.5
t
d
f
Sig.
(2-
taile
d)
Mea
n
Diff.
Anticipation of obtaining a regular
position after contractual position
3 2.00 .000 .386 2 .001 .000
Scope for training and skill development 3 2.00 .000 .386 2 .001 .000
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Career development opportunities 3 1.67 .577 .500 2 .667 .167
Scope for continuing /higher education 3 1.67 .577 .500 2 .667 .167
Adequate drugs/equipment at the rural
health centre
3 1.33 .577 -
.500
2 .667 -.167
Improved support, supervision and
mentoring
3 1.33 .577 -
.500
2 .667 -.167
More autonomy in current place of
posting
3 1.33 .577 -
.500
2 .667 -.167
Satisfied with salary 3 1.00 .000 - - - -
Getting adequate financial incentives/Rural allowances/performance incentives
3 1.00 .000 - - - -
Improved working condition 3 1.00 .000 - - - -
Job Security 3 1.00 .000 - - - -
Flexible working hours with minimal
workload
3 1.00 .000 - - - -
Strong Teamwork and interpersonal
relationship
3 1.00 .000 - - - -
Adequate living conditions 3 1.00 .000 - - - -
Achievement is recognized and rewarded 3 1.00 .000 - - - -
Geographical affinities(Hometown
near)and familial associations
3 1.00 .000 - - - -
Good schools for children/ education prospects of children
3 1.00 .000 - - - -
Opportunity for both spouses to work and live in the same location
3 1.00 .000 - - - -
4.4.4.2. PUSH FACTORS OF LIKELIHOOD OF MIGRATION OFPHYSICIANS, NURSES AND MID-WIVES- CHOICE TO MIGRATE
In this section, it is attempted to explore the push factors that contributed for
the decision to migrate from the present rural area health institution of the employees.
The eighteen (16) preset factors were included for the same.
The Cronbach’s alpha coefficient for the factor items is α =(0.607) on item 16
and N=271.
Push factors for migration of Physicians, Nurses and Mid-wives: It is analysed
and found that the top 10 factors that contributed for intention for migration of the
physicians, nurses and mid-wives from the present rural area to other rural area, urban
area or to leave the sector are: 1) Lack of adequate financial incentives/ Rural
allowances/performance incentive (1.57), 2) Poor working condition (1.54), 3) Poor
salaries (1.45), 4) Inadequate drugs/equipment (1.28), 5) Lack of Career development
opportunities (1.24), 6) Inadequate living conditions (access to amenities like
housing, water, electricity, conveyance and communication) (1.18), 7) Lack of scope
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for continuing education/higher education (1.13), 8) Lack of others cadres,
teamwork and interpersonal relationship (1.07), 9) Lack of Job security (1.07) and 10)
Poor support, supervision and mentoring (1.04). Out of which, two factors that is the
Lack of adequate financial incentives / Rural allowances/performance incentives and
poor working condition is statistically significant at Mean Test Value=1.5, 95% C.I, it
is significant at t(270)= 2.265 , p=.024 and t(270)=1.400, p=.036.
Table 103: Descriptive statistics for contributing push factors for physicians,
nurses and mid-wives
Factors
N
Mea
n
Std.
Dev
.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mea
n
Diff.
Lack of adequate financial
incentives/ Ruralallowances/performance
incentives
271 1.57 .496 2.265 270 .024 .068
Poor working condition 271 1.54 .499 1.400 270 .036 .042
Poor salaries 271 1.45 .498 -1.769 270 .078 -.054
Inadequate drugs/equipment 271 1.28 .450 -8.031 270 .001 -.220
Lack of Career development
opportunities
271 1.24 .428 -10.011 270 .001 -.260
Inadequate living conditions 271 1.18 .389 -13.365 270 .001 -.315
Lack of scope for continuing
education/higher education
271 1.13 .340 -17.775 270 .001 -.367
Lack of others cadres,
teamwork and interpersonal
relationship
271 1.07 .256 -27.665 270 .001 -.430
Lack of Job security 271 1.07 .249 -28.610 270 .001 -.434
Poor support, supervision and
mentoring
271 1.04 .206 -36.401 270 .001 -.456
Limited or no good schools for
children/ education prospects of
children
271 1.04 .198 -38.253 270 .001 -.459
Achievement not recognized 271 1.03 .170 -45.674 270 .001 -.470
Limited opportunity of trainingand skill development
271 1.02 .147 -53.365 270 .001 -.478
Unusual working hours and
excess work load
271 1.02 .147 -53.365 270 .001 -.478
Lack of safety at workplace 271 1.02 .147 -53.365 270 .001 -.478
Lack of Autonomy 271 1.02 .147 -53.365 270 .001 -.478
Push factors for migration of Physicians: While analysing the responses, the top 10
factors found contributing for intention of migration of the physicians from the
present rural area to other rural area, urban area or to leave the sector are: 1) Lack of
adequate financial incentives/ Rural allowances/performance incentive (1.61), 2) Poor
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working condition (1.51), 3) Lack of Career development opportunities (1.34), 4)
Inadequate drugs/equipment (1.31), 5) Poor salaries (1.29), 6) Lack of scope for
continuing education/higher education (1.23), 7), Inadequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.22), 8) Lack of Job security (1.08), 9) Lack of Autonomy(1.05),10) Limited or no
good schools for children/ education prospects of children (1.05). Out of which, only
one factor that is the Lack of adequate financial incentives / Rural
allowances/performance incentives is statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(82)= 2.129 , p=.036. However, the poor working
condition also seems to be one of the factors that influencing with Mean of 1.51.
Table 104: Descriptive statistics for contributing push factor for physicians
Push factors for migration of permanent Physicians: While analysing further
breaking down to nature of employment as permanent physicians, it is found that thefollowing factors contributed for intention of migration of the permanent physicians
Factors
NMea
nStd.Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mea
nDiff.
Lack of adequate financial incentives/
Rural allowances/performance
incentives
83 1.61 .490 2.129 82 .036 .114
Poor working condition 83 1.51 .503 .109 82 .913 .006
Lack of Career development opportunit 83 1.34 .476 -3.115 82 .003 -.163
Inadequate drugs/equipment 83 1.31 .467 -3.646 82 .001 -.187Poor salaries 83 1.29 .456 -4.211 82 .001 -.211
Lack of scope for continuingeducation/higher education
83 1.23 .423 -5.843 82 .001 -.271
Inadequate living conditions 83 1.22 .415 -6.221 82 .001 -.283
Lack of Job security 83 1.08 .280 -13.545 82 .001 -.416
Lack of others cadres, teamwork and
interpersonal relationship
83 1.05 .215 -19.103 82 .001 -.452
Limited or no good schools for childre
/education prospects of children
83 1.05 .215 -19.103 82 .001 -.452
Lack of Autonomy 83 1.05 .215 -19.103 82 .001 -.452
Unusual working hours and excess
work load
83 1.04 .188 -22.504 82 .001 -.464
Poor support, supervision & mentoring 83 1.04 .188 -22.504 82 .001 -.464
Achievement not recognized 83 1.04 .188 -22.504 82 .001 -.464
Limited opportunity of training and
skill development
83 1.02 .154 -28.103 82 .001 -.476
Lack of safety at workplace 83 1.02 .154 -28.103 82 .001 -.476
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from the present rural area to other rural area, urban area or to leave the sector: 1)
Lack of adequate financial incentives/ Rural allowances/performance incentives
(1.68), 2) Poor working condition (1.47), 3) Inadequate drugs/equipment (1.28), 4)
Lack of Career development opportunities (1.11), 5) Inadequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.11), 6) Lack of scope for continuing education/higher education (1.08), 7) Lack of
Autonomy (1.06), 8) Lack of others cadres, teamwork and interpersonal
relationship (1.06), 9) Unusual working hours and excess work load (1.06) and
10) Limited or no good schools for children/ education prospects of children (1.02).
Out of which, only one factor that is the Lack of adequate financial incentives / Rural
allowances/performance incentives is statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(52)= 1.243 , p=.020.
Table 105: Descriptive statistics for contributing push factor for permanent
physicians
Factors
N
Mea
n
Std.
Dev.
Test Value = 1.5
t df
Sig.
(2-
tailed)
Mea
n
Diff.
Lack of adequate financial incentives/Rural allowances/performance
incentives
53 1.68 .497 1.243 52 .020 .085
Poor working condition 53 1.47 .504 -.409 52 .684 -.028
Inadequate drugs/equipment 53 1.28 .455 -3.473 52 .001 -.217
Lack of Career development opportunitie 53 1.11 .320 -8.803 52 .001 -.387
Inadequate living conditions 53 1.11 .320 -8.803 52 .001 -.387
Lack of scope for continuingeducation/higher education
53 1.08 .267 -11.589 52 .001 -.425
Unusual working hours/excess work load 53 1.06 .233 -13.836 52 .001 -.443
Lack of others cadres, teamwork and
interpersonal relationship
53 1.06 .233 -13.836 52 .001 -.443
Lack of Autonomy 53 1.06 .233 -13.836 52 .001 -.443Limited opportunity of trng.& skill dev. 53 1.02 .137 -25.500 52 .001 -.481
Poor support, supervision and mentoring 53 1.02 .137 -25.500 52 .001 -.481
Limited or no good schools for children/
education prospects of children
53 1.02 .137 -25.500 52 .001 -.481
Poor salaries 53 1.00 .000 - - - -
Lack of Job security 53 1.00 .000 - - - -
Achievement not recognized 53 1.00 .000 - - - -
Lack of safety at workplace 53 1.00 .000 - - - -
Push factors for migration of contract Physicians: While analysing the responses
of contract physicians, it is found that these factors contributed for intention of
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migration of the contract physicians from the present rural area to other rural area,
urban area or to leave the sector are: 1) Poor salaries (1.80), 2) Lack of adequate
financial incentives/ Rural allowances/performance incentives (1.77), 3) Lack of
Career development opportunities (1.73), 4) Poor working condition (1.57), 5) Lack
of scope for continuing education/higher education (1.50), 6) Inadequate living
conditions (access to amenities like housing, water, electricity, conveyance and
communication)(1.40), 7) Inadequate drugs/equipment (1.37), 8) Lack of Job security
(1.23), 9) Limited or no good schools for children/ education prospects of children
(1.10) and 10)Achievement not recognized (1.10). Out of which, three factors that
are the Poor salaries, lack of adequate financial incentives/ Rural
allowances/performance incentives and lack of Career development opportunities are
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(29)=
4.039 , p= .001, t(29)= 1.904 , p=.037 and t(29)= 2.841 , p=.008 respectively.
Table 106: Descriptive statistics for contributing push factor for contract
physicians
Factors
N Mean
Std.
Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Poor salaries 30 1.80 .407 4.039 29 .001 .300
Lack of adequate financial incentives/
Rural allowances/performance
incentives
30 1.77 .479 1.904 29 .037 .167
Lack of Career development
opportunities
30 1.73 .450 2.841 29 .008 .233
Poor working condition 30 1.57 .504 .724 29 .475 .067
Lack of scope for continuingeducation/higher education
30 1.50 .509 .000 29 1.00 .000
Inadequate living conditions 30 1.40 .498 -1.099 29 .281 -.100
Inadequate drugs/equipment 30 1.37 .490 -1.490 29 .147 -.133
Lack of Job security 30 1.23 .430 -3.395 29 .002 -.267
Achievement not recognized 30 1.10 .305 -7.180 29 .001 -.400Limited or no good schools for children
education prospects of children
30 1.10 .305 -7.180 29 .001 -.400
Poor support, supervision and
mentoring
30 1.07 .254 -9.355 29 .001 -.433
Lack of safety at workplace 30 1.07 .254 -9.355 29 .001 -.433
Limited opportunity of training &skill
development
30 1.03 .183 -14.00 29 .001 -.467
Lack of others cadres, teamwork and
interpersonal relationship
30 1.03 .183 -14.00 29 .001 -.467
Lack of Autonomy 30 1.03 .183 -14.00 29 .001 -.467
Unusual working hours and excess
work load
30 1.00 .000 - - - -
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Push factors for migration of Nurses: From the responses of the nurses, it is found
that these factors contributed for intention of migration of the nurses from the present
rural area to other rural area, urban area or to leave the sector are: 1) Lack of adequate
financial incentives/ Rural allowances/performance incentives (1.62), 2) Poor working
condition (1.62), 3) Poor salaries (1.48), 4) Inadequate drugs/equipment (1.26), 5)
Lack of Career development opportunities (1.18), 6) Inadequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.16), 7) Lack of scope for continuing education/higher education (1.08), 8)Lack of
others cadres, teamwork and interpersonal relationship (1.05), 9) Lack of Job security
(1.05) and 10) Limited opportunity of training and skill development (1.05). Out of
which, two factors, the Lack of adequate financial incentives/ Rural
allowances/performance incentives and Poor working condition are statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(72)= 2.032 , p= .046
both.
Table 107: Descriptive statistics for contributing push factor for nurses
N
Mea
n
Std.
Dev
Test Value = 1.5
t df
Sig.(2-
tailed
)
Mean
Diff.Lack of adequate financial incentives/
Rural allowances/performance incentives
73 1.62 .490 2.032 72 .046 .116
Poor working condition 73 1.62 .490 2.032 72 .046 .116
Poor salaries 73 1.48 .503 -.349 72 .728 -.021
Inadequate drugs/equipment 73 1.26 .442 -4.636 72 .001 -.240
Lack of Career development opportunities 73 1.18 .385 -7.140 72 .001 -.322
Inadequate living conditions 73 1.16 .373 -7.684 72 .001 -.336
Lack of scope for continuing
education/higher education
73 1.08 .277 -12.908 72 .001 -.418
Limited opportunity of training and skill
development
73 1.05 .229 -16.600 72 .001 -.445
Lack of Job security 73 1.05 .229 -16.600 72 .001 -.445
Lack of others cadres, teamwork andinterpersonal relationship
73 1.05 .229 -16.600 72 .001 -.445
Poor support, supervision and mentoring 73 1.04 .200 -19.616 72 .001 -.459
Limited or no good schools for children/
education prospects of children
73 1.04 .200 -19.616 72 .001 -.459
Achievement not recognized 73 1.03 .164 -24.566 72 .001 -.473
Unusual working hours and excess work load
73 1.01 .117 -35.500 72 .001 -.486
Lack of safety at workplace 73 1.01 .117 -35.500 72 .001 -.486Lack of Autonomy 73 1.00 .000 - - - -
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Push factors for migration of permanent nurses: While analysing further breaking
down to nature of employment of nurses as permanent nurses, it is found from the
responses, the following factors contributed for intention of migration of the
permanent nurses from the present rural area to other rural area, urban area or to leave
the sector: 1) Lack of adequate financial incentives/ Rural allowances/performance
incentives (1.64), 2) Poor working condition (1.61), 3) Inadequate drugs/equipment
(1.22), 4) Inadequate living conditions (access to amenities like housing, water,
electricity, conveyance and communication) (1.08), 5) Lack of others cadres,
teamwork and interpersonal relationship (1.06), 6) Limited or no good schools for
children/ education prospects of children (1.06), 7) Limited opportunity of training
and skill development (1.06), 8) Poor support, supervision and mentoring (1.03), 9)
Lack of Career development opportunities (1.03) and 10) Unusual working hours
and excess work load (1.03). Out of which, only one factor that is the Lack of
adequate financial incentives / Rural allowances/performance incentives is
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(35)=
1.711 , p=.046. However, poor working condition also has seems contributing to the
intention with Mean of 1.61.
Table 108: Descriptive statistics for contributing push factor for regular nurses
N
Mea
n
Std.
Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
Mea
n
Diff.
Lack of adequate financial incentives/ Rural
allowances/performance incentives
36 1.64 .487 1.711 35 .046 .139
Poor working condition 36 1.61 .494 1.348 35 .186 .111
Inadequate drugs/equipment 36 1.22 .422 -3.953 35 .001 -.278
Inadequate living conditions 36 1.08 .280 -8.919 35 .001 -.417
Limited opportunity of training and skill dev. 36 1.06 .232 -11.479 35 .001 -.444
Lack of others cadres, teamwork and
interpersonal relationship
36 1.06 .232 -11.479 35 .001 -.444
Limited or no good schools for children/
education prospects of children
36 1.06 .232 -11.479 35 .001 -.444
Lack of Career development opportunities 36 1.03 .167 -17.000 35 .001 -.472
Unusual working hours and excess work load 36 1.03 .167 -17.000 35 .001 -.472
Poor support, supervision & mentoring 36 1.03 .167 -17.000 35 .001 -.472
Poor salaries 36 1.00 .000 - - - -
Lack of scope for continuing /higher education36 1.00 .000
Lack of Job security 36 1.00 .000
Achievement not recognized 36 1.00 .000 - - - -
Lack of safety at workplace 36 1.00 .000 - - - -Lack of Autonomy 36 1.00 .000 - - - -
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Push factors for migration of contract nurses: While analysing the responses of
contract nurses, it is found that the following factors contributed for migration of the
contract nurses from the present rural area to other rural area, urban area or to leave
the sector: 1) Poor salaries (1.95), 2) Lack of adequate financial incentives/ Rural
allowances/performance incentives (1.62), 3) Poor working condition (1.59), 4) Lack
of Career development opportunities (1.32), 5) Inadequate drugs/equipment (1.30), 6)
Inadequate living conditions (access to amenities like housing, water, electricity,
conveyance and communication) (1.24), 7) Lack of scope for continuing
education/higher education (1.16), 8) Lack of Job security (1.11), 9) Achievement
not recognized (1.05) and 10) Lack of others cadres, teamwork and interpersonal
relationship (1.05). Out of which, two factors that is the Poor salary and Lack of
adequate financial incentives / Rural allowances/performance incentives are
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(36)=
11.833 , p= .001 and t(36)= 1.505 , p=.041 respectively.
Table 109: Descriptive statistics for contributing push factor for contract
nurses
Factors
N
Mea
n
Std
Dev
Test Value = 1.5
t df
Sig(2-
taile
d)
ean
Diff.Poor salaries 7 1.95 .229 11.833 36 .001 .446
Lack of adequate financial incentives/ Rural
allowances/performance incentives
7 1.62 .492 1.505 36 .041 .122
Poor working condition 7 1.59 .498 1.156 36 .255 .095
Lack of Career development opportunities 7 1.32 .475 -2.25236 .031 -.176
Inadequate drugs/equipment 7 1.30 .463 -2.66136 .012 -.203
Inadequate living conditions 7 1.24 .435 -3.59136 .001 -.257
Lack of scope for continuing
education/higher education
7 1.16 .374 -5.49936 .001 -.338
Lack of Job security 7 1.11 .315 -7.57236 .001 -.392
Limited opportunity of training and skilldevelopment
7 1.05 .229 -11.83336 .001 -.446
Poor support, supervision and mentoring 7 1.05 .229 -11.83336 .001 -.446
Lack of others cadres, teamwork and
interpersonal relationship
7 1.05 .229 -11.83336 .001 -.446
Achievement not recognized 7 1.05 .229 -11.83336 .001 -.446
Lack of safety at workplace 7 1.03 .164 -17.50036 .001 -.473
Limited or no good schools for children/education prospects of children
7 1.03 .164 -17.50036 .001 -.473
Unusual working hours and excess work
load
7 1.00 .000 - - - -
Lack of Autonomy 7 1.00 .000 - - - -
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Push factors for migration of Mid-Wives: While analysing for the group of Mid-
wives, it is found that the following factors contributed for migration from the present
rural area to other rural area, urban area or to leave the sector: 1) Poor salaries (1.74),
2) Poor working condition (1.64), 3) Lack of adequate financial incentives/ Rural
allowances/performance incentives (1.50), 4) Inadequate drugs/equipment (1.27), 5)
Lack of Career development opportunities (1.21), 6) Inadequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.17), 7) Lack of scope for continuing education/higher education (1.10), 8) Lack of
others cadres, teamwork and interpersonal relationship (1.10), 9) Lack of Job security
(1.06) and 10) Poor support, supervision and mentoring (1.05). Out of which, two
factors that is the Poor salaries, and Poor working condition are statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(114)= 1.838 , p=
.044 and t(114)= 1.465 , p=.050 respectively.
Table 110: Descriptive statistics for contributing push factor for mid-wives
N MeanStd.Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
MeanDiff.
Poor salaries 1151.74 .601 1.838 114 .044 .239
Poor working condition 1151.64 .502 1.465 114 .050 .142
Lack of adequate financial incentives/ Ruralallowances/performance incentives
1151.50 .402 .093 114 .926 .004
Inadequate drugs/equipment 1151.27 .446 -5.545 114 .001 -.230
Lack of Career development opportunities 1151.21 .408 -7.654 114 .001 -.291
Inadequate living conditions 1151.17 .381 -9.186 114 .001 -.326
Lack of scope for continuing /higher education 1151.10 .295 14.679 114 .001 -.404
Lack of others cadres, teamwork and
interpersonal relationship
1151.10 .295 14.679 114 .001 -.404
Lack of Job security 1151.06 .240 19.610 114 .001 -.439
Poor support, supervision and mentoring 1151.05 .223 21.502 114 .001 -.448
Limited or no good schools for children/education prospects of children 1151.03 .184 27.109 114 .001 -.465
Achievement not recognized 1151.03 .160 31.745 114 .001 -.474
Lack of safety at workplace 1151.03 .160 31.745 114 .001 -.474
Unusual working hours and excess work load 1151.02 .131 39.418 114 .001 -.483
Lack of Autonomy 1151.02 .131 39.418 114 .001 -.483
Limited opportunity of training and skill
development
1151.00 .000 - - - -
Push factors for migration of Permanent Mid-Wives: While analysing further
breaking down from the bunch of Mid-wives, to nature of employment as permanent
Mid-wives, it is found that the following 8 factors have valid mean and contributed
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for migration of the permanent mid-wives from the present rural area to other rural
area, urban area or to leave the sector: 1) Lack of adequate financial incentives/ Rural
allowances/performance incentives (1.65), 2) Poor working condition (1.63), 3)
Inadequate drugs/equipment (1.16), 4) Inadequate living conditions (access to
amenities like housing, water, electricity, conveyance and communication) (1.09), 5)
Lack of others cadres, teamwork and interpersonal relationship (1.05), 6) Lack of
Autonomy (1.02), 7) Limited or no good schools for children/ education prospects of
children (1.02) and 8) Lack of Career development opportunities (1.02). Out of which,
two factors that is the Lack of adequate financial incentives/ Rural
allowances/performance incentives and Poor working condition are statistically
significant at Mean Test Value=1.5, 95% C.I, it is significant at t(42)= 2.055 , p=.036
and t(42)= 1.715 , p=.044 respectively.
Table 111: Descriptive statistics for contributing push factor for permanent
mid-wives
Factors
N MeanStd.Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
MeanDiff.
Lack of adequate financial incentives/
Rural allowances/performance incentives
43 1.65 .482 2.05542 .036 .151
Poor working condition 43 1.63 .489 1.71542 .044 .128
Inadequate drugs/equipment 43 1.16 .374 -5.92042 .001 -.337Inadequate living conditions 43 1.09 .294 -9.08042 .001 -.407
Lack of others cadres, teamwork and
interpersonal relationship
43 1.05 .213 -13.95642 .001 -.453
Lack of Career development opportunities 43 1.02 .152 -20.50042 .001 -.477
Limited or no good schools for children/
education prospects of children
43 1.02 .152 -20.50042 .001 -.477
Lack of Autonomy 43 1.02 .152 -20.50042 .001 -.477
Poor salaries 43 1.00 .000 - - - -
Lack of scope for continuing
education/higher education
43 1.00 .000- - - -
Limited opportunity of training and skill
development
43 1.00 .000- - - -
Lack of Job security 43 1.00 .000 - - - -
Unusual working hours and excess work load 43 1.00 .000 - - - -
Poor support, supervision and mentoring 43 1.00 .000 - - - -
Achievement not recognized 43 1.00 .000 - - - -
Lack of safety at workplace 43 1.00 .000 - - - -
Push factors for migration of Contract Mid-Wives: While analysing further
breaking down from the bunch of Mid-wives, to nature of employment as contract
Mid-wives, it is found that the following top 10 factors contributed for migration of
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the contract mid-wives from the present rural area to other rural area, urban area or to
leave the sector: 1) Poor salaries (1.86), 2) Poor working condition (1.77), 3) Lack of
adequate financial incentives/ Rural allowances/performance incentives (1.42), 4)
Inadequate drugs/equipment (1.33), 5) Lack of Career development opportunities
(1.32), 6) Inadequate living conditions (access to amenities like housing, water,
electricity, conveyance and communication) (1.22), 7) Lack of scope for continuing
education/higher education (1.15), 8) Lack of others cadres, teamwork and
interpersonal relationship (1.12), 9) Lack of Job security (1.10) and 10) Poor
support, supervision and mentoring (1.08). Out of which, two factors that is poor
salaries and Poor working condition are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(71)= 8.798 , p= .001 and t(71)= 1.705 , p=
.048 respectively.
Table 112: Descriptive statistics for contributing push factor for contract mid-wives
Test Value = 1.5
Factors N Mean
Std.Dev t df
Sig.(2-
tailed)
MeanDiff.
Poor salaries 72 1.86 .348 8.798 71 .001 .361
Poor working condition 72 1.77 .502 1.705 71 .048 .205
Lack of adequate financial incentives/
Rural allowances/performance incentives
72 1.42 .496 -1.424 71 .159 -.083
Inadequate drugs/equipment 72 1.33 .475 -2.979 71 .004 -.167
Lack of Career development opportunities 72 1.32 .470 -3.263 71 .002 -.181
Inadequate living conditions 72 1.22 .419 -5.630 71 .001 -.278
Lack of scope for continuing
education/higher education
72 1.15 .362 -8.132 71 .001 -.347
Lack of others cadres, teamwork and
interpersonal relationship
72 1.13 .333 -9.554 71 .001 -.375
Lack of Job security 72 1.10 .298 -11.456 71 .001 -.403
Poor support, supervision and mentoring 72 1.08 .278 -12.703 71 .001 -.417
Achievement not recognized 72 1.04 .201 - - - -Lack of safety at workplace 72 1.04 .201 -19.327 71 .001 -.458
Limited or no good schools for children/
education prospects of children
72 1.04 .201 -19.327 71 .001 -.458
Unusual working hours & excess workload 72 1.03 .165 -24.213 71 .001 -.472
Lack of Autonomy 72 1.01 .118 -35.000 71 .001 -.486
Limited opportunity of training and skill
development
72 1.00 .000
- - - -
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4.4.4.3. PUSH FACTORS OF LIKELIHOOD TO MIGRATE ACCORDING TOTHE CHOICE OF PLACE
The above section tells us in detail the migration intention of the physicians,
nurses and mid-wives according to the category and nature of employment. In this
section it is aimed to explore the issue of intention to migrate according to the place of
choice. The exploration is based on finding the issue that, why the employees have the
choice for either vertical or the horizontal movements that is from rural to rural areas,
from rural to urban and migrates to other sector or to other places outside the state.
This effort is needed to track the issues of these health workforce migration
and understanding of factors contributing to it and may perhaps have these health
workforce retained in rural and remote areas of Arunachal Pradesh or country at large.
Migrating from rural area to another rural area: This section explores the
intention of migration of physicians, nurses and mid-wives from the present rural
health institute to any other rural health institute. The exploration of the preset factors
from the responses is presented below in table 113.
The top 10 factors that contributed to the intention of the migration of another
rural health institute of these employees are: 1) Lack of others cadres, teamwork and
interpersonal relationship (1.65), 2) Lack of Autonomy (1.59), 3) Poor support,
supervision and mentoring (1.07), 4) Poor working condition (1.05), 5) Unusual
working hours and excess work load (1.05), 6) Lack of adequate financial incentives/
Rural allowances/performance incentives (1.04), 7) Inadequate living conditions
(access to amenities like housing, water, electricity, conveyance and communication)
(1.04), 8) Lack of scope for continuing education/higher education (1.02), 9) Lack of
safety at workplace (1.02) and 10) Inadequate drugs/equipment (1.02). Out of which,
two factors, the lack of others cadres, teamwork and interpersonal relationship, lack of
Autonomy are statistically significant at Mean Test Value=1.5, 95% C.I, it is
significant at t(80)= 4.238 , p= .001 and t(71)= 3.546 , p= .001 respectively.
Table 113: Descriptive statistics of push factors for migration of physicians,nurses and mid-wives to another rural area
Factors N Mean
Std.Dev.
Test Value = 1.5
t df Sig. (2-
tailed)
MeanDiff.
Lack of others cadres, teamwork and
interpersonal relationship
81 1.65 .331 4.238 80 .001 .151
Lack of Autonomy 81 1.59 .264 3.546 80 .001 .090
Poor salaries 81 1.31 .465 -3.705 80 .001 -.191
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Limited opportunity of training andskill development
81 1.05 .218 -18.602 80 .001 -.451
Poor support, supervision and
mentoring
81 1.05 .218 -18.602 80 .001 -.451
Lack of adequate financial incentives/
Rural allowances/performanceincentives
81 1.04 .190 -21.926 80 .001 -.463
Unusual working hours and excesswork load
81 1.04 .190 -21.926 80 .001 -.463
Lack of Career development
opportunities
81 1.02 .156 -27.395 80 .001 -.475
Lack of scope for continuing
education/higher education
81 1.02 .156 -27.395 80 .001 -.475
Inadequate living conditions 81 1.02 .156 -27.395 80 .001 -.475
Poor working condition 81 1.01 .111 -39.500 80 .001 -.488
Inadequate drugs/equipment 81 1.01 .111 -39.500 80 .001 -.488
Lack of Job security 81 1.00 .000 - - - -
Achievement not recognized 81 1.00 .000 - - - -
Lack of safety at workplace 81 1.00 .000 - - - -
Limited or no good schools for
children/ education prospects of children
81 1.00 .000 - - - -
Migrating from rural area to urban area: This section explores the intention of
migration of physicians, nurses and mid-wives from the present rural health institute
to any other urban area health institute. The exploration of the preset factors from the
responses is presented below in table 114. The top 10 factors that contributed to the
intention of the migration of urban area health institute of these employees are: 1)
Poor working condition (1.83), 2) Lack of adequate financial incentives/ Rural
allowances/performance incentives (1.79), 3) Poor salaries (1.45), 4) Inadequate
drugs/equipment (1.38), 5) Inadequate living conditions (access to amenities like
housing, water, electricity, conveyance and communication) (1.28), 6) Lack of Career
development opportunities (1.25), 7) Lack of scope for continuing education/higher education (1.11), 8) Limited or no good schools for children/ education prospects of
children (1.07), 9) Lack of others cadres, teamwork and interpersonal relationship
(1.05) and 10) Poor support, supervision and mentoring (1.05). Out of which, two
factors, the Poor working condition and Lack of adequate financial incentives/ Rural
allowances/performance incentives are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(168)= 11.290 , p= .001 and t(168)= 9.369 ,
p= .001 respectively.
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Table 114: Descriptive statistics of push factors for migration of physicians,
nurses and mid-wives to rural to urban
N MeanStd.Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
MeanDiff.
Poor working condition 169 1.83 .378 11.290 168 .001 .328
Lack of adequate financial incentives/
Rural allowances/performance incentives
169 1.79 .406 9.369 168 .001 .293
Poor salaries 169 1.45 .499 -1.310 168 .192 -.050
Inadequate drugs/equipment 169 1.38 .487 -3.241 168 .001 -.121
Inadequate living conditions 169 1.28 .452 -6.208 168 .001 -.216
Lack of Career development
opportunities
169 1.25 .433 -7.543 168 .001 -.251
Lack of scope for continuing
education/higher education
169 1.11 .309 -16.53 168 .001 -.393
Limited or no good schools for children/education prospects of children
169 1.07 .247 -22.852 168 .001 -.435
Lack of others cadres, teamwork and
interpersonal relationship
169 1.05 .225 -25.788 168 .001 -.447
Poor support, supervision and mentoring 169 1.05 .213 -27.629 168 .001 -.453
Lack of safety at workplace 169 1.04 .186 -32.535 168 .001 -.464
Unusual working hours & excess workload 169 1.02 .132 -47.337 168 .001 -.482
Limited opportunity of training and skilldevelopment
169 1.01 .108 -58.511 168 .001 -.488
Lack of Job security 169 1.00 .000 - - - -
Achievement not recognized 169 1.00 .000 - - - -
Lack of Autonomy 169 1.00 .000 - - - -
Migrating to other sector or outside state: This section explores the intention of
migration of physicians, nurses and mid-wives from the present rural health institute
to any other sector or outside the state. The exploration of the preset factors from the
responses is presented below in table 115. The top 8 factors found to be with valid
mean that contributed to the intention of the migration to other sectors or outside state
are: 1) Lack of Career development opportunities (2.00), 2) Poor salaries (1.95), 3)
Lack of Job security (1.86), 4) Lack of adequate financial incentives/ Rural
allowances/performance incentives (1.81), 5) Lack of scope for continuing
education/higher education (1.76), 6) Inadequate drugs/equipment (1.52), 7)
Achievement not recognized (1.38) and 8) Poor working condition (1.29). Out of
which, five factors, the Lack of Career development opportunities, Poor salaries, Lack
of Job security, Lack of adequate financial incentives/ Rural allowances/performance
incentives and Lack of scope for continuing education/higher education are
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(20)=
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11.568 , p= .001, t(20)= 9.5 , p= .001, t(20)= 4.564 , p= .001, t(20)= 3.525 , p= .002
and t(20)= 2.750 , p= .012 respectively.
Table: 115: Descriptive statistics of push factors for migration of physicians,
nurses and mid-wives to other employer or outside state
N Mean
Std.
Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Lack of Career development
opportunities
21 2.00 .000 11.568 20 .001 .500
Poor salaries 21 1.95 .218 9.500 20 .001 .452
Lack of Job security 21 1.86 .359 4.564 20 .001 .357
Lack of adequate financial incentives/
Rural allowances/performance incentives
21 1.81 .402 3.525 20 .002 .310
Lack of scope for continuing
education/higher education
21 1.76 .436 2.750 20 .012 .262
Inadequate drugs/equipment 21 1.52 .512 .213 20 .833 .024
Achievement not recognized 21 1.38 .498 -1.096 20 .286 -.119
Poor working condition 21 1.29 .463 -2.121 20 .047 -.214
Limited opportunity of training and skill
development
21 1.00 .000 - - - -
Unusual working hours & excess workload21 1.00 .000 - - - -
Poor support, supervision and mentoring 21 1.00 .000 - - - -
Lack of others cadres, teamwork and
interpersonal relationship
21 1.00 .000 - - - -
Inadequate living conditions 21 1.00 .000 - - - -Lack of safety at workplace 21 1.00 .000 - - - -
Limited or no good schools for children/
education prospects of children
21 1.00 .000 - - - -
Lack of Autonomy 21 1.00 .000 - - - -
4.4.4.4. RELATIONSHIP OF DEMOGRAPHIC AND SATISFACTION
ATTRIBUTES WITH THE MAJOR INTENTION TO MIGRATE TO URBANAREAS
It is known from the study that the intention to migrate is having relationship
with job satisfaction. Hence, the exploration is attempted along with the exploration
with demographic attributes like age, sex, family background, marital status, length
of service, hierarchy level of place of posting and nature of employment of the
employees on intention to migrate to urban areas. The variable –(sex) has been
drooped from interpretation for the relationship because there are few cases of male
and female classification in the data, and classification is only in the Physicians
group, where as the nurses and mid-wives does not have the classification of male
and female, except 1 (one) no. of male in the nurse group of employee.
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From the study, it is found that there is no relationship exists between the
demographic attributes of age (2=1.523, p=.677), family background (2=0.008,
p=.929), marital status (2=0.927, p=.336), nature of employment (2=0.056,
p=.813), and place of posting (2=0.820, p=.845) with urban migration. Only theattribute of length of service (2=10.825, p=.029), is significant and revealed the
relationship with the migration to urban areas. And job satisfaction has been
statistically significance relationship at (2=84.930), p=.001), with the intention of
migration to urban area.
Table 116: Relationship of demographic attributes to intention to migrate in
physicians, nurses and mid-wives
Sl.
No.
Demographic and Satisfaction Attributes Chi-Square (2) P
1 Age 1.523 .6772 Family Background 0.008 .929
3 Marital Status 0.927 .3364 Length of Service 10.825 .0295 Hierarchy level of Health institutes-place of 0.820 .8456 Nature of Employment 0.056 .8137 Job Satisfaction 84.930 .001
While analysing by separating the positions of the workforce as Physicians, it
is found that there is no relationship exists between the demographic attributes of age
(2=3.729, p=.292), Sex (2=0.007, p=.933), family background (2=1.299,
p=.245), marital status (2=0.337, p=.562), nature of employment (2=0.598,
p=.439), and place of posting (2=1.981, p=.576), length of service (2=4.062, p=
.398), except job satisfaction has statistically significance relationship at
(2=33.227), p< .001), with the intention of migration to urban area.
Table 117: Relationship of demographic attributes to intention to migrate in
physiciansSl. No Demographic and Satisfaction Attributes Chi-Square (2) P
1 Age 3.729 .2922 Sex 0.007 .9333 Famil Back round 1.299 .2544 Marital Status .337 .5625 Length of Service 4.062 .3986 Hierarchy level of Health institutes-place of 1.981 .576
7 Nature of Em lo ment .598 .4398 Job Satisfaction 33.227 .001
While analysing separating the positions of the workforce as Nurses, it isfound that there is no relationship exists between the demographic attributes of age
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(2=1.341, p=.719), family background (2=.001, p=1.00), marital status (2=.051,
p=.821), nature of employment (2=.041, p=.839), and place of posting (2=4.668,
p=.097), length of service (2=5.384, p=.250), except job satisfaction has statistically
significance relationship at (2=33.797), p< .001), with the intention of migration to
urban area.
Table 118: Relationship of demographic attributes to intention to migrate in
nurses
Sl. No Demographic and Satisfaction Attributes Chi-Square (2) P
1 Age 1.341 .719
2 Famil Back round .001 13 Marital Status .051 .8214 Len th of Service 5.384 .250
5 Hierarchy level of Health institutes-place of posting
4.668 .097
6 Nature of Employment .041 .8397 Job Satisfaction 33.797 .001
While analysing separating the positions of the workforce as Mid-wives, it is
found that there is no relationship exists between the demographic attributes of family
background (2=1.153, p=.238), marital status (2=1.886, p=.176), nature of
employment (2=1.747, p=.186), and place of posting (2=2.334, p=.506) with urban
migration and significant relationship has been found with age (2=9.110, p=.011)
and length of service (2=10.552, p=.032). And job satisfaction has statistically
significance relationship at (2=13.048), p=.005), with the intention of migration to
urban area.
