Rural recruitment and retention of health workers across cadres and types of contract in north-east India: a qualitative study

Background Like many other low- and middle-income countries, India faces challenges of recruitingand retaining health workers in rural areas. Efforts have been made to address this through contractualappointment of health workers in rural areas. While this has helped to temporarily bridge the gaps in humanresources, the overall impact on the experience of rural services across cadres has yet to be understood.This study sought to identify motivations for, and the challenges of, rural recruitment and retention of nurses,doctors and specialists across types of contract in rural and remote areas in India’s largely rural north-easternstates of Meghalaya and Nagaland.Methods A qualitative study was undertaken, in which 71 semi-structured interviews were carried out withdoctors (n = 32), nurses (n = 28) and specialists (n = 11). In addition, unstructured key informant interviews(n = 11) were undertaken, along with observations at health facilities and review of state policies. Datawere analysed using Ritchie and Spencer’s framework method and the World Health Organization’s 2010framework of factors affecting decisions to relocate to, stay in or leave rural areas.Results It was found that rural background and community attachment were strongly associated withhealth workers’ decision to join rural service, regardless of cadre or contract. However, this aspiration waschallenged by health-systems factors of poor working and living conditions; low salary and incentives; andlack of professional growth and recognition. Contractual health workers faced unique challenges (lack of payparity, job insecurity), as did those with permanent positions (irrational postings and political interference).Conclusion This study establishes that the crisis in recruiting and retaining health workers in rural areaswill persist until and unless health systems address the core basic requirements of health workers in ruralareas, which are related to health-sector policies. Concerted attention and long-term political commitmentto overcome system-level barriers and governance may yield sustainable gains in rural recruitment andretention across cadres and contract types.

Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey

Background: The availability of reliable and comprehensive information on thehealth workforce is crucial for workforce planning. In India, routine informationsources on the health workforce are incomplete and unreliable. This paperaddresses this issue and provides a comprehensive picture of India’s healthworkforce.Methods: Data from the 68th round (July 2011 to June 2012) of the NationalSample Survey on the Employment and unemployment situation in India wereanalysed to produce estimates of the health workforce in India. The estimateswere based on self-reported occupations, categorized using a combination of bothNational Classification of Occupations (2004) and National Industrial Classification(2008) codes.Results: Findings suggest that in 2011–2012, there were 2.5 million healthworkers (density of 20.9 workers per 10 000 population) in India. However, 56.4%of all health workers were unqualified, including 42.3% of allopathic doctors,27.5% of dentists, 56.1% of Ayurveda, yoga and naturopathