Biborton English

Bangladesh is the seventh most populous country in the world with a high poverty rate.  More than half of its population lives in the rural areas. In their day to day life, people in the remote and rural areas are facing thousands of problems.

Inadequacy of health care service is one of the most important but neglected part of their miserable life story. Mothers are dying due to lack of adequate maternity care; children are suffering from various infectious diseases and malnutrition while their fathers can not help them due to limited accessibility to qualified health care providers. Whenever they get sick, they try to get them cured with traditional methods provided by local kabiraj, herbalists, practitioners of ‘Folk Medicine’ and faith healers etc. Access to qualified health care providers is far beyond their reach.

They are too poor to buy medicine. They cannot afford to seek expensive health care from limited existing private clinics or hospitals. Health centres run by the Government and some other working NGOs are their only destination. After suffering for long days when they reach the health centres, however, they find the situation more miserable.

In the health centres there are not enough doctors, nurses or other health workers to serve this unfortunate population. Equipments are left unused aside, but there is no one to operate them. There are some diagnostic facilities but not enough technicians to perform necessary laboratory tests. People are suffering a lot to get even the primary health care there. The one or two doctors, who stay in the remote centres, work so hard to deal with the extra load of patients. In addition, they become tired and frustrated as they face other problems of lack of training opportunities and delayed career development.

Moreover, their comparative low salary forces them to think differently to earn more money to meet the growing demand of life. Ultimately, they try to move to the places where additional facilities and opportunities are available.  
Conversely, in the urban areas, in the government hospitals, where facilities for training are available, there are over concentration of doctors. In private sector, in spite of facing some difficulties doctors are working due to have the opportunities for extra earning.

Besides, some other Government doctors who have their posting in the rural health centres, they are staying in the urban areas for long time by arranging deputation or some other local orders. Some are going monthly to their rural workplace ignoring the Government rules and regulations. Thus, the doctors in the urban areas, occupying the position of health centres in the rural areas, staying at the urban areas for better opportunities, making the total country health system vulnerable and depriving those unfortunate patients in the rural areas from getting the quality health care services.

Currently, in Bangladesh, Health and Family welfare centers in the whole country has been facing a great human resource crisis. At present, approximately 17,832 posts for health workers are vacant. With in these vacant positions, about 5,225 are for doctors. Due to proper planning and supervision of Government the posts are remaining vacant in the rural areas. Whereas, in the urban areas there are lots of history of over placement of doctors. In Bangladesh 30 % nurses are located in four metropolitan districts where only 15% of the population lives.

Not only for Bangladesh, the problem of health worker shortage in remote and rural areas is a global concern. 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. 5 The absence of well educated and properly managed health workers are identified as one of the health systems constraints in many developing countries to achieve the MDGs, along with poor infrastructure, drugs and supply systems and information systems.

In these perspectives, increasing health worker motivation and retention is a global issue to address. So, majority of the countries are paying attention to identify the factors associated with motivation of health workers to stay and work in remote areas. This is also emerging and important issue for Bangladesh. There is a growing need to strengthen health systems to help meet the MDGs. So, along with the development of infrastructures and proper, effective drug supply system and information systems, this is the time to assess the level of health worker motivation and associated factors.

A cross sectional study was conducted among the intern doctors of different medical college hospitals where an attempt has been made to find out the factors associated with motivation of doctors towards serving the rural population. Recently graduated intern doctors of three medical college hospitals in Dhaka division were interviewed to explore different aspects of their career plan and interest to work and stay in remote and rural areas. The interview was based on particulars of the doctors, their socio-economic aspects and motivational aspects like interest in Government Internship Extension Scheme, length of staying at the rural health centres and the way how they want to serve the rural population.

Majority of our recently graduated doctors want to start post graduate study in the country within two years of internship; a significantly large number want to appear at BCS examination. Some of them want to go abroad for higher education. Among the other plans within two years after completion of internship some wanted to immigrate to foreign countries, some wants to join private medical college hospitals, some wanted to work with NGOs, but their percentage is very minimum. More than half of the participant (58%) showed interest to join Govt. internship extension scheme. About 42% were not interested to join. About 15% respondents wanted to take part in BCS and post graduate entrance examination instead to join internship extension scheme; 8.27% showed no interest because that training is not counted for post graduation examination qualification Others mentioned lack of proper guidance, accommodation problems, family problems and lack of security as the reasons for not joining. But their percentage was not so significant.

Among the doctors female appeared to be more interested in extension scheme than male. Although some of them do not want to take the option of internship extension, they have the interest to serve rural population. Most of the respondents (89%) had interest to serve rural population. Majority of them believed that it is their duty to serve the rural people; around 16% wanted to serve rural population as rural areas were their place of birth. According to others parents’ wish, pollution free environment, cool living were the reasons for choosing rural areas to work and stay in.

Majority of intern doctors wanted to serve rural people by joining BCS. About 19% wished to setup health facilities of their own. Some of them wanted to do general practice while some of them wanted to join NGOs or any private clinic on part-time basis. Their proportion is less. Almost halves of respondents wanted to work in rural areas after joining BCS; about 41% wanted to do the same after completion of post graduation. Least number of respondents (7.6%) showed Majority wanted to serve rural areas for a period not more than 2 years. So, from the findings it can be concluded that, majority of the doctors have the interest to go to rural areas but they do not want to stay there for long time. Most of them had more than one reasons for not willing to stay in the remote and rural areas.

Lack of opportunities for training and post-graduation was the main obstacle for the doctors to work in rural areas. Some mentioned delayed career development as the cause. Lack of adequate accommodation and Lack of security was reported thereafter. Lack of security, lack of congenial working environment, lack of comfortable transport facilities, lack of resources and equipments were mentioned as the reasons by an average number of doctors.
Increment in salary was stated as leading factor to stay in rural areas followed by Easy and available training facilities.

Many of then wanted opportunities for career development to stay at rural areas. Among the other factors necessary many of them mentioned about the availability of resources and equipments, social security, personal transport facilities, job security, comparative better administration, and personal recognition and appreciation.

Recently, health worker motivation and retention is one of the major concerns for global health policy makers. It is the time to evaluate the factors associated with health worker motivation and to take appropriate measures accordingly. The study tried to identify the factors in the context of Bangladesh among the most recently graduated doctors.

It is identified that majority of the doctors feel responsibility to serve rural population. They believe it as one of their duties. Majority of them want to work in the rural areas but due to some problems they do not want to stay there for long time. Among the male doctors, the lack of opportunities for training and post-graduation, delayed career development were mentioned as primary causes while among the female doctors lack of accommodation and social security were identified as major reasons.

The study also explored the factors necessary to stay and work in the rural areas. Majority of them agreed on the increment of salary. Others responded about the matter of training facilities, development of resources and equipments and comfortable transport facilities.

So, in the perspective of Bangladesh, if the above mentioned factors are properly addressed and appropriate measures can be taken, from the starting of their professional life, doctors’ motivation towards serving the rural population can be significantly improved.

Thus, increasing access to health workers in remote areas will appreciably improve the health status of the country which ultimately leads to the achievement of MDGs.