Table 119: Relationship of demographic attributes to intention to migrate in
mid-wives
Sl.
No
Demographic and Satisfaction Attributes Chi-Square
(2)
P
1 Age 9.110 .011
2 Family Background 1.153 .238
3 Marital Status 1.886 .176
4 Length of Service 10.552 .032
5 Hierarchy level of Health institutes-place of posting 2.334 .506
6 Nature of Employment 1.747 .1867 Job Satisfaction 13.048 .005
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4.4.5. FACTORS THAT MAY MOTIVATE THE PHYSICIANS,
NURSES AND MID-WIVES TO RETAIN IN CURRENT JOB IN
RURAL AND REMOTE AREA- WHAT IS THEIR CHOICE?
The use of financial incentives as important motivators has been over
emphasised in the recent past. However, research in human relations and behaviour
sciences has shown that “where as money incentive had not proved effective, psychic
rewards worked” (Gellerman, 1963). Later research by Herzberg (1968) & Lawler
(1971) confirmed the fact that pay has very little to do with motivation. However,
several research studies in India have indicated the positive relationships between pay
and employee performance (Dwivedi, 1980). Therefore, the need is to understand the
various factors which motivate physicians, nurses and mid-wives to retain themselves
in the present rural posting. Taking all these factors into consideration, financial as
well as non-financial incentives can be planned.
So forth, in this section, it is attempted to explore the preset factors that may
motivate the physicians, nurses and mid-wives to retain themselves in the present
rural area health institution. The responses of these employees reveal the motivational
factors for retain themselves for the rural services. However, this section is based on
all responses of 334 health workforce and the eighteen (19) preset factors were
included in the section of the questionnaire.The Cronbach’s alpha coefficient for the factor items is α =(0.603) on item 19
and N=334.
Factors that may motivate the physicians, nurses and mid-wives : While
exploring the motivational factors that may motivate the physicians, nurses and mid-
wives to retain themselves in the present rural area health institution. The responses of
these employees reveal the following top 10 motivational factors for retain themselves
for the rural services: 1) Financial incentives for rural posting/ Rural
allowances/performance incentives (1.93), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.87), 3)
Career development opportunities (1.63), 4) Good reward and achievement
recognition system (1.55), 5) Training and skill development Opportunities (1.53),
6) Improved working condition (1.49), 7) Adequacy of equipment, drugs and supplies
at Health centre (1.48), 8) Increase salary by half (1.34), 9) Opportunities of
continuing education/higher education (support for further education) (1.33) and 10)
Job Security (1.32). Out of which, four factors, financial incentives/ Rural
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allowances/performance incentives, improved living condition, career development
and Good reward and achievement recognition system are statistically significant at
Mean Test Value=1.5, 95% C.I, it is significant at t(334)= 31.938 , p= .001,
t(334)=20.598, p= .001 and t(334)= 4.984 , p= .001 and t(334)= 2.867 , p= .043
respectively.
4.4.5.1. FACTORS THAT MAY MOTIVATE THE PHYSICIANS TO STAY
Getting a more refined picture, the analysis was done according to the
category of these groups of health workforce. While, exploring the motivational
factors that may motivate the physicians to retain themselves in the present rural area
health institution, the responses of these employees reveal the following top 10motivational factors for retain themselves for the rural services: 1) Financial
Table 120 : Descriptive statistics of factors that may motivate the physicians,
nurses and mid-wives to retain in current job in rural and remote area
Factors
N MeanStd.Dev.
Test Value = 1.5
t df
Sig.(2-
tailed)
MeanDiff.
Financial incentives for rural posting/ Rural
allowances/performance incentives
3341.93 .248 31.938 333.001 .434
Improve living conditions 3341.87 .332 20.598 333.001 .374
Career development opportunities 3341.63 .483 4.984 333.001 .132Good reward & achievement recognition
system
3341.61 .489 2.867 333.043 .111
Training & skill development Opportunities 334 1.53 .500 .985 333.325 .027
Improved working condition 3341.49 .501 -.437 333.662 -.012
Adequacy of equipment, drugs and suppliesat Health centre
3341.48 .506 -.865 333.388 -.024
Increase salary by half 3341.34 .474 -6.236 333.001 -.162
Opportunities of continuing
education/higher education (support for
further education)
3341.33 .470 -6.758 333.001 -.174
Job Security 3341.32 .466 -7.160 333.001 -.183
Good teamwork and good interpersonal
staffs relationship
3341.30 .457 -8.135 333.001 -.204
Security & Safety at workplace 3341.23 .420 -11.859 333.001 -.272
Supportive supervision, management &
mentoring
3341.19 .389 -14.755 333.001 -.314
Adequate patients/clients at current facility 3341.16 .366 -17.047 333.001 -.341
Increase salary by double 3341.12 .329 -20.978 333.001 -.377
Rotational posting 3341.11 .314 -22.630 333.001 -.389
Availability of good schools for children 334 1.11 .314 -22.630 333.001 -.389
Opportunity of autonomy 3341.03 .171 -50.333 333.001 -.470Flexible working hours with minimal workloa 3341.01 .122 -72.888 333.001 -.485
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incentives for rural posting/ Rural allowances/performance incentives (1.90), 2)
Improve living conditions (Access to amenities like housing, water, electricity,
conveyance and communication) (1.79), 3) Career development opportunities (1.73),
4) Improved working condition (1.66), 5) Good reward and achievement recognition
system (1.65), 6) Training and skill development Opportunities (1.53), 7) Adequacy
of equipment, drugs and supplies at Health centre (1.50), 8) Opportunities of
continuing education/higher education (support for further education) (1.46), 9) Good
teamwork and good interpersonal staffs relationship (1.38) and 10) Adequate
patients/clients at current facility (1.36). Out of which, five factors, Financial
incentives for rural posting/ rural allowances/performance incentives, Improve living
conditions (Access to amenities like housing, water, electricity, conveyance and
communication), Career development opportunities, 4) Improved working condition
and Good reward and achievement recognition system are statistically significant at
Mean Test Value=1.5, 95% C.I, it is significant at t(112)= 14.376 , p= .001, t(112)
7.442, p= .001, t(112)= 5.620 , p= .001, t(112)= 3.667 , p= .001 and t(112)= 2.035 ,
p= .030 respectively.
Table 121: Descriptive statistics of factors that may motivate the physicians to
retain in current job in rural and remote area
Factors
N MeanStd.Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
MeanDiff.
Financial incentives for rural posting/
Rural allowances/performance incentives
1131.90 .298 14.376 112 .001 .403
Improve living conditions 1131.79 .411 7.442 112 .001 .288
Career development opportunities 1131.73 .444 5.620 112 .001 .235
Improved working condition 1131.66 .475 3.667 112 .001 .164
Good reward and achievement recognition
system
1131.65 .490 2.035 112 .030 .159
Training & skill development Opportunity 1131.53 .501 .657 112 .513 .031
Adequacy of equipment, drugs andsupplies at Health centre
1131.50 .502 .094 112 .926 .004
Opportunities of continuing /higher
education
1131.46 .501 -.846 112 .400 -.040
Good teamwork and good interpersonalstaffs relationship
1131.38 .488 -2.604 112 .010 -.119
Adequate patients/clients at current facility 1131.36 .483 -3.019 112 .003 -.137
Supportive supervision,management&ment 1131.22 .417 -7.107 112 .001 -.279
Increase salary by half 1131.21 .411 -7.442 112 .001 -.288
Job Security 1131.20 .404 -7.792 112 .001 -.296
Availability of good schools for children 1131.11 .309 -13.528 112 .001 -.394Rotational posting 1131.10 .298 -14.376 112 .001 -.403
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Security & Safety at workplace 1131.10 .298 -14.376 112 .001 -.403
Increase salary by double 1131.09 .285 -15.334 112 .001 -.412
Opportunity of autonomy 1131.06 .242 -19.231 112 .001 -.438
Flexible working hours with minimal
work load
1131.00 .000 - - - -
Factors that may motivate the contract physicians: Getting a more refined picture,
the analysis was done according to the nature of employment inside the category of
groups of Physicians. While, exploring the motivational factors that may motivate the
contract physicians to retain themselves in the present rural area health institution, the
responses of these employees reveal the following top 10 motivational factors for
retain themselves for the rural services: 1) Career development opportunities (2.00),
2) Opportunities of continuing education/higher education (support for further
education) (1.97), 3) Financial incentives for rural posting/ Rural
allowances/performance incentives (1.82), 4) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.76), 5)
Increase salary by half (1.71), 6) Job Security (1.68), 7) Training and skill
development Opportunities (1.62), 8) Improved working condition (1.59),
9)Adequacy of equipment, drugs and supplies at Health centre (1.53) and 10)
Good teamwork and good interpersonal staffs relationship (1.50). Out of which, six
factors, Career development opportunities, Opportunities of continuing
education/higher education (support for further education), Financial incentives for
rural posting/ Rural allowances/performance incentives , Improve living conditions
(Access to amenities like housing, water, electricity, conveyance and
communication), Increase salary by half and Job Security are statistically significant
at Mean Test Value=1.5, 95% C.I, it is significant at t(33)= 18.00 , p= .001, t(33)=
16.00 , p= .001, t(33)= 4.875 , p= .001, t(33)= 3.585 , p= .001, t(33)= 2.596 , p= .014,
and t(33)= 2.167 , p= .038, respectively.
Table 122: Descriptive statistics of factors that may motivate the contract
physicians to retain in current job in rural and remote area
Factors
N ean
Std.
Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Career development opportunities 34 2.00 .000 18.000 33 .001 .500
Opportunities of continuing education/higher
education (support for further education)
34 1.97 .171 16.000 33 .001 .471
Financial incentives for rural posting/ Ruralallowances/performance incentives 34 1.82 .387 4.875 33 .001 .324
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Improve living conditions 34 1.76 .431 3.585 33 .001 .265
Increase salary by half 34 1.71 .462 2.596 33 .014 .206
Job Security 34 1.68 .475 2.167 33 .038 .176
Training and skill development Opportunities 34 1.62 .493 1.391 33 .174 .118
Improved working condition 34 1.59 .500 1.030 33 .311 .088
Adequacy of equipment, drugs and suppliesat Health centre
34 1.53 .507 .339 33 .737 .029
Good teamwork and good interpersonal
staffs relationship
34 1.50 .508 .000 33 1.00 .000
Good reward &achievement recognition system34 1.44 .504 -.681 33 .501-.059
Adequate patients/clients at current facility 34 1.32 .475 -2.167 33 .038-.176
Increase salary by double 34 1.29 .462 -2.596 33 .014-.206
Security & Safety at workplace 34 1.29 .462 -2.596 33 .014-.206
Supportive supervision, management and
mentoring
34 1.26 .448 -3.064 33 .004 -.235
Availability of good schools for children 34 1.18 .387 -4.875 33 .001-.324Rotational posting 34 1.09 .288 -8.340 33 .001-.412
Opportunity of autonomy 34 1.09 .288 -8.340 33 .001-.412
Flexible working hours with minimal workload 34 1.00 .000 - - - -
Factors that may motivate the permanent physicians: Similarly, while exploring
the motivational factors that may motivate the permanent physicians to retain
themselves in the present rural area health institution, the responses of these
employees reveal the following top 10 motivational factors for retain themselves for
the rural services: 1) Financial incentives for rural posting/ Rural
allowances/performance incentives (1.94), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.80),
3) Improved working condition (1.70), 4) Career development opportunities
(1.62), 5) Good reward and achievement recognition system (1.62), 6) Training and
skill development Opportunities (1.52), 7) Adequacy of equipment, drugs and
supplies at Health centre (1.49), 8) Adequate patients/clients at current facility (1.38),
9) Good teamwork and good interpersonal staffs relationship (1.33),and 10) Opportunities of continuing education/higher education (support for further
education) (1.24). Out of which, five factors, Financial incentives for rural posting/
Rural allowances/performance incentives, Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication), Improved
working condition, Career development opportunities and Good reward and
achievement recognition system are statistically significant at Mean Test Value=1.5,
95% C.I, it is significant at t(78)= 15.840 , p= .001, t(78)= 6.537 , p= .001, t(78)=
3.768 , p= .001 , t(78)= 2.188 , p= .032 and t(78)= 2.188 , p= .032 respectively.
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Table 123: Descriptive statistics of Factors that may motivate the permanent
physicians to retain in current job in rural and remote area
Factors
N MeanStd.Dev
Test Value = 1.5
t df Sig
-tailed)
MeanDif.
Financial incentives for rural posting/ Ruralallowances/performance incentives
79 1.94 .245 15.840 78 .001 .437
Improve living conditions 79 1.80 .404 6.537 78 .001 .297
Improved working condition 79 1.70 .463 3.768 78 .001 .196
Career development opportunities 79 1.62 .488 2.188 78 .032 .120
Good reward &achievement recognition system79 1.62 .488 2.188 78 .032 .120
Training and skill development Opportunities 79 1.52 .503 .336 78 .738 .019
Adequacy of equipment, drugs and supplies at
Health centre
79 1.49 .503 -.112 78 .911 -.006
Adequate patients/clients at current facility 79 1.38 .488 -2.188 78 .032 -.120
Good teamwork and good interpersonal staffsrelationship 79 1.33 .473 -3.212 78 .002 -.171
Opportunities of continuing education/higher
education (support for further education)
79 1.24 .430 -5.362 78 .001 -.259
Supportive supervision, management and
mentoring
79 1.20 .404 -6.537 78 .001 -.297
Rotational posting 79 1.10 .304 -11.67 78 .001 -.399
Availability of good schools for children 79 1.08 .267 -14.13 78 .001 -.424
Opportunity of autonomy 79 1.05 .221 -18.10 78 .001 -.449
Security & Safety at workplace 79 1.01 .113 -38.500 78 .000 -.487
Increase salary by half 79 1.00 .000 - - - -
Increase salary by double 79 1.00 .000 - - - -Job Security 79 1.00 .000 - - - -
Flexible working hours with minimal workload 79 1.00 .000 - - - -
4.4.5.2. FACTORS THAT MAY MOTIVATE THE NURSES TO STAY
Getting a more refined picture, the analysis was done for the group of the
nurses. While, exploring the motivational factors that may motivate the nurses to
retain themselves in the present rural area health institution, the responses of these
employees reveal the following top 10 motivational factors for retain themselves for
the rural services: 1) Financial incentives for rural posting/ Rural
allowances/performance incentives (1.93), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.88), 3)
Career development opportunities (1.71), 4) Training and skill development
Opportunities (1.53), 5) Good reward and achievement recognition system (1.48), 6)
Adequacy of equipment, drugs and supplies at Health centre (1.47), 7) Improved
working condition (1.46), 8) Increase salary by half (1.35), 9) Job Security
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(1.34) and 10) Good teamwork and good interpersonal staffs relationship (1.33). Out
of which, three factors, Financial incentives for rural posting/ Rural
allowances/performance incentives, Improve living conditions (Access to amenities
like housing, water, electricity, conveyance and communication) and Career
development opportunities are statistically significant at Mean Test Value=1.5, 95%
C.I, it is significant at t(97)= 16.389 , p= .001, t(97)= 11.344 , p= .001, t(97)= 4.672 ,
p= .001 respectively.
Table 124 : Descriptive statistics of factors that may motivate the nurses to
retain in current job in rural and remote area
Factors
N MeanStd.Dev
Test Value = 1.5
tdf
Sig.(2-
tailed)
MeanDiff.
Financial incentives for rural posting/ Ruralallowances/performance incentives
98 1.93 .259 16.38997 .001 .429
Improve living conditions 98 1.88 .329 11.34497 .001 .378
Career development opportunities 98 1.71 .454 4.67297 .001 .214
Training and skill development Opportunities 98 1.53 .502 .60497 .547 .031
Good reward& achievement recognition syste 98 1.48 .502 -.40297 .688 -.020
Adequacy of equipment, drugs and supplies
at Health centre
98 1.47 .522 -.58197 .563 -.031
Improved working condition 98 1.46 .501 -.80797 .422 -.041
Increase salary by half 98 1.35 .478 -3.16797 .002 -.153
Job Security 98 1.34 .475 -3.40297 .001 -.163Good teamwork and good interpersonal
staffs relationship
98 1.33 .471 -3.64397 .001 -.173
Security & Safety at workplace 98 1.23 .426 -6.16597 .001 -.265
Opportunities of continuing education/higher
education (support for further education)
98 1.20 .405 -7.23197 .001 -.296
Supportive supervision,management&mentori 98 1.19 .397 -7.62697 .001 -.306
Availability of good schools for children 98 1.14 .352 -10.05297 .001 -.357
Increase salary by double 98 1.11 .317 -12.09897 .001 -.388
Rotational posting 98 1.10 .304 -12.94897 .001 -.398
Adequate patients/clients at current facility 98 1.08 .275 -15.04997 .001 -.418
Flexible working hours with minimal work load
98 1.03 .173 -26.83697 .001 -.469
Opportunity of autonomy 98 1.01 .101 -48.00097 .001 -.490
Factors that may motivate the Contract Nurses: Getting a more refined picture
within the group of nurses, the analysis was done for the group of the contract nurses.
While, exploring the motivational factors that may motivate the contract nurses to
retain themselves in the present rural area health institution, the responses of these
employees reveal the following top 10 motivational factors for retain themselves for
the rural services: 1) Financial incentives for rural posting/ Rural
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allowances/performance incentives (2.00), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (2.00),
3)Career development opportunities (1.93), 4) Increase salary by half (1.76), 5) Job
Security (1.73), 6) Training and skill development Opportunities (1.56), 7) Adequacy
of equipment, drugs and supplies at Health centre (1.56), 8) Improved working
condition (1.56), 9) Good reward and achievement recognition system (1.51) and 10)
Good teamwork and good interpersonal staffs relationship (1.42). Out of which, five
factors, Financial incentives for rural posting/ Rural allowances/performance
incentives, Improve living conditions (Access to amenities like housing, water,
electricity, conveyance and communication), Career development opportunities ,
Increase salary by half and Job Security are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(44)=12.543 , p= .001, t(44)=12.543 , p= .001,
t(44)=11.523 , p= .001, t(44)=3.944 , p= .001 and t(44)=3.500 , p= .001, respectively.
Table 125: Descriptive statistics of factors that may motivate the contract
nurses to retain in current job in rural and remote area
Factors
N Mean
Std.
Dev
Test Value = 1.5
t df Sig
(2-taile
Mean
Diff.
Financial incentives for rural posting/ Rural
allowances/performance incentives
45 2.00 .000 12.54344 .001 .500
Improve living conditions 45 2.00 .000 12.54344 .001 0.5
Career development opportunities 45 1.93 .252 11.52344 .001 .433
Increase salary by half 45 1.76 .435 3.94444 .001 .256
Job Security 45 1.73 .447 3.50044 .001 .233
Improved working condition 45 1.56 .503 .74244 .462 .056
Adequacy of equipment, drugs and supplies at
Health centre
45 1.56 .503 .74244 .462 .056
Training and skill development Opportunities 45 1.56 .503 .74244 .462 .056
Good reward & achievement recognition
system
45 1.51 .506 .14744 .883 .011
Good teamwork and good interpersonal staffs
relationship
45 1.42 .499 -1.04544 .302 -.078
Security & Safety at workplace 45 1.33 .477 -2.34544 .024 -.167
Opportunities of continuing education/higher
education (support for further education)
45 1.31 .468 -2.70644 .010 -.189
Increase salary by double 45 1.24 .435 -3.94444 .001 -.256
Availability of good schools for children 45 1.24 .435 -3.94444 .001 -.256
Supportive supervision,management& mentori 45 1.22 .420 -4.43244 .001 -.278
Rotational posting 45 1.11 .318 -8.20844 .001 -.389
Adequate patients/clients at current facility 45 1.04 .208 -14.66344 .001 -.456
Flexible working hours with minimal workload 45 1.02 .149 -21.50044 .001 -.478
Opportunity of autonomy 45 1.00 .000 - - - -
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Factors that may motivate the Permanent Nurses: Getting a more refined picture
within the group of nurses, the analysis was also done for the group of the permanent
nurses. While, exploring the motivational factors that may motivate the permanent
nurses to retain themselves in the present rural area health institution, the responses of
these employees reveal the following top 10 motivational factors for retain themselves
for the rural services: Financial incentives for rural posting/ Rural
allowances/performance incentives (1.87), Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.77),
Good reward and achievement recognition system (1.63), Training and skill
development Opportunities (1.51), Career development opportunities (1.45),
Adequacy of equipment, drugs and supplies at Health centre (1.40), Improved
working condition (1.38), Good teamwork and good interpersonal staffs relationship
(1.25), Supportive supervision, management and mentoring (1.17) and Security &
Safety at workplace(1.15). Out of which, three factors, Financial incentives for rural
posting/ Rural allowances/performance incentives, Improve living conditions (Access
to amenities like housing, water, electricity, conveyance and communication), Good
reward and achievement recognition system are statistically significant at Mean Test
Value=1.5, 95% C.I, it is significant at t(52)= 7.836 , p= .001, t(52)= 4.715 p= .001
and t(52)= 2.409 , p= .044 respectively.
Table 126: Descriptive statistics of factors that may motivate the permanent
nurses to retain in current job in rural and remote area
Factors
N Mean
Std.
Dev
Test Value = 1.5
t df
Sig.(2-
tailed)
Mean
Diff.
Financial incentives for rural posting/ Rural
allowances/performance incentives
53 1.87 .342 7.836 52 .001 .368
Improve living conditions 53 1.77 .423 4.714 52 .001 .274
Good reward and achievement recognition
system
53 1.63 .504 2.409 52 .044 .130
Training and skill development
Opportunities
53 1.51 .505 .136 52 .892 .009
Career development opportunities 53 1.45 .503 -.683 52 .497 -.047
Adequacy of equipment, drugs andsupplies at Health centre
53 1.40 .531 -1.422 52 .161 -.104
Improved working condition 53 1.38 .489 -1.824 52 .074 -.123
Good teamwork and good interpersonal
staffs relationship
53 1.25 .434 -4.269 52 .001 -.255
Supportive supervision, management and
mentoring
53 1.17 .379 -6.342 52 .001 -.330
Security & Safety at workplace 53 1.15 .361 -7.031 52 .001 -.349
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Opportunities of continuing
education/higher education (support for further education)
53 1.11 .320 -8.803 52 .001 -.387
Adequate patients/clients at current facility 53 1.11 .320 -8.803 52 .001 -.387
Rotational posting 53 1.09 .295 10.008 52 .001 -.406
Availability of good schools for children 53 1.06 .233 13.836 52 .001 -.443Flexible working hours with minimal work
load
53 1.04 .192 17.493 52 .001 -.462
Opportunity of autonomy 53 1.02 .137 25.500 52 .001 -.481
Increase salary by half 53 1.00 .000 - - - -
Increase salary by double 53 1.00 .000 - - - -
Job Security 53 1.00 .000 - - - -
4.4.5.3. FACTORS THAT MAY MOTIVATE THE MID-WIVES TO STAY
Getting a more refined picture, the analysis was done for the group of the Mid-
wives also. While, exploring the motivational factors that may motivate the mid-
wives to retain themselves in the present rural area health institution, the responses of
these employees reveal the following top 10 motivational factors for retain themselves
for the rural services: 1) Financial incentives for rural posting/ Rural
allowances/performance incentives (1.97), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (1.95), 3)
Good reward and achievement recognition system (1.63), 4) Training and skill
development Opportunities (1.50), 5) Career development opportunities (1.47), 6)
Adequacy of equipment, drugs and supplies at Health centre (1.46), 7) Increase salary
by half (1.45), 8) Job Security (1.41), 9) Improved working condition (1.35) and 10)
Security & Safety at workplace (1.34). Out of which, three factors, Financial
incentives for rural posting/ Rural allowances/performance incentives, Improve living
conditions (Access to amenities like housing, water, electricity, conveyance and
communication) and Good reward and achievement recognition system are
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(122)=
29.110 , p= .001, t(122)= 23.137 p= .001 and t(122)= 2.877 , p= .005 respectively.
Table 127 : Descriptive statistics of Factors that may motivate the Mid-wives
to retain in current job in rural and remote area
Factors
N MeanStd
Dev.
Test Value = 1.5
t df Sig.-tailed)
eanDif.
Financial incentives for rural posting/ Rural
allowances/performance incentives
1231.97 .178 29.110 122.001 .467
Improve living conditions 1231.95 .216 23.137 122.001 .451
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Good reward and achievement recognitionsystem
1231.63 .486 2.877 122.005 .126
Training and skill development
Opportunities
1231.50 .502 .090 122.929 .004
Career development opportunities 1231.47 .501 -.630 122.530 -.028
Adequacy of equipment, drugs andsupplies at Health centre
1231.46 .500 -.992 122.323 -.045
Increase salary by half 1231.45 .499 -1.174 122.243 -.053
Job Security 1231.41 .493 -2.102 122.038 -.093
Improved working condition 1231.35 .479 -3.484 122.001 -.150
Security & Safety at workplace 1231.34 .476 -3.693 122.001 -.159
Opportunities of continuing /higher
education (support for further education)
1231.30 .460 -4.797 122.001 -.199
Good teamwork and good interpersonal
staffs relationship
1231.20 .398 -8.497 122.001 -.305
Increase salary by double 1231.16 .371 -10.099 122.001 -.337
Supportive supervision, management andmentoring
1231.15 .355 -11.052 122.001 -.354
Rotational posting 1231.13 .338 -12.146 122.001 -.370
Availability of good schools for children 1231.09 .287 -15.892 122.001 -.411
Adequate patients/clients at current facility 1231.03 .178 -29.110 122.001 -.467
Opportunity of autonomy 1231.02 .127 -42.246 122.001 -.484
Flexible working hours with minimal work
load
1231.02 .127 -42.246 122.001 -.484
Factors that may motivate the Contract mid-wives: Getting a more refined picture
within the group of mid-wives, the motivational factors that may motivate the contract
mid-wives to retain themselves in the present rural area health institution, the
responses of these employees reveal the following top 10 motivational factors for
retain themselves for the rural service: 1) Financial incentives for rural posting/ Rural
allowances/performance incentives (2.00), 2) Improve living conditions (Access to
amenities like housing, water, electricity, conveyance and communication) (2.00),
3) Increase salary by half (1.73), 4) Job Security (1.67), 5) Good reward and
achievement recognition system (1.65), 6) Career development opportunities (1.61),
7) Training and skill development Opportunities (1.57), 8) Security & Safety at
workplace (1.53), 9) Adequacy of equipment, drugs and supplies at Health centre
(1.44) and 10) Opportunities of continuing education/higher education (support for
further education) (1.43). Out of which, six factors, Financial incentives for rural
posting/ Rural allowances/performance incentives, Improve living conditions (Access
to amenities like housing, water, electricity, conveyance and communication),
Increase salary by half, Job Security, Good reward and achievement recognitionsystem and Career development opportunities are statistically significant at Mean Test
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Value=1.5, 95% C.I, it is significant at t(74)= 10.534 , p= .001, t(74)= 10.534 , p=
.001, t(74)= 4.539 , p= .001, t(74)= 3.041 , p= .003, t(74)= 2.772 , p= .007 and t(74)=
2.002 , p= .049 respectively.
Table 128: Descriptive statistics of factors that may motivate the contract Mid-wives to retain in current job in rural and remote area
Factors N Mean Std.
Dev.
Test Value = 1.5
t df Sig.(2-
tailed)
MeanDiff.
Financial incentives for rural posting/ Ruralallowances/performance incentives
75 2.00 .000 10.534 74 .001 .500
Improve living conditions 75 2.00 .000 10.534 74 .001 .500
Increase salary by half 75 1.73 .445 4.539 74 .001 .233
Job Security 75 1.67 .475 3.041 74 .003 .167
Good reward and achievement recognition system 75 1.65 .479 2.772 74 .007 .153Career development opportunities 75 1.61 .490 2.002 74 .049 .113
Training and skill development Opportunities 75 1.57 .498 1.275 74 .206 .073
Security & Safety at workplace 75 1.53 .502 .575 74 .567 .033
Adequacy of equipment, drugs and supplies at
Health centre
75 1.44 .500 -1.040 74 .302 -.060
Opportunities of continuing education/higher
education (support for further education)
75 1.43 .498 -1.275 74 .206 -.073
Improved working condition 75 1.37 .487 -2.253 74 .027 -.127
Increase salary by double 75 1.27 .445 -4.539 74 .001 -.233
Rotational posting 75 1.20 .403 -6.452 74 .001 -.300
Good teamwork & good interpersonal staffs
relationship
75 1.19 .392 -6.918 74 .001 -.313
Supportive supervision, management &mentoring 75 1.12 .327 -10.059 74 .001 -.380
Availability of good schools for children 75 1.08 .273 -13.318 74 .001 -.420
Adequate patients/clients at current facility 75 1.04 .197 -20.193 74 .001 -.460
Opportunity of autonomy 75 1.01 .115 -36.500 74 .001 -.487
Flexible working hours with minimal work load 75 1.00 .000 - - - -
Factors that may motivate the permanent mid-wives: Similarly, exploring the
motivational factors that may motivate the permanent mid-wives to retain themselvesin the present rural area, the responses of these employees reveal the following top 10
motivational factors for retain themselves for the rural service: 1) Financial incentives
for rural posting/performance incentives (1.92), 2) Improve living conditions (1.88),
3) Good reward and achievement recognition system (1.78), 4) Adequacy of
equipment, drugs and supplies at Health centre (1.48), 5) Training and skill
development Opportunities (1.40), 6) Improved working condition (1.31), 7) Career
development opportunities (1.25), 8) Good teamwork and good interpersonal staffs
relationship (1.21), 9) Supportive supervision, management and mentoring (1.21) and
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10) Availability of good schools for children (1.19). Out of which, three factors,
Financial incentives for rural posting/ Rural allowances/performance incentives,
Improve living conditions and Good reward and achievement recognition system are
statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at
t(47)=10.335 , p= .001, t(47)= 7.774 , p= .001 and t(47)=3.159 , p=.022 respectively.
Table 129: Factors that may motivate the permanent Mid-wives to retain in
current job in rural and remote area
Factors N Mean Std.
Dev
Test Value = 1.5
t df Sig(2-
tailed)
Mean
Diff.
Financial incentives for rural posting/ Rural
allowances/performance incentives
48 1.92 .279 10.33547 .001 .417
Improve living conditions 48 1.88 .334 7.77447 .001 .375Good reward & achievement recognitionsystem
48 1.78 .398 3.15947 .022 .283
Adequacy of equipment, drugs and supplies at
Health centre
48 1.48 .505 -.28647 .776 -.021
Training and skill development Opportunities 48 1.40 .494 -1.46047 .151 -.104
Improved working condition 48 1.31 .468 -2.77347 .008 -.188
Career development opportunities 48 1.25 .438 -3.95847 .001 -.250
Good teamwork & good interpersonal staffsrelationship
48 1.21 .410 -4.92447 .001 -.292
Supportive supervision, management
&mentoring
48 1.19 .394 -5.48947 .001 -.313
Opportunities of continuing /higher education 48 1.10 .309 -8.88347 .001 -.396
Availability of good schools for children 48 1.10 .309 -8.88347 .001 -.396
Flexible working hours with minimal workload 48 1.04 .202 -15.72547 .001 -.458
Security & Safety at workplace 48 1.04 .202 -15.72547 .001 -.458
Rotational posting 48 1.02 .144 -23.00047 .001 -.479
Opportunity of autonomy 48 1.02 .144 -23.00047 .001 -.479
Adequate patients/clients at current facility 48 1.02 .144 -23.00047 .001 -.479
Increase salary by half 48 1.00 .000 - - - -
Increase salary by double 48 1.00 .000 - - - -
Job Security 48 1.00 .000 - - - -
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SECTION 5
ANALYSIS OF THE REFORMINITIATIVES FOR DISTRIBUTION,
ATTRACTION AND RETENTION
OF PHYSICIANS, NURSES AND
MID-WIVES
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4.5.1. REFORM INITIATIVES FOR RECRUITMENT AND
DEPLOYMENT (DISTRIBUTION)This section of the chapter addresses the descriptive finding of reform
initiatives in respect of the human resources in the public health sector, specifically
the initiatives related to distribution, attraction and retention of physicians, nurses and
mid-wives in the rural and remote areas for ensuring primary health care with especial
emphasize on maternal and child health. This part of the descriptive analysis also
presents the views of physicians, nurses and mid-wives on reform initiatives.
4.5.1.1. REFORM INITIATIVES TO ADDRESS THE ISSUE OF NUMERICAL
INADEQUACY OF HEALTH WORKFORCE (PHYSICIANS, NURSES &
MIDWIVES) IN THE STATE
a) Emphasized on contractual appointments for rural and remote area: While it
is true that human resource is one of the biggest challenges in Indian public health
sector, Government of India has brought the thrust on human resource in centre stage.
The serious issue in human resource management is huge gaps in critical health
manpower in government health institutions, particularly in rural areas, that provide
healthcare to the poorer segments of population. A large number of vacant posts of
physicians, nurses and mid-wives are reported at the primary level in government
hospitals. Also, almost all of the specialist positions in government hospitals in rural
areas in the state are lying vacant. Most of the management representatives have
pointed out for the difficulty in getting physicians, Nurses for the health posts. The
management representatives pointed out the crisis is more for the GNMs and the
physicians for rural and remote areas. It is may be due to lower graduates of
medicines and nursing candidates. They also revealed that they have many post lying
vacant in search of the GNMs (Nurses) and some of them are even personally
arranging these cadres for the rural health services. It is also pointed out by the
management representatives that in the light of very limited candidates for the posts
they have to compromise on the technical expertise and experience of the candidates
and have to appoint them for the rural and remote areas which obviously affect the
quality of the services in the rural and remote areas.
The situation at the secondary and tertiary level is somewhat better, as doctors
generally prefer to reside in urban areas.
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“Increasing the number of health worker is a major challenge in improving
the health system, to address the issue of numerical adequacy with cost effectiveness
is contracting the human resource”-State Level Official.
The past one decade has seen a growing tendency of contractual employment
in the public health sector in the state, toward a fundamental restructuring for
addressing the inadequacy issue under National Rural Health Mission (NRHM). A
significant change in placement of human resource has been seen since 2005 in the
country. Several measures were initiated to fill the wide gaps of health workforce
shortage in the state under the Reform process in human resource for health sector.
Within the scope of this flagship programme one of the measures that have
been adapted by the state with vis-à-vis to the national policy is of recruiting the
health workforce is in contract appointment. This process has involved recruiting the
health workforce to minimize the gaps of numerical inadequacy and supported the
tremendous growth in contract employment in this sector in Arunachal Pradesh along
with rest of the states in the country. In the last seven years of Government of India
flagship programme National Rural Health Mission in the state has tried reforms with
resources available. Measures were initiated to fill the vacant posts of Medical
officers, Nurses and Mid-wives in the state with higher preference to rural and remote
areas. The NRHM division of the state undertakes the recruitment and placement of
Physicians including the Specialist cadres, Nurses and Mid-wives.
According to the statistics of MoHFW, Govt. of India and Govt. of Arunachal
Pradesh, 1 no. of Specialist , 57 nos. of Doctors , 21 nos. AYUSH Doctors , 15 Dental
Surgeons, 196 nos. of Staff Nurses and 158 nos. of ANM have been appointment by
the State Govt. on contract for the health institutes in Arunachal Pradesh. Similarly, in
the country an addition of total numbers of 2460 Specialist, 8624 MBBS doctors,
7692 Ayush Doctors, 26793 Staff Nurses, 46690 ANM and 14490 other Para Medics
have been recruited in contract employment.
Management Perspective: Pros and cons of recruiting in contract
I. Pros :
i) Cost Effectiveness: “The contractual employees are cheaper than the permanent
employees, it cost the department in much less than permanent employees, as
there are no provision of other financial benefits other than a consolidated
salary”.- Management Representative from the state. The remuneration structure
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is affected through the department using the services of a contractual employee.
Thus, there is no burden upon the government for benefits like-insurance, medical,
leave encashment and retirement benefits etc. as it is given to the permanent
employee. It is also a viable alternative to the sector as long as
downsizing/restructuring is concern. Using the contract employees the health
department gets the ability to grow in size to meet the demand in large scale
without large scale effect on financial burdens.
ii) Flexibility: To a large extent the provision of contractual employee is a resource
balancing exercise of the sector. Fitting the human resource requirement in
existing resource pool of salary structure, when a permanent employment in
respect of higher rate pay is a problematic.
iii) Availability of manpower for higher days –Less employees on long leaves:
“No burden for paying benefits to these employees”- District Management
Representative. This group of employees is not entitled to all range of leaves as it
is entitled to the permanent employees. This group gets very short term leaves
and not entitled to long term leaves and thus ensures the availability of manpower
for higher days in a year.
iv) Simplified way of recruitment and reduce cost on recruitment and selection
process: “The contractual employees are recruited by walk-in-interview process
in the state, which reduces the cost of recruitment process”-Management
Representative from the state. In the state of Arunachal Pradesh, all the vacancies
under NRHM, both new and recurring are immediately filled up through open
advertisement in the local newspapers at the district level. In order to ensure
rational deployment of contractual manpower, recruitment is done at district level
and appointments are made for specific health centres without provision of
transfer. The appointments are district and facility specific and non transferable.
However, intra district relocation is allowed in certain exceptions.
v) Reduce unemployment percentage: “ All the contractual staff under NRHM is
normally employed for the entire NRHM period, subject to renewal of annual
contract based on performance, unless otherwise terminated on grounds of
breach of contract” ”-Management Representative from the state. By engaging a
huge numbers of employees in contract has reduce the unemployment percentage.
It has to an extent solved the unemployment problem, though it is a temporary
arrangement and valuable to the current short-term development.
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II. Cons :
i) Investment on training and development of contractual employees: Under this
programme in public health sector, huge investments in the employees are done in
the form of training and development opportunities. In the terms of stability of the
trained employee is less, as the employees are contractual and may leave the
sector in order to ensure their stability in other work/job. In order to ensure a
return on those investments, it is the public health sector that stands at instability.
“Under NRHM different types of skill up-gradation training such at Skill Birth
Training, Medical Termination of Pregnancy, Life Saving Anesthesia Training,
Emergency Obstetrics Care, Neo-natal care etc. which are provided irrespective
of contract or permanent employee”- ”-Management Representative from the
state.
ii) Performance: The issue of the performance of the contract employees was
divided into two different opinions of the management representatives. The
opinion on performance cannot be generalizing the two groups of employees –
contract and permanent. Those favored the best performance by contract
employee is due to the fear of non renewal of contract and compulsion to show the
performance. Those who support the worst performance by contract employees
had echoed the comments that due to the insecurity of job, discrimination as a
contract employee in pays and perks may be one of the reasons the productivity
issue could be compromised.
iii) Employee Turnover or attrition: “Some contract employees had left contract
jobs over dissatisfaction with the low pay and lack of benefits”- comment by a
state level management representative. In the interests of stability of employment,
contractual employees may shift their job to other sector who offers employment
stability and to take steps to reduce turnover and re-filling of vacant position may
cost the department. However, there is no concrete data on attrition; the
management representatives estimate it to 05-10% attrition per year.
iv) Short –term arrangement (Less long-term feasibility): The contractual
arrangement of employees in public health sector only provides a short-term
solution for the inadequacy in human resource. The management representatives
also favor the statement, as it is time bound specific program for architectural
correction of health delivery system and it only provides the short term solution of
the problem unless the employees are made a permanent employee in the sector.
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The contract employees felt no attachment to their employers' long-term strategies
because they are on short-term contracts.
Employee Perspective: view on contracting the pros and cons
Almost all of those interviewed were positive about their experience at this
sector, only in positivity in thinking in future they will be turned out to be a
permanent employee in the sector and they come up at par to the other existing
permanent employees. The following section focuses on findings of interaction and
questionnaire responses with the physicians, nurses and mid-wives).
I. Pros:
i) Solved unemployment problem of the employee: The contractual employment
has solved the unemployment problem of this group of peoples and now they areengaged in employment activity to earn their livelihood and atleast solved
financial hardship.
ii) Access to simplified process of recruitment process- “Walk-in-interviews”:
Most of the contractual employees those who were part of the study were
appointed through walk-in-interview. Some of them were appointed through
double stage of recruitment and selection process of written examination and
interview process. It is observed that major portion of the employees were
appointed in contract were simple process of Walk-in-interview. This process of
recruitment and selection process takes less time and efforts in respect of the
prospect candidates to be appointed on contract.
iii) Flexibility in job shifting/ Easy on job shifting: The existing norms for leaving
the job are very simple for the contractual employees. Giving one month advance
notice to the employer or in lieu of one month salary a contractual employee can
terminate the contract and leave the job. “The job shifting is easy in terms of
contract norms. I can easily leave the job if I get a new job that lead to an offer to
be brought on board full-time as a regular”.- A physician.
iv) Training opportunity: Majority of contract employees stated in response to the
questionnaire that they are getting full opportunity for skill up-gradation trainings
from the department. There is no discrimination regarding the status of
employment for proving various skill up-gradation training. Availability of
training opportunities can be seen as a factor of attraction and retention of the
contractual employees. They are getting opportunity for skill acquisition and have
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the access to all type of training in the department as per their eligibility. They are
provided with a wide variety of training opportunity and provide exposure to
different type skill up-gradation of their related work and techniques. It can also
be developmental in a wider sense of developing both technical and professional
skills.
v) Contracting jobs may ultimately lead to a permanent offer : The physicians
and nurses generally expected employer will give them permanent offer. This is
one of the advantage and retention factor. “Number of the earlier contract
physician and nurses were offered and regularized from the contract pool to the
state govt. permanent posts”- A Physician. Most of the respondents believed that
they will be significantly regularized if they remain in government service.
II. Cons:
i) Provides a short-term and temporary solution: This is a temporary solution to
their employment needs. Contract employees shared that they are going to be
short-term tend to be invisible as per the health program in which they are
appointed. “There is a huge contractual employee in the state, which may be
difficult for the government to regularize us in a short period of time, they tend to
be treated by many as just not really there”-A Nurse.
ii) Feeling of job in-security: Security issues were important for many contract
physicians, nurses and mid-wives. They commented on the lack of security and
less reliable working arrangement for them. It doesn’t provide the security and
benefits of full-time employment. Thus, the level of security that employment
offers insecurity arose as an issue.
iii) Financial and other Pay: Different pay scale is followed for a contract which is
not at par with the permanent employee. They are paid less than those of
permanent employees performing the same tasks and they were without other
employment benefits, pension contribution/retirement benefits/plans, medical
benefits, life insurance, paid vacation, educational reimbursement etc. and
opportunities for employment. One of the respondent shared-“the bank is not
going to loan you money because I am a contract employee. This puts additional
stress factors in their lives that are absent in permanent employees' lives. Contract
employees were less satisfied with certain aspects of their jobs, such as
compensation and benefits at par with the existing contract employees. Different
set of pay and conditions can create an environment where conflict is possible.
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One of the example of agitation in India is from Rajasthan –“No other benefits
Strike by Rajasthan contractual employee under NRHM” for other benefits.
iv) Lack of opportunity for career advancement: The ladder of career is absence in
the scenario of contract employment. “Career advancement and promotion avenue
are almost absent for contract employees”- A Mid-wive. The respondents stated
that they do not have the avenues for career advancement and promotional ladder
unless and until they are regularized in the department.
v) Lack of coordination and discrimination as in contract between Regular &
Contractual employee: The contract employee respondents stated that permanent
employee may not invite them in to their “inner circle” or share as much
information. “There is always a discrimination of being contract workers in the
middle of the circle of permanent employee”- A nurse. In addition to individual
level problems with perceived inequity, group level problems have also been
identified. It is observed that the contract employees are treated differently in the
workplace by employer, by management, by human resource policies, and by
permanent coworkers.
vi) Lack of loyalty, commitment and lack of motivation: They also stated that they
have less commitment towards their employer. The commitment is less and they
felt no attachment to their employer’s long-term or short-term strategies. Their
short-term contract meant they probably would not be employed long enough to
see long-term objectives achieved. A hard feeling among contract employees has
been observed. All contract employees admitted suffering stress connected to
contract employment and less motivation.
4.5.1.2. EMPHASIZING ON PROFESSIONAL TRAINING INSTITUTES FOR
ENHACING THE NUMBERS OF TECHNICAL HUMAN RESOURCE IN
THE STATE
Enhancing the pool of physicians, nurses and mid-wives within the state is a
alarming issue. It has not been kept pace with the need, especially with the physicians,
nurses and mid-wives. Absence of adequate training institutes for medical and nursing
courses results in low numbers of medics and paramedics produced for the state. Till
today, there is no medical college in public sector or in private sector for Allopathic
disciplines besides a Homeopathy Medical College in private sector. Yearly a fixed
numbers of students according to the Govt. of India quota seats, are placed in various
Medical colleges all over India. 32 seats in First nomination 2010 and 34 seats in first
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nomination 2011 has been allotted to the students for the MBBS course in various
Medical Colleges in India (DHTE, 2010 & DHTE, 2011). For the training of nursing
personnel, the state runs a lone Nursing School for ANMs at General Hospital,
Pasighat, East Siang District of Arunachal Pradesh. The institute runs training
programs on midwifery (ANM) nursing courses. There are no fix numbers of ANM
admission seats per year in this ANM School, in the year 2009-10, the number was
70, a year before in 2008-09, it was 47. The variation depends on Government of
Arunachal Pradesh continuing changing policy. In the state there is a chronic and
serious shortage of GNMs, as there is no GNM training school in govt. sector in
Arunachal Pradesh. A few number of GNMs are produced in GNM School at
Ramakrishna Mission Hospital, Itanagar. With this inadequacy in teaching schools,
insufficient numbers of professionally trained personnel to compensate the situation.
Under the reform process the state government is keen to address this issue,
and at this moment one nursing school at Daporijo, the Headquarter of Upper
Subansiri District and 3 ANM schools at Tawang at Tawang District, Aalo (Along) at
West Siang District and Namsai at Lohit District are on project execution level and
expected to be completed in 2013-14.
“The Govt of India has recently released first instalment fund for
establishment of one GNM school in Upper Subansiri district. As per the civil works
norms framed by the Indian Nursing Council, the construction projects are being
undertaken through Works department of the state government. The construction is
going on. The projects are expected to take 1 year for completion and the nursing
schools will start functioning from the financial year 2013-14. This is expected to
augment the supply of nurses and reduce the deficiency confronted by the State health
sector presently”. “The HRTC at Pasighat is the lone institute in the entire State for
the training of para medical staff which is fully functional. The institute trains ANM
and Health Assistants. GoI has sanctioned 3 Para medic schools during 2010-11. The
constructions are going on at Tawang, Aalo and Namsai (ANM School)”.
(Source : SPIP, 12-13).
Regarding medical education in the state, Arunachal Pradesh Government, in
the month of September 2011, signed a tripartite memorandum of understanding
(MOU) with Union Health Ministry and Hospital Services Consultancy Cooperation
(HSCC) India Limited, for strengthening and up-gradation of Arunachal State
Hospital at Naharlagun. The health and family welfare ministry, Govt. of India is
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supporting the up-gradation of the 140 bedded hospitals to a 300 bedded multi-
disciplinary hospital. MoHFW had sanctioned the Rs. 185 crore 300-bedded hospital
projects on priority with a target time of 24 months for its upgrading to a medical
college subsequently. (With inputs from Arunachal Times, 23rd
Sept’ 2011).
However, it will take a couple of years to completely established Medical College,
after fulfilment of several formalities.
The State level training Centre is under implementation through funding
support from GoI at a cost of Rs 2 Crores. The construction work of the training
centre is presently in full swing. Once completed, this is expected to reduce the
dependence of the health department on other department for conducting training
activities. Comprehensive training course materials, training methods and equipment
in place to ensure quality of training. (SPIP, 2012-13)
Most of the management representatives have pointed out for the difficulty in
getting physicians, Nurses for the health posts. The management representatives
pointed out the crisis is more for the GNMs and then the physicians for rural and
remote areas. It is may be due to lower graduates of medicines and nursing
candidates. They also revealed that they have many post lying vacant in search of the
GNMs (Nurses) and some of them are even personally arranging these cadres for the
rural health services.
4.5.1.3. INITIATIVES FOR HR POLICIES FOR RECRUITMENT AND
DEPLOYMENT OF DOCTORS, NURSES AND MID-WIVES:
There is no comprehensive HR Policy in Public health sector in Arunachal
Pradesh. There are recruitment rules for different category of health workforce. The
recruitment and other service conditions for staff in health services of the state
government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The
regular doctors and specialist cadre comes under the purview of service rule of APHS.The State health department has in place a concrete system for career progression for
physicians, nurses and mid-wives, where all have promotional avenues as per
seniority and availability of vacancies. The recruitment rules are the specific
instrument of the state govt. for recruitment, classification, method of
recruitment/promotion including constitution of departmental promotion committee,
salary etc. However, there is no specific HR Policy for contractual physicians, nurses
and midwives and other health workers.
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The state Govt. is preparing a 5 year strategies and policy document for
augmentation and maximization of Human Resources. This includes sustainable HRD
and policy reform from restructuring/ rationalization of HR deployment. The vibrant
HR policy includes terms of recruitment / filling up of vacancies, rationalising
posting, specific tenure of posting, career progression and incentives. The policy is
focussing on improving maternal and child health indicators through posting of
required manpower for maximising performance at identified functional facilities.
(SPIP-NRHM Arunachal Pradesh, 2012-13).
In order to ensure rational deployment of contractual physicians, nurses and
mid-wives, recruitment is done at district level and appointments are made for
specific health centres without provision of transfer. The contractual position is on
facility based need and recruitment is only for that facility other than district health
society. The appointments are district and facility specific and non transferable.
However, intra district relocation is allowed in certain exceptions.
The state is also contemplating rational transfer of permanent physicians and
nurses & mid-wives on rotation after completion of atleast 3 years in a particular
posting place. The measures include compulsory rural posting for certain period,
earmarking certain percentage of postgraduate seats for doctors who have served in
rural areas, and provision of rural service allowance, etc.
Thus, the state Govt. is preparing a 5 year strategies and policy document for
augmentation and maximization of Human Resources. This includes sustainable HRD
and policy reform from restructuring/ rationalization of HR deployment. The HRD
issues related to contractual manpower under NRHM is in placed that include the
following:
1. The contractual manpower has been put in place following gap analysis through
facility survey report.
2. All the contractual appointments are decentralized to the District Health Society.
3. The recruitment process is done transparently through advertisement in the
newspaper.
4. The process of selection is based on the performance of the candidate in the walk
in interview.
5. The contractual position is on facility based need and recruitment is only for that
facility other than district health society.
6. The appointment is only for a period ending in the 31st
year of the year.
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7. The appointment is purely temporality and non transferable. However, intra
district rational relocation as required by the District Health Society is allowed in
exceptional cases.
8. The extension of contractual services is subject to good performance and
recommendation by the appraisal board.
9. An undertaking is sign by the contractual appointee to abide by the appointee for
the period of appointment.
10. A new indicators based appraisal format is being used for ANM for further
extension of the services.
11. Monthly appraisal of all the PMSU staff is in place for regular monthly appraisal.
12. In term of carrier progression/incentive, the State Govt. is regularizing their job
into the state health services especially for technical manpower from time to time.
13. Further improvement in the working condition and careers progression will be put
in place during 2012-13 and years to come.
4.5.1.4. DECENTRALIZATION OF HR ACTIVITIES UNDER REFORM
PROCESS
Health service decentralization is being pursued by Government of India under
National Rural Health Mission at all levels, decentralization of authority,
responsibility, and resources for personnel functions is delegated in a decentralized
way in reform process. It is important to achieve effective human resource
management and to improve staff performance. However, decentralization itself
entails large-scale development of capacity at the local level for health planning,
financing, allocation and accounting for resources, and HR management functions
including staff recruitment, payroll and allowance documentation, and maintenance of
personnel records. The Human Resource Management functions including
recruitment and deployment are decentralized to the districts level. The recruitment
transfer and posting of manpower are done at the District level. The District is
ensuring rationality, appropriate placing of manpower to the facilities to make
functional. As per the District requirement, manpower is sanctioned from the state
level and District are recruiting & posting as per the guidelines and requirement. The
recruitment reform process is only for the contractual workforce with non-transferable
and district specific and with their performance appraisal.
Though decentralization is used as an ornamental word into the reform process, the actual implementation in the view of low capacity at the lower level is a
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concern. The new decentralized organizational structures mean that the role of district
authority as employer is transferred from state level, but to configure the new
structure of decentralized environment there is no provision reform process for HRM
system and HRM personnel in the organisation at state or the district level, that to
strategically support the initiation. The transfer of human resources functions from
State level to district level without a comprehensive design and structure is quite a big
challenge for the district administration. Over all in the absence of an appropriate HR
policy at state and district level on human resource, is still provide a big deal of
challenge for the district authority. Decentralization brings considerable new skill
needs, particularly in management competencies. District managers’ capacity to
respond to these and other performance gaps through training is, however, there is a
budget constraint. The new structures of administration, new budgeting style and
reporting mechanisms, under reform process is the side of decentralization, but the
local capacity of absorptions is always a matter of concern. District health managers
have a range of new responsibilities, depending on the powers that have been
decentralized to them. Decentralization makes district health managers responsible for
improving the way health services are targeted to meet priority health needs,
organized, and managed within the available budget. To do this, they need a
workforce whose staff numbers and mix are as appropriate as possible to these needs,
and whose cost is affordable. However, the study finds that in the reform process in
Arunachal Pradesh, decentralization in many field including HR management issues
have be percolated down up-to the district level and to some extend to the health
institutes, but there is a need of far greater attention to HR skill deficits. The
decentralization has been done in respect of power and resources to the district level
and lower level of health administration for HR administration and management.
Under this decentralised process, the recruitment is done with the District
Recruitment Board, as formed at the district level to perform the functions of
Recruitment and selection. The main human resource management roles at the district
level were to identify staff requirements i.e., Human Resource planning, and their
training needs and to ensure that health facilities had the minimum staffing
requirements. In addition, the powers to recruit, exercise disciplinary control, and to
remove persons from district service were delegated to the District. Pay determination
is heavily centralized at state level and national level, as part of broad based culture as
other public sector. Decentralized the district autonomy is facilitating the local
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preference and to retain the workforce in the district. However, as mentioned earlier
to manage the decentralized activities there is shortage of HR management personnel
in the district level, which create a challenging environment at this and subsequent
level of administration. As to increase the requirement for administrative and
managerial staff in the system and likely to associated increase requirement for
performance management also.
4.5.2. REFORM INITIATIVES FOR ATTRACTION AND
RETENTION
4.5.2.1. ADOPTION OF SIMPLIFIED WAY OF RECRUITMENT AND
SELECTION PROCESS
The contractual employees are recruited by walk-in-interview process in most
of the districts, which reduces the cost of recruitment process. The process of
selection is based on the performance of the candidate in the walk in interview. All
the vacancies for contractual appointments both new and recurring are immediately
filled up through open advertisement in the local newspapers at the district level in a
decentralised manner. The appointments are made for a period of 1 year on
contractual basis, with the provision for renewal of contract further for another year
on the basis of previous year’s performance. 4.5.2.2. EMPHASIZED ON TRAINING AND DEVELOPMENT
OPPORTUNITIES Training and development is vital for every organization to cope with changes
from time to time and perform well. This helps in honing of skills, developing
versatility and adaptability. In this content Mark Twain’s statement is crucial which
states. “There is nothing that training cannot do. Nothing is above its reach or below
it”(Ramani, 2003). In case of growing and learning organizations the importance of
training is even much more crucial. Andragogy (the science of adult learning)
demands tremendous effort from the trainer what should be more effective and
purposeful (Rao, 2003).
There is tremendous efforts can be seen in the reform process for skill up-
gradation of the training and the physicians, nurses and mid-wives are satisfied with
the process and most of the workforce are attracted and retain themselves due to this
factor in the sector. A major pre-requisite for providing quality health care service is
upgrading the skills and knowledge of all health personnel as well as this is an
integral factor for retaining technical human resource in rural and remote areas. The
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Government is providing frequent scope for programme based training with time to
time refresher training to all level of functionaries including ANMs, GNMs &
Medical Officers. Huge investments on the employees are done in the form of training
and development opportunities. There are different types of skill up-gradation training
such at Skill Birth Training, Medical Termination of Pregnancy, Life Saving
Anesthesia Training, Emergency Obstetrics Care, Neo-natal care etc. which are
provided to physicians, nurses & midwives in primary and secondary level of health
institutes. There is no discrimination regarding the status of employment for proving
various skill up-gradation training. Availability of in service training opportunities
can be seen as a factor of attraction and retention of the employees in primary and
secondary health institutes in rural and remote areas. They are getting opportunity for
skill acquisition and have the access to all type of training in the department as per
their eligibility and location of the health institutes. They are provided with a wide
variety of training opportunity and provide exposure to different type skill up-
gradation of their related work and techniques. It can also be developmental in a
wider sense of developing both technical and professional skills. The multi-skill
trainings & capacity building of the workforce are emphasized on physicians, nurses
& mid-wives from the rural and remote area. Skill up-gradation is an essential
component of in-service training programmes. The skill up-gradation varies
enormously depending upon the qualifications of the personnel and the institution
where he/she is working. For optimum utilization of human resources, skill and
competence enhancement is of paramount importance. Therefore, with the objective
to maintain the skill and competence level of the employees as well as to improve
upon these skills, different training programmes are designed and undertaken in
Health Sector under NRHM.
Table 130: Gist of various training under NRHM for physicians, nurses andmid-wives
Sl.
No.
Type of Training Category of participants Duration
1 SBA SN/ANM/LHV 3-6 weeks
2 EmOC MOs 16 weeks
3 Life Saving Skills in
Obs. Anesthesia
MOs 18 weeks
4 Blood storage MOs, Lab. Tech. 3 days
5 RTI/STI MO/SN/ANM/LHV 2 days
6 MTP including MVA MOs 15 days7 IMNCI MO/ANM/LHV/AWW etc 8 days
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8 Immunization Health Workers 2 days
9 MiniLap MOs for CHCs/FRU &DH 12 working days
10 Lap. Sterilization Gynecologist, Surgeon with
OT nurse and Assist.
12 working days
11 IUCD ANM/LHV 5 days
12 NSV MOs 5 days13 Adolescent Health Mos/ANM 5 days
14 PDC CMO/Civil sur./hospital suptd. 10 weeks
15 PMU 5 days
Source : MoHFW, Govt. of India
Under this training and development component for the technical workforce of
physicians, nurses and mid-wives, the achievement from 2005 to 2012 under NRHM
is presented detail in table 131. Training programmes are conducted on specific thrust
areas of maternal health, child health and family planning.
Table 131: Achievement cumulative Training for Maternal and Child Health
(March 2005-2012)
Type of
Training for Maternal and Child Health
Achievement cumulative
till March 2012
LSAS 7EmOC 8BEmOC 12SBA (MO/GNM/ANM) 256
MTP (MO) 124
RTI/STI (MO/GNM/ANM) 258IMNCI (MO) 184IMNCI (SN) 79
IMNCI (ANM) 208F-IMNCI (MO) 69F-IMNCI (SN) 108
NSSK (MO) 203
NSSK (SN) 156 NSSK ANM 16
Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
4.5.2.3. OPPORTUNITY FOR CAREER ADVANCEMENTThe State health department has in place a concrete system for career
progression for permanent physicians, nursing staff where physicians and nurses have
promotional avenues as per seniority and availability of vacancies. The ladder of
career is also not absence in the scenario of contract employment of physicians and
nurses & mid-wives. The State Govt. provides avenue for career advancement for
contractual doctors and nurses by absorbing them into permanent service subject to
availability of vacancies and based on the satisfactory performance and placed at the
rural and remote areas. Thus, contracting jobs for physicians, nurses and Mi-wives
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may ultimately lead to a permanent offer. A good number of the contract physician
and nurses were offered and regularized from the contract pool to the state govt.
permanent posts.
In Arunachal Pradesh it has compulsory for all the medical graduates to serve
in rural areas for a duration varying from 2 - 3 years and also has made it mandatory
for all the graduates to complete two to three years of rural service for admission to
the PG degree programs. In the state of Arunachal Pradesh Medical Officers on
completion of two years of rural service in permanent capacity are eligible to be
sponsored by the State, which will cover all expenses of their PG training.
4.5.2.4. FINANCIAL AND OTHER INCENTIVE SCHEMESConsolidated pay rates have been revised on the lines of the rates fixed by the
6th Pay Commission so as to attract contractual physicians, nurses and mid-wives to
rural jobs. Salary increments are periodically enhanced subject to availability of fund
in the NRHM budget. It is proposed to enhance the pay by about 5% every year from
2013-14. According to the Arunachal Pradesh State Programme Implementation
Plan, 2011-12 and 12-13, in order to ensure stay of Health workers in difficult rural
and remote areas, the state proposed incentive schemes. Incentive for Difficult Area
(A Category) @Rs 2000 per month to 83 ANM, 41 MO, 2 Specialist, 57 Pharmacist,
1 Radiographer, 24 Lab. Tech, and 115 Staff Nurse. For Most Difficult Area (B
Category) @Rs 4000 per month to 57 ANM, 16 MO, 21 Pharmacist, 4 Lab. Tech,
and 41 Staff Nurse. For Inaccessible Area (C Category) @Rs 6000 per month, 74
ANM, 13 MO, 13 Pharmacist, 5 Lab. Tech, and 26 Staff Nurse are proposed. Among
the inaccessible areas, the state has further identified 11 health facilities as most
difficult to access. Over and above their salary and incentives proposed above, the
health staff will get special package - Medical officer@ Rs 10,000 per month and
Nurses @Rs 5,000/- per month. However, the incentives are yet to be seen
materialized, it may be due to financial constraints in the state.
Table 132: Categorization of rural and remote area for incentive scheme for
workforce
Sl.
No.
Staff
Category
Difficult Area
(A Category)
Most difficult area
(B Category)
Inaccessible area
(C category)
Total
1 Specialist 2 - - 2
2 MO 41 16 13 70
4 Staff Nurse 115 41 26 182
6 ANM 83 57 74 214
Total 323 139 131 593Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
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4.5.2.5. AVAILABILITY OF EQUIPMENTS FOR HEALTH WORKFORCE
IN RURAL AND REMOTE AREAS
Availability of essential equipments is an imperative for functionalising a
health centre as per IPHS and attracts and retain health workforce in rural services.
There are several health centres devoid of the essential functional equipments. In
view of this, under reform initiatives fully equip PHC and CHC are ensured through
regular needs assessment. A robust system of indenting and procurement in respect
of medical equipment are in process of development and put in place. Identification
of non repairable / functional equipments is done annually and unserviceable
equipments are condemned and disposed off to scrapes. As far as possible, the state
is looking into awarding of AMC for all categories of equipments and instruments.
(Source: SPIP 2012-13)
4.5.2.6. SUPPORTIVE SUPERVISIONSupervision of supporting nature has been found relatively more effective. It
supportive supervision includes identification of the gap and subsequent immediate
best possible immediate solution on the spot with an objective to strengthening the
capacity of person being supervised on one hand and obtaining the result through
smooth implementation of the programme. The State and District level supervisory
monitoring team are regularly visiting the field up to the community level besides
facility on the way. The periodical meetings of all concern from the field at district
and the State level are also accelerating the pace of both way communications
resulting the minimising of impediments in case there is any.
4.5.2.7. INFRASTRUCTURE DEVELOPMENT INITIATIVES INCLUDING
ACCOMMODATION FACILITIES AT RURAL AND REMOTE AREAS FOR
UNDER REFORM PROCESS
Chronically there is inadequacy of residential quarters for workforce at rural
and remote areas. For ensuring deploying, attraction and retention of physicians,
nurses and especially Mid-wives in rural and remote area, the reform process is
emphasizing to develop the residential facilities all over the state. However within the
limited resources, prioritization is done to provide residential quarters in the health
facilities phase-wise. The identification of the health facilities has been done linking
the HR availabilities and acceptable infrastructure. Table 133 to 138 put more light on
the infrastructure development in the state regarding residential quarters.
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Table 133: Information on new Constructions of infrastructure in the state under
reform processHealth
Facility
New Construction sanctioned
under NRHM so far in High Focus
Districts
New Construction sanctioned under
NRHM so far in Non High FocusDistricts
Total
2 0 0 7 - 0 8
2 0 0 8 - 0 9
2 0 0 9 - 1 0
2 0 1 0 - 1 1
2 0 1 1 - 1 2
2 0 0 7 - 0 8
2 0 0 8 - 0 9
2 0 0 9 - 1 0
2 0 1 0 - 1 1
2 0 1 1 - 1 2
CHCs 1 1
SCs 6 4 0 4 3 44 21 0 11 12 105
Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
Table 134: Information on Upgradations of infrastructure in the state under
reform processHealthFacility
New Construction sanctioned under NRHM so far in High Focus Districts
New Construction sanctioned under NRHM so far in Non High Focus
Districts
T o t a l
2 0 0 7 - 0 8
2 0 0 8
- 0 9
2 0 0 9 - 1 0
2 0 1 0 - 1 1
2 0 1 1 - 1 2
2 0 0 7 - 0 8
2 0 0 8 - 0 9
2 0 0 9 - 1 0
2 0 1 0 - 1 1
2 0 1 1 - 1 2
DH 2
(Staff Qtr.)
3
C/o. of
tore
ouse)
7
(Staff
Qtrs).
3
(Staff
Qtr.)
14
C/o. of
tore
ouse)
29
CHCs 2
(C/o of
residential
Qtr.)
2
C/o of
esidential
tr.)
10 6
(C/o of
residential
Qtr.)
3(C/o. of
LR)
1
(C/o. of
2
(C/o of
residential
Qtr.)
22
PHCs 2(Upgra
dation)
4(Staff
Qtts.)
1
(Upgradati
on)
2
(Staff Qtr.)
7
(C/o of
residential
Qtr.)
2
(C/o. of
LR)
3
(Provision
of waiting
room &
Furniture)
3
(C/o of
resident
ial Qtr.)
Upgrada
ion)
6
(Staff
Qtr)
3
(Staff
Qtr.)
16
(C/o of
residential
Qtr.)
9
(C/o. of
LR)
17
(Provision
of waiting
room &
Furniture)
11
(C/o of
residential
Qtr.)
89
Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
Table 135: New Constructions of infrastructure in the state under reform process 2012-13
Sl.No Type of Health Institute New ConstructionPh sic al Tar et
1 District Hospital 13 (Qtrs)
2 CHC 4 (Residential Qtr.), 2 LRs,
10 (Residential Qtr.)
3 PHC 28 (Residential Qtr.), 5 LRs
4 SC 34
5 Training Centre 1(On going)Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
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Table 136: Identified District Hospitals where New Residential Quarters to be
constructed in 2012-13
District Hospitals Existing Qtrs Nos. of New Residential Qtrs
proposed
Tawang 18 1
Bomdila 24 1Seppa 15 1
Ziro 21 1
Aalo 25 1Daporijo 20 1GH-Pasighat 31 1Yingkiong 18 1Roing 25 1Anini 8 1Tezu 22 1Changlang 22 1
Khonsa 20 1Total 299 13Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
Table 137: Identified List of facilities (PHCs) that are proposed for new
construction of Residential Quarters in 2012-13
District Name of PHCs
West Kameng Thrizino, Sinchung
E/ Kameng Bameng, Bana, Pakke kesang
P/ Pare Jote
L/Subansiri PoruKurung Kumey Sangram, Yangte
West Siang Gensi, Tirbin, Kaying
East Siang Yembung, Namsing, Borguli, Koyu
U/Siang Jeying
LD Valley Anpum
D/Valley Etalin
Lohit New Mohong
Anjaw Wallong
Changlang Khimiyong, Kharsang
Tirap Wakka, Panchou
Upper Subansiri MaroSource: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
Table 138 : Identified CHCs for Construction of Residential Quarters in 2012-13
District Name of CHCs
West Siang Rumgong, Likabali
Tirap Deomali, Longding
Upper Siang Geku
Papumpare Balijan
East Siang Ruksin
East Kameng SeijosaLower Subansiri Yazali
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Additional 30 nos. of SCs with ANM quarters were constructed from state
govt. financial resources in the year 2010-11.
4.5.3. EXPLORING THE VIEWS ON HEALTH SECTOR REFORM FROM THE PERSPECTIVE OF PHYSICIANS,
NURSES AND MID-WIVESTo explore the views of the physicians, nurses and mid-wives upon the
ongoing reform processes which include the HR activities related to public health
sector. The questionnaire was included with seventeen (17) nos. of preset statements
on a scale of 1 to 5 of degree of agreement [1) Strongly Disagree 2) Disagree 3)
Undecided 4) Agree 5) Strongly agree]. The analysis of the responses has the
following descriptive.
The analysis of the responses, it is revealed that these three categories have
different views on the health sector reform process on Human resource activities.
The analysis of the all responses with the preset variable factors is presented point-
wise below:
1. Statement : The Reform has made the Human Resource Policies clear and
understandable at all level
The first question in this part of questionnaire was to explore that theemployees are clear about the human resource policies of the organization and that is
also it their own context and level. All the employees are quite reserved at this, that
they are clear about the HR policies of the organization, the mean of the response is
only 2.06 in the scale of 5, which is lower and signifies that there is more
disagreement to the statement that reform has succeeded to clear presentation of the
HR policies in the context of the physicians, nurses and mid-wives. The responses
revealed that there is difference between the groups, the values of F(2, 331) = 6.093,
p = .003. The Physicians have the mean of 2.25 for the responses, 2.03 for the nurses
and 1.92 for the mid-wives. It seems the physicians are little understanding, but we
cannot say this group is also in favour that the reform has made the Human Resource
Policies clear and understandable at your level. However, the mean of the responses
are the lowest we cannot say that the reform process has made human resource
policies understandable at all level and contributed to the HR function of the
organisation.
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2. Statement: Reforms have made the placement, transfer and promotion
transparent, fairer and unbiased
All the employees are quite reserved and disagreed on this statement; the mean
of the responses is only 2.05 in the scale of 5, which is lower at side. The responses
revealed that there is no significant difference between the groups, the values of F(2,
331) = 1.110, p=.331 and the groups thinks in similar way. The physicians have the
mean of 2.12, nurses have 2.04 and the mid-wives only 1.92. The mean scores clearly
indicating in the scale of five, that there is no change in the scenario and still no
existing of transparent, fairer and unbiased placement, transfer and promotion. The
groups have the view that the reform has failed to make placement, transfer and
promotion to transparent, fairer and unbiased.
3. Statement: The reform has made your job description clear
All the employees agreed in some extent of agreement but the agreement is
not so strong on this statement; the mean of the responses is only 3.73 in the scale of
5. The responses revealed that there is statistically significant difference between the
groups, the values of F(2, 331) = 3.450, p= .033 and the groups have difference on
this. The physicians have the mean of 3.83; nurses have 3.79 and the mid-wives only
1.99. The mean scores clearly indicating, that there is differences in agreement on the
statement and the physicians and nurses are likely to agree upon, but no agreement
from the mid-wives.
Thus, it is found that the physicians and nurses are familiar with their job
description clear as they agree upon the statement, but not so strongly. Whereas, the
mid-wives has no agreement on the statement and it seems, may be they are not so
clear about the job description of the mid-wives and has no agreement.
4. Statement: The reform has increased your chances of being promoted
No agreement could be seen in all the employee responses, they are quite
reserved and disagreed on this statement; the mean of the responses is only 2.15 in the
scale of 5, which is lower at side. The responses revealed that there is statistically
significant difference between the groups, the values of F(2, 331) = 5.344, p= .005.
The physicians have the mean of 2.35, nurses have 2.04 and the mid-wives only 2.07.
The mean scores clearly indicating in the scale of five, that the reform process has not
increased the change of their promotion. Thus, it is found that the physicians, nurses
and mid-wives do not think that they are getting promotional chances strongly.
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5. Statement: The reform has made the Salary structure Competitive for rural
area posting
No agreement could be seen as well for this statement also. No groups agree
upon that the reform process has created the salary structure competitive for the rural
area posting. There is no difference between the groups, the values of F(2, 331) =
1.211, p= .299. The mean of the responses is only 2.85 in the scale of 5, which is
lower at side. The responses revealed that there is statistically no significant
difference between the groups. The physicians have the mean of 2.93, nurses have
2.88 and the mid-wives only 2.76. Thus, it is found that the reform process has failed
to achieve a competitive salary structure for the rural area postings.
6.
Statement: The reform has made regular and adequate financial incentives and allowances for rural area posting
The statement that reform has made available regular and adequate financial
incentives for rural areas physicians, nurses and mid-wives has no agreement between
the group responses. The groups have differences, the values of F(2, 331) = 12.479,
p=.001. The mean of the responses is only 2.21 in the scale of 5, which is lower at
side. The responses revealed that there is statistically significant difference between
the groups. The physicians have the mean of 2.21, nurses have 2.43 and the mid-
wives only 2.11. The group of nurses has little higher mean than that of the two other
groups. Thus, reform has failed to made regular and adequate financial incentives and
allowances for physicians, nurses and mid-wives who are posted in remote and rural
areas.
7. Statement: The reform has increased the activities for your performance
appraisal and positive action them
All the employees are disagreed or undecided on this statement; the mean of
the responses is only 2.29 in the scale of 5. The responses revealed that there is no
significant difference between the groups, the values of F(2, 331) = 1.510, p=.222
and the groups thinks in similar way. The physicians have the mean of 2.37, nurses
have 2.28 and the mid-wives only 2.24. The mean scores clearly indicating in the
scale of five, that there are no increase activities for actual performance appraisals and
positive actions on them.
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8. Statement: The reform has made an improvement in working condition in your
work place
This statement that reform has made an improvement in working condition at
the respondent’s posted health institutes has agreement in group responses, though themean of the responses is 3.40, quite no so impressive, but we can say that the
statement have a favorable response. The groups have differences, the values of F(2,
331) = 23.958, p=.001. The mean of the responses is 3.40 in the scale of 5. The
responses revealed that there is statistically significant difference between the groups.
The physicians have the mean of 3.53, nurses have 3.69 and the mid-wives only 3.05.
The group of mid-wives has little lower mean than that of the two other groups. Thus,
it seems at the lower level of the health care delivery system where the Mid-wives are
largely posted are deviated of improving the working conditions. However, the other
two groups have also do not have the highest mean, which also revealed that there is
no sufficient improvement of work conditions at their workplace.
9. Statement: The reform has increased the training & skill development opportunity
This statement that reform has increased the training and skill development
opportunities for the respondent’s posted rural health institutes has agreement in
group responses, though the mean of the responses is 3.72, which shows the statement
have a favorable response. The groups have statistically significant differences, the
values of F(2, 331) = 4.958, p=.008. The physicians have the mean of 3.55, nurses
have 3.86 and the mid-wives only 3.78. The group of physicians has little lower mean
than that of the two other groups. Thus, it seems at the physicians do not get more
chance for training and development opportunities in comparison to the nurses and
mid-wives. Thus, it reveals that the reform has failed to address the need of training
and development in equal manner to all the groups of the employees.
10. Statement: The reform has improved the availability of equipment, drugs and
supplies essential to perform your assigned tasks
This statement that reform has improved the availability of equipments, drugs
and essential supplies for performing the assigned tasks for the respondent’s posted
rural health institutes has been agreed in group responses, though the mean of the
responses is 3.35, however, the favor is not so strong. The groups have statistically
significant differences, the values of F(2, 331) = 47.220, p=001. The physicians have
the mean of 3.59, nurses have 3.81 and the mid-wives only 2.76. The group of mid-
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wives has lowest mean than that of the two other groups. Thus, it seems at the mid-
wives do not get adequate equipments, drugs and essential supplies and the reform has
failed to provide them as well, in comparison to the physicians and nurses. Thus, it
reveals that the reform has failed to address 360 degrees of these needs too.
11. Statement: The reform has improved mix of other cadres in your workplace
This statement that reform has improved the mix of cadres in respondent’s
posted rural health institutes has low agreement, that’s the mean of the responses is
3.28, however, the favor is not so strong. The groups have statistically significant
differences, the values of F(2, 331) = 13.465, p= .001. The physicians have the mean
of 3.39, nurses have 3.58 and the mid-wives only 2.93. The group of mid-wives has
lowest mean than that of the two other groups. Thus, it seems at the mid-wives do notget team-work on with other cadres, while physicians and nurses also revealed that
they are also not so adequately gets improved atmosphere of team. Thus, it reveals
that the reform has failed to address 360 degrees of these needs too.
12. Statement: The reform has made your workload more manageable
There was no agreement revealed from the responses from the groups, the
mean of the responses is 2.25. The groups have statistically significant differences,
the values of F(2, 331) = 4.144, p=017 . The physicians have the mean of 2.39, nurseshave 2.24 and the mid-wives only 2.09. The group of mid-wives has lowest mean than
that of the two other groups. Thus, it seems at the mid-wives are more affected bythe
reform process, but all the groups still have the same situation rather high or low.
They do not agree upon that the reform process has made their work load manageable
but rather they think more unmanageable at their level. The disagreement increases at
the lower level of the groups. Thus, it reveals that the workload are more
unmanageable to all level due to the reform process.
13. Statement: The reform has made improvement in supportive supervision,
management and mentoring form higher authority
This statement that reform has made improvement in supportive supervision,
management and mentoring form higher authority, has an agreement mean of the
responses is 3.65. The groups have statistically significant differences, the values of
F(2, 331) = 3.850, p=.022. The physicians have the mean of 3.50, nurses have 3.68
and the mid-wives only 3.76. Thus, the responses reveals that there is an improvementof supervision and mentoring due to the reform process, and the trend is higher to the
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lower health institutes because the mean of the mid-wives is higher than that of the
two other higher groups.
While putting light from the management representative interview responses
that the supervision services also suffers from the financial constraints, geographical
constraints and overall suffers from the skill scarcity that is scarcity of supervisors.
The supervision structures starts from very state level to the lowest layer of SCs, the
SCs are supervised by the Medical Officers (Physicians) at PHCs or CHCs and these
PHCs/CHCs by the district level. The matter is more concern upon lot of higher
institutes is without the supervisors and if they are also, they are concern with the
clinical abilities and lacks the managerial skills like supervision and monitoring at
various levels.
14. Statement: The reform has made work independent and more autonomy
When the responses are analyzed the mean comes to 3.06, which revealed that
there is more undecided or neutral about the statement rather agreement or no
agreement. While the responses are analyzed separately according to the different
groups, physicians have Mean of 3.55, which shows an agreement but a weak one.
Other two groups, nurses have 2.49, which reveal that they have disagreement and
mid-wives are undecided on this statement thus making the group in neutral position
with Mean of 3.07. The responses revealed that there is significant difference between
the groups, the values of F(2, 331) = 27.992, p=.001. The mean scores clearly
indicating in the scale of five, that there is more autonomy to physicians rather than
that of nurses and mid-wives in the reform process.
15. Statement: The reform has made improvement in housing and other amenities
at your workplace
When overall responses are analyzed the mean comes to 2.53, which revealed
total disagreement with the statement that reform has shown an improvement in
housing and other amenities at the workplace of the respondents. While the responses
are analyzed separately according to the different groups, physicians have Mean of
3.24, which shows an agreement but a weak one. Other two groups, nurses have 2.13
and 2.20 for mid-wives, which reveal that they have disagreement on this statement
thus making the group significant different, the values of F(2, 331) = 41.599, p=.001.
The mean scores clearly indicating in the scale of five, that there is an improvement in
housing and other amenities at the workplace of the physicians that is at the higher
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level of health institute rather in the lower health institute where the nurses and mid-
wives are posted.
16. Statement: The reform has made rural health care services an attraction for the
potential physicians, nurses and mid-wives to work in rural and remote area
The response to this statement reveals that none of the respondents think that
the reform process has succeeded or made rural health care services an attraction for
the potential physicians and nurses to work in rural and remote area. When overall
responses are analyzed the mean comes to 2.01, which is the worst side of the
response, which revealed total disagreement with the statement that reform has made
the rural service an attraction for the physicians, nurses and mid-wives. While the
responses are analyzed separately according to the different groups, physicians haveMean of 2.08, nurses have 2.11 and 1.87 for mid-wives, which reveal that they have
disagreement and highly disagreement on this statement thus making the group
significant different, the values of F(2, 331) = 3.171, p=.043. The mean scores clearly
stated that there is no attraction on rural health services for physicians, nurses and
mid-wives and reform process has failed to attend so.
17. Statement: The reform has made overall HR practice effective and conducive in
the organization
Reform process has the HR dimension along with other activities on the
pipeline also. The responses revealed that the reform had failed to attend the
contribution to make the overall HR practice effective and conductive for the
organization and to the physicians, nurses and mid-wives. The Mean is 1.99 for all the
responses, which is strongly disagreement with the statement. While the responses are
analyzed separately according to the different groups, physicians have Mean of 2.21,
nurses have 1.95 and 1.81 for mid-wives, which reveal that they have disagreementand strong disagreement on this statement. The group has significant difference, the
values of F(2, 331) = 10.716, p=.001. The mean scores clearly stating that reform has
less attended overall HR practice effective and conducive in the organization for
physicians, nurses and mid-wives. It also revealed that the reform process failed to
give attention to the HR front rather giving attention to the other components of
reform process in the state.
The table 139 to 143 has the descriptive tables for putting more light on these
issues point-wises.
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Table 139 : Descriptive Statistics of views on health sector reform process on
HR by physicians, nurses and mid-wives
Sl.
No.Attributes
N MinMax
Mean
Std.
Dev.
Stati
stic
Std.
Error
1 The reform has made the Human ResourcePolicies clear and understandable at your level
334 1 4 2.06 .041 .743
2 The reform has made the placement, transfer and promotion transparent, fairer and unbiased
334 1 4 2.05 .037 .685
3 The reform has made your job description clear 334 2 5 3.73 .042 .772
4 The reform has increased your chances of being
promoted
334 1 4 2.15 .043 .781
5 The reform has made the Salary structure
Competitive for rural area posting
334 1 5 2.85 .046 .834
6 The reform has made regular and adequate
financial incentives and allowances for ruralarea posting
334 1 4 2.21 .034 .617
7 The reform has increased the HR activities for
your performance appraisal
334 1 4 2.29 .034 .613
8 The reform has made an improvement in
working condition in your work place
334 1 5 3.40 .043 .779
9 The reform have increased the training and skill
development Opportunities
334 1 5 3.72 .042 .761
10 The reform have improved the availability of equipment, drugs and supplies essential to
perform your assigned tasks
334 1 5 3.35 .053 .968
11 The reform have supported to create andimprovement in good mix of other cadres in
your workplace
334 1 5 3.28 .055 .997
12 The reform has made your workload more
manageable
334 1 5 2.25 .041 .756
13 The reform has made improvement in
supportive supervision, management and
mentoring form higher authority
334 1 5 3.65 .042 .763
14 The reform has made work independent and
more autonomy
334 1 5 3.06 .060 1.10
5
15 The reform has made improvement in housing
and other amenities at your workplace
334 1 5 2.53 .062 1.13
0
16 The reform has made rural health care services
an attraction for the potential physicians and
nurses to work in rural and remote area
334 1 5 2.01 .044 .798
17 The reform has made overall HR practice
effective and conducive in the organization
334 1 5 1.99 .038 .689
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Table 140: Descriptive Statistics of views on health sector reform process on HR
by physicians
Sl.
No.
N Min ax
Mean
Std.
Dev.
Stati
stic
Std.
Error
1 The reform has made the Human ResourcePolicies clear and understandable at your level
113 1 4 2.25 .068 .726
2 The reform has made the placement, transfer and promotion transparent, fairer and unbiased
113 1 4 2.12 .059 .629
3 The reform has made your job description clear 113 2 5 3.83 .065 .693
4 The reform has increased your chances of being promoted
113 1 4 2.35 .086 .914
5 The reform has made the Salary structureCompetitive for rural area posting
113 1 4 2.93 .071 .753
6 The reform has made regular and adequate
financial incentives and allowances for rural area posting
113 1 4 2.43 .059 .625
7 The reform has increased the HR activities for
your performance appraisal
113 1 4 2.37 .056 .601
8 The reform has made an improvement in
working condition in your work place
113 1 5 3.53 .070 .745
9 The reform have increased the training and skill
development Opportunities
113 1 5 3.55 .096 1.018
10 The reform have improved the availability of
equipment, drugs and supplies essential to
perform your assigned tasks
113 1 5 3.59 .081 .862
11 The reform have supported to create and
improvement in good mix of other cadres in your
workplace
113 2 5 3.39 .080 .850
12 The reform has made your workload more
manageable
113 1 5 2.39 .085 .901
13 The reform has made improvement in supportive
supervision, management and mentoring formhigher authority
113 1 5 3.50 .084 .888
14 The reform has made work independent and
more autonomy
113 1 5 3.55 .092 .982
15 The reform has made improvement in housingand other amenities at your workplace
113 1 5 3.24 .119 1.270
16 The reform has made rural health care services
an attraction for the potential physicians and
nurses to work in rural and remote area
113 1 5 2.08 .077 .814
17 The reform has made overall HR practiceeffective and conducive in the organization
113 1 5 2.21 .076 .807
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Table 141 : Descriptive Statistics of views on health sector reform process on
HR by nurses
Sl.
No. Attributes
N Min Max
Mean
Std.
Dev.
Stati
stic
Std.
Error
1 The reform has made the Human ResourcePolicies clear and understandable at your
level
98 1 4 2.03 .073 .724
2 The reform has made the placement, transfer
and promotion transparent, fairer and
unbiased
98 1 4 2.04 .071 .702
3 The reform has made your job descriptionclear
98 2 5 3.79 .071 .707
4 The reform has increased your chances of
being promoted
98 1 3 2.04 .065 .641
5 The reform has made the Salary structure
Competitive for rural area posting
98 1 5 2.88 .092 .911
6 The reform has made regular and adequate
financial incentives and allowances for rural
area posting
98 1 4 2.11 .063 .624
7 The reform has increased the HR activities
for your performance appraisal
98 1 3 2.28 .059 .588
8 The reform has made an improvement in
working condition in your work place
98 2 5 3.69 .072 .709
9 The reform have increased the training andskill development Opportunities
98 2 5 3.86 .058 .574
10 The reform have improved the availabilityof equipment, drugs and supplies essential to
perform your assigned tasks
98 2 5 3.81 .068 .668
11 The reform have supported to create andimprovement in good mix of other cadres in
your workplace
98 2 5 3.58 .072 .717
12 The reform has made your workload more
manageable
98 1 4 2.24 .058 .645
13 The reform has made improvement in
supportive supervision, management and
mentoring form higher authority
98 2 5 3.68 .075 .741
14 The reform has made work independent andmore autonomy
98 1 5 2.49 .103 1.01
15 The reform has made improvement in
housing and other amenities at your
workplace
98 1 4 2.13 .079 .782
16 The reform has made rural health care
services an attraction for the potential
physicians and nurses to work in rural and
remote area
98 1 5 2.11 .093 .918
17 The reform has made overall HR practice
effective and conducive in the organization
98 1 4 1.95 .042 .415
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Table 142: Descriptive Statistics of views on health sector reform process on HR
by Mid-wives
Sl.
No. Attributes
N Min Max
Mean
Std.
Dev.
Stati
stic
Std.
Error
1 The reform has made the Human ResourcePolicies clear and understandable at your level
123 1 4 1.92 .067
2 The reform has made the placement, transfer and promotion transparent, fairer and unbiased
123 1 4 1.99 .065 .719
3 The reform has made your job description clear 123 2 5 3.59 .078 .868
4 The reform has increased your chances of
being promoted
123 1 3 2.07 .065 .721
5 The reform has made the Salary structure
Competitive for rural area posting
123 1 5 2.76 .076 .840
6 The reform has made regular and adequate
financial incentives and allowances for ruralarea posting
123 1 3 2.07 .049 .546
7 The reform has increased the HR activities for
your performance appraisal
123 1 4 2.24 .058 .641
8 The reform has made an improvement in
working condition in your work place
123 2 4 3.05 .066 .734
9 The reform have increased the training and
skill development Opportunities
123 2 5 3.78 .051 .566
10 The reform have improved the availability of
equipment, drugs and supplies essential to
perform your assigned tasks
123 1 5 2.76 .088 .976
11 The reform have supported to create andimprovement in good mix of other cadres in
your workplace
123 1 5 2.93 .108 1.199
12 The reform has made your workload more
manageable
123 1 4 2.09 .068 .675
13 The reform has made improvement in
supportive supervision, management andmentoring form higher authority
123 2 5 3.76 .057 .628
14 The reform has made work independent and
more autonomy
123 1 5 3.07 .096 1.069
15 The reform has made improvement in housing
and other amenities at your workplace
123 1 5 2.20 .082 .905
16 The reform has made rural health care services
an attraction for the potential physicians and
nurses to work in rural and remote area
123 1 4 1.87 .059 .652
17 The reform has made overall HR practice
effective and conducive in the organization
123 1 5 1.81 .063 .694
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Table 143: Analysis of Variance of views on health sector reform process on
HR by physicians, nurses and mid-wives
Sl.
No.Attributes
Sum of
Squares df
Mean
Squar F Sig.
1 The reform has made the Human
Resource Policies clear andunderstandable at your level
Between
Groups
6.523 2 3.261 6.093 .003
Within
Groups
177.157 331 .535
2 The reform has made the
placement, transfer and
promotion transparent, fairer and
unbiased
Between
Groups
1.041 2 .520 1.110 .331
Within
Groups
155.094 331 .469
3 The reform has made your jobdescription clear
BetweenGroups
4.048 2 2.024 3.450 .033
WithinGroups
194.159 331 .587
4 The reform has increased your
chances of being promoted
Between
Groups
6.356 2 3.178 5.344 .005
Within
Groups
196.856 331 .595
5 The reform has made the Salary
structure Competitive for rural
area posting
Between
Groups
1.685 2 .842 1.211 .299
WithinGroups
230.127 331 .695
6 The reform has made regular and
adequate financial incentives and
allowances for rural area posting
Between
Groups
8.887 2 4.443 12.47
9
.001
WithinGroups
117.859 331 .356
7 The reform has increased the HR
activities for your performance
appraisal
Between
Groups
1.132 2 .566 1.510 .222
Within
Groups
124.113 331 .375
8 The reform has made an
improvement in working
condition in your work place
Between
Groups
25.574 2 12.78 23.95
8
.001
Within
Groups
176.665 331 .534
9 The reform have increased the
training and skill developmentOpportunities
Between
Groups
5.603 2 2.802 4.958 .008
Within
Groups
187.055 331 .565
10 The reform have improved the
availablity of equipment, drugs
and supplies essential to performyour assigned tasks
Between
Groups
69.262 2 34.63 47.22
0
.001
Within
Groups
242.753 331 .733
11 The reform have supported to
create and improvement in good
mix of other cadres in your
workplace
Between
Groups
24.911 2 12.45 13.46
5
.001
Within
Groups
306.194 331 .925
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12 The reform has made your
workload more manageable
Between
Groups
4.651 2 2.325 4.144 .017
Within
Groups
185.724 331 .561
13 The reform has made
improvement in supportivesupervision, management and
mentoring form higher authority
Between
Groups
4.411 2 2.205 3.850 .022
Within
Groups
189.604 331 .573
14 The reform has made work
independent and more autonomy
Between
Groups
58.851 2 29.42 27.99
2
.001
Within
Groups
347.952 331 1.051
15 The reform has madeimprovement in housing and
other amenities at your
workplace
BetweenGroups
85.395 2 42.69 41.599
.001
WithinGroups
339.743 331 1.026
16 The reform has made rural health
care services an attraction for the
potential physicians and nurses
to work in rural and remote area
Between
Groups
3.985 2 1.992 3.171 .043
Within
Groups
207.967 331 .628
17 The reform has made overall HR
practice effective and conducive
in the organization
Between
Groups
9.605 2 4.803 10.71
6
.001
WithinGroups
148.347 331 .448
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SECTION 6ANALYSIS OF THE HR POLICIES
AND PRACTICES ON
ATTRACTION, DISTRIBUTION
AND RETENTION OF
PHYSICIANS, NURSES AND MID-
WIVES FOR RURAL AND
REMOTE AREA IN THE STATE
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4.6.1. INTRODUCTION
As the human resource practices is related to the day-to-day HR activities of
job responsibilities, included administrative duties and recruitment; supervision
(including performance appraisals, conflict resolution, and mentoring); training; staff
deployment (including placement, transfer and benefits functions); and HR planning
and policy (covering policy-making, budgeting, and advising senior management).
HRM practices, which play a central role in the exchange relationships between the
organisation's management and its employees, are connected to every stage of the
employment circle, and through these engagements employees obtain valuable
information about the organisation and the way it is managed. These activities show
employees, in practice, what is valued in general, and how the organisation views
them in particular. When employees deal with customers they bring to the interaction
their perceptions of HRM practices (Ulrich, Halbroock, Meder, Stuchlick & Thorpe
1991).
This section is particularly for exploring and discussion on the HR policies
and practices related to Attraction, distribution and retention. It also presents the
satisfaction level of the physicians, nurses and mid-wives of these practices.
4.6.2. POLICIES FOR HR PLANNING, RECRUITMENT(ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION
Manpower planning or human resource planning is essentially the process of
getting the right number of qualified people into the right job at the right time. It is a
system of matching the supply of people (existing employees and those to be hired or
searched for) with opening the organization expects over a given time frame. (Rao,
2000). Further the efficient utilization of resources, manpower or other does not just
happen. It requires a careful planning. According to Sikula (1976) “maximum
productive use of any organization input can only be attained through the conscious
and prolonged attention to planning details. Hence, raised the need and importance of
Human Resource Planning (HRP).
Every organization has a view of the people it employs. It is fact that no
organization can rise above the calibre of its personnel. It is no accident, therefore,
that the managements’ emphasis must be laid with acquisition of right personnel. But
acquisition of right personnel is not an easy task (Samantray & Pradhan, 1998).The
selection, promotion and placement process includes all those activities related to the
internal movement of people across positions and external hiring into the
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organisation. The essential process is one of matching available resources to jobs in
the organisation. It entails defining the organisations human needs for particular
positions and assessing the available pool of people to determine the best fit.
(Fombrun, C., et al. (1984).
There is no comprehensive HR Policy in Public health sector in Arunachal
Pradesh. There are recruitment rules for different category of health workforce. The
recruitment and other service conditions for staff in health services of the state
government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The
regular doctors and specialist cadre comes under the purview of service rule of APHS.
The State health department has in place a concrete system for career progression for
physicians, nursing staff where physicians and nurses have promotional avenues as
per seniority and availability of vacancies. The recruitment rules are the specific
instrument of the state govt. for recruitment, classification, method of
recruitment/promotion including constitution of departmental promotion committee,
salary etc. However, there is no specific HR Policy for contractual physicians, nurses
and midwives and other health workers.
The state Govt. is preparing a 5 year strategies and policy document for
augmentation and maximization of Human Resources. This includes sustainable HRD
and policy reform from restructuring/ rationalization of HR deployment. The vibrant
HR policy includes terms of recruitment / filling up of vacancies, rationalising
posting, specific tenure of posting, career progression and incentives. The policy is
focussing on improving maternal and child health indicators through posting of
required manpower for maximising performance at identified functional facilities.
Absence of appropriate and concrete human resources policies on deployment,
there is always a hindrance in managing people at work (interviewee from district- 1
to 16). Moreover, the 5 year strategies and policy document for augmentation and
maximization of Human Resources. This includes sustainable HRD and policy reform
from restructuring/ rationalization of HR deployment.
In order to ensure rational deployment of contractual physicians, nurses and
mid-wives, recruitment is done at district level and appointments are made for
specific health centres without provision of transfer. The contractual position is on
facility based need and recruitment is only for that facility other than district health
society. The appointments are district and facility specific and non transferable as far
as the documents. However, intra district relocation is allowed in certain exceptions
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on mutual transfer and postings. The state is also contemplating rational transfer of
permanent physicians and nurses & mid-wives on rotation after completion of atleast
3 years in a particular posting place (State interviewee). The measures include
compulsory rural posting for certain period, earmarking certain percentage of
postgraduate seats for doctors who have served in rural areas, and provision of rural
service allowance, etc.
For the regular groups of employees the intra-district transfer and posting are
handled by the District Medical Officer and inter-districts transfer is handled by the
Director of Health Services.
The recruitment and other service conditions for staff in health services of all
the state government are regulated by the respective central or state services
recruitment rules. These rules are elaborate and provide clear cut guidelines for
recruitment, promotions etc.
Effective recruitment, selection practices are cohesively depends on the HR
policies and in the absence of the same, a number of difficulties have been highlighted
in the interview. Thus, in the absence of the human resource policies, personnel
decisions like recruitment, placement, transfer and promotion are the major problems.
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for Policies for placement, transfer and promotion is
not very low and above the average of the scale (N=334, mean=3.28) in the scale of 1
to 5.
Table 144: Scale of satisfaction on Policies for planning, placement, transfer
and promotion by position of Respondents
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 0 (0%) 6(5.3%) 33(29%) 74(65.1%) 0
Nurses 3(3.06%) 13(13.2%) 29(29.59% 53(54.08%) 0
Mid-wives 4(3.2%) 34(27.64%) 50(40.6%) 35(28.4%) 0
Total 7(2.09%) 53(15.8%) 112(33.5%) 162(48.5%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the mid-wives have the lowest level of satisfaction that is
mean=2.94, whereas physicians and nurses have mean=3.60 and 3.35 respectively,
and the Contract employee has mean of 3.2 and Permanent Employee has 3.36. The
ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331)= 22.743, p =.001.
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Table 145: Descriptive statistics on scale of satisfaction on policies for
planning, placement, transfer and promotion by position of respondents
Category N Mean Std. Dev. Std. Error Min Max
Physician 113 3.60 .591 .056 2 4
Nurse 98 3.35 .826 .083 1 4
Mid-Wife 123 2.94 .833 .075 1 4Total 334 3.28 .805 .044 1 4
Table 146: Analysis of Variance for scale of satisfaction on policies for
placement, transfer and promotion among the physicians, nurses and mid-
wives among the group of respondents
Sum of Squares Df Mean Square F Sig.
Between Groups 26.094 2 13.047 22.743 .001
Within Groups 189.885 331 .574
Total 215.979 333
4.6.3. HR PLANNING, RECRUITMENT AND SELECTION
PROCESS
The core HRM practices for fairness in the distribution according to the norms
are based on HR planning, recruitment and selection process in the organisation. HRP
as a process is essentially a careful thought-out strategy with a futuristic lookout of
the kind of human resource requirements of an organization. Planning the health
workforce is not only a technical process, but also a political one, as decisions on the
number, types and distribution of health workers depend on the political choices and
values enshrined in the organization of national health systems (Fulop and Roemer
1987; Dussault et al. 1997). As the question itself is indicating towards the Health
Human Resources Planning that further aimed at having the right number of people
with the right skills in the right place at the right time to provide the right services to
the right people (Birch 2002, adapted from Birch et al, 2007).
Planning is most important in every sectors including health sector especially in
manpower recruitment and placing. It involves comparing estimates of futurerequirements for and supplies of human resources and considering policy options for
addressing any differences between requirements and supplies (Lomas et al. 1985-
adapted from Birch et al, 2007). Research Observation shows that accurate
information systems on staffing trends and conditions are not in place-e.g., there is
more difficulty in part of knowing the sanction post in the district or in the state, also
there is no tradition of research on workforce issues in the state. HR planning under
NRHM division is theoretically based on decentralized system, however, in the
absence of proper information, and trends of staffing makes HR planning more
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exhaustive and difficult. While, the HR planning in permanent physicians, nurses and
mid-wives are done by the Health Directorate and based on vacancies and annual
operating plans. It is also found that there is lack of extensive co-ordination between
the two divisions for planning.
As manpower planning involves assessment of current and future demand &
supply and analyzing the gap and formulating short and long term strategies for
ensuring availability of sustainable levels of staff. The states do not have a formal
mechanism in place to undertake manpower planning on a continuous basis except the
Annual Action Plans. Planning exercise in the department of health is primarily
focused on creation of new infrastructure/institutions.
The recruitment and selection process of physicians, nurses and mid-wives
after the initiation of Reproductive and Child Health programme in 1997 and
subsequently National Rural Health Mission in 2005 has been concentrated to the
contractual manpower and the process is decentralised to the district level since 2010-
11. The decentralisation of this process is only for the contractual physicians, nurses
and mid-wives. For the recruitment of the permanent employee of this category, the
contractual employees are regularised and continued their services as regular
employees, the process is basically based on the sanctioned post vacancies and
seniority based and the process is undertaken by the Directorate of Health Services
headed by the Director of Health Services.
However, decentralization of recruitment and selection process to the district
included HR planning, recruitment; transfer and maintenance of human resource have
at the district level only for the contractual physicians, nurses and mid-wives. District
authority is now had to play a new role as employers, often without the appropriate
technical abilities to do so. The recruitment process under the decentralised
arrangement in the district is closely linked to the instruction and financial provision
at the state level.
The implementation of the decentralisation policy is only for the contractual
manpower in the district. Whereas, the appointment and deployment of the permanent
physicians, nurses and mid-wives are not comes under the decentralised recruitment
and deployment. So, it does not left any room for majority of the recruitment process
and deployment. Thus, the recruitment under centralisation, whereby the state level
would post permanent physicians, nurses and mid-wives to district may be without
taking into consideration the specific needs of each district. Thus districts requiring
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more physicians, nurses and mid-wives could not get the required number or the
willed workforce.
Management representatives Interviewees from all the districts have the
common consensus that they do not have the sufficient pool of the candidates and
suffered from the shortage of entry level physicians and nurses (GNM). However, two
of the district (3, 8) faced problems in Mid-wives pool also. Hughes (2002) has
pointed out that when supply is scarce; the development of an effective recruitment
and selection strategy becomes significantly more challenging and imperative.
Interviewees from Districts (3, 6, 8 and 11) put light on recruitment & selection of
less skilled candidates in the light of the scare pool of the candidates. The majority of
the management representatives emphasized that there is a need for a division of
responsibilities between the districts and the state level in matters related to
recruitment and distribution of health workers, to gain a favourable impact on
recruiting and deploying the physicians, nurses and mid-wives in rural and remote
areas.
In order to select the skilled physicians, nurses and mid-wives, various
recruitment sources are utilised by the districts. Advertising in state level newspapers,
local newspapers, office notice board publications and informal way of word of
mouths of present employees (district 1,2, 5, 8, 10, 13, 16) are used as the medium for
recruitment of these category of employees. The recruitment advertisement for the
contractual vacancies is only undertaken for this kind of process in the districts. The
recruitment advertisement for permanent positions is placed in the newspaper and
office board by the Directorate of Health Services. However, the internal source of
recruitment is widely used, whenever a sanctioned regular post is vacant. This process
of recruitment of internal candidates for regular posts supports career development
opportunities for internal contractual employees.
Selection is basically a matching process. How well an employee is matched
to a job affects the amount and quality of a employee’s work. Improper job placement
affects his moral as well. Ultimately, it costs an organization a great deal of money,
time and trouble. Effective human resource management requires constant monitoring
of the ‘fit’ between person and job. (Rao, 2000). As rightly pointed out, “If a
systematic selection procedure (test, patterned interview and so forth) prevented one
or two selection errors a year, it would represent a substantial return on investment”
(Durbin, 1981). Now –a-days some new methods like ‘walk-in-interview’ are
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becoming so popular that many corporations are adopting it. In this process the venue
is just checked out from the advertisement and if one becomes successful in the
interview, he gets a plum job and pay package within two and half hours. More and
more companies recruiting for entry-level and front-line jobs are opting for the walk-
in method (Beach, 1980).
So forth, the selection processes is based on Walk-in-interview (districts-2, 8,
12, 16), Written-test and panel interview (district-1,3,4,5,6,7,9,10,11,13,14,15) across
districts for these categories of contractual employees. In every district, a standing
recruitment and selection board is in place, which is headed by Deputy Commissioner
of the District and involved in every recruitment and selection process in the
individual districts. The section process is based on merit in written test and technical
and skill knowledge, personality and attitude assessment of the candidates in panel
interview.
For final selection, the selection committee assess the comparative merits of
each candidate in terms of his / her qualifications, experience if any and on the basis
of performance in the selection tests as per criteria laid down and come to a
conclusion as to whether or not the candidate would measure up to the requirements
of the job. However wherever marks are assigned, committee members give marks on
the basis of criteria laid down. Finally, candidates found suitable are empanelled in
order of merit. The panel / merit list so prepared are subject to the approval of the
competent authority and remain valid for a period of six months from the date of such
approval. If required the authority may extend the validity of the panel for a further
period not exceeding six months. Lastly, after the final selection of the candidates,
appointment offers are issued to the required number of candidates from the panel in
order of merit with the approval of the competent authority. All the appointment
offers are centrally issued by the establishment section.
The assessment of the requirement of Physicians, Nurses and Mid-wives
particularly for rural and remote areas is done annually in the form of Health Action
Plan based on the service based facility planning and it is a recurring planning in
nature. But these requirement planning are based for contractual employees. While
assessment of requirement of permanent Physicians, nurses and mid-wives, under
Annual Operating Plan in Directorate of Health Services under Planning and
Development Branch is done. However, the planning is done to create sanction post.
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Thus, the recruitment and selection process of the employee in the state public
health system is a traditional approach and lack the professional forefront in this
process. The system of recruitment and selection methods may be judged as the
traditional, and the advertisement, walk-in-interview, written-test with panel interview
as the dominant tools in use. However, the system failed to use a good recruitment
and selection techniques or the process for the recruitment of right skill and the right
number of employees in the system. It seems, the transfer of human resources
functions from State level to district level without a comprehensive design and
structure is quite a big challenge for the district administration. To manage the
decentralized activities there is no proper system of professional HR management
personnel in the district level or in the state level, which create a challenging
environment at this and subsequent level of administration.
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for Recruitment and selection process is low (N=334,
mean=2.43) in the scale of 1 to 5. It may be there is no concrete HR policy for
recruitment and selection process, and may lead to favouritism, political dictates, and
nepotism in the recruitment and selection process.
Table 147: Scale of satisfaction on Recruitment and selection process and
Position of RespondentCategory Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor Dissatisfied
Satisfied Highly
Satisfied
Physicians 3 (2.6%) 66(58.4%) 31(27.4%) 13(11.5%) 0
Nurses 6(6.1%) 61 (62.2%) 28(28.5% 3(3.06%) 0
Mid-wives 15(12.1%) 50(40.6%) 41(33.3%) 17(13.8%) 0
Total 24(7.18%) 177(52.9%) 100(29.9%) 33(9.8%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the nurses have the lowest level of satisfaction that is
mean=2.29, whereas physicians and mid-wives have mean=2.48 and 2.49
respectively, and the Contract employee has mean of 2.51 and Permanent Employee
has 2.35. The ANOVA test shows that there is a no significant difference in the scale
of satisfaction for this theme among the three groups, the values of F(2, 331) = 2.318,
p =0.1.
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Table 148: Descriptive statistics on scale of satisfaction on Recruitment and
selection process by position of respondents
Table 149: Analysis of variance for Scale of satisfaction on Recruitment
and selection process among the group of respondents
Sum of Squares Df Mean Square F Sig.
Between Groups 2.702 2 1.351 2.318 .100
Within Groups 192.926 331 .583
Total 195.629 333
4.6.4. HR PRACTICE FOR PLACEMENT, TRANSFER AND
PROMOTIONThe deployment of contractual physicians, nurses and mid-wives are done
according to the recruitment done for the particular vacancies for the specific health
institution. However, the deployments are interchange able on mutual consent of the
employees or the management decisions at the district level.
The deployment of the regular cadre employee is done according to the
requirement of the district and the District Medical Officer looks the matter and
depends on the physical infrastructure and basic amenities in the health institution e.g.
accommodation.
The common tenure following transfer posting is of minimum 3 years of
posting in one location, however, which is not followed at the district level or the state
level. The current practices however are non systematic and non transparent in many
district.
Promotion acts as an important motivational factor even when it is not
accompanied by substantial monetary benefits. The contractual groups do not have
any scope of promotion, as they are considered as the temporary employees.
Promotion as an internal source of recruitment is a long established policy in the
department. As per the recruitment rules the states follow the promotional avenues for
their permanent workforce. However, time bound promotions are not practices for
several reasons to these categories of staff. However, seniority-cum-merit promotions
are followed by the state.
N Mean
Std.
Deviation
Std.
Error Min Max
Physician 113 2.48 .733 .069 1 4 Nurse 98 2.29 .626 .063 1 4
Mid-Wife 123 2.49 .881 .079 1 4
Total 334 2.43 .766 .042 1 4
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The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for fairness of HR Practice for placement, transfer and
promotion is low (N=334, mean=2.11) in the scale of 1 to 5. The result revealed that
there may exists some extent of favouritism and unfairness in practicing related to the
placement, transfer and promotional avenues to the employees.
Table 150: Scale of satisfaction on fairness in HR Practice for placement,
transfer and promotion and Position of Respondent
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 16 (14%) 77(68%) 14(12.3%) 6(5.3%) 0
Nurses 10(10.2%) 65 (66%) 17(17.3% 6(6.12%) 0
Mid-wives 23(18.6%) 78(63.3%) 14(11.3%) 8(6.5%) 0
Total 49(14.6%) 220(65.8%) 45(13.4%) 20(5.9%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the mid-wives have the lowest level of satisfaction that is
mean=2.06, whereas physicians and nurses have mean=2.01 and 2.19 respectively.
The ANOVA test shows that there is a no significant difference in the scale of
satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p
=.346.
Table 151: Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position of respondents
Category N Mean Std. Deviation Std. Error Min Max
Physician 113 2.09 .689 .065 1 4
Nurse 98 2.19 .698 .071 1 4
Mid-Wife 123 2.06 .750 .068 1 4
Total 334 2.11 .715 .039 1 4
Table 152 : Analysis of Variance for the scale of satisfaction on fairness of HR
Practice for placement, transfer and promotion among the group of respondent
Sum of Squares Df Mean Square F Sig.Between Groups 1.087 2 .543 1.064 .346
Within Groups 169.033 331 .511
Total 170.120 333
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for magnitude of management favouritism and
political interference in transfer and posting is low (N=334, mean=2.36) in the scale
of 1 to 5. The result revealed that, the employees feel that there may existence of
management favouritism and political interference in the transfer and posting of these
groups of employees.
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Table 153: Scale of satisfaction on Magnitude of management favouritism and
political interference in transfer and posting among the group of respondents
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor Dissatisfied
Satisfied Highly
Satisfied
Physicians 10 (8.8%) 64(56.6%) 32(28.3%) 7(6.1%) 0 Nurses 10(10.2%) 43 (43.8%) 36(36.7% 9(9.18%) 0
Mid-wives 12(9.7%) 68(55.2%) 35(28.4%) 8(6.5%) 0
Total 32(9.5%) 175(52.39%) 103(30.8%) 24(7.18%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the physicians and mid-wives have the lowest level of
satisfaction that is mean=2.32, whereas nurses have mean=2.45. And the Contract
employee has mean of 2.41 and Permanent Employee has 2.31. The ANOVA test
shows that there is a no significant difference in the scale of satisfaction for this theme
among the three groups, the values of F(2, 331) = 1.052, p =0.350.
Table 154: Descriptive statistics on scale of satisfaction on magnitude of
management favouritism and political interference in transfer and posting by the
position of respondents
N Mean Std. Deviation Std. Error Min Max
Physician 113 2.32 .723 .068 1 4
Nurse 98 2.45 .801 .081 1 4
Mid-Wife 123 2.32 .739 .067 1 4Total 334 2.36 .753 .041 1 4
Table 155: Analysis of Variance for the scale of satisfaction on Magnitude of
management favouritism and political interference in transfer and posting
among the group of respondents
Sum of
Squares
Df Mean Square F Sig.
Between Groups 1.192 2 .596 1.052 .350
Within Groups 187.410 331 .566
Total 188.602 333
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for magnitude of response of
administration/management on your placement, transfer and promotional grievances
is low (N=334, mean=2.39) in the scale of 1 to 5. The result revealed that, the
employees feel that there exists a delay in response of administration/management on
your placement, transfer and promotional grievances of these groups of employees.
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Table 156:Scale of satisfaction on response of administration/management on
your placement, transfer and promotional grievances
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 10 (8.8%) 46(40.7%) 40(35.3%) 16(14.1%) 1 (0.8%)
Nurses 10(10.2%) 59 (60.2%) 23(23.4% 6(6.1%) 0
Mid-wives 18(14.6%) 57(46.3%) 38(30.8%) 10(8.1%) 0
Total 38(11.3%) 162(48.5%) 101(30.2 %) 32(9.5%) 1 (0.29%)
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the nurses have the lowest level of satisfaction that is
mean=2.26, whereas physicians and nurses have mean=2.58 and 2.33 respectively.
And the Contract employee has mean of 2.36 and Permanent Employee has 2.41. The
ANOVA test shows that there is a significant difference in the scale of satisfaction for
this theme among the three groups, the values of F(2, 331) = 4.663 , p =.01.
Table 157: Descriptive statistics on scale of satisfaction on response of
administration/ management on your placement, transfer and promotional
grievances by the position of respondents
N Mean
Std.
Deviation
Std.
Error Minimum Maximum
Physician 113 2.58 .874 .082 1 5
Nurse 98 2.26 .722 .073 1 4
Mid-Wife 123 2.33 .825 .074 1 4
Total 334 2.39 .823 .045 1 5
Likewise, the analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for participation and involvement in the decision
making of employees placement and transfer is low (N=334, mean=2.32) in the scale
of 1 to 5. The result revealed that, the employees feel non existence of participation
and involvement of employees in placement and transfer decisions.
Table 158: Analysis of Variance for the scale of satisfaction on Response of
administration/management on your placement, transfer and promotional
grievances among the group of respondents
Sum of
Squares Df Mean Square F Sig.
Between Groups 6.176 2 3.088 4.663 .010
Within Groups 219.225 331 .662
Total 225.401 333
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Table 159: Scale of satisfaction on Participation and involvement in the
decision making of your placement and transfer
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 13 (11.5%) 57(50.4%) 39(34.5%) 4(3.5%) 0
Nurses 4 (4.08%) 51 (52%) 40(40.8% 3(3.06%) 0
Mid-
wives
15(12.1%) 68(55.2%) 35(28.4%) 5(4.06%) 0
Total 32(9.5%) 176(52.6%) 114(34.1%) 12(3.5%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the mid-wives have the lowest level of satisfaction that is
mean=2.24, whereas physicians and nurses have mean=2.30 and 2.43 respectively.
And the Contract employee has mean of 2.36 and Permanent Employee has 2.28. The
ANOVA test shows that there is a no significant difference in the scale of satisfaction
for this theme among the three groups, the values of F(2, 331)=1.991, p=0.138.
Table 160: Descriptive statistics on scale of satisfaction on participation and
involvement in the decision making of your placement and transfer by the
position of respondents
N Mean Std.
Deviation
Std. Error Minimum Maximum
Physician 113 2.30 .718 .068 1 4 Nurse 98 2.43 .626 .063 1 4
Mid-Wife 123 2.24 .717 .065 1 4
Total 334 2.32 .694 .038 1 4
Table 161: Analysis of variance for the scale of satisfaction on Participation
and involvement in the decision making of your placement and transfer
among the group of respondents
Sum of
Squares Df Mean Square F Sig.
Between Groups 1.906 2 .953 1.991 .138Within Groups 158.453 331 .479
Total 160.359 333
4.6.5. HR PRACTICE FOR RETENTION - FINANCIAL & NON-
FINANCIAL INTERVENTIONSThere is no provision of financial and non-financial incentives for rural and
remote area deployment and retention. In the light of no provision of such incentives
for the physicians, nurses and mid-wives for rural area services and the compensation
package also is same irrespective of the place of posting. Other non financial benefits
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such quarters with electricity, water facilities etc. are minimum in the system to retain
the workforce in those underserved areas. Moreover, other rewards system linked to
performance is also not the system, may resulted to the low job satisfaction and
motivation of the workforce. The reward and recognition for the performance and
achievement is also there in the system which could boost the satisfaction and
motivation to perform by the workforce. The study findings seem that the workforce
is dissatisfied with these components in the system.
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for financial incentives as retention interventions is
low (N=334, mean=2.13) in the scale of 1 to 5. The result revealed that there is no
satisfaction regarding the HR Practice for retention taking financial incentives as an
intervention.
Table 162: Scale of satisfaction of HR Practice for retentions –Financial
Interventions
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 36 (31.9%) 50(44.2%) 15(13.3%) 12(10.6%) 0
Nurses 24 (24.5%) 46 (46.9%) 20(20.4% 8(8.2%) 0
Mid-wives 28 (22.8%) 52(42.3%) 28(22.8%) 15(12.2%) 0
Total 88(26.3%) 148(44.3%) 63(18.9%) 35(10.5%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the physicians have the lowest level of satisfaction that is
mean=2.03, whereas mid-wives and nurses have mean=2.24 and 2.12 respectively.
The ANOVA test shows that there is a no significant difference in the scale of
satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p
=0.195.
Table 163: Descriptive statistics on scale of satisfaction of HR Practice for
retentions –Financial Interventions by the position of respondents
Category N Mean Std. Deviation Std. Error Minimum Maximum
Physician 113 2.03 .940 .088 1 4
Nurse 98 2.12 .877 .089 1 4
Mid-Wife 123 2.24 .944 .085 1 4
Total 334 2.13 .925 .051 1 4
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Table 164: Analysis of variance for the Scale of satisfaction of HR Practice for
retentions –Financial Interventions among the group of respondents
Sum of Squares df
Mean
Square F Sig.
Between Groups 2.803 2 1.402 1.644 .195
Within Groups 282.134 331 .852Total 284.937 333
The analysis of employee attitude survey revealed that the Level of
satisfaction of these employees for non-financial incentives as retention interventions
is low (N=334, mean=2.36) in the scale of 1 to 5. The result revealed that, the
employees feel that there exists management favouritism and political interference in
the transfer and posting of these groups of employees.
Table 165: Scale of satisfaction of HR Practice for retentions –Non- Financial
InterventionsCategory Highly
Dissatisfied
Dissatisfied Neither
Satisfied Nor
Dissatisfied
Satisfied Highly
Satisfied
Physicians 2 (1.8%) 33(29.2%) 42(37.2%) 36 (31.9%) 0
Nurses 24 (24.5%) 26 (26.5%) 25(25.5%) 23(23.5%) 0
Mid-wives 15 (12.2%) 65(52.8%) 33(26.8%) 10(8.1%) 0
Total 41(12.3%) 124(37.1%) 100(29.9%) 69(20.7%) 0
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the nurses and mid-wives have the lowest level of
satisfaction that is mean=2.48 and 2.31, whereas physicians have mean=2.99. The
ANOVA test shows that there is a significant difference in the scale of satisfaction for
this theme among the three groups, the values of F(2, 331) = 17.722, p =.001.
Table 166: Descriptive statistics on scale of satisfaction of HR Practice for
retentions – Non Financial Interventions by the position of respondents
Category N Mean Std. Deviation Std. Error Min Max
Physician 113 2.99 .829 .078 1 4
Nurse 98 2.48 1.105 .112 1 4
Mid-Wife 123 2.31 .791 .071 1 4
Total 334 2.59 .950 .052 1 4
Table 167: Analysis of variance of Scale of satisfaction of HR Practice for
retentions – Non Financial Interventions among the workforce among
the group of respondents
Sum of Squares df
Mean
Square F Sig.
Between Groups 29.095 2 14.547 17.722 .001
Within Groups 271.710 331 .821Total 300.805 333
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4.6.6. HR PRACTICE FOR RETENTION - TRAINING AND
DEVELOPMENTIn this context Mark Twain’s statement is crucial which states. “There is
nothing that training cannot do. Nothing is above its reach or below it” (Ramani,
2003). Andragogy (the science of adult learning) demands tremendous effort from the
trainer what should be more effective and purposeful (Rao, 2003).
Skill up-gradation and multi skilling practices are much emphasizes in the
sector. Lot of skill up-gradation and multi skilling training are undertaken and the
physicians, nurses and mid-wives are satisfied with the process and most of the
workforce are attracted and retain themselves due to this factor in the sector. A major
pre-requisite for providing quality health care service is upgrading the skills and
knowledge of all health personnel as well as this is an integral factor for retaining
technical human resource in rural and remote areas. The Government is providing
frequent scope for programme based training with time to time refresher training to all
level of functionaries including ANMs, GNMs & Medical Officers. Huge investments
on the employees are done in the form of training and development opportunities.
There are different types of skill up-gradation training such at Skill Birth Training,
Medical Termination of Pregnancy, Life Saving Anesthesia Training, Emergency
Obstetrics Care, Neo-natal care etc. which are provided to physicians, nurses &midwives in primary and secondary level of health institutes. There is no
discrimination regarding the status of employment for proving various skill up-
gradation training. Availability of in service training opportunities can be seen as a
factor of attraction and retention of the employees in primary and secondary health
institutes in rural and remote areas. They are getting opportunity for skill acquisition
and have the access to all type of training in the department as per their eligibility and
location of the health institutes. They are provided with a wide variety of training
opportunity and provide exposure to different type skill up-gradation of their related
work and techniques. It can also be developmental in a wider sense of developing
both technical and professional skills.
The multi-skill trainings & capacity building of the workforce are emphasized
on physicians, nurses & mid-wives from the rural and remote area. Skill up-gradation
is an essential component of in-service training programmes. The skill up-gradation
varies enormously depending upon the qualifications of the personnel and the
institution where he/she is working. For optimum utilization of human resources, skill
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and competence enhancement is of paramount importance. Therefore, with the
objective to maintain the skill and competence level of the employees as well as to
improve upon these skills, different training programmes are designed and undertaken
in Health Sector.
The analysis of employee attitude survey revealed that the Level of
satisfaction of training and development as retention interventions is low (N=334,
mean=3.22) in the scale of 1 to 5. The result revealed that, the employees are to the
extent satisfied with the training and development practices of the organisation.
Table 168: Scale of Satisfaction of Training and Development
Category Highly
Dissatisfied
Dissatisfied Neither
Satisfied
Nor Dissatisfied
Satisfied Highly
Satisfied
Physicians 2 (1.8%) 27 (23.9%) 27(28.4%) 48 (42.5%) 9(8%)
Nurses 5 (5.1%) 26 (26.5%) 33(34.7%) 34(34.7%) 0
Mid-wives 6 (4.9%) 17(13.8%) 35(36.8%) 59(48.0%) 6 (4.9%)
Total 13(3.9%) 70 (21%) 95(28.4%) 141(42.2%) 15(4.5%)
The separate analysis of the scale of satisfaction of this component by the
group of these employees, the nurses have the lower level of satisfaction that is
mean=2.98, whereas physicians and mid-wives have mean=3.31 and 3.34. The
ANOVA test shows that there is a significant difference in the scale of satisfaction for
this theme among the three groups, the values of F(2, 331) = 4.658, p =.010.
Table 169: Descriptive statistics on scale of satisfaction of HR Practice of
Training and Development by position of the respondents
N Mean Std. Deviation Std. Error Min Max
Physician 113 3.31 .983 .092 1 5
Nurse 98 2.98 .908 .092 1 4
Mid-Wife 123 3.34 .948 .085 1 5Total 334 3.22 .959 .052 1 5
Table 170: Analysis of variance of Scale of Satisfaction of Training and
Development among the group of respondents
Sum of Squares df Mean Square F Sig.
Between Groups 8.382 2 4.191 4.658 .010
Within Groups 297.777 331 .900
Total 306.159 333
The overall descriptive table on satisfaction of employees on HR practice of
planning, recruitment and placement in respect of physicians, nurses and mid-wives is presented in table: 171 to 173.
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Table 171 : Descriptive statistics on level of satisfaction on HR practice of
planning, recruitment & placement in respect of physicians, nurses & mid-wivesSl. No. Dimensions N Scale Mean SD
1 Recruitment and selection process 334
1 to 5
2.43 .766
2 Policies for placement, transfer and promotion 334 3.28 .8053 Fairness of HR Practice for placement, transfer and
promotion
334 2.11 .715
4 Magnitude of management favouritism and politicalinterference in transfer and posting
334 2.36 .753
5 Response of administration/management on your
placement, transfer and promotional grievances
333 2.39 .824
6 Participation and involvement in the decision making
for placement and transfer
334 2.32 .694
7 Practice for retentions –Financial Interventions 334 2.13 .925
8 Practice for retentions – Non Financial Interventions 334 2.59 .950
9 Training and Development Practices 334 3.22 .959
Table 172 : Descriptive statistics on level of satisfaction of Contractual
employees on HR practice of planning, recruitment and placement
Attributes N Mean SD
Recruitment and selection process 154 2.51 .834
Policies for placement, transfer and promotion 154 3.20 .858
Fairness of HR Practice for placement, transfer and promotion 154 2.01 .657
Magnitude of management favouritism and political interference in
transfer and posting
154 2.41 .772
Response of administration/management on your placement, transfer and promotional grievances
154 2.36 .847
Participation and involvement in the decision making for placement
and transfer
154 2.36 .729
Practice for retentions –Financial Interventions 154 2.16 .937
Practice for retentions – Non Financial Interventions 154 2.38 .951
Training and Development Practices 154 3.36 .861
Table 173: Descriptive statistics on level of satisfaction of Permanent employees
on HR practice of planning, recruitment and placement
Attributes N Mean SD
Recruitment and selection process 180 2.35 .697Policies for placement, transfer and promotion 180 3.36 .752
Fairness of HR Practice for placement, transfer and promotion 180 2.19 .753
Magnitude of management favouritism and political interference intransfer and posting
180 2.31 .735
Response of administration/management on your placement, transfer and promotional grievances
180 2.41 .804
Participation and involvement in the decision making for placement
& transfer
180 2.28 .662
Practice for retentions –Financial Interventions 180 2.12 .917
Practice for retentions – Non Financial Interventions 180 2.77 .916
Training and Development Practices 180 3.11 .024
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CHAPTER- 5
MAJOR FINDINGS,SUGGESTIONS AND
CONCLUSION
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SECTION 1
MAJOR HR ISSUES IN
DISTRIBUTION OF PHYSICIANS,
NURSES AND MIDWIVES
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5.1.1. INTRODUCTIONAfter having an analysis and descriptive interpretational previous chapter, this
chapter presents the major findings on distribution, attraction and retention of
physicians, nurses and mid-wives in rural and remote areas. Section 1 highlights the
major findings of HR issues on Distribution, Section 2 highlights major HR issues on
Attraction and Section 3 highlights major HR issues on retention and Section 4
provides a preview of the specific findings on Health Sector Reform initiatives and
Section 5 presents the major issues in HR Practice related to attraction, distribution
and retention of physicians, nurses and mid-wives in rural and remote areas.
Thereafter, Section 6 highlights possible options in form of suggestion on the major
issues and followed by Section 7 the Conclusion of the study.
5.1.2.MAJOR HR ISSUES IN DISTRIBUTION OF PHYSICIANS,
NURSES AND MIDWIVES
5.1.2.1. DISPARITIES IN ESTABLISHMENT OF HEALTH INSTITUTIONS:
ISSUE OF HEALTHCARE DELIVERY SYSTEM WHICH LINK DIRECTLY TO
HR ISSUES.
Over the last few decades the establishment of health institutions in rural areas
of the state are haphazard and not kept pace with adhering to the norms. The state has
created 468 numbers of Sub-centres out of which only 286 no. of SCs are functional
likewise 119 PHCs were established, whereas functional 24x7 PHC is 29, and
functional CHC are 49 numbers, where as functional as FRUs is only one (1).
Moreover, the figures of the health institution at the rural areas are different in the
central database and the state figures.
Health institution Central Figure (RHS, 2010) State Figure
SC 286 468
PHC 97 119
CHC 48 49
However, the government have attempted the disparities and on the verge of
rectification and de-notification of many of the SCs in the rural areas, which were
created randomly.
The average population covered by the health institutions district wise has no
similarities and the nurses were not followed it ranges from 6064 to 781 population
for a Sub-centre in the districts. However, at the state level the figure is 2954 which is
better than that of the norms for a SC. While a PHC covers a population from 22048
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to 1590 in the district and the state figure is 11619 which is also a better figure at the
state level. Similarly, CHC covered a population from 8822 to 48513 and the state
level figure is 28217 which is also a better figure than that of the norms. This trends
show that the institution were randomly created without thinking the consequences of
human resource requirement and without keeping in mind the Govt. of India norms. It
seems the inter district disparities are there in respect of creation of the health
institution, which in repulsion create the problem of inadequacy of human resource
and inadequacy of importance.
5.1.2.2. THE HUMAN RESOURCE CRISIS IN RURAL AREA: NUMERICAL
INADEQUACY OF PHYSICIANS, NURSES AND MID-WIVES The ramped and unplanned creation of health institution in the state has
created a demand of Physicians, nurses and mid-wives. There is huge gaps of demand
and supply, placement of Physicians, nurses and mid-wives in the region.
Consequently, many rural communities/areas are deprived of the primary health care
and desperately need the attention. However, the population norms of establishment
of the health institutions does not fit in the state like Aruanchal Pradesh, because the
state have lesser population in comparing to the other states in India. The state has the
lowest density of population in the country. However, the norms are norms and
should be followed by the state. Besides, the in-equities in distribution of Physicians,
nurses and mid-wives, there is huge gaps and shortage of these category of health
workforce, to cater the maternal and child health needs as well as primary health care
in the state. This study found that there are geographical imbalances and shortages of
Physicians, nurses and mid-wives. The inequities in the geographic distribution of
Physicians, nurses and mid-wives, itself has meant too many rural and remote areas
with the shortage of Physicians, nurses and mid-wives.
This is a major reason for Arunachal’s weak health sector performance is due
to the crisis in the health workforce. There is a critical shortage of skilled manpower
like doctors, nurses and midwives. There are also shortages of personnel trained in
concerned disciplines like various specialists, we can say this deals with number and
the composition of health workforce, major public health issues. The health systems
of the region were characterized by an insufficient number of medical specialists,
MBBS doctors, and other professionals such as nurses and mid-wives. Other level of
problem is that at many places posts are vacant in wants of appropriate candidate or procedural delays in appointing staff.
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Shortage of human resources is a major problem facing Arunachal’s Health
sector, where more than 80% of the population lives in rural areas. Most of the
districts have the rural population, maximum of the districts are having urban areas
only in their District HQ and the rest are comprises of rural areas. Every District is
having a district level hospital in its HQ, but these hospitals are also having acute
shortage of manpower especially the graduate doctors, PG doctors and staff nurses.
Whereas, the availability of ANMs in the state is quite good but this category of
workforce is having an artificial crisis. However, under NRHM, doctors, staff nurses
and mid-wives are currently recruited on a contractual basis. Among the newly
recruited doctors, many of them do not join the service and some numbers leave the
job within short span of time.
As per the existing practices, staff nurse are recruited from those having
passed out of nursing college and the nursing schools at the state and off-course from
outside state. Although, the existing pool are not adequate to fill the vacant posts.
Further, new requirements have come up after the launch of central government
flagship programmes. There is demand for additional positions under these
programmes in many of the district out of their sanctioned posts. The vacancy rates
are particularly high for skills that are mostly needed. However, the determination of
sanctioned post and vacancies there on, is also not cleared at the district as well as the
state level. Most health occupations are highly interdependent when carrying out their
tasks. Problems in one professional category may spill over into another. For
example, a shortage of nurses resulting from inadequate planning may have adverse
effects on the work of doctors.
The shortfall of Physicians, nurses and mid-wives are continues to represent
one of the major constraints to the development of health services and access to basic
health care in Arunachal Pradesh.
According to the Indian Public Health Standards, the availability of HR is one
of the vital prerequisites for competency in the rural health care delivery system in the
country. It is also very important where 77% of the population lives in rural and
remote areas and poverty is the dominating factors among the population.
Requirement based on the IPHS norms for Physicians, nurses and mid-wives
for existence health institution are – 570 midwives with current shortage of 51%, 926
Nurses with current shortage of 70% and 510 Physicians with current shortage of
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53%. The shortage of mid-wives among the districts ranges from 6% to 82%, nurses
from 37% to 92% and 1% to 85% of physicians for all the existing health institution.
Similarly, the requirement for rural and remote area is similarly high. We find
that the requirement of mid-wives is 714 nos. with current shortfall of 65%, nurses is
747 nos. with current shortfall of 78% and physicians are 545 with current shortage of
66%. The situation is critical in respect of the requirement and the shortfall in rural
and remote areas. This is a serious indicator of inadequacy of Physicians, nurses and
mid-wives in rural and remote areas in comparison to the urban areas. The
requirement is more because of the concentration of more Physicians, nurses and mid-
wives in urban areas, which creates inequity in the distribution as well as the shortage
of Physicians, nurses and mid-wives.
Therefore, it is found that there is acute shortage of Physicians, nurses and
mid-wives in the region and especially in rural and remote areas, while the urban
areas have more concentration though there is also have the shortage in some
numbers. While, the disparity of distribution of Physicians, nurses and mid-wives in
rural and urban co-exists and contributing to the shortage and the huge gaps in the
region.
Thus, the poor availability of Physicians, nurses and mid-wives co-exists and
creating an imbalance and a problem with debilitating health care delivery system in
the region. The shortage of these categories of the health workforce is reaching the
crisis proportion and should be the centre of attraction of the government machineries.
5.1.2.3. PRODUCTION ISSUES OF PHYSICIANS, NURSES AND MID-
WIVES
Generation of health workers is another issue in the state. It has not been kept
pace with the need, especially with the physicians (MBBS) and nurses (GNMs).
Absence of adequate training institutes for medical and nursing courses results in low
numbers of medics and paramedics produced for the state. There is no medical college
in public sector or in private sector for Allopathic disciplines besides a Homeopathy
Medical College in private sector. Yearly a fixed numbers of students according to the
Govt. Of India quota seats, are placed in various Medical colleges all over India. 32
seats in First nomination 2010 and 34 seats in first nomination 2011 has been allotted
to the students for the MBBS course in various Medical Colleges in India (DHTE,
2010 & DHTE, 2011). For the training of nursing personnel, the state runs a lone
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Nursing School for ANMs at General Hospital, Pasighat, East Siang District of
Arunachal Pradesh. The institute runs training programs on midwifery (ANM)
nursing courses. There are no fix numbers of ANM admission seats per year in this
ANM School, in the year 2009-10, the number was 70, a year before in 2008-09, it
was 47. The variation depends on Government of Arunachal Pradesh continuing
changing policy. There exists a chronic and serious shortage of Nureses (GNMs) at
present time, as there is no GNM training school in govt. sector in Arunachal
Pradesh. A few number of GNMs are produced in GNM School at Ramakrishna
Mission Hospital, Itanagar. With this inadequacy in teaching schools, insufficient
numbers of professionally trained personnel to compensate the situation.
5.1.2.4. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVESAMONG THE DISTRICTS: GEOGRAPHIC INEQUITY
Adding to the acute shortage of manpower in the health sector in Arunachal
Pradesh, the issues and options for deploying health workforce is always a big deal of
concern. Mal-distribution, that is the distribution of health workforce is characterized
by urban concentration and rural deficits, but these imbalances are perhaps most
disturbing from a district perspective also. Urban/rural imbalance in the distribution of
health workers is a problem in the past and present also, and it may be worsening
more. There is an over-concentration of qualified health personnel in urban hospitals
and urban centres, coupled with shortages in poor neighbourhood districts and rural
areas that are not equally distributed, especially to manage change in the health sector.
Health workforce especially the nursing staffs, the physicians are concentrated
to the urban hospitals. Doctors and nurses are reluctant to relocate to remote areas and
forest locations that offer poor communications with the rest of the main land and few
amenities for health professionals and their families. Urban areas in the states are
good and convenient to health care professionals for their comparative social, culturaland professional advantages. The Health workforce have been reluctant to work in
rural and remote areas in the state, possibly because of little support at these areas, a
lack of material resources for them, poor working and living conditions, isolation
from professional colleagues and possibly less opportunities for self professionally
developed and Silently the education opportunities for their (workforce) children.
Moreover, there is a poor distribution of doctors as well as an acute shortage of
midwives outside the capital city, particularly in remote areas and sparsely populated
communities.
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Doctors and nurses are currently recruited on a contractual basis under
NRHM, among the newly recruited doctors and nurses do not join the service if they
are posted in remote and inaccessible areas in the state and some of them leave the job
within short span of time on being regularized or of other reasons. The percentage of
such doctors varies from district to district. Furthermore, there is no financial
incentive for Working in rural, remote and inaccessible areas, that’s why the problem
of geographic mal-distribution of health workers persists.
The majority of skilled health service providers are concentrated in urban
areas and the mal-distribution is concern for artificial crisis of health workforce in the
rural and inaccessible areas in the state.
The accessibility of Physicians, nurses and mid-wives has been threatened
mostly in the rural and remote area of the state. While 77% of the population lives in
rural and remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives
are serving in rural and remotes areas of the state. This creates urban and rural
imbalance in distribution. The phenomenon of urban skewness and mal-distribution
among the districts are there, consequently, many rural and remote areas are in
desperate need of the physicians, nurses and mid-wives. Thus, creating inequities in
the geographical distribution of physicians, nurses and mid-wives have meant a wide
range of rural & remote area are deprived of the primary healthcare at the doorsteps.
In Arunachal Pradesh, the depth of inequities in the distribution of physicians,
nurses and mid-wives in urban and rural area is truly a breathtaking. It is also found
that the distribution of physicians, nurses and mid-wives is skewed among the
districts. It is observed that the physicians, nurses and mid-wives concentrated to the
districts which are with good accessibility and communication. The specialist cadre
essential for the maternal and child health- Paediatrician, Gynaecologist and
Anaesthetist are almost zero in the rural and remote areas and only concentrated to the
urban areas. The 449 nos. of physicians are distributed across the health institutions
having 1:3079 of doctor population ratio, which is poor than that of the norms. The
doctor population ratio among the districts have different and ranges from 1506 to
8972 population per physicians (doctor). It is observed that the concentration of the
physicians to the district is asymmetrical and maximum of them are concentrated to
the three district with good communication and with more urban and semi urban area
and easy rural area accessibility. The distribution of the physicians ranges from 17%
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to 1% among the districts, which creates a wide gap in the distribution. The remotest
and harder districts have lesser number of physicians.
Similarly, the nurses share the same situation. 390 number of nurses area
distributed across the geographical boundary of the state. It is observed that the
similar situation like the physicians to nurses. The nurse population ratio is 1:3545
for the state and does not fulfil the norms. The nurses are also concentrated to the
same three districts as similar to the physicians. These three districts have good
communication and urban areas. The distribution of nurses among the districts ranges
from 23% to 1% among the districts. This trend resulted in Nurse Population ratio
ranging from 1597 to 9802. It is observed that the nurses are also concentrated to the
easy and good districts, whereas the hard and the remotest districts are deprived of the
adequacy of the nurses in rural area.
There are 542 numbers of Mid-wives and this category of health workers are
to be placed in SCs, which is the lowest and the first contract points to the population.
The mid-wives population ratio is 1:2551 in the state, which is also a worst among the
ratio norms. The density of min-wives among the districts has the inequities ranging
from 1 mid-wife serving 883 to 4722 populations. It is also observed similar to the
other two categories – physicians and nurses, that the distribution is also skewed
among the district. The district with good communication and urban concentration has
the highest mid-wives. The distribution ranges from 12% to 2% of the mid-wives
across the districts. The distribution pattern of the mid-wives in the region shares the
similar situation as the physicians and nurses have and concentrated to the same three
districts.
Thus, we found that there is poor distribution of physicians, nurses and mid-
wives, wherein the ratio and percentage of distribution varies across the districts.
5.1.2.5. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVES
IN RURAL AND REMOTE AREAS AMONG THE DISTRICTS There are 283 numbers of Physicians, 210 numbers of nurses and 390 nos. of
mid-wives distributed across the rural and remote areas of the state. This accounted
for 32% of physicians, 24% of nurses and 44% of mid-wives in this pool. Physicians
outnumbered the nurses, whereas in norms the nurses should outnumber the
physicians. Whereas, the nursing cadre in rural area consists of 35% of nurses and
65% of mid-wives.
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The total 283 numbers of physicians are distributed among the rural health
institutes across districts. The highest numbers are concentrated to the three districts,
which have easy to access rural areas from the urban areas. The percentage
distribution ranges from 13% to 2%, the deviation exist in the remotest and hardest
districts. While the doctor population ratio in the rural areas is 1:3797, which is 74%
deviation from the norms and wider that the state ratio of 1:3079. The district ratio
ranges from 1:1506 to 1:8972. The better ratio can be observed in the district with
smaller populated district followed by the same three districts which have highest
numbers of Physicians, nurses and mid-wives and have the good communication and
easy access of the rural areas.
Similarly, the distribution of nurses has almost the same picture as of
physicians. The 210 numbers of nurses are distributed asymmetrically among the
districts. The average rural population serve by the nurses is 5117, which is 90%
deviated from the norms. The distribution ranges from 16% to 1% among the districts.
The ratio ranges from 2164 to 15039 among the district. The better ratio among the
districts is of the three districts. Out of these, two districts are of good communication
and easy access of rural areas.
While, it is observed that 390 nos. of mid-wives are distributed
asymmetrically among the districts. The distribution pattern ranges from 9% to 2%
among the districts. The average rural population served by mid-wives is 2755 against
the 2551 of the state, which deviates to 82% of the norms. The mid-wives ratio ranges
from 883 to 6332 among the districts. The lowest population districts are having the
good ratio among the districts and followed by the good accessible districts.
Thus, we find that there is also poor distribution of Physicians, nurses and
mid-wives among the districts in the rural and remote areas.
5.1.2.6. URBAN AND RURAL DISPARITY IN THE DISTRIBUTION OF
PHYSICIANS, NURSES AND MID-WIVES IN WITHIN THE DISTRICTS: ACHRONIC PROBLEM
The inequitable distribution of physicians, nurses and mid-wives found
between districts. Almost all districts display serious disparities between levels of
physicians, nurses and mid-wives between urban and rural areas. Most of the
management representatives have a common consensus that the difficulty in
distribution of the workforce particularly in the district level. The process of the
transfer and posting are a challenging matter in the absence of the residential quarters
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and basic amenities at the rural and remote areas. They also pointed out that in the
absence of comprehensive HR policy it is very difficult to rationalise the distribution.
Overall, the shortage of the staffs is the main challenges in rational distribution of
staffs in the rural areas. It is a matter of concern that the urban areas are also running
out of the staffs and it is very difficult on their part to get equitable distribution. It is
also pointed out that there are many cases of personal and medical reasons in which
the management representative cannot force the staffs to be in the remote and rural
areas for long durations. It is also sensed from the interview that there is influence of
political pressure for the distributional process. However, it is not outspoken by the
management representatives.
Thus, the urban-rural disparity in distribution is observed within the districts.
The analysis of urban and rural distributional disparity was done in the previous
chapter, where the urban and rural areas were also defined in conceptual framework
section in chapter of literature review, as being based in a hospital in urban areas
especially only the institute in the district headquarter. Urban areas have 37% of
physicians in urban areas and 63% in rural areas. The figures ranges from 14% of
physicians to 57% of physicians concentrated to the urban health institutions within
the districts. The tendency of urban concentration has been observed in the study of
distribution of the physicians, out of 16 districts, 8 districts have more than 40% of
physicians concentrated to the urban health institutions of the districts, wherein only
one health institution is established in almost of the entire districts in the state.
This signals inefficiencies in the distribution of physicians, nurses and mid-
wives. The situation is grimmer in the cases of the nurses. The percentage of urban –
rural distribution is 46% and 54% respectively. It is observed the nurses are more
concentrated to the urban health institutions. The figures of urban concentration
ranges from 79% of nurses to 16% of nurses in the districts. The highest number of
concentration of 79% of nurses is in the capital district of the state. There are more
than 8 districts having more than 40% of nurses concentrated to the urban health
institution within the districts. This creates a huge gap in rural and urban disparities in
the distribution of nurses within the districts.
Moreover, the distribution pattern of mid-wives is 28% in urban and 72% in
rural areas in the state. However, the urban concentration of the mid-wives is
observed within the districts. It ranges from the 59% of urban concentration to 7% of
urban concentration. Basically mid-wives are meant for rural areas and meant for
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especially the SCs in huge numbers. But huge numbers are concentrated to the urban
health institutions. 8 nos. of the districts have more than 20% of mid-wives
concentrated to urban areas, creating a havoc situation in the rural areas. The most of
the mid-wives are concentrated to the higher health institutions in the urban areas.
Thus, we find a disparity in the distribution of Physicians, nurses and mid-
wives in urban –rural areas within the districts. These trends of Physicians, nurses
and mid-wives to gravitate in urban health institutions where urban areas have
facilities of good communication, accommodation and other basic amenities, this has
create a vacuum in rural area and left the primary health care in the mercy of god and
this in turn compels the rural mass to seek services to the urban tertiary level health
institutes. This situation has also created the patient crowd in the urban level health
institutions.
5.1.2.7. DECENTRALISATION OF DISTRIBUTIONAL FUNCTIONSDecentralisation of HR functions like distribution and deployment of
Physicians, nurses and mid-wives had a twin context, in the sense that the function of
distribution, deployment of contractual manpower is in the hand of district authority,
rather the deployment criteria centralised to state level for regular employees. The
second context was the transformation of roles in the health sector in response to
crisis in local level only. So, matters relating to the deployment and distribution are a
part of district authority as well as the state level authority.
The core HRM practices for the distribution according to the norms are based on
recruitment and selection process in the organisation. The recruitment and selection
process of physicians, nurses and mid-wives after the initiation of Reproductive and
Child Health programme in 1997 and subsequently National Rural Health Mission in
2005 has been concentrated to the contractual manpower and the process is
decentralised to the district level since 2010-11. The decentralisation of this process is
only for the contractual physicians, nurses and mid-wives. For the recruitment of the
permanent employee of this category, the contractual employees are regularised and
continued their services as regular employees, the process is basically based on the
sanctioned post vacancies and seniority based and the process is undertaken by the
Directorate of Health Services headed by the Director of Health Services.
However, decentralization of recruitment and selection process to the district
included HR planning, recruitment; transfer and maintenance of human resource have
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at the district level only for the contractual physicians, nurses and mid-wives. District
authority is now had to play a new role as employers, often without the appropriate
technical abilities to do so. The recruitment process under the decentralised
arrangement in the district is closely linked to the instruction and financial provision
at the state level.
The implementation of the decentralisation policy is only for the contractual
manpower in the district. But the appointment and deployment of the permanent
physicians, nurses and mid-wives are not comes under the decentralised recruitment
and deployment. So, it does not left any room for majority of the recruitment process
and deployment. Thus, the recruitment under centralisation, whereby the state level
would post permanent physicians, nurses and mid-wives to district may be without
taking into consideration the specific needs of each district. Thus districts requiring
more physicians, nurses and mid-wives could not get the required number or the
willed workforce.
5.1.2.8. OTHER ISSUES
In addition to the above major issues, the other persistent issues remain on
eyes. The issues are of data inconsistency on HR deployment, use of the data for
planning. In this study it is found that the information on human resource is in
consistence among the state and district level, while it is also found that the
inconsistency between the divisions of the health department. The official figures are
very difficult to match on and come to any conclusive and concrete data on the human
resource placement records, especially in the state level. This makes difficulty in
estimating and establishment of facts and plan accordingly. The situation is grimmer
in the state level taking the HR deployment data in the district level. There is absence
of data base related to deployment of physicians, nurses and mid-wives, which could
give the planner help.
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SECTION 2
MAJOR HR ISSUES IN
ATTRACTION OF PHYSICIANS,
NURSES AND MIDWIVES
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5.2.1. MAJOR HR ISSUES IN ATTRACTION OF PHYSICIANS,
NURSES AND MIDWIVES
5.2.1.1. COMPULSION OF STAY IN THE RURAL AND REMOTE
LOCATION
The study revealed that the workforces who are presently working in the rural
and remote areas of the state are either working to finish their minimum rural service
tenure for PG courses especially the physicians, or on non-transferable positions like
contractual employees or either they in transferred from other urban or rural areas by
the Management and political pressure or demand. The cases are different but
altogether they are staying at compulsion. It is found that 58% of the workforce is
service in rural and remote areas in the compulsion, either they are in hurry to
complete minimum rural service tenure or the nature of the position is non-transferable or Management relocations or in political pressure.
When the groups of physicians, nurses and mid-wives are compared
separately, 66% out of total physicians, 74% out of contract physicians and 63% out
of permanent physicians agreed that they are in compulsion posting. Whereas, the
group of nurses have, 49% out of total nurses, 71% out of contract nurses and 30%
out of permanent nurses are agreed on the compulsion posting. While, the group of
mid-wives have 58% out of total mid-wives, 77% out of contract mid-wives and 27%
out of permanent mid-wives have agreed the compulsion.
It is found that the situation is worst in the case of Physicians as more of them
are in compulsion. When it is compared of permanent and contract workforce, the
situation is worst on the part of the contractual. Secondly, the situation of the mid-
wives is also a matter of concern; this group have more percentages of compulsion
posting.
The situation of compulsion posting among the workforce is a matter of
concern and contributes to a high challenge for attraction and retention in the rural
and remote areas. In addition, attracting physicians to rural areas has been a
longstanding challenge (Rao, et al, 2009). In this study also we found that the
situation is more alarming of the Physicians. Evidence on compulsory service from the previous studies seems to be
unfavourable to the organisation. It seems to be less motivation and less commitment
of these workforces and it may result in weak health indicators and low quality in the
services. There are unanimous agreements in several studies that the compulsory
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positing does attract doctors, nurses and mid-wives to rural areas but there is no
guarantee of commitment and improved service in the rural areas. International
evidence on compulsory rural service has not been very favourable. Thus, such
compulsion was not well received and has not really succeeded in solving the long
term problem.
At best, it is seen to address health worker mal-distribution in the short term,
but tends to alienate people from the medical profession itself (WHO 2009). A recent
review of compulsory education schemes recorded that such schemes rarely got
support from health professionals, and health workers rarely continued on the same
job after the compulsory stint was over affecting continuity of care (Seble F et al
2010). Many international studies point out that compulsory rural service programmes
should be accompanied by support and incentives given to the health personnel (Liaw,
et al 2005, Omole, et al 2005). Whereas, in India, compulsory rural service is not
well-received by medical students. The level of opposition to this compulsion
suggests that implementation is a huge challenge especially with the currently weak
governance structures. Further, there exists little evidence of the effectiveness of
compulsory rural service initiatives. (Rao & Ramani, 2011). Compulsory rural
service schemes (with no incentive attached) may not be the best way to face doctors
in rural areas- such schemes have little appeal among doctors and adherence to such
schemes has been found to be lacking. The effectiveness of compulsory placement
has been assessed by descriptive surveys with inconclusive results (it addresses the
short-term mal-distribution, but is criticized for alienating people from the profession,
and for the difficulties in administration and enforcement) (Dolea 2009). In the Indian
context, linking Post Graduate (PG) programmes to rural service appears to be a
particularly influential incentive for attracting doctors to rural posts. There is a strong
desire for specialization among doctors after their first degree (MBBS). (Rao, et al
2011).
So, the main element in the attraction of the physicians, nurses and mid-wives
in the rural and remote area of Arunachal Pradesh here is compulsion rural postings,
and other factors contributes less among these groups of employees. Since, more of
them are in compulsion, that may lack in commitment towards work, team working,
absenteeism, lack of motivation and so on and so forth, which will create a non
performing environment within the system and resulted in to low indicator of health
services.
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5.2.1.2. LACK OF CAREER DEVELOPMENT OPPORTUNITYLack of career development opportunities seems to be one of the issues in the
attraction of these workforces. With the option of career development opportunity
only 23% of physicians, 21% of nurses and 29% mid-wives are attracted to the rural
area services in the state. The figures are alarming and it tells us that there is limited
scope of career development in the rural service in public health sector. The lack of
this component in the public health services in the rural and remote areas keeps the
physicians, nurses and mid-wives from the rural areas than that of the urban areas in
the state. The missing component of career development along with the promotion
opportunities in the rural health service seems to push away the physician, nurses and
mid-wives from the rural areas to urban which gives that a potentiality for personal
growth in profession, career development and they can be in job hunting if they are in
the urban areas in comparing to the rural areas. Career progression and development
is always an important point while dealing with the new and young physicians, nurses
and mid-wives. Thus, it seems from the selection of the respondents that there is no
enough scope of career progression that has attracted them to rural area and for new
entrants and it is also revealed that the nurses, mid-wives and especially physicians
are reluctant to work in rural areas as opportunities for career development were
typically less than in urban areas. So, the study found that the physicians, nurses and
mid-wives are at the present posting place at rural and remote areas not for that they
have the opportunity to progress.
5.2.1.3. INACTIVE RECRUITMENT STRATEGY
Recruitment strategy for the physicians, nurses and mid-wives for rural and
remote areas are not attractive and lack strategic recruitment and selection process. It
is found that the organisation is not utilizing other means of recruitment advertisement
other than that of newspaper advertisement. It seems that the strategy is only to lurethe local candidates for the services in the rural areas, whereas to attract it is necessary
for a wider circulation of the recruitment notices for a greater pool of potential
candidates who are interested for the rural areas services for either reason. The
organisation is not utilising the other strategy of recruitments and only relies on days
old form of recruitment and selection tactics. There is little information for HR policy
for the state or for the district. Absence of appropriate human resources policies, there
is always a hindrance in managing people at work. Effective recruitment, selection
practices are cohesively depends on the HR policies and in the absence of the same, a
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number of difficulties have been highlighted in the interview. The recruitment and
selection process in the sector is characterised as traditional way of approach, only
newspaper medium is used, no practical test, no scientific selection techniques used
and overall there is no written policies that the contractual positions will be
regularised if there is any relevant vacancies. The policy of the recruitment approach
focused on the same geographic areas where staffs were needed, in the expectation
that people would be less likely to want to transfer if they worked close to home. But,
unfortunately this not in reality, the findings revealed that the factor for attraction in
this study for preference for rural areas home town that is the current health facility is
closer to town or Closer to family and friends does have only minimum selection as
one of the factor of attraction are 16% for mid-wives, 20% for Physicians and 26% for
nurses. Moreover, in the absence of HR Policy in the sector is great hurdle on
recruitment and selections procedures. As many research studies concludes that in the
absence of the comprehensive state HR Policies the personnel decisions are too often
guided by favouritism, political dictates, and nepotism. As it is also seems that
recruitment of right people through scientific recruitment and selection process is a
significant aspect of HRM. The experience of the yesteryears in this sector in the
above context is traumatic. As the "new" employment structure requires new/or
modified HRM system to deal with the new organizational types and structure but the
researcher could establish the traditional way of acquiring and managing employees
are stand till date, there is still existence concept of personnel management rather
through the new concept of Human resource management and Human Capital
management. The study has revealed that recruitment of physicians, nurses and mid-
wives under a decentralised arrangement has only been characterised by complex
bureaucratic procedures and political influences and adversely affect the attraction of
this workforce of the government service in the rural areas.
5.2.1.4. LACK OF HOSPITAL INFRASTRUCTURE & RESOURCE
AVAILABILITY IN RURAL AREA AND POOR WORKING CONDITIONS
The study found that, the attraction factor of availability of equipment, drugs
and supplies for the smooth duty discharge of physicians, nurses and mid-wives is
very low. It comes to 8% of physicians, 4% of nurses and 3% of mid-wives that are
attracted to the rural and remote health care service in the state. It reveals that the
hospital infrastructure and resource availability is scares at the rural and remote areas.
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While looking at the data of the state public health sector, it is very depressing
and from no angle it seems the rural health service an attraction to this workforce.
Out of 486 SCs only 286 SCs are functional all together deviated from one or other
requirements. Taking 486 SCs at stock, 114 SCs are only with staff quarter, 212 SCs
are without proper water supply, 263 SCs does not have electricity. Out of 119 PHCs,
only 97 are functional (as per RHS, 2010) in which taking all 119 PHCs in stock, 52
nos. are without Labour room, 108 nos. are without minor operation theatre, 59 nos.
have indoor facilities and 53 nos. of PHCs are without electricity. Whereas in the 49
CHCs, 3 nos. does not have labour room, 12 nos. does not have OT rooms, 11 nos.
not having laboratories, X-ray machines in only 13 CHCs, only 3 of the CHCs have
quarter facilities for specialist for the CHC and none of the CHCs have atleast 30
beds. Overall none of the health facilities are functioning as per IPHS.
The situation of the poor health infrastructure and resource availability in the
rural areas is a matter of concern and which is an issues on attraction of physicians,
nurses and mid-wives. In the event of lack of equipments, drugs and supplies, it is
very hard for a physician, nurse or a mid-wife to discharge their duty adequately, it is
just like a soldier without arms in a battlefield. So, this is a very discouraging event
for the physicians, nurses and mid-wives to attract towards the rural area services.
However, this factor of attraction is not the only which can attract the physicians,
nurses and mid-wives by its alone.
While, the above points do have an impact on the working condition by which
the attraction of the physicians, nurses and mid-wives could have attraction. The
attraction from the improve working condition in the system in rural areas have
attracted only 10% mid-wives, 8% nurse and 10% physicians. In the absence of
hospital infrastructure and resource availability, it is obvious that the working
condition will be poor in nature and have an adverse effect on the attraction of the
physicians, nurses and mid-wives. Here in the system in rural areas, the working
condition is characterised by poor working conditions and lack of corresponding
inputs, which also contribute to the disillusionment of the health workforce.
Workforce in the different districts and health institutes in Arunachal Pradesh are
facing poor work environment and security at the workplace. Work conditions are
characterised by absence of proper facilities at the health centre, ill-equipments,
inadequate drugs and supplies, unusual working hours and excess work load,
inaccessibility of accommodation, water and electricity etc.
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5.2.1.5. LACK OF OTHER CADRES, TEAMWORK AND INTERPERSONAL
STAFFS RELATIONSHIP
Teamwork and interpersonal relationship is always a contributing factor for
attraction or leaving the job for any jobs positions. It is revealed that 2% of Mid-
wives, 3% of Nurses and 4% of Physicians have selected as one of the factor that
attracted to the rural and remote areas service. So, the organisation climate internally
is no conducive for the employees. In the absence of adequate cadres in the fields are
one of the non-attracting factors in the sector. It is also found in this study that the
lack of others cadres, teamwork and interpersonal relationship with Mean of 1.65 has
the highest mean among the factors for migration in rural to rural health institutes.
Good mixer of cadres is absent in many of the health institutes, as compared to
requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM atSCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs
without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses
in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without
doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians &
Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know
from the interview of the management representative that many of the health posts in
the rural area are manned by the less skilled workers like nursing assistant and other
semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and
mid-wives or rather they are staying at urban areas. The impact of this mal-
distribution on health care delivery in rural areas is profound, at times resulting in
primary health care facilities being staffed mostly by other staffs. As per primary data
available for this study, there are total no. of sanctioned sub centres are 468, out of
which only 301 have existing infrastructure, 222 No. of SCs having only one ANM
each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical
Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3
ANMs, none of the CHCs except are having full complement of specialists i.e.
Gynaecologist, Anaesthetist and Paediatrician.
And it is also revealed in this study that there is no good interpersonal
relationship between the permanent employees and the contractual. The contractual
are always look down and lack recognition.
So, the lack of good mixer of cadres, team work and interpersonal seems to be
an issue and concern in the rural and remote areas.
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5.2.1.6. POOR REWARDING, RECOGNIZING AND APPRECIATION OF
ACHIEVEMENT IN THE SYSTEM
The reward and recognition for the performance and achievement is not there
in the system which could attract the physicians, nurses and mid-wives in the rural
area service. The study findings revealed that none of the respondents have attracted
to the rural and remote areas due to this reason. There is no distinction of the
performer and non-performer and it is known by everybody in the system and outside
system in the public health sector in the state. The analysed results indicated that the
lowest mean factors with the lowest score. That means the absence of reward and
recognition for performance is one of the major issues for attraction of physicians,
nurses and mid-wives. It is well know factor in several studies that only the financial
incentives could not attract the health workers to the rural and remote areas. Almostall (90%) of studies discussed the importance of financial incentives on health worker
motivation. However, it was noted that financial incentives should be integrated with
other incentives, particularly with regard to migration where it was concluded that
financial incentives alone would not keep health workers from migrating (Shattuck, et
al., 2008). The reward and recognition and appreciation of service is a important
component of attraction in the rural area service, which is absent in the system in the
state.
5.2.1.7. POOR USE OF FINANCIAL (IN TERMS OF SALARY OR
INCENTIVES) MEANS OF ATTRACTIONFor the attraction of the physicians, nurses and mid-wives for the rural and
remote areas services the state does not have any concrete policies and
implementation. There are no financial rural incentives for the physicians, nurses and
mid-wives, however, there is a provision of hard area allowances under state govt.
norms for only for the harder areas but the allowances are so little that it is negligible.
The study revealed that none of the respondent has selected this option as one of the
reason behind the attraction. It is found that the factors that may motivate the
workforce to stay back commonly seem are financial incentives/ rural
allowances/performance incentives along with other factors. So forth, the same
situational factors may attract the physicians, nurses and mid-wives.
Nevertheless, low salaries were found to be particularly de-motivating as
health workers felt that their skills were not valued. Furthermore, they became
overworked when taking a second job to supplement their income (Shattuck, et al.,
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2008). Likewise the salary is also not competitive; there is no gaps or no difference
in the urban posting or rural posting and even more no difference in the salary of
performer or non performer.
It is found in this study that the contractual appointments are done majorly to
man the rural posts and the salary for the contractual are not competitive in compare
to the permanent workforce and associated with a low and stagnant salaries
especially for the contractual workforce.
Further, the lack of a linkage between the skills and experience of staff to their
remuneration package is absence the system. While, the compensation level of the
workforce place in the rural and remote area and the urban areas are paid the same
remuneration. The study found no difference in the pay range in the same category of
the health workforce, whether being posted in remote rural area or the urban areas of
the state. As here one can interpret that the remuneration and financial incentives for
rural and remote areas are not competitive than of the urban areas, resulted in non
attraction of the rural area services.
Thus, the issue of low remuneration or salary and non existence of the
financial incentives, which could in either, attract the physicians, nurses and mid-
wives in rural areas.
5.2.1.8. TRAINING AND SKILL DEVELOPMENT ISSUESThe study revealed that only 19% of the respondents have training and skill
development opportunities in their list of attraction. While, the data revealed that only
16% of Physicians, 26% of nurses and 17% of Mid-wives have selected the factors as
one of the factors of attraction for rural and remote areas. This seems that this factor
has a limited scope of attraction especially to Physicians and the Mid-wives than that
of the Nurses, however, the gaps are not wide and can be generalised that the factor
have no much contribution for the attraction of this workforce. This creates a vacuum
in the efforts of the health sector reform to greatly emphasize in the skill up-gradation
and multi-skilling training practices. The non-attraction by this factor could be that
the trainings are not given in regular intervals, with right access of the needs of the
employees etc. The main issues found in the study is there is no random access of
training needs, the planning of training and the execution of the same have a random
mismatch in the district and as well as in the state level. The training needs are
basically planned according to the services to be provided or it is in the health
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institutes, it’s no way access the personal training needs of these workforces that
could also enhance their skills in personal fronts and interest. Overall, it is also found
that the post evaluation of the training is not done and not in the process and not in
implementation at the ground level.
5.2.1.9. LACK OF SUPERVISION IN CERTAIN AREAS
Poor supervision and mentoring is always associated to the public sector. The
same situation can be seen in the public health sector in the state. It is found that none
of the respondents have attracted due to this factor. That means the factor have no
contribution to the attraction of this workforce. It is also highlighted by the
management representatives that in the absence of adequate workforce with trained in
the matter at the higher level of health institution also contributed to this issue and it is
a concern for the management. In reform initiatives the structural changes had taken
place but the situation of the supervision could not be changed or improved. While
putting light from the management representative interview responses that the
supervision services also suffers from the financial constraints, geographical
constraints and overall suffers from the skill scarcity that is scarcity of supervisors.
The supervision is lack in the upper health institutes than that of SCs, however, whole
of the workforce are not getting comprehensive supervision and mentoring.
Thus, this component does not have the weightage in the sector that could
attract physicians, nurses and mid-wives at the present scenario.
5.2.1.10. OTHER FINDINGS
5.2.1.10.1. FACTORS THAT ATTRACTED: CURRENT DETERMINANTS OF ATTRACTION AND PLACEMENTS
It is found that the compulsion posting is the major determinant of physicians,
nurses and mid-wives in rural and remote areas in the state. The other few factors are
career opportunity, health facility is closer to town or family and training and skilldevelopment. However, the majority influential factor is Compulsion and it is
statistically significant at mean test of 1.5. The study also revealed that the factor that
attracted physicians is basically on Compulsion. Beside this factor, other few factors
are -Continuing education/higher education Opportunities, Career development
opportunity. In the case of nurses also compulsion is the factor, by which they are at
the rural and remote areas. Beside the compulsion other few factors are- Current
health facility is closer to town or closer to family and friends, Training and skill
development Opportunities. In the case of Mid-wives also the have the same factor,
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the compulsion. Beside the compulsion, Career development opportunity, Training
and skill development Opportunities etc. Compulsion is only the factor which is
statistically significant at Mean Test Value=1.5 for all of the three groups.
5.2.1.10.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THEDEMOGRAPHIC CHARACTERISTICS
The study revealed the relationship of factors of Attraction and the
demographic characteristics of physicians. It is found that there is a relationship
between age group of the physicians and attraction factors like availability of
equipment, drugs and supplies ,; Authority, independency and autonomy, Amenities
like housing & conveyance provided, Safety at workplace and Current health facility
is closer to town or closer to family and friends. Similarly, Family background of the
physicians has the relationship to availability of good schools for children nearby
town. It is also found that the Marital Status of the physicians has relationship with
amenities like housing & conveyance provided; safety at workplace and availability
of good schools for children nearby town. Relationship also found of Length of
service and availability of equipment, drugs and supplies, Authority, independency
and autonomy, Compulsion, Amenities like housing & conveyance provided,
Teamwork and Interpersonal staffs relationship, Availability of good schools for
children nearby town and Current health facility is closer to town or closer to familyand friends. Similarly, it is found that there is a relationship between Nature of
Employment of physicians and attraction factors like Availability of equipment,
drugs and supplies, Authority, independency and autonomy, Career development
opportunity, Amenities like housing, conveyance provided. Wherein, we did not
found any relationship between the factors and sex of the physicians.
While analysing the relationship of factors of Attraction and the demographic
characteristics of Nurses, it is found that there is a relationship between age group of
the nurses and Career development opportunity, Training and skill development
Opportunities and Compulsion. No association has been found of marital status and
other attraction factors. Similarly, the length of services (group) has the relationship
to Career development opportunity, Compulsion, Amenities like housing &
conveyance provided and Current health facility is closer to town or closer to family
and friends. It is also found that the nature of employment has relationship with
Career development opportunity, Compulsion, Flexible working hour with minimal
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workload, Amenities like housing & conveyance provided and Current health facility
is closer to town or closer to family and friends.
While analysing the relationship of factors of Attraction and the demographic
characteristics of Mid-wives, it is found that there is a relationship between age group
of the nurses and improved working condition, Availability of equipment, drugs and
supplies, Training and skill development Opportunities, Compulsion, Flexible
working hour with minimal workload, Amenities like housing & conveyance
provided and Teamwork and Interpersonal staffs relationship. Similarly, we found
relationship between Marital status of Mid-wives and Amenities like housing &
conveyance provided, Availability of good schools for children nearby town, Current
health facility is closer to town or closer to family and friends, besides the
Compulsion. The length of service has a relationship with the factor of attraction like
-Availability of equipment, drugs and supplies, Continuing education/higher
education Opportunities, Training and skill development Opportunities, Flexible
working hour with minimal workload, Amenities like housing, conveyance provided,
Availability of good schools for children nearby town, Current health facility is
closer to town or Closer to family and friends, besides the Compulsion. Meanwhile, it
is also found that the nature of employment also have relationship with the factors of
attraction like Authority, independency and autonomy, Career development
opportunity, Continuing education/higher education Opportunities, Flexible working
hour with minimal workload, Amenities like housing, conveyance provided,
Teamwork and Interpersonal staffs relationship, Current health facility is closer to
town or Closer to family and friends, besides the above factor Compulsion also
contribute to factor relationship. However, we found no association between Family
Background and other attraction factors.
5.2.1.10.3. FACTORS THAT MAY ATTRACT - CHOICE OF CURRENT
PHYSICIANS, NURSES AND MID-WIVES
The few highest percentage selection of the factors are Higher Salary package
in compare to urban posting, Conducive working condition, Training and skill
development Opportunities, Access to amenities like housing & conveyance,
Financial incentives / Rural allowances/ Performance incentives, Safety at workplace,
Rotational Posting after completing minimum rural service tenure and Career
development opportunities. These factors are statistically significant at Mean TestValue (1.5). While the Mean Test value revealed the following factors significant
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factors for Physicians- Training and skill development Opportunities, Access to
amenities like housing & conveyance, Career development opportunities, Financial
incentives / Rural allowances/ Performance incentives, Rotational Posting after
completing minimum rural service tenure, Conducive working condition, Good
reward and recognition system, Higher Salary package in compare to urban posting
and Continuing education/higher education Opportunities.
While the combination of seven factors are having statistically significant for
Nurses: Higher Salary package in compare to urban posting, Conducive working
condition Access to amenities like housing & conveyance, Training and skill
development Opportunities, Financial incentives / rural allowances/ Performance
incentives, Good reward and recognition system and Safety at workplace.
While the combination of ten factors are having statistically significant being
found for Mid-wives: Higher Salary package in compare to urban posting, Access to
amenities like housing & conveyance, Conducive working condition, Training and
skill development Opportunities, Good reward and recognition system, Rotational
Posting after completing minimum rural service tenure, Financial incentives / Rural
allowances/ Performance incentives, Continuing education/higher education
Opportunities, Career development opportunities and Safety at workplace.
While analysing the variance in the choice of the factors that may attract the
physicians, nurses and mid-wives, it is found that there is difference in the groups in
the view of factors that may attract to the rural and rural areas services. It is found that
the physicians may be attracted to the rural and remote area service when they see
there is scope of training and skill development, a good working environment,
accommodation facilities, incentives and recognition system with a competitive salary
that is more than that of urban areas. That meant that the physicians first look at self
development by training and development, living condition and to the monetary
factors. While, the nurses and mid-wives have attraction of higher salary first, good
work environment, accommodation training and development, recognition and Safety
at workplace. That meant that the group of nurses and mi-wives are more attracted to
financial benefits and then they look after the work and living condition and off-
course to the Safety at workplace. Thus, it meant that the preferences are not in the
same order and the factor cannot be generalised for all the three groups.
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SECTION 3
MAJOR HR ISSUES IN
RETENTION OF PHYSICIANS,
NURSES AND MIDWIVES
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5.3.1. MAJOR HR ISSUES IN RETENTION OF PHYSICIANS,
NURSES AND MIDWIVES
5.3.1.1. ISSUES OF INTENTION OF INTERNAL MIGRATION AND
RETENTION
The study revealed that the factors that hindering the state’s effort to retain
physicians, nurses and mid-wives in rural and remote areas are the migration of these
health workforces within the state, very negligible amongst them are intent to search
for an alternative employer. The major problem within the board is the problem of
rural-urban migrations than that of rural to rural migration or outside migration. The
study reveals that only 19% of them want to continue with their present rural posting
place. 24% wants to shift to another rural health institute, 51% wants to shift to
another urban health institute and 6% wants to shift to another job in some other
State/sector in search of an alternative employer. This shows that the physicians,
nurses and mid-wives are eager to shift their current locations. It was also revealed in
the attraction findings that more than half of the workforce that is 58.1% of these
groups is located in the present rural and remote locations in compulsions and it is
obvious that these groups are very eagerly intended to shift their locations.
This is an issue for the group of the physicians that 41.6 % of them intend to
migrate to urban area, 24.8% physicians willing to migrate to other rural area and
7.1% Physicians willing to search for an alternative employer. Wherein, 50% of
nurses are willing to migrate to urban area, 19.4% nurses willing to migrate to other
rural area and only 25.5% wants to retain in the present health institution in rural area
and 5.1% nurses intend to search for an alternative employer. Similarly, 59.3% of
mid-wives intend to migrate to urban area, 27.6% mid-wives willing to migrate to
other rural area and 6.5% nurses intend to migrate in search of new employer.
Similarly, at the other side of the coin which is also an important angle toaccess the issue of migration that is the nature of the employment of these groups. The
finding are 51.3% of contract physicians, nurses and mid-wives are intend to migrate
to urban area, whereas, 50% of the permanent physicians, nurses and mid-wives have
that intention. So, more of the contractual are intended to migrate.
This study also revealed that the intention of migration of this workforce is
related with the level of job satisfaction of these groups of health workforce and
propel them to migrate. The variable job satisfaction is significant at p<.001, has an
impact on the decision of employees to stay at the present rural place of posting.
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While, the study revealed that there is no significant relationship of job satisfaction
and parallel migration from one rural area to another rural area. It is also explore that
there is a strong relationship of the job satisfaction and urban migration. The variable
job satisfaction significant at p<.001, has an impact and predictive power for the
decision of employees to urban migration. Job satisfaction also has significant
relationship and predictive for migrating in search of an alternative employers.
This intention of migration of physicians, nurses and mid-wives is attributed
by several factors within the health system and it’s co-exist external environment. The
Factors that contributed for migration of the physicians, nurses and mid-wives as a
whole, from the present rural area to other rural area, urban area or to leave the sector
have two factors significant that are the Lack of adequate financial incentives / rural
allowances/performance incentives and poor working condition.
The Factors contributed for intention of migration of the permanent physicians
have the Lack of adequate financial incentives. While, contract physicians have three
factors significant that are the Poor salaries, lack of adequate financial incentives and
lack of Career development opportunities. For intention of migration of the nurses
have two factors, the Lack of adequate financial incentives and Poor working
condition. In which, permanent nurses have the Lack of adequate financial incentives
/ rural allowances/performance incentives. While, contract nurses have two factor that
is the Poor salary and Lack of adequate financial incentives.
The Factors contributed for intention of migration of the mid-wives have two
factors, the Poor salaries and Poor working condition. In which, permanent mid-wives
have two factors that is the Lack of adequate financial incentives and Poor working
condition. While, contract mid-wives have two factors that is poor salaries and Poor
working condition.
The issue of intention to migrate according to the place of choice is that the
highest number of 51% of them is intended to migrate to urban areas. The factors that
contribute highest to migration of this workforce to urban areas have two factors, the
Poor working condition and Lack of adequate financial incentives. While, factors that
contributed to the intention of migration to another rural health institute had the lack
of others cadres, teamwork and interpersonal relationship and lack of Autonomy.
Similarly, five factors found for migrating outside the state, the Lack of Career
development opportunities, Poor salaries, Lack of Job security, Lack of adequate
financial incentives and Lack of scope for continuing education/higher education.
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The need is to understand the various factors which motivate physicians,
nurses and mid-wives to retain themselves in the present rural posting for taking
decisions into consideration for planning the financial as well as non-financial
incentives, thus, the factors that may motivate the physicians, nurses and mid-wives to
retain themselves in the present rural area have the four factors -financial incentives,
improved living condition, career development and Good reward and achievement
recognition system. For the physicians are financial incentives for rural postings,
Improve living conditions, Career development opportunities, improved working
condition and Good reward and achievement recognition system. While, contract
physicians have six factors, Career development opportunities, Opportunities of
continuing education/higher education, financial incentives for rural posting, Improve
living conditions, Increase salary by half & Job Security. Similarly, the permanent
physicians have five factors, financial incentives for rural posting, Improve living
conditions, improved working condition, Career development opportunities and Good
reward and achievement recognition system.
The motivational factors that may motivate the nurses have three factors,
Financial incentives for rural posting, Improve living conditions and Career
development opportunities. While, the contract nurses have five factors, financial
incentives for rural posting, improve living conditions, Career development
opportunities, Increase salary by half and Job Security are statistically significant.
Similarly, the permanent nurses have three factors, financial incentives for rural
posting, improve living conditions, Good reward and achievement recognition system.
The factors that may motivate the mid-wives have three factors, financial
incentives for rural posting, improve living conditions and Good reward and
achievement recognition system. While, the contract mid-wives have six factors,
financial incentives for rural posting, improve living conditions, Increase salary by
half, Job Security, Good reward and achievement recognition system and Career
development opportunities are statistically significant. Similarly, the permanent mid-
wives have three factors, financial incentives for rural posting, Improve living
conditions (Access to amenities like housing, water, electricity, conveyance and
communication) and Good reward and achievement recognition system are
statistically significant.
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Thus, the issue of migration is a major issue in the sector, more of the
workforce wanted to migrate to urban area. So, the major problem within the board is
the problem of rural-urban migrations than that of rural to rural migration or outside
migration and Job satisfaction as a decision maker theme.
5.3.1.2. ISSUES OF DECLINE AND VARIANCE IN JOB SATISFACTIONIn this study finding, in addition to the other issues and concerns, there is a
growing dissatisfaction among the physicians, nurses and mid-wives in presently
working in the rural and remote areas. The mean of overall scale of job satisfaction of
these entire workforce is 2.26 (N=334) in a scale of 1-5, which shows an average low
scale of satisfaction. In the group comparison, the Physicians (2.53, N=113), Nurses
(2.32, N=98) and Mid-wives (1.98, N=123) means respectively. This shows a lower
job satisfaction in the groups this workforce. Low job satisfaction and motivation can
lead to non-adherence to guidelines, dangerous practices, or negative attitudes
towards patients (Rowe et al, 2005 as cited in Logie et al, 2008). The analysis also
shows that the groups of Mid-wives have the lowest scale of job satisfaction, followed
by the group of nurses and the physicians. The satisfaction of Physicians are little
higher than that of the other two groups and the trend of declining job satisfaction is
seen according to the category of employment as the lower groups is having declining
job satisfaction. This may be that the lower group are being posted at the lower health
institute and they represent a more remote and rural location. The Medical professions
like doctor and nurses has been long among the most attractive and satisfied
profession in the society, but when it is analysed in the context of rural and remote
area services, the results suggests that these group of employees are increasingly
dissatisfied with their jobs in rural and remote areas.
It is already explained at the above point of migration and the intention of
migration of this workforce is also related with the level of job satisfaction of these
groups of health workforce and propels them to migrate. It is one of the determinants
of the retention and migration of the physicians, nurses and mid-wives. It is well
known that the job satisfaction is effected by the demographic attributes of the
employees. It is found statistically significant that there is a positive relationship of
job satisfaction with the age, length of service, place of posting and nature of
employment. It is found that as higher age employee has higher job satisfaction,
higher length of service has higher job satisfaction, employee posted at the higher
level of health institute has higher job satisfaction and permanent employees have the
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higher job satisfaction than the contractual employees. It is also found the correlation
between the marital status and job satisfaction. However, it is found that there is no
relationship between family background and job satisfaction of employees in rural
setting. Thus, statistically it seems that age, length of service, place of posting and
nature of employment has the positive impact on job satisfaction in the rural setting.
While in the group of Physicians, it is found that there is a positive
relationship of job satisfaction of physicians with the age, length of service, and
nature of employment. No relationship found between family background and job
satisfaction of employees in rural setting. While in the group of nurses, it is found
that there is a positive relationship of job satisfaction with the age, length of service
and nature of employment. While in the group of mid-wives, it is statistically
significant that there is a positive relationship of job satisfaction with the age and
nature of employment and the correlation between the lengths of service. No
significance found in marital status and family background with job satisfaction.
However, in entire group of the workforce the common demographic in context of
the nature of employment has a relationship with the job satisfaction or dis-
satisfaction in rural setting. It is found that Salary and Training & Skill development
opportunities are the main contributors to the Job satisfaction in current time of
physicians, nurses and mid-wives altogether in rural and remote area setting.
Thus, there is a growing dissatisfaction among the physicians, nurses and mid-
wives in presently working in the rural and remote areas, more on there is an issue of
job satisfaction differentiation between the groups of physicians, nurses and mid-
wives and the job satisfaction if diminishes according the lower category and it also
revealed that there is a gap of job satisfaction between the contract workforce and
permanent workforce at large. Only the components like Salary and Training & skill
development opportunities found to be the main predictors of job satisfaction and no
other factors found to significantly contributing to the job satisfaction in these
categories of health workforce at the present time in the rural setting.
5.3.1.3. LACK OF ADEQUATE FINANCIAL, RURAL ALLOWANCES AND
PERFORMANCE INCENTIVES
As it is mentioned in earlier sections that the Health workforce are reluctant to
work in rural and remote areas in the state, possibly because of little support in these
areas, a lack of material resources for them, poor working and living conditions,
isolation from professional colleagues and possibly less opportunities for self
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professionally development. To fuel on this the study found that there is no financial
rural incentives for the physicians, nurses and mid-wives, however, there is a
provision of hard area allowances under state govt. norms for only for the harder areas
but the allowances are so little that it is negligible. Whereas, such allowances for the
contractual health workforce are not recorded in this study. The questionnaire survey
with the options has not selected by any of the respondents that has contributed their
attraction factors or retention factors. It is found that the factors that many motivate
the workforce to stay back commonly seem are financial incentives/ rural
allowances/performance incentives along with other factors.
In the light of no provision of such incentives for the physicians, nurses and
mid-wives for rural area services and the compensation package also is same
irrespective of the place of posting. Other non financial incentives such quarters with
electricity, water facilities etc. are also not in the system to retain the workforce in
those underserved areas.
Moreover, other rewards system linked to performance is also not the system,
resulted to the low morale and motivation of the workforce. The below statement was
found in the documents of the state govt. but till now there is no sign of such
incentives in the field.
“To motivate the manpower located at remote and hard areas will be
given incentives. The incentives will be conditional on regular staying and performance based. The incentives will be given through respective RKS at
facility level. Detail incentive policies are addressed under NRHM Additionalities”-(Govt. of Arunachal Pradesh, 2009, SPIP 2010-11)
Staff job satisfaction has been affected through rapid change, and the
perception of health workers that their compensation levels and working conditions
have been negatively obviously affected the motivational level of physicians, nurses
and mid-wives.Thus, it is one of the major issues; a mixer of interventions both financial and
non-financial is not in place for retention of human resource. Though, the health need
related issues are looked into by the individual states and Govt. of India supports
financially. All the states prepare annual plans to include this intervention in human
resource issues, but still there are no accounts for these incentives in the field.
Few statements on incentives by the respondents are:
“Furthermore, there is no provision of extra incentives till date for us living
in rural area and even did n’t heard about this in my 3-4 years of rural posting ". –A Physician.
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“ Financial incentives only will not be adequate for us, what do here in rural and remote area….. if we cannot make use of that money in a productive and
entertaining way…, no basic amenities like good housing, regular water and
electricity supply, good road connectivity is not there”. –A Physician.
According to the State Programme Implementation Plan, 2011-12 of all thestates, in order to ensure stay of Health workers in difficult rural and remote areas, the
states proposed incentive schemes. However, the incentives are yet to be seen
materialized, it may be due to financial constraints in the state.
5.3.1.4. ISSUE OF EQUITY IN COMPENSATION:
It is found in this study the public health service is associated with a low and
stagnant salaries especially for the contractual workforce. The issue of low
remuneration or salary is consistent for the health workforce especially for thecontractual employees, the recent pay enhancement corresponding to the Pay
Commission recommendation in the state has been only implemented to the regular
staffs and it has also created a wide gap in the pay parity of contractual staffs and the
regular staffs, but the compensation level was enhanced little to this groups in the year
2011-12, but no how it reaches the level of the regular workforce in the same working
conditions and the nature of job.
As here one can interpret that the contractual health workforce in Arunachal
Pradesh are underpaid, poorly motivated and very dissatisfied and may have an
adverse impact on the health delivery system. Further, the lack of a linkage between
the skills and experience of staff to their remuneration package is absence the system.
While, the compensation level of the workforce place in the rural and remote area and
the urban areas are paid the same remuneration. The study found no difference in the
pay range in the same category of the health workforce, whether being posted in
remote rural area or the urban areas of the state. Moreover, the workforces that are
posted in the urban areas have other options for earning if they will to do so. There are
greater opportunities in urban areas for additional incomes to supplement the ever
increasing inflation that that of rural and remote areas. This creates a burn out in the
rural and remote area physicians, nurses and mid-wives and adversely affects their
retention intention. Moreover, as a result of poor compensation, the available
workforce such as physicians, specialist, nurses and mid-wives do not want to join the
duty and serve in rural areas for longer duration. There is no clear cut policy
implementation regarding duration of service in rural areas by these categories of
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workforce. Over all it is also mentioned in the earlier point that there is no financial
incentive for working in rural, remote areas. Low pay ranges is also a major reason
for the sector to face difficulty in attracting and retaining staff along with there are no
differences in the compensation packages for serving in urban, rural, inaccessible
areas. Thus, the state is failed to use the Salary component as means of retention of
physicians, nurses and mid-wives in rural and remote areas. The government has
failed to raise the real value of compensation differentiation on the basis place of
posting to be using it as a retention strategy.
Here, it is also understandable on the part of the government to unable to raise
the salaries but the govt. is no doubt capable of being develop a policy implication on
different pay structures for the urban and rural with remote areas for retention of the
physicians, nurses and mid-wives.
5.3.1.5. DISPARITY IN REGULAR AND CONTRACT WORKFORCE,
AFFECTING ADVERSELY IN JOB SATISFACTION AND RETENTION:
We found that contract workforce is more dissatisfied from the job than the
permanent workforce. In the group comparison as per the Nature of Employment, the
means of contractual employees (1.99, N=154) and permanent (2.50, N=180)
respectively. This interprets as the contractual employees have low job satisfaction in
comparison to the permanent employees. There is a difference in the job satisfaction
between the groups. The mean difference is -.513 between the contractual and
permanent employees.
If we analysed the situation in categorizing the workforce in nature of
employment, we found that contract workforce are more dissatisfied than the
permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2%
are satisfied in the group of the contracts. While, the permanent employees have 9.6%
are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only 0.6% arehighly satisfied. Thus, permanent employees have the higher job satisfaction than the
contractual employees.
The job characteristics of contractual employment are very much responsible
for motivating factors to the contractual employee, the factors such as job security,
low pay, no benefits and other factors are fuelling the low satisfaction and low
motivation in the employees. Contract employees are less satisfied with certain
aspects of their jobs, than permanent employees. Contract people are also in job stress
from workload and lack of opportunity for career advancement. Contractual
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employees receive fewer fringe benefits, have no promotional opportunities, and
receive little or no long training opportunities. Therefore, a job with fewer of these
characteristics would reduce the person's job satisfaction.
While exploring to the variance of factors of job satisfaction in between the
contractual and permanent physicians, nurses and mid-wives, it is observed the
components like salary, job security, career development opportunities, opportunities
of continuing education/higher education, Teamwork and Interpersonal staffs
relationship and Access to free accommodation (Housing) have the differentiation.
While talk about there is differentiation in the compensation package another issue of
job security is one of the most significant issues in contractual employments, which
may create a greater sense of insecurity in short-term and long-term. Moreover, the
work life balance is tough in the context of this contract workforce, who gets only few
days of causal leave with no other kinds of paid leave as compare to the permanent
employees, the contract employees face the difficulties to maintain the family and
work life balance. There is no flexibility for contract employees for leaves to dispose
of their family duties. “Juggling between family and contractual is very difficult”-
one of contractual employee said while informally discussing the topic.
Financially the compensation is less, when they compared their incomes to
those of permanent employees. Contract employee is not eligible for benefits, other
employment benefits, pension plans, medical and dental benefits, life insurance,
educational reimbursement and training etc. “Even the bank is not providing loan to
me as I am a contractual employee” – one of contractual employee said while
discussing the topic. Human resource policies define how an employee is treated in
the workplace, which is absence in the reform process in the sector. There is an
inequity in perception in respect of contractual employees in respect of opportunity
within the organisation, with fuelling of no definite path of career advancement and
most of them are of younger generation and concern about their career advancement
as well. There also an existing of a cold ill treatment of contractual employees by the
fellow permanent employees at the work place. This makes contractual employee
stress, and affects the working ability of the employee. The more stress comes when
under to meet the demands of contract employment. All contract employees (who
were informally interviewed including ) admitted suffering stress connected to contract
employment. “I felt discriminated when I sat with other permanent employees of the
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department and when they talk about enhanced pay package and accumulated arrears
being paid to them”- one of contractual mid-wife said while discussing the topic.
So, these staff motivation has been affected through rapid change, and the
perception of health workers that their compensation levels and working conditions
have been negatively affected the satisfaction level converted to low motivational
level.
5.3.1.6. POOR WORKING CONDITION:
It has long been known that employees behaviour and attitudes are affected by
the nature of the work they do and the environment they do it in. Much
experimentation and research have taken place in attempts to discover optimal designs
of work and workplaces for maximizing results in organizational improvement and
quality of working life. The studies of Kagi (1985) and Surti (1986), confirms the
desire of workers for better working conditions. Working conditions in the absence of
necessities for human resource in health sector in Arunachal is yet another major issue
in this confront. The working condition is characterised by poor working conditions
and lack of corresponding inputs, which also contribute to the disillusionment of the
health workforce. Workforce in the different districts and health institutes in
Arunachal Pradesh are facing poor work environment and security at the workplace.
Work conditions are characterised by absence of proper facilities at the health
centre, ill-equipments, inadequate drugs and supplies, unusual working hours and
excess work load, inaccessibility of accommodation, water and electricity etc. Work
required certain supplies and logistics which are currently inadequate. These supplies
and logistics should be made available adequately thus ensuring steady and better
service delivery. Added to the ill health infrastructure, absence of proper equipments
and proper office infrastructure, there is no proper toilet facilities in maximum of the
health facilities especially for the woman workforce, which may adversely affect.
Often poor working condition resulted in frustration, low motivation less
effectiveness, and sustainability among the workforce especially in woman
workforce. Thus, poor working conditions and lack of corresponding inputs also
contribute to the disillusionment of the health workforce.
According to Rural Health Statistics (2010), in the state out of 286 SCs only
114 (39.9%) are with quarter facilities, 12 (4.2%) are without regular water supply, 63
(22%) without electricity and out of 97 functioning PHCs, 31 (32%) is without
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electricity, 29 (29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are
having residential facility for specialist physicians.
Few statements by the respondents on work condition are:
“We are overburden, not with our clinical practice…….there are hardly
5-10 patients in this place daily, which is not a matter of concern for us. But what I am writing about is the managerial and programme management
works entrusted upon us. We are technical and clinical persons, but various
health programs including the health institutions management are to be look
after by us alone with little support of staffs for these works.”-Physician.
“My requirements for works are clinical equipments, adequate medicines
and finance. My requirement was of Rs. 4 lakhs but they provided me as little
as 50,000/- to 80,000/-. So, how can I work in this situation.”-Physicians. “We are teaches for patients care- putting IV fluids, injections,
medicines, bed and ward management…. But here I have to work for all these including maintaining huge registers daily, preparing reports in many
numbers for all health programmes and also management of this healthinstitution.”-Nurse.
"We are performing without adequate supplies and equipments, working
condition should be crucial at the work place."-A Physician respondent.
We can interpret the above statements by the respondents that they are very
much involved and concerned about their working environment. They are entangled
between the clinical and programme management work at present environment. They
also emphasized for adequate supplies, equipments and adequate funding for
discharging their duties of rural health care services.
"Urban areas in counterpart are rich living standards and better income
opportunities. I can even practice privately after my duty hours, where I can
earn a little to support my financial earnings. Overall I am fade up of the less
patient load, sometimes it comes to nil. I can’t keep pace with my clinical side…
I m forgetting all my learning of practice here… now I am becoming a dak (official letter) runner or above that I am becoming a good clerk. This is the
situation where I am becoming isolated from my profession.”
With the above comment of the respondent, it is known that not only the work
environment characterized with over burden, which makes an effect on the interest of
the respondent. But as a professional they are worried about the patient load in their
health institutes in rural area. They can’t keep pace with their clinical side practice in
some of the rural areas. So, overburden as well as under-work makes an effect on the
situational preference of rural services.
Many medical, technical, and managerial positions in health programs and
facilities are needed in a health sector reform environment, and scarce medical
personnel are misused for management tasks at various levels. The supply of professional staff is now severely constrained at the leadership and managerial levels.
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Shortage of human resource for health with ill-equipped, both technical and
managerial workforce at various levels often resulted in duality of roles, overburden
and workload to the existing health workforce. Staff shortages have increased the
workloads and stress levels, further de-motivating the physicians, nurses and mid-
wives. The formal as well as informal discussion with the staffs for this study shows
that the staffs are frustrated for the duality or roles, over burden with the works and
the workload, with additional with lack of equipment to discharge their duties.
As many of the technical/ clinical health workforce have to do the managerial,
health data information works and other financial management works for which they
not appointed. In this situation they have to often discharge a duality of role in the
existing system and they have to divide themselves for clinical works and other
managerial works, which often have an adverse impact on the discharge to their own
duty of primary health care for the mass. Health workers described their workload as
being relatively to the data and financial related work and often lead them to work
stress. It is the result of new structures, practices, and technologies are imposing a
heavy strain on an already weak human resource base in the health sector.
While with the quantitative data findings revealed the factors that may attract
physicians, nurses and mid-wives for rural and remote services has the working
condition component and followed the percentage of selection of 74%. It is analysed
and found that the factors that contributed for intention of migration of the physicians,
nurses and mid-wives- from the present rural area to other rural area, urban area or to
leave the sector have the factor of Poor working condition after Lack of adequate
financial incentives/ rural allowances/performance incentive. The factor of poor
working condition and inadequate equipments, drugs and supplies have accounted as
top factors for intention of migration among the physicians, nurses and mid-wives.
While the impact of health sector reform on work condition is a matter of
concern. They do not agree upon that the reform process has made their work load
manageable but rather they think more unmanageable at their level. Thus, it reveals
that the workload is more unmanageable to all level due to the reform process. The
statement that reform has improved the availability of equipments, drugs and essential
supplies for performing the assigned tasks for the respondent’s posted rural health
institutes has been agreed in group responses. The group of mid-wives has lowest
mean than that of the two other groups. Thus, it seems at the mid-wives do not get
adequate equipments, drugs and essential supplies and the reform has failed to
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provide them as well, in comparison to the physicians and nurses. Thus, it reveals that
the reform has failed to address 360 degrees of these needs too.
5.3.1.7. POOR LIVING CONDITIONS
Poor living condition is directly not comes under an HR issues but it affects
the availability of workforce in the rural and remote areas of the state which have lack
of road network, hilly terrains, lack of communication, transport, other
communication facilities and lack of accommodation facilities, lack of television and
radio services and other recreation facilities, lack of effective communication systems
like telephones and mobile service at the place of posting resulted in lack of proper
living environment. The physicians, nurses and mid-wives have disinclined to rural
services, primarily due to absence of accessibility of communication and basicamenities in rural and remote areas. Some of the places are only reachable on foot and
more of the rural and remote areas living standards are characterized by poor basic
facilities and amenities, for which reluctances in workforce can be seen. RHS, 2010,
in the state, out of functional 286 SCs, 95 (33.2%) is without all-weather motor able
approach road. Out of 97 functional PHCs, 11 (11.3%) without all-weather motor able
approach road, 13 PHCs (13.4%) only with telephone facilities and none of the PHCs
having computer access facilities. While, out of 286 SCs only 114 (39.9%) are with
quarter facilities, 12 (4.2%) are without regular water supply, 63 (22%) without
electricity and out of 97 functioning PHCs, 31 (32%) is without electricity, 29
(29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are having residential
facility for specialist physicians.
Absence of accessibility and basic amenities in rural areas is more emphasized
by the respondents in this study. Few statements by the respondents on the
accessibility and amenities are:
"Urban areas are good and convenient because they provide us with basic
facilities and amenities which are needed for a human being in today’s world. But
here posted in rural and inaccessible area, where we are disconnected to outer
world due to the natural and topographic reason. This deprived me of basic
facilities like good accommodation quarter, electricity, and over all connectivity
like regular mobile and internet facilities. This is also having an adverse effect on
my preparation of entrance for PG, I do not have internet access which is a basic
need for an academics preparing for entrance.”-A Physicians.
“I m an ANM (mid-wife) at Sub centre, but I m attached to a PHC and
working for the PHC and visits once a week to the SC area. This is only because
of, there is no provision of residential quarter in that health facility and overall
being a lady there is always a safety and security issue, so why do I prefer the
rural posting….” - Nurse.
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“Even if we appoint the physicians for rural areas especially specialist cadre,
they are more reluctant to join the area, they did not even join the place. This may
be because of the reason that the places are deprived of the material resources,
poor living standards in the village/rural level and possibly less opportunities for
their practice and educational opportunities for their children.". “They are shows
reluctance to work in rural and remote areas in the state (Arunachal Pradesh),often they come to state headquarters for seeking transfer and posting to capital
and district headquarters areas….some presents their health issues, family
problems and other genuine reasons for to be shifted to the urban areas.-Key
Informant Official.
"We have no quarters for accommodation, good school for our children, so
we are staying in a rent house in nearby urban area and daily I have to cover total
40 KMs in Bus to attend my duty, which cost me physically and financially".- A
Nurse respondent.
"I always will look for basic facilities and amenities like housing, water
supply, electricity and communication facilities at my preferred work place. These
also will include a good school for my child."-A Physician respondent.
“I am frustrated only because I was not posted to my home village, which is
in the same district, I could have been stayed at my own home and attends the
duty.”-A Physician.
We can interpret the above statements by the respondents that the doctors and
nurse including the mid-wives disinclined to rural services in the state, primarily due
to absence of accessibility of communication and basic amenities in rural and remote
areas. Thus, living standards are characterized by poor basic facilities and amenities in
the area where the health institutes are situated, for which reluctances in workforce
can be seen. Moreover, many of the staff prefer to and are allowed to stay in a nearby
town from where they commute to their place of work; it is obviously in the absence
of basic amenities in the posting place. This means that the health services are not
available 24 hours at the health centers as planned. At lower levels health institute,
there is no one to provide care at the time of need after duty hours, or when staff is on
leave. To add to this, many workers do not go to their place of work regularly. There
are also many other interruptions in the regular work such as review meetings, various
camps, and trainings. However, the staffs that stay at their place of posting and
provide 24 hour service get the same salary as staff that are absent or are available for
only three to four hours a day. Other unavoidable situation of staff absenteeism are
due to illness of themselves or their family members, some are due to chasing their
salaries, allowances, and other bureaucratic tasks at the HQ, etc.
5.3.1.8. LACK OF GOOD MIXER OF CADRES, TEAM WORK AND
INTERPERSONAL RELATIONSHIP
Teamwork in health care occurred throughout the 20th century and, morerecently, effective inter-professional teamwork has been identified as an appropriate
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response to the complex issues in many health care settings. Effective teamwork has
been identified as enhancing staff motivation (Wood et al. 1994), including increased
job satisfaction and improved mental health (Borrill et al. 2000; Peiro et al. 1992),
and improving retention and reducing turnover (Borrill et al. 2001). It is found in this
study that the intention of migration of physicians, nurses and mid-wives from a rural
area health institute to another rural health institute is propelled mainly by the factor
of team work and interpersonal relationship in the present place of work. So, the rural
to rural migration is mainly due to the factor of absence of teamwork and
interpersonal relationship in the workplace.
Good mixer of cadres is absent in many of the health institutes, as compared to
requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM at
SCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs
without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses
in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without
doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians &
Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know
from the interview of the management representative that many of the health posts in
the rural area are manned by the less skilled workers like nursing assistant and other
semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and
mid-wives or rather they are staying at urban areas. The impact of this mal-
distribution on health care delivery in rural areas is profound, at times resulting in
primary health care facilities being staffed mostly by other staffs. As per primary data
available for this study, there are total no. of sanctioned sub centres are 468, out of
which only 301 have existing infrastructure, 222 No. of SCs having only one ANM
each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical
Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3
ANMs, none of the CHCs except are having full complement of specialists i.e.
Gynaecologist, Anaesthetist and Paediatrician.
Most of the management representatives have a common consensus that the
difficulty in distribution of the workforce particularly in the district level. The process
of the transfer and posting are a challenging matter in the absence of the residential
quarters and basic amenities at the rural and remote areas. They also pointed out that
in the absence of comprehensive HR policy it is very difficult to rationalise the
distribution. Overall, the shortage of the staffs is the main challenges in rational
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distribution of staffs in the rural areas. It is a matter of concern that the urban areas are
also running out of the staffs and it is very difficult on their part to get equitable
distribution. It is also pointed out that there are many cases of personal and medical
reasons in which the management representative cannot force the staffs to be in the
remote and rural areas for long durations. It is also sensed from the interview that
there is influence of political pressure for the distributional process. However, it is not
outspoken by the management representatives.
So, the lack of good mixer of cadres, team work and interpersonal seems to be
a issue and concern in the rural and remote areas.
5.3.1.9. LACK OF JOB SECURITY AND CAREER DEVELOPMENT FOR
CONTRACTUAL PHYSICIANS, NURSES AND MID-WIVES
Lack of job Security in the health sector for contractual physicians, nurses and
mid-wives have adverse effect on the job satisfaction and thereon the motivation to
stay and work in rural and remote areas in the state. There is no provision of job
security for this group of workforce in the sector. The whole workforce under NRHM
is contractual and liable to terminate at any time without assigning any reason with
one month prior notice or in lieu one month salary. This is also a factor for low job
satisfaction and motivations of contractual health workforce. The service of the
employees is renewal every one year on performance based. However, the
performance appraisal process is also not effective due to various reasons. Moreover,
there is no career path or career development for these employees for which the
motivational factor could be high. The study explores the intention of migration of
physicians, nurses and mid-wives from the present rural health institute to any other
sector or other employer. The exploration of the preset factors from the responses job
security option and indicate that this is one of the major issues which propelling the
workforce for quite from the state health sector services in rural areas. The viewsabove of the workforce are quite claimed to be of concern in the part of management
who expresses fear about the issue. To talk about the issue of intention to migrate in
search of other sector and other employer in the same sector, we found five factors
significant that are the Lack of Career development opportunities, Poor salaries, Lack
of Job security, Lack of adequate financial incentives and Lack of scope for
continuing education/higher education. However, in order to give a boost to
contractual employment, the state govt. started pulling senior contract physicians,
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nurses and mid-wives for permanent vacant posts, but in reality the incumbents have
to act upon on.
While, exploring the motivational factors that may motivate the physicians,
nurses and mid-wives to retain themselves in the present rural area health institution,
the responses of these employees revealed that Career development opportunities and
Job Security as one of the factor for retention. While, exploring the motivational
factors that may motivate the contract physicians to retain, the responses of these
employees revealed factors which include-Career development opportunities and Job
Security. In the group of the contract nurses also includes Job Security as one of the
motivating factor. In the group of contract mid-wives have also Job Security as one of
the motivating factor.
Therefore, the issue of job security and career development is an alarming and
major issue in the retention of the contractual physician, nurses and mid-wives in the
rural and remote areas in the state.
5.3.1.10. WEAK AND IN-EFFECTIVE PERFORMANCE APPRAISAL
SYSTEMS
There are not concrete and effective performance appraisal systems on board.
Historically, the permanent physicians, nurses and mid-wives have service book and
annual confidential report on the performance conduct of the permanent workforce.
However, the system is not effective and does not do anything with the performance
in the field and does not have any link with the rewards or incentives upon them.
Neither there is any mechanism which can monitor the daily activities undertaken by
each workforce, only some clinical services provided are monitored under monthly
reports, which is not at all have any connection with rectification of the performance
or anything to reward or incentives. While, the contractual part of the workforce are
altogether face annual performance appraisal, that is only for the further extension of the contract, which in no way is used effectively for review of the contract. This
performance systems on the board is seems only to be the formalities in the nuisance
public health environment. However, the performance appraisal of permanent
physicians, nurses and mid-wives are used in the service book for pay roll increments,
transfers, and other additional determinants in the service life of the incumbents.
Discussions with the management representatives expressed doubts about
performance appraisal systems and the reports by the concern supervisors that they
give the right feedbacks, which could be used for real performance appraisal for any
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rewards or any rectification. Moreover, the performance benchmarks were not put in
place at the time of initiating the contracts or start of services in the rural areas.
Thus, although the performance appraisal system is placed in the sector but the
system is almost defunct and to be very weak. Little evidence exists on their effective
use at hospital, district and health facility levels in the state.
5.3.1.11. TOTAL ABSENCE REWARDING AND RECOGNIZING
ACHIEVEMENT SYSTEM:
The use of financial incentives as important motivators has been over
emphasised in the recent past. However, research in human relations and behaviour
sciences has shown that “where as money incentive had not proved effective,
psychic rewards worked” (Gellerman, 1963). Later research by Herzberg (1968) &
Lawler (1971) confirmed the fact that pay has very little to do with motivation.
However, several research studies in India have indicated the positive relationships
between pay and employee performance (Dwivedi, 1980). The reward and
recognition for the performance and achievement is not there in the system which
could boost the satisfaction and motivation to performance in the workforce. The
study findings seem that the workforce is dissatisfied with this component in the
system. There is no distinction of under performer or good performer in the system.
The variable Reward system and recognition have constants or have missing
correlations in the responses of the respondents. The analysed results indicated that
the lowest mean factors of job satisfaction and retention have one of the factors that
are Reward system and recognition system (1.00) which is the lowest scores. That
means the absence of reward and recognition for performance is one of the major
contributors to the dissatisfaction and migration of the physicians, nurses and mid-
wives. Out of the top 8 factors found that contributed to the intention of the
migration to outside the sector, the factor of Achievement not recognized or rewarded with Mean 1.38 can be seen. That means the factor is not in selection for
the internal migrations because the respondents know that there is no such provision
now and they doubt it could be in future in the system. That’s why who are intended
to go out of the system are only selecting this factor as a factor of migration.
Therefore, the need is to understand the various factors which motivate physicians,
nurses and mid-wives to retain themselves in the present rural posting. Taking all
these factors into consideration, financial as well as non-financial incentives can be planned.
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5.3.1.12. LACK OF SUPERVISION IN CERTAIN AREAS While the analysis of the factors that contributed to stay at the place of posting
for more 3-5 years for both contract and permanent physicians, nurses and mid-wives
for rural and remote services was done it is found that the selection of improved
support, supervision and mentoring with a Mean of 1.17 is only there, which is a
lower mean of contribution. That means the factor failed to contribute to the factor of
stay back in rural and remote place. It shows that there is a system of poor supervision
and support. It is also highlighted by the management representatives that in the
absence of adequate workforce with trained in the matter at the higher level of health
institution also contributed to this issue and it is a concern for the management. In
reform initiatives the structural changes had taken place but the situation of the
supervision could not be changed or improved.
However, the statement that reform has made improvement in supportive
supervision, management and mentoring form higher authority, has an agreement
from the respondents. The physicians have the mean of 3.50, nurses have 3.68 and the
mid-wives only 3.76. Thus, the responses revealed that there is an improvement of
supervision and mentoring due to the reform process, and the trend is higher to the
lower health institutes because the mean of the mid-wives is higher than that of the
two other higher groups. While putting light from the management representative
interview responses that the supervision services also suffers from the financial
constraints, geographical constraints and overall suffers from the skill scarcity that is
scarcity of supervisors. The supervision structures starts from very state level to the
lowest layer of SCs, the SCs are supervised by the Medical Officers (Physicians) at
PHCs or CHCs and these PHCs/CHCs by the district level. The matter is more
concern upon lot of higher institutes is without the supervisors and if they are also,
they are concern with the clinical abilities and lacks the managerial skills likesupervision and monitoring at various levels. The supervision is lack in the upper
health institutes than that of SCs, however, whole of the workforce are not getting
comprehensive supervision and mentoring. Many staff, particularly those working in
the upper health institution in periphery according to the above analysis of Mean
factors of all the health groups revealed are deprived of the supervision and mentoring
activities. For this reason it can be resulted in lower job satisfaction and retention in
rural and remote areas. Ideally, supervision is a formalized HRM instrument to correct
shortcomings and to support good practice, on the basis of which recommendations
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are provided to help improve individual and facility performance. The weak
supervision at all levels may result in lack of availability and accountability of the
staff at the working place. The supervision system is placed in the system but it is
weak as the supervisors only monitor the work of their subordinates through the
reports they submit of the numerical achievements of targets at the end of the month.
Moreover, it is also mentioned performance appraisal is also very weak. Appraisal
systems in use are basically and practically tend to be based on an assessment of
personal characteristics rather than on achievements against agreed-upon work
objectives or targets.
5.3.1.13. OTHER MINOR FINDINGS RELATED TO DEMOGRAPHIC
ATTRIBUTES
The Medical professions like doctor and nurses has been long among the most
attractive and satisfied profession in the society, but when it is analysed in the context
of rural and remote area services, the results suggests that these group of employees
are increasingly getting dissatisfied with their jobs in rural and remote areas. The
analysis shows that the groups of Mid-wives have the lowest scale of job satisfaction,
followed by the group of nurses and the physicians, similarly contractual employees
have low job satisfaction in comparison to the permanent employees.
We found that there is a positive relationship of job satisfaction with the age,
length of service, place of posting and nature of employment. It is significantly found
in the study that the higher age of these groups of workforce has higher job
satisfaction, higher length of service has higher job satisfaction, and employee posted
at the higher level of health institute has higher job satisfaction in rural setting. It is
also found about negative relationship between the marital status and job satisfaction.
Wherein, it signifies that the more married employees the less satisfaction level in
rural setting. And there is no relationship between family background and jobsatisfaction of employees in rural setting. Thus, there is no effect of family
background on job satisfaction of the employees. Only the Salary and Training &
Skill development opportunities are the main contributors to the prediction of Job
satisfaction in current time of physicians, nurses and mid-wives altogether in rural and
remote area setting which is a matter of concern.
It is known from the study that the intention to migrate is having relationship
with job satisfaction. Here it is explore the effect of the demographic attributes of the
employees on intention to migrate to urban areas. From the study, it is found that
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there is no relationship exists between the demographic attributes of age, family
background, marital status, nature of employment, and place of posting. Only the
length of service is significant and reveals the relationship with the migration to
urban areas. And job satisfaction has been statistically significance relationship with
the intention of migration to urban area. While analysing separating the positions of
the workforce as Physicians, it is found that there is no relationship exists between
the demographic attributes of age, Sex, family background, marital status, nature of
employment and place of posting and length of service with the intention of
migration to urban area. As in the case of Nurses, it is found that there is no
relationship exists between the demographic attributes of age, family background,
marital status, nature of employment, place of posting and length of service with the
intention of migration to urban area. While in Mid-wives, it is found that there is no
relationship exists between the demographic attributes of family background, marital
status, nature of employment and place of posting with urban migration but found a
significant relationship with age and length of service.
Thus, it is found that the demographic factors do contribute to job satisfaction
and intention to migrate.
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SECTION 4
MAJOR REFORM INITIATIVES
AND ISSUES THEREON
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5.4.1. MAJOR REFORM INITIATIVES AND ISSUES THEREON
5.4.1.2. THE RISE OF CONTRACTUAL EMPLOYMENT: ESTABLISHED
NEW EMPLOYMENT SYSTEMS AND CONDITIONS OF SERVICE WHICH
LINK DIRECTLY TO HR ISSUES.
The vital ingredient in human resource management in health system consists
of workforce management, skill mix, workforce performance capacity building and
the numerical adequacy. To address the issue of numerical adequacy with cost
effectiveness is contracting the human resource. In Arunachal Pradesh along with the
country, increasing the number of health worker is a major challenge in improving the
health system. The past one decade has seen a growing tendency of contractual
employment in the public health sector in the state, toward a fundamental
restructuring for addressing the inadequacy issue under reform process. A significant
change in placement of human resource has been seen since 2005 in the state.
The task of ensuring the availability of physicians, specialists and nurses to
human resource pool by contracting of them is only short-term solution for the
inadequacy. One of the greatest drawbacks is possibility of attrition, non-commitment
of the employee in compulsion of performance which is very real risk in long run for
both employer and employer in the public health sector. In this way, contracting is no
better than engaging permanent employee in the sector in long run. The healthservices are a continuous need of the community and can only be delivered with the
adequacy in numbers of the health care provider and supports competitive strategies
in long run. Contracting is more likely to be successful only when there is a
competitive strategy in long run to convert the contract employment into permanent in
a stipulated time period because healthcare sector is highly dependency on key
professionals like physicians, nurses and mid-wives. It should also be supported by
appropriate policies and guidelines regarding this for the attraction and retention of
the healthcare providers. Contract employment is offered for performance under
pressure to an employee, which may adversely affect both the employee and
employer. It also leads to perceptions of inequity among the co-workers. They also
faced a certain degree of uncertainty and change, regardless of their choice. Thus, the
permanent employment status should be supported by administrative systems and
processes that enable the relationship to operate smoothly in long run. While, the
nature of the contract is also not cleared and the basic framework of expectations and
obligations are also is not cleared in the system.
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Health professional’s choice regarding contract employment, in this study,
was conditioned by job security and compensation at par with the permanent
employee in the sector. The contract employees were placed in a position of having
insecurity and short-terms and conditions of employment of one year. They were
forced to choose the contracting job as there is no other options remains within the
state. Contract employees are treated differently in the workplace than permanent
employees. They faced a certain degree of uncertainty and change, regardless of their
choice of being permanent employee. Contract employees have a different attitude to
the workplace and their position. Bringing the management perspective contract
employees are off-course manageable and cost less to the department but it does not
seems long run sustainability and free from HR issues arising out of it.
5.4.1.3. EMERGING ISSUES OF PROFESSIONAL MEDICAL EDUCATION
IN ARUNACHAL PRADESH IN REFORM PROCESSThere is existing issues of access, growth and expansion within the agenda of
health sector reform in Arunachal Pradesh, which could to some extend helpful in
solving the problem of inadequacy of physicians, nurses and mid-wives in the state in
long run. Arunachal Pradesh is lagging behind in the field of medical education in
comparison to other states of the country. Production of the graduate doctors, nurses
and mid-wives in comparison to expanding health infrastructure is becoming a matter
of concern and a challenge for the public health sector in the state and its inclusion
under agenda of health sector reform is most an issue and a challenge. There is no
medical college in govt. sector or private sector for Allopathic disciplines, and it is not
adequately addressed by the reform process. It is observed that the aggregate number
of seats for medical and para-medical education for the state is not inadequate
comparing to the requirement of physicians, nurses and mid-wives especially in the
rural and remote areas of the state.
State Public Funding for Medical Colleges, Nursing schools is a matter of
concern and it is not widely addressed in the reform process. In the light of resource
constraints of the state government, state funding for establishment of Medical
Institutes is a matter of concern and challenge. The growth and expansion is only
possible with the interventions of central govt. public funding or attracting private
funds. The government, which is the major funder of medical education institutes for
the state has failed to develop training institutes for medical, nursing, and related
professions in the state. This may be subjected to lack of funds. The growth of
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potential teaching hospitals for establishment of new medical schools and nursing
school in itself is a challenging issue in the reform process. Wherein, in the entire
state only two hospitals namely State Hospital, Naharlagun with bed strength of 148
nos. and General Hospital, Pasighat with bed strength of 150 are nearly in shape that
can be upgraded to Medical Colleges but proper initiation under the reform process
has not been taken up.
5.4.1.4. ISSUES REGARDING DEVELOPMENT OF COMPREHENSIVE HR
POLICY IN THE HEALTH SECTOR OF ARUNACHAL PRADESH UNDER
REFORM PROCESS
There is no comprehensive HR Policy in Public health sector in Arunachal
Pradesh. There are recruitment rules for different category of health workforce. The
recruitment and other service conditions for staff in health services of the state
government is regulated by the APHS (Arunachal Pradesh Health Service) rules and
central recruitment rules are followed. However, there is no specific HR Policy for
recruitment, deployment, retention of the physicians, nurses and mid-wives and other
health workers especially for remote and rural areas. This issue is not adequately
addressed in reform process, the state govt. is preparing a 5 year strategies and policy
document for augmentation and maximization of Human Resources as per the
management representative, but it is no way would be soon available and its
sustainability, as it is well known in the public sector all comes late. And it is also
found that the policies regarding recruitment, deployment and retention is much more
emphasized on contractual employees only leaving a loose tight on permanent
employees.
5.4.1.5. ISSUE OF HR FUNCTIONS DECENTRALIZATION UNDER
REFORM PROCESS: CHALLENGES FOR LOCAL CAPACITY
The process of decentralization in the reform process has its own issue.
Decentralization of authority, responsibility, and resources for personnel functions is
delegated in a decentralized way in reform process to the district level. It is important
to achieve effective human resource management and to improve staff performance.
However, decentralization itself entails large-scale development of capacity at the
local level for health planning, financing, allocation and accounting for resources, and
HR management functions including staff recruitment, payroll and allowance
documentation, and maintenance of personnel records. The Human Resource
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Management functions including recruitment and deployment are decentralized to the
districts level.
Though decentralization is used as an ornamental word into the reform
process, the actual implementation in the view of low capacity at the lower level is a
concern. The new decentralized organizational structures mean that the role of district
authority as employer is transferred from state level, but to configure the new
structure of decentralized environment there is no provision reform process for HRM
system and HRM personnel in the organisation at state or the district level, that to
strategically support the initiation. The transfer of human resources functions from
State level to district level without a comprehensive design and structure is quite a big
challenge for the district administration. Over all in the absence of an appropriate HR
policy at state and district level on human resource, is still provide a big deal of
challenge for the district authority. The study finds that in the reform process in
Arunachal Pradesh, decentralization in many field including HR management issues
have been percolated down up-to the district level and to some extend to the health
institutes, but there is a need of far greater attention to HR skill deficits. The
decentralization has been done in respect of power and resources to the district level
and lower level of health administration for HR administration and management.
Under this decentralised process, the recruitment is done at the district level, Human
Resource planning, and their training needs and to ensure that health facilities had the
minimum staffing requirements. In addition, the powers to recruit, exercise
disciplinary control, and to remove persons from district service were delegated to the
District. Pay determination is heavily centralized at state level and national level, as
part of broad based culture as other public sector. Decentralized the local autonomy is
facilitating the local preference and to retain the workforce in the district. However, as
mentioned earlier to manage the decentralized activities there is shortage of HR
management personnel in the district level, which create a challenging environment at
this and subsequent level of administration. As to increase the requirement for
administrative and managerial staff in the system and likely to associated increase
requirement for performance management also.
5.4.1.6. ISSUES OF RECRUITMENT AND SELECTION PROCESSThe reform process more emphasized on the contractual employees and the
policies are developed only for the same. The recruitment process adapted in the
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reform process is inadequate and lack professionalism. Only newspaper
advertisement, walk-in-interviews are utilized and no other options are ever tried to
explore to include for better recruitment and selection process in the system of reform.
The recruitment and selection processes are often guided by the personal bias and
favouritism in the system. After that the appointments are made and no proper
performance appraisals are done and many of the physicians, nurses and mid-wives
get regularisation. It is also found that the performance appraisal in the system of
reform process is not effective and comprehensive.
Most of the management representatives have pointed out for the difficulty in
getting physicians, Nurses for the health posts. The management representatives
pointed out the crisis is more for the GNMs and then the physicians for rural and
remote areas. It is may be due to lower graduates of medicines and nursing
candidates. They also revealed that they have many post lying vacant in search of the
GNMs (Nurses) and some of them are even personally arranging these cadres for the
rural health services. It is also pointed out by the management representatives that in
the light of very limited candidates for the posts they have to compromise on the
technical expertise and experience of the candidates and have to appoint them for the
rural and remote areas which obviously affect the quality of the services in the rural
and remote areas.
5.4.1.7. ISSUES IN TRAINING AND DEVELOPMENT SYSTEM UNDER
REFORM PROCESSSkill up-gradation and multi skilling practices are much emphasizes in the
sector. Lot of skill up-gradation and multi skilling training are undertaken and the
physicians, nurses and mid-wives, but the main issues is there is no random access of
training needs, the planning of training and the execution of the same have a random
mismatch in the district and as well as in the state level. The training needs are basically planned according to the services to be provided or it is in the health
institutes, it’s no way access the personal training needs of these workforces that
could also enhance their skills in personal fronts and interest. Overall, it is also found
that the post evaluation of the training is not done and not in the process and not in
implementation at the ground. The reform process has failed to addressed the access
of training needs and post evaluation of the training in the field and in personal front
of the employees.
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5.4.1.8. ISSUES IN FINANCIAL AND NON-FINANCIAL INTERVENTIONSThe reform process has tried to address the issue of financial and non financial
incentive for the rural and remote areas physicians, nurses and mid-wives. But the
process had failed to comprehensively plan and execute the same. No adequate
emphasized on making use of provision of financial and non-financial incentives for
rural and remote area posting and retention is there. Over all the reform process has
failed to give emphasizing the compensation equity in the workforce and their
differentiation according to the urban and rural posting. Moreover, other rewards
system linked to performance is also not the system, resulted to the low morale and
motivation of the workforce. The reward and recognition for the performance and
achievement is also not there in the system.
5.4.1.9. ISSUES IN INFRASTRUCTURE DEVELOPMENT INITIATIVES
INCLUDING ACCOMMODATION FACILITIES AT RURAL AND REMOTE
AREAS FOR UNDER REFORM PROCESS
However, the infrastructure development is directly a HR activity, but is no
doubt it contribute to HR practice in the organisation, particularly in health sector.
Chronically there is inadequacy of residential quarters for workforce at rural and
remote areas. For ensuring deploying, attraction and retention of physicians, nurses
and especially Mid-wives in rural and remote area, the reform process is emphasizing
to develop the residential facilities all over the state, but it has failed to do it with
proper planning and wide coverage. However within the limited resources,
prioritization is done to provide at-least residential quarters in the health facilities
phase-wise. The identification of the health facilities has been done linking the HR
availabilities and acceptable infrastructure.
5.4.1.10. THE VIEW OF WORKFORCE ON HEALTH SECTOR REFORM IN
ARUNACHAL PRADESHThe exploration of health sector reform process on physicians, nurses and mid-
wives has pointed out some of the issues in understanding of health sector reform
process and the employees. It is revealed that these three categories have different
views on the health sector reform process on Human resource activities. All the
employees are quite reserved at human resource policies of the organization, that they
are clear about the HR policies of the organization, the mean of the response is only
2.06 in the scale of 5, which can be interpreted that reform has not succeeded to clear
presentation of the HR policies (whatever is there exists at present ) in the context of
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the Physicians, nurses and mid-wives. It seems the physicians are having little
understanding of this, but we cannot say all other groups are equally aware of this
component. However, the mean of the responses are the lowest we cannot say that the
reform process has made human resource policies understandable at all level and
contributed to the HR function of the organisation.
All the employees emphasized on that there is no change in the scenario of
transparency, fairness and unbiased placement, transfer and promotion. The groups
have the view that the reform has failed to make placement, transfer and promotion to
transparent, fairer and unbiased.
However, it is found that the physicians and nurses are familiar with their job
description clear they agree upon the statement, but not so strongly. Whereas, the
mid-wives has no agreement on the statement and may be they are not so clear about
the job description of the mid-wives. It is also found that the physicians, nurses and
mid-wives do not think that they are getting promotional chances are strong in the
light of reform process.
According, the responses of the respondents, the reform process has also failed
to make the compensation a competitive one for rural and remote area posting, as the
salary structure have no differentiation for urban or rural areas. No groups have
agreed upon that the reform process has created the salary structure competitive for
the rural area posting. Moreover, the physicians, nurses and mid-wives have the views
that the reform has failed to made regular and adequate financial incentives and
allowances for physicians, nurses and mid-wives who are posted in remote and rural
areas. They also agreed on that there are no increase activities for actual performance
appraisals and positive actions on them.
On the front of improvement in working condition at the respondent’s posted
health institutes has agreement in group responses, though the mean of the responses
is 3.40, quite no so impressive. However, more on the issue, we can say that the lower
levels of the health care delivery system where the Mid-wives are largely posted are
deviated of improving the working conditions.
The workforce has agreed that reform has increased the training and skill
development opportunities for the respondent’s posted rural health institutes, but the
group of physicians has little lower mean than that of the two other groups. Thus, it
seems at the physicians do not get more chance for training and development
opportunities in comparison to the nurses and mid-wives. Thus, it reveals that the
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reform has failed to address the need of training and development in equal manner to
all the groups of the employees.
While on the front that reform has improved the availability of equipments,
drugs and essential supplies for performing the assigned tasks for the respondent’s
posted rural health institutes has been agreed in group responses, though the mean of
the responses is 3.35.The group of mid-wives has lowest mean than that of the two
other groups. Thus, it seems at the mid-wives do not get adequate equipments, drugs
and essential supplies and the reform has failed to provide them as well, in
comparison to the physicians and nurses. Thus, it reveals that the reform has failed to
address of these needs too. Reform has also failed to improved the mix of cadres in
respondent’s posted rural health institutes and has made the work load un-
manageable. The disagreement increases at the lower level of the groups. Thus, it
reveals that the workloads are more unmanageable to all level due to the reform
process.
Reform has made improvement in supportive supervision, management and
mentoring form higher authority. It is also found that, there is an improvement in
housing and other amenities at the workplace of the physicians that is at the higher
level of health institute rather in the lower health institute where the nurses and mid-
wives are posted.
In overall, the physicians, nurses and mid-wives, concludes that the reform
process has failed or has not succeeded for making rural health care services an
attraction for the potential physicians and nurses to work in rural and remote area.
And it is also revealed in overall that the reform process failed to give attention to the
HR front rather giving attention to the other components of reform process in the
state.
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SECTION 5
MAJOR ISSUES IN HR PRACTICE
RELATED TO ATTRACTION,
DISTRIBUTION AND RETENTION
OF PHYSICIANS, NURSES ANDMID-WIVES
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5.5.1. MAJOR ISSUES IN HR PRACTICE FOR ATTRACTION,
DISTRIBUTION AND RETENTION OF PHYSICIANS, NURSES
AND MID-WIVES
5.5.1.1. INTRODUCTIONIn addressing the three dimensions of HR Practice for Attraction, distribution
(deployment) and retention of physicians, nurses and mid-wives, the researcher could
establish that the HRM system and practice in the organisation is mere personnel
management functions rather a strategic human resource management approach in a
reform environment. In this study researcher could established that the HR practices
for attraction, distribution and retention are to an extent not utilized optimally to
improve organizational performance and to retain the physicians, nurses and mid-
wives. The study found that the HRM practice for Attraction, distribution
(deployment) and retention of physicians, nurse and midwives in rural and remote
areas is not a comprehensive one and its design, the platform is weak. It is found that
from the policies to implementation, there is no concrete and strategic management is
followed.
The major findings may be outlined as - There is inadequate Human resource
capacity as there is no dedicated HRM staffs, department and the staffs handling the
HR activities are having limited experience in the organisation; Annual HR plans
exists but it is an exhaustive process in the organisation, but it is not further evaluated
for effectiveness; Comprehensive HRD policy in Arunachal Pradesh is very weak;
Employee data such as number of staff, location, skill, education, gender, age, year of
hire, and the salary level are maintained manually and partially at the district level;
performance appraisal system is in place, it is done periodically at the interval of one
year, but it does not include the work plans of individual employees and performance
objectives jointly developed with the staff, it is rather a traditional singular downwardappraisal; skill up-gradation training is an integral part of the programme, however,
there is little space for induction trainings and further training and development of
employee is a concern with follow up of training. Further, Key ways to motivate
employees are also inadequate in the system. Nor was there recognition of the
importance of employee empowerment as a powerful mean of developing a service-
oriented culture.
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5.5.1.2. ISSUES IN POLICIES FOR HR PLANNING, RECRUITMENT
(ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION
There is no comprehensive HR Policy in Public health sector in Arunachal
Pradesh. There are recruitment rules for different category of health workforce. The
recruitment and other service conditions for staff in health services of the state
government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The
regular doctors and specialist cadre comes under the purview of service rule of APHS.
However, there is no specific HR Policy for contractual physicians, nurses and
midwives and other health workers.
Absence of appropriate and concrete human resources policies on deployment,
there is always a hindrance in managing people at work as the entire district agreed to
this. However, the state Govt. is preparing a 5 year strategies and policy documentfor augmentation and maximization of Human Resources. This includes sustainable
HRD and policy reform from restructuring/ rationalization of HR deployment. The
vibrant HR policy includes terms of recruitment / filling up of vacancies, rationalising
posting, specific tenure of posting, career progression and incentives. The policy is
focussing on improving maternal and child health indicators through posting of
required manpower for maximising performance at identified functional facilities.
In order to ensure rational deployment of contractual physicians, nurses and
mid-wives, recruitment is done at district level and appointments are made for
specific health centres without provision of transfer. For the regular groups of
employees the intra-district transfer and posting are handled by the District Medical
Officer and inter-districts transfer is handled by the Director of Health Services.
However, the system is not so transparent and lack in proper implementation. Most of
the management representatives have a common consensus that the difficulty in
distribution of the workforce particularly in the district level. The process of the
transfer and posting are a challenging matter in the absence of the residential quarters
and basic amenities at the rural and remote areas. They also pointed out that in the
absence of comprehensive HR policy it is very difficult to rationalise the distribution.
Overall, the shortage of the staffs is the main challenges in rational distribution of
staffs in the rural areas. It is a matter of concern that the urban areas are also running
out of the staffs and it is very difficult on their part to get equitable distribution. It is
also pointed out that there are many cases of personal and medical reasons in which
the management representative cannot force the staffs to be in the remote and rural
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areas for long durations. It is also sensed from the interview that there is influence of
political pressure for the distributional process. However, it is not outspoken by the
management representatives.
5.5.1.3. ISSUES IN HR PLANNING, RECRUITMENT AND SELECTION
PROCESSResearch Observation shows that accurate information systems on staffing
trends and conditions are not in place. There is no tradition of research on workforce
issues in the state. HR planning for contractual employees is theoretically based on
decentralized system, however, in the absence of proper information, and trends of
staffing makes HR planning more exhaustive and difficult. While, the HR planning in
permanent physicians, nurses and mid-wives are done by the Health Directorate and
based on vacancies and annual operating plans. It is also found lack of extensive
coordination among the two divisions regarding HR planning. The sector does not
have a formal mechanism in place to undertake manpower planning on a continuous
basis except the Annual Action Plans. Planning exercise in the department of health is
primarily focused on creation of new infrastructure/institutions.
Decentralization of recruitment and selection process to the district is often
undertaken without the appropriate technical abilities to do so. There are no staffs
specifically to develop and implement HRM system in the organisation. District and
state level offices do not have staff adequately trained in personnel administration, nor
do they have simple or robust systems for managing personnel affairs. HR
management structures and systems at the district level are weak; District offices are
inadequately staffed and are poorly resourced. There are staffs generally meant for
other services are engaged to look after the HRM activities in the organisation at state
and district level. But these sections of staffs are having limited experience related to
this field such as personnel recruitment, management or have other functions in the
organisation as well as HRM functions. Over all they are at the level of only to
maintain basic procedures and record keeping functions, which cannot be comparable
to the full functions of HRM system in the organisation. The recruitment process
under the decentralised arrangement in the district is closely linked to the instruction
and financial provision at the state level. The implementation of the decentralisation
policy is only for the contractual manpower in the district. Whereas, the appointment
and deployment of the permanent physicians, nurses and mid-wives are not comes
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under the decentralised recruitment and deployment. So, it does not left any room for
majority of the recruitment process and deployment.
Utilization of various recruitment sources is under-utilised only newspaper
advertising is the source. The recruitment advertisement for the contractual vacancies
is only undertaken for this kind of process in the districts. The recruitment
advertisement for permanent positions is placed in the newspaper and office board by
the Directorate of Health Services. However, the internal source of recruitment is
widely used, whenever a sanctioned regular post is vacant. This process of
recruitment of internal candidates for regular posts supports career development
opportunities for internal contractual employees.
The selection processes is based on Walk-in-interview across the districts for
contractual employees and for permanent employees it is found the contractual
physicians, nurses and mid-wives are taken up to fill the vacancies.
Thus, the recruitment and selection process of the employee in the state public
health system is a traditional approach and lack the professional forefront in this
process, and the newspaper advertisement, walk-in-interview, written-test with panel
interview as the dominant tools in use.
5.5.1.4. ISSUES IN HR PRACTICE FOR PLACEMENT, TRANSFER ANDPROMOTION
The deployment of contractual physicians, nurses and mid-wives are done
according to the recruitments are done for the particular vacancies for the specific
health institution. However, the deployments are interchange able on mutual consent
of the employees or the management decisions at the district level. The deployment of
the regular cadre employee is done according to the requirement of the district and the
district medical officer looks the matter and depends on the physical infrastructure
and basic amenities in the health institution. The common minimum tenures are not
followed along with the time bound promotions are not practices for several reasons
to these categories of staff.
5.5.1.5. ISSUES IN HR PRACTICE FOR RETENTION - FINANCIAL NON-
FINANCIAL INTERVENTIONSThere is no use of provision of financial and non-financial incentives for rural
and remote area posting and retention. In the light of no provision of such incentives
for the physicians, nurses and mid-wives for rural area services and the compensation
package also is same irrespective of the place of posting. Other non financial
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incentives such quarters with electricity, water facilities etc. are also not in the system
to retain the workforce in those underserved areas. Moreover, other rewards system
linked to performance is also not the system, resulted to the low morale and
motivation of the workforce. The reward and recognition for the performance and
achievement is also not there in the system.
5.5.1.6. ISSUES IN HR PRACTICE FOR RETENTION - TRAINING AND
DEVELOPMENT
Skill up-gradation and multi skilling practices are much emphasizes in the
sector. Lot of skill up-gradation and multi skilling training are undertaken and the
physicians, nurses and mid-wives are satisfied with the process and most of the
workforce are attracted and retain themselves due to this factor in the sector. But the
issues is there is no random access of training needs, the planning of training and the
execution of the same have a random mismatch in the district and as well as in the
state level. The training needs are basically planned according to the services in the
health institutes and likely to starting of the services, it’s no way access the personal
training needs of these workforces that could also enhance their skills in personal
fronts and interest. Overall, it is also found that the post evaluation of the training is
not done and not in the process and not in implementation at the ground. The trainings
are undertaken only the sake of performance in the training activities, but the real
evaluation of the trainings is not done. The trainings are once done, the achievement
of the training achieved and no further plans for evaluation. Expensive and important
skill-up-gradation trainings are given to these groups especially to the physicians, but
the matching of posting place and their performance after the training is not accessed.
This creates a gap in the training skilled acquired and utilisation for the benefit of the
organisation, society and self development of these workforces.
The multi-skill trainings & capacity building of the workforce are emphasized
on physicians, nurses & mid-wives from the rural and remote area. Multi-skilling
training is randomly given to a concentrated workforce and makes them jack of all
trade, master of nothing. There are many cases the research could establish that a
single physician is trained in many skills which makes him confused and specialized
in nothing and it does not helped in their self development.
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SECTION 6
SUGGESTION
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5.6.1. INTRODUCTIONThis section of the chapter puts lights on the broad suggestions on the issue of
distribution, attraction and retention of Physicians, nurses and mid-wives. It is found
in the study that most of the workforce is on compulsion to stay at the rural and
remote areas and these workforces have low level of satisfaction and resulted in low
commitment and motivation towards the service. The contributions of other factors
for attraction are very less and seems that the sector has not given due importance and
tried to improve the other bricks of the wall. Most of the workforce is intended to
migrate to urban or to other sector, it is more of the environmental issues and
organisational issues more than that of the personal issues at the current time. The
factors that can attract and motivate them to stay at the rural and remote areas have
been found in this study. The factors like salary in comparison to the urban areas,
conducive working condition, training and development opportunities,
accommodation, financial incentives/rural allowances, rotational postings, safety at
the workplace and career development opportunity. While, the following factors have
been found for the retention of theses workforces: financial incentives, improved
living condition, career development, good reward and recognition system. These
factors for attraction and retention seem to be a blend of financial & non-financial
benefits. The distributional issues have an impact on the shortage of staffs in rural and
remote areas with mal-distribution. The HR practices having many loop holes and the
reform process have failed grossly to take the train on the track smoothly. The
situation of the Rural Public Health Sector in Arunachal Pradesh is “Like riding a
tiger, not knowing how to get off without being eaten”-(Cappelli, et al, 2011). While
the suggestion should be “50 miles to a gallon” (Cappelli, et al, 2011).
Based on the research findings, retention strategies need to include creating a
more positive work environment for rural availability of physicians, nurses and mid-wives. To fill the gap of mal-distribution, recruitment and retention in rural
community in the state is dependent on the perception of the workforce's non-
monetary and monetary needs. A blend of interventions into professional fulfilment,
financial remuneration and lifestyle needs are to be taken into consideration while
making policies or plans. There should be a strategic planning to address the three
fulfilments of manpower. Recruiting and selecting the right people with making
conducive working environment will help greatly with retention in rural areas.
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Professional fulfilments include the need of adequate supplies, equipments and
fund. Conducive working condition at the work place with a good mixture of other
cadres at the posting place is the some requirements. Due to highly regulated
environment in which health sector operates, professional training needs, career
development and opportunity for continuous education of the workforce must be kept
into account for attraction and retention of the workforce and their interest on the job
and the organisation. Training and multi-skilling will also facilitate the production
issues and professional needs, advancement of the workforce and willingness to
continue their works in the rural sector. The respondents put light on the workload
also; the workload is unlikely due to other management works of a health institution,
which can be minimized by posting of clerical or managerial cadres in health
institutes. Rotational posting of the physicians and nurses are to be taken into
consideration, to increase exposure to rural conditions and overstaying of one staff in
rural areas. One of the factors that we saw in this study is compensation, benefits and
incentives needs, which will enhance attraction and retention of workforce in rural
areas. Likewise, the planners must now recognize the importance of non-monetary
incentives and recognition, special award; career path of the workforce along with the
incentives for rural posting. This study suggests giving importance to the lifestyle
needs of the workforce in today's time for retention. The development of rural
infrastructure of basic facilities and amenities is great need of the time. For example
housing, water supply, electricity and third party's work for development of
communication and other facilities in rural areas should be given emphasize on long
run. Policies and retention strategies needs to consider rural manpower family lives.
Retention strategies should also include recreation and education opportunities for
workforce's children.
Factors affecting rural recruitment and retention are complex and inter-linked;
hence a package of interventions is likely to work better than any incentive in
isolation. So keeping the points above, the following broad suggestion is presented for
this study.
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5.6.2. BROAD SUGGESTION
5.6.2.1. EMPHASIZE ON RURAL HEALTH INSTITUTE AND PRODUCTION
ISSUE
Building strong institutions for education is essential to secure the numbers
and qualities of health workers required by the health system (WHO, 2006). Creation
of medical and nursing schools for enhanced seats for medical and nursing studies
should be ensured. It should be emphasized that the establishment of the institution in
rural areas, so to create a pool of workforce for rural areas. The options for task-
shifting can also be put into the system. The MBBS physicians can be replaced by a
Registered Medical Practitioner (which is adopted by the State of Assam and other
state in India), State can undertake experimentation in medical education by
introducing 3 ½ year course of Bachelor of Rural Medicine and Surgery to fill the
deficiency of physicians in villages. However, one arguments can be that, 3 ½ course
would produce poor quality doctors. Other in favor argument would be full duration
of MBBS course is not necessary for educating the public about health, hygiene and
treating preliminary ailments in village level. Likewise the inadequacy of nurses can
be filled up by the Mid-wives after getting adequate Nurse training and the vacant
post of Mid-wives can be filled up after the training of the eligible Village Health
worker with education and experience. This will ensure the creation of rural health
workers pool to minimize the gap in the inadequacy.
5.6.2.2. ENHANCING CAPACITY OF MEDICAL EDUCATION THROUGH
PUBLIC-PRIVATE PARTNERSHIP
Access of Medical Education by prospective students within the state is a great
challenge at this time. There is a need of widening of access of medical education
within the state. The state is on the process to setup one Medical college with
upgrading one of its hospitals in recent time. It is important here to consider that, in a
study by Hall (Hall, 1998) shows that a 10% rise in the number of students registering
with medical schools will produce only a 2% increase in the supply of doctors after 10
years. So, the requirement of aspirations and capacities of the increased number of
potential students and to meet up the requirement of physicians seems difficult with
establishing only one Medical College in the state. A healthy Public/Private
partnership can do much in this regard. The state should explore the PPP models to
establishment of more Medical colleges in the state. However, it should be based on
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accountability and evidence based regulations by both the medical council and the
state. The issue of fees and seats should be monitored by the government. Moreover,
the areas which are not capable of attracting private funds should be supported
sufficiently well from public funds.
5.6.2.3. STRENGTHENING HRM POLICYMAKING, PLANNING AND
SYSTEMS – THE REFORM PRIORITES SHOULD BE!Getting HR policy ‘right’ in order to create a well motivated, appropriately
skilled and deployed workforce needs to be at the core of any sustainable solution to
health system performance (Dussault & Diallo et al. 2003). The HR policy should be
comprehensive and should be completed at the earliest to guide the whole process of
HR system in the sector. The policy should include all the component of the HR
system in an organization so that it will guide the system to implement in all level,
particularly in a decentralized environment. Better distribution of personnel by
categories and places is still a challenge for the health sector in Arunachal Pradesh;
maximum number of health workforce is concentrated to urban and easily accessible
areas counterpart to the rural and remote areas. Interpreting this issue, suggestion
could be to formulate a human resource policy to the deployment and incentives for
attracting the human resource in the needy and remote places.
5.6.2.4. ROBUST RECRUITMENT, SELECTION AND DEPLOYMENT
PROCESSInvestment in employee begins with recruiting process and selection process
should be revived and extensive use of different sources of recruitment should be
used. Recruitment and selection processes should be based on an objective system to
eliminate bias and discrimination. The use of newspaper advertisement should be
continued along with the use of other medium like internet, advertisement in regional
papers or on national papers etc. to search a wide range of pool for the vacant posts.
The selection process should not be bracketed to walk-in-interview only, it should
comprises of written test, interviews and professional practical test along with a
understanding of the candidate’s will to work in rural and remote areas. Side to it the
decentralization of the recruitment should be strengthen in terms of ability to do so.
The new recruiters or the existing physicians, nurses and mid-wives should be
properly deployed based on the needs of each part of the state and the district and job
descriptions. New graduates from training institutions should be promptly absorbed to
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avoid frustration and consequent brain drain, but the eligibility and recruitment norms
should be followed.
5.6.2.5. FINANCIAL INCENTIVES INCLUDING THE SALARY
COMPONENT Direct financial incentives to practice in rural areas may encourage rural
practice, especially in developed countries, but reports from developing countries are
not positive (Smith, 2010). In the study it is found that the workforce are more trends
to financial incentives and salary differentiation than that of urban areas and salary
hikes in the context of the contractual, while talking about the attraction and retention
of the workforce. There is a need of development and implementation of financial
incentives for rural and remote area posting, it should be plan and adequate budget
provision should be there. Side by side, it is high time to make a differentiation in the
salary structure of the urban posting and rural posting, featured by higher in rural and
lower in urban areas. Along with these interventions, there is a need of enhancing the
salary of contractual physicians, nurses and mid-wives, so that their salary could
match the permanent workforce salary structure. The incentive system should be
competitive that could be accepted by the Physicians, nurses and mid-wives. The
incentive should be placed according to the category of the post and categorization of
place of posting.
5.6.2.6. REWARD AND RECOGNITION PROGRAMS
Irene (1997), advises not to force and manipulate staff to accept rural posting
after their will. Financial incentives are generally ineffective when used alone (Smith,
2010). Many international studies point out that compulsory rural service programmes
should be accompanied by support and incentives given to the health personnel (Liaw
ST et al 2005, Omole O et al 2005). It is well known compulsion alone cannot work
and a mechanism of differential rewards, appreciation and recognition programme
should be developed within the system. It is also suggested to differentiate the
performers and non-performers, which is a missing component presently in the
system. This will motivate the performers to perform more and the non-performer will
kick start.
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5.6.2.7. FOCUS ON CAREER DEVELOPMENT OPPORTUNITIES AND JOB
SECURITY
Equitable distribution of health professionals and their retention is in turn
related to the prospects of career progression and the incentive packages associated
with the posts (Martinez & Martineau, 2002). Every individual whether working at
the lower level or higher level needs growth in professional life. Thus, the career
development opportunities can attract and retain workforce in job. In this study also it
is found that the respondents are looking for the career develop path while attracting
and retention is concern in rural and remote area. Therefore, the career path should be
pre-defined and strict to rules and regulation, and the implementation should be fair
and un-biased and strictly be based on merit and then seniority based. The policies on
career development should be revived and make strong career path which can attract physicians, nurses and mid-wives in rural and remote areas. The career path
especially of contractual are to be given emphasized at present along with the job
security issue of the contractual. There should be clear written policies for providing
permanent positions to the contractual. It is also suggested that the minimum period of
contractual service should be 3-5 years not 1 year of at present. It will improve the
sustainability of contract positions.
5.6.2.8. IMPROVING LIVING CONDITION
It is found in this study that the living conditions are likely to be important in
determining health workers’ decisions to move to and remain in underserved areas.
The importance of living condition is seems to be higher in ensuring the physicians,
nurses and mid-wives in the rural and remote areas. The living condition including the
housing, electricity, water supply and transport & communication does not directly
relate to the HR activities. Though, the issues have a greater impact on HR attraction,
deploying and retaining in the rural and remote areas. Most of the respondents
emphasized on improve living condition for attracting and retention factors. Thus, the
doable point is infrastructure development for proper accommodation facilities,
provision of electricity (where electricity is not possible Solar could be the option)
and provision of water supply should be ensured. However, the other components are
not directly in the hand of the sector but it can be solved with the convergence with
the other departments and local governance, thus improving the living conditions.
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5.6.2.9. IMPROVE WORKING CONDITIONS
To attract and retain the workforce is rural areas, it is necessary to improve the
working conditions in the health institutions. It start with it can be done with the
provision of equipments, drugs and supplies and other working conditions like other
basic amenities in the work place and overall the safety of the workforce should be
the priority. The function of the health facilities should be improved by adequate
provision of work related items.
5.6.2.10. INTENSIVE TRAINING AND SKILL DEVELOPMENT WITH POST
EVALUATIONTraining should be designed to help employees not only their positions but is
should be altogether have a benefit to the professional traits also that means they
should take personal benefits also from the training. The training and skill
development should include inductions and refreshing training as well. The post
evaluation of training at the field level should be started and support the workplace to
increase their performance.
5.6.2.11. EMPHASIZE ON SUPERVISION AND MENTORING
‘We believe a great supervisor is actually an excellent coach, not just a boss –
Dr. Reddy’s Lab. (Chapelli,2011). It is suggested that to strengthen up the supervision
and mentoring activities of the Physicians, Nurses and Mid-wives, especially the new
comers. The mentoring and supervision should not be just fault taking out of their
works but to mentor and guide them. This will create conducive environment between
the employees and management and it will give a boost in the job satisfaction of the
workforce and will contribute to motivation to continue in the rural and remote area
service.
5.6.2.12. REGULATING WORKLOAD AND INCENTIVES
Minimizing the workload in a flick is not possible in the inadequacy of
workforce. However, it is suggested that the duty hours should be fixed for every
groups and individual in a manner that it do not adversely affect the mental stability
of an already frustrated groups of employees. The overtime facilities should be
provisioned to boost their morale. The technical workforce should not be waste for
management and clerical works. The posting of clerical and managerial cadres should
be ensured.
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5.6.2.13. ROTATIONAL POSTING
The option for rotational posting and follow up of minimum rural area posting
may be ensured. The minimum tenure of the posting should be ensuring with the
fairness and without any bias. The transfer and posting should not be influenced by
the favoritism and political influences. The minimum tenure of 3 years for rural
service may be extended to 5 years, but it should be strictly followed by rotational
posting to urban areas.
5.6.2.14. STRENGTHEN PERFORMANCE APPRAISAL
The system of performance appraisal should be further strengthen and make it
meaningful. No performance appraisal should be done in merely to complete the
formalities; rather it should be based on the reality and actual facts. It should be used
regularly to enhance the performances of the workforce. The performance appraisal
should be used for the reward and recognition program and the incentive programs.
Much of the challenge in health reform involves shifting incentives to improve
productivity, quality, and performance (Forgia,2005).Good performance should be
linked to incentives and the system should be based on objective criteria to avoid
favouritism.
5.6.2.15. CONSISTENCY OF DATA ON WORKFORCE
To ensure that the right health worker is in the right place with the right skills,
managers need accurate HRH data for HR planning from beginning to work together
to develop a HRIS that tracks health professionals from training until they leave the
workforce. HRH planning in the absence of reliable data is not optimally possible,
therefore, there is a need of reliable database i.e., more comprehensive data on other
categories of health workers, which is absence in the current position. The HR data
should be maintain properly with the detail of the workforce and their service tenure
in a place. It should be computerized and the consistency of data for every sections of
the department should use the same HR data to plan and execute. By this the proper
distribution of the physicians, nurses and mid-wives can be possible and the minimum
tenures can be managed.
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SECTION 7
CONCLUSION
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5.7.1. CONCLUSION
This study has attempted to document the gravity and complexity of the HR
issues in Public Health Sector in ensuring attraction, deployment and retention of the
Physicians, Nurses and Mid-wives along with the contribution of Health Sector Reform in this HR issues along with HR Practice in Reform Process in the health
sector in Arunachal Pradesh.
Adequate human resources for health (HRH) are a key requirement for
reaching health goals, the study found that, the shortages of physicians, nurses and
mid-wives are an ongoing problem in the public health sector in Arunachal Pradesh.
One of the most enduring characteristics of the rural health landscape is the uneven
distribution and relative shortage of health care professionals (Hart, 2002). To fuel on
this part the urban-rural disparities in distribution of this workforce is there, with an
intention of migrating is more and the trend is to migrate to urban areas. There is low
job satisfaction in the workforce in the current job at rural and remote areas. It is
contributed by many of the factors including financial and non-financial benefits.
Attraction and retention of physicians, nurses and mid-wives in remote and rural areas
are determined by many factors including financial incentive, career development
opportunities, recognition etc. But, the factor of compulsion is the main factor of
stock in rural and remote areas, and rest of the factors have less contribution, and the
financial benefits along with non-financial benefits seems to be migrating factors. The
attraction, deployment and retention of physicians, nurses and mid-wives in rural and
remote areas are a real challenge and a difficult situation, and affected by several
factors ranging from organisational factors to external environmental factors and to
personal factors. However, the personal factors have less affect on the situation. The
massive poor living conditions in the rural and remotes areas, poor working condition
in health institutes, poor career development opportunities with lack of financial
benefits are some of the factors that contribute to the reluctances of the physicians,
nurses and mid-wives to serve the rural and remote areas in the state. The sector has
nothing to offer presently, to attract and retain and to distribute rationally this
workforce, which in result deteriorating the situation in the rural and remote areas.
Moreover, the reform process is doing less for the HRM perspectives and the HR
practices are not effective enough to solve the problems in the state.
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353
This study shows that a blend of interventions is needed to improvised the
situation. Nevertheless, the implementation of financial as well as non-financial
interventions are to be ensured for improving the situation of Physicians, nurses and
mid-wives in rural and remote areas.
Thus, it is clear that many factors affect the rational distribution, attraction and
retention of Physicians, nurses and mid-wives in the rural and remote area ranging
from environment issues, organisation issues as well as the personal issues, along with
the production issues, the facilities and basic amenities along with financial incentives
are determinant of manpower in rural areas of the state. It is also known that to solve
these HR issues, no individual interventions are not adequate, it need a pyramid of
interventions to ensure the minimization of the issues.
Moreover, a blend of initiatives is needed to address the problems of distribution,
attraction and retention of manpower in the state, there is a need of continue focus and
commitment on the part of government and as well as the political will to solve the
problem. In conclusion, efforts to strengthen health sector must address the HR issues
and a good Human Resource Management and a far sight in HR requirements are
needed.
==============
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Appendix
Appendix – 1: Manpower Recommended under IPHS
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QUESTIONNAIRE FOR PHYSICIANS NURSES AND MID-WIVES
A. DEMOGRAPHIC INFORMATION
1. Respondent ID :
2. Position:
a) Physician (Medical Officer)
b) Nurse (GNM/Staff Nurse)
c) Mid-wife (ANM)
3. Age:
4. Sex:
a) Male
b) Female
5. Family Background:
a) Rural
b) Urban
6. Marital Status:
a) Married
b) Unmarried
7. Length of Service in rural area:
8. Working in:
a) SC
b) PHC
c) CHC
d) DH
9. Nature of Employment:
a) Permanent
b) Contract
Appendix: 2
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B. EXPLORING THE DIMENSIONS IN ATTRACTION ISSUES FOR RURAL AND
REMOTE AREAS SERVICES
i) Please select the factors that attracted or placed you to current job in the rural
and remote area?Sl.
No.
Attributes Select
(Tick)
1 Financial incentives / Rural allowances/ Performance incentives
2 Improved working condition
3 Availability of equipment, drugs and supplies
4 Authority, independency and autonomy
5 Career development opportunity
6 Continuing education/higher education Opportunities
7 Training and skill development Opportunities
8 Compulsion (minimum rural service tenure or non-transferable or
Management or political pressure)9 Flexible working hour with minimal workload
10 Supportive supervision and mentoring
11 Amenities like housing, conveyance provided
12 Reward and recognition system
13 Teamwork and Interpersonal staffs relationship
14 Safety at workplace
15 Availability of good schools for children nearby town
16 Current health facility is closer to hometown or Closer to family and friends
ii) Please select the factors that may attract you and new physicians, nurses and
midwives towards rural and remote area?
Sl.
No.
Attributes Select
(Tick)
1 Higher Salary package in compare to urban posting
2 Financial incentives / Rural allowances/ Performance incentives
3 Conducive working condition
4 Availability of equipment, drugs and supplies
5 Opportunity for authority, independency and autonomy
6 Career development opportunities
7 Continuing education/higher education Opportunities
8 Training and skill development Opportunities
9 Rotational Posting after completing minimum rural service tenure
10 Job security
11 Flexible working hours with minimal workload
12 Supportive supervision and mentoring
13 Access to amenities like housing & conveyance
14 Better teamwork and good interpersonal staffs relationship
15 Safety at workplace
16 Good reward and recognition system
17 Availability of good schools for children
18 Current health facility is closer to home-town or Closer to family andfriends
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C. EXPLORING THE DIMENSIONS IN RETENTION ISSUES FOR RURAL AND
REMOTE AREAS SERVICES
i) On a scale of 1 to 5, Please rate how satisfied are you with your present job in rural
area?
[ 1) Highly Dissatisfied 2)Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) Highly Satisfied ]
Attributes 1 2 3 4 5
Overall Job satisfaction
ii) Please select the factors that contributed to your satisfaction level of your current job
in rural and remote area service?
Sl.No.
Attributes Pleasetick
1 Salary
2 Better Job Prospects in future
3 Job security
4 Career development opportunities
5 Opportunities of continuing education/higher education
6 Training and skill development Opportunities
7 Work environment
8 Adequacy of equipment, drugs and supplies
9 Financial incentives linked to rural posting
10 Non-financial benefits/allowances linked to rural posting
11 Appropriate Work load
12 Matching of skills and tasks
13 Support, supervision, management and mentoring
14 Reward system and recognition
15 Social recognition and opportunities of public services/ care to patients
16 Teamwork and Interpersonal staffs relationship
17 Safety at the workplace from external environment
18 Access to free accommodation (Housing)with basic amenities
iii) Please share your intention to migrate keeping the salary constant, what will be your
choice to migrate?
Sl. No Attributes Tick one
1 To continue in your present rural area posting (if yes pl. go to no. iv)
2 To shift to another rural health institute (if yes pl. go to no. v)
3 To shift to another urban health institute (if yes pl. go to no. v)
4 To shift to another job in some other State/sector (if yes pl. go to no. v)
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iv) Please select the factors that motivate you to continue in the current job for at least
3-5 years or more in rural and remote areas
Serial
no.
Attributes Select
(Tick)
1 Satisfied with salary
2 Getting adequate financial incentives/ Rural allowances/performanceincentives
3 Improved working condition
4 Adequate drugs/equipment at the rural health centre
5 Career development opportunities
6 Scope for continuing education/higher education
7 Scope for training and skill development
8 Job Security
9 Flexible working hours with minimal workload
10 Improved support, supervision and mentoring
11 Strong Teamwork and interpersonal relationship
12 Anticipation of obtaining a regular position after contractual position
13 Adequate living conditions (access to amenities like housing, water,electricity, conveyance and communication)
14 Achievement is recognized and rewarded
15 Geographical affinities(Hometown near)and familial associations
16 Good schools for children/ education prospects of children
17 Opportunity for both spouses to work and live in the same location
18 More Autonomy in current place of posting
v) Please select the push factors for your intentions of leaving or seeking transfer from
the current job in rural and remote areas for urban areas.
Sl.
no.
Attributes Select
(Tick)
1 Poor salaries
2 Lack of adequate financial incentives/ Rural allowances/performance
incentives
3 Poor working condition
4 Inadequate drugs/equipment
5 Lack of Career development opportunities
6 Lack of scope for continuing education/higher education
7 Limited opportunity of training and skill development
8 Lack of Job security
9 Unusual working hours and excess work load
10 Poor support, supervision and mentoring
11 Lack of others cadres, teamwork and interpersonal relationship
12 Inadequate living conditions (access to amenities like housing, water,electricity, conveyance and communication)
13 Achievement not recognized
14 Lack of safety at workplace
15 Limited or no good schools for children/ education prospects of children
16 Lack of Autonomy
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vi) Please select the factors that may motivate you to retain the current job in rural and
remote area other than that of factors that what you are satisfied with current time.
Sl.no.
Attributes Select
(Tick)
1 Increase salary by half
2 Increase salary by double3 Financial incentives for rural posting/ Rural allowances/performance
incentives
4 Improved working condition
5 Job Security
6 Adequacy of equipment, drugs and supplies at Health centre
7 Career development opportunities
8 Opportunities of continuing education/higher education (support for further education)
9 Training and skill development Opportunities
10 Rotational posting
11 Opportunity of autonomy12 Flexible working hours with minimal work load
13 Adequate patients/clients at current facility
14 Supportive supervision, management and mentoring
15 Good reward and achievement recognition system
16 Good teamwork and good interpersonal staffs relationship
17 Security & Safety at workplace
18 Availability of good schools for children
19 Improve living conditions (Access to amenities like housing, water,electricity, conveyance and communication)
vii) Please Share any other point related regards your current job in rural area in the
context of HRM.
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
viii) Please share your perspective on contractual employment (only for contractual)
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
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D. EXPLORING THE VIEWS IN HEALTH SECTOR REFORM
i) On a scale of 1 to 5 please rate the following statement regarding ongoing health
sector reform process in your organisation?
[ 1) Strongly Disagree 2) Disagree 3) Undecided 4) Agree 5) Strongly agree ]
Serial
No.
Attributes 1 2 3 4 5
1 The Reform has made the Human Resource Policies clear andunderstandable at your level
2 The reform has made the placement, transfer and promotion
transparent, fairer and unbiased
3 The reform has made your job description clear
4 The reform has increased your chances of being promoted
5 The reform has made the Salary structure Competitive for ruralarea posting
6 The reform has made regular and adequate financial incentives andallowances for rural area posting
7 The reform has increased the activities for your performanceappraisal and positive action on them
8 The reform has made an improvement in working condition in
your work place
9 The reform have increased the training and skill developmentOpportunities
10 The reform have improved the availability of equipment, drugs
and supplies essential to perform your assigned tasks
11 The reform have improved mix of other cadres in your workplace
12 The reform has made your workload more manageable
13 The reform has made improvement in supportive supervision,management and mentoring form higher authority
14 The reform has made work independent and more autonomy
15 The reform has made improvement in housing and other amenitiesat your workplace
16 The reform has made rural health care services an attraction for the potential physicians, nurses and mid-wives to work in rural and
remote area
17 The reform has made overall HR practice effective and conducivein the organization
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E. EXPLORING THE DIMENSIONS IN HR POLICIES AND PRACTICE IN
ACQUIRING (ATTRACTION), DISTRIBUTION AND RETENTION IN RURAL
AND REMOTE AREAS
i) On a scale of 1 to 5 how do you feel about the following practices in yourorganisation regarding rural and remote area services?
[ 1) Highly Dissatisfied 2) Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) HighlySatisfied ]
Serial
No.
Attributes 1 2 3 4 5
1 Recruitment and selection process
2 Policies for placement, transfer and promotion
3 Fairness of HR Practice for placement, transfer and promotion
4 Magnitude of management favoritism and politicalinterference in transfer and posting
5 Response of administration/management on your placement,transfer and promotional grievances
6 Participation and involvement in the decision making of your placement and transfer
7 HR Practice for retentions –Financial Interventions
8 HR Practice for retentions – Non Financial Interventions
9 Training and Development
:::::::::Thank You:::::::::
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INTERVIEW SCHEDULE FOR STATE AND DISTRICT MANAGEMENT
REPRESENTATIVES
Part –I
DEMOGRAPHIC INFORMATION
1. Your current post/position? ………………………………………………….
2. Gender? Male Female
3. Age? ………………………..
7. Years of management experience? …………………………….
1. EXPLORING DIMENSION OF HR ISSUES IN DISTRIBUTION,
ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES FOR
RURAL AND REMOTE AREAS
1. In your opinion, what are the key human resource issues on distribution of
physicians and nurses in rural and remote areas in your state/district?
2. In your opinion, what are the key human resource issues on attraction and
retention of physicians and nurses in rural and remote areas in your state/district?
3. What you think could be the main reasons for physicians and nurses turnover from the rural and remote areas of area of operation?
4. Could you please summaries the main HR issues and challenges regarding
physicians and nurses that you are facing in order to implement Health Sector
Reform effectively?
5. Do you have any further plans as reform initiatives for addressing the above
mentioned issues regarding distribution, attraction and retention of physicians
and nurses in rural and remote areas of your area? If yes what are they, would
you like to share?
6. Are there any comments you would like to provide regarding the subjects not
covered in this interview regarding HR issues of Physicians and nurses?
2. EXPLORING DIMENSION OF HRM PRACTICE IN REFORM PROCESS
IN DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS
AND NURSES FOR RURAL AND REMOTE AREAS
1. What is the name of the Department/Section which looks after Human ResourceManagement function in the organization at your level?
2. What is the staffing pattern of this section?
3. What HR functions are performed by the Department?
4. How do you assess the requirement of Physicians and nurses for the organization,
particularly for rural and remote areas?
Appendix :3
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5. What are the HR practices used for attraction of physicians and nurses in ruralareas?
6. What are the sources are utilized for the recruitment for recruiting physicians and
nurses?
7. Did you find any problem in filling up vacancies of physicians and nurses for rural
and remote areas? If yes. Please share the issue and the problems?8. What are the criteria for placing and transfer physicians and nurses in rural and
remote areas at your level?
9. What are the HR practices and core HR area used for retention of physicians and
nurses in rural areas?
10. Does the organization have any financial incentives for rural and remote areas
placement of physicians and nurses for attracting and retaining them in rural area
services? If yes, would you like to share what are the types of incentives aregiven?
11. Does the organization have any non- financial incentives for rural and remoteareas placement of physicians and nurses for attracting and retaining them in rural
area services? If yes, would you like to share what are the types of incentives aregiven?
12. Does the training and promotional system have linked as a kind of incentives for
rural area placement?
13. If Yes, How do you select these employees for training?
14. What are the initiatives at your level to maintain the minimum posting tenure in
rural areas of physicians and nurses?
15. Are there any comments you would like to provide regarding the subjects not
covered in this interview regarding HR practice regarding Physicians and nurses?
16. Would you like to through a light on the following issues under reform initiativesin the state? (TO BE ASKED ONLY FOR STATE LEVEL MANAGEMENT
REPRESENTATIVE)a. Development of HRM & HRD policy especially related to contractual
physicians and nurses under NRHM b. Availability of essential equipments, drugs and supplies for functionalizing a
health centers in rural areas
c. Capacity building
d. Supervision of supporting nature
e. Nursing and Paramedical education and Schools
f. Medical Education and Colleges
g. Accommodation facilities (New Residential Qtrs) in the rural areas health
institutions
3. INFORMATION ON HUMAN RESOURCE IN THE DISTRICTS
1. Would you like to share the details on Health Institution in the district/state?
a. Number of Total Health institutes in the District/State
Sl.No. No of Health institutes in the District Numbers
1 District hospitals/ General Hospitals
2 CHCs
3 PHCs
4 SCs
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b. Number of Health institutes in Rural and remote areas in the District/State
Sl.No. No. of Health facilities Total
1 Total no. of sanctioned sub centres
2 Total no. of functional sub centres3 Total no. of sanctioned PHCs
4 Total no. of functional PHCs
5 Total no. of 24x7 PHC
6 Total no. of non 24x7 PHCs
7 Total no. of CHC
8 Total no. of CHC (FRUs)
9 Total no. of CHC which are non-FRUs
2. Would you like to share the details on the numbers of physicians, nurses and mid-
wives in the district/state?
c. Numbers of MO, GNM & ANM according to the Health institutions in the District
Sl. No.Health institute in the
District
Total Number of
P h y s i c i a n s
( M e d i c a l
O f f i c e r s )
( i n n o s . )
N u r s e s
S t a f f
n u r s e / G N M
i n n o s .
M i d - w i v e s
A N M
( i n n o s . )
P a e d i a t r i c i a n s
A n a e s t h e t i c s
G y n a e c o l o g i s t
1 District Hospital
2 CHCs
3 PHCs
4 SCs
Total
d. Numbers of MO, GNM & ANM according to the Rural and remote areas Health
institutions in the District/state
Sl. No. No. of facilities Total
1 Total no. of SCs existing / having infrastructure
2 No. of SCs having one ANM
3 Total no. of SCs having two ANMs
4 No. of PHCs not having any MO (MBBS)
5 Total no. of PHCs not having 3 staff nurses/ 3 ANMs
6 No. of CHCs not having full complement of specialists
i.e. Gynaecologist, Anaesthetist, Paediatrician
:::::::::Thank You:::::::::
7/29/2019 Attraction and Retention of Physicians and Nurses in Rural Areas in India
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CONFERENCE ATTENDED
1. NATIONAL CONFERENCE ON INFORMATION AND KNOWLEDGE
MANGEMENT, 12TH
MARCH 2011
AT FAKIR MOHAN UNIVERSITY, VYASA VIHAR, BALASORE,
ORISSA
(Presented a paper entitled: Knowledge management improve
effectiveness in Human Resource Management)
2. INTERNATIONAL SEMINAR ON RESOURCE, TRIBES AND STATE,
13TH
TO 15TH
FEBRUARY 2012
AT RAJIV GANDHI UNIVERSITY, RONO HILLS, DOIMUKH,
ITANAGAR, ARUNACHAL PRADESH
(Presented a paper entitled: A study on distribution, attraction and
retention of physicians and nurses to combat maternal and child
mortality in four predominately tribal state of North-Eastern India)3. INTERNATIONAL 5
THDOCTORAL THESES CONFERENCE, 2
NDTO
3RD
APRIL 2012
AT IBS, ICFAI FOUNDATION FOR HIGHER EDUCATION,
HYDERABAD, ANDHRA PRADESH
(Presented a paper entitled: An exploratory study on distribution,
attraction and retention of physicians and nurses in rural areas in
Arunachal Pradesh)
4. NATIONAL CONFERENCE ON HUMAN RESOURCE
MANAGEMENT (2ND
), 8TH
APRIL 2012
AT MANAGEMENT DEVELOPMENT RESEARCH FOUNDATION,
NEW DELHI
(Presented a paper entitled: Human Resource for Health in rural
communities-A Study on distribution, attraction and retention in Indian
public health system with special reference to Arunachal Pradesh)
5. INTERNATIONAL CONFERENCE ON CONTEMPORARY
INNOVATIVE PRACTICES IN MANAGEMENT, 13TH
TO 14TH
APRIL
2012
AT PACIFIC UNIVERSITY, UDAIPUR, RAJASTHAN
(Presented a paper entitled: The 21st century employment contract for
solving numerical inadequacy of health workforce in Indian rural public
health system – 2005-12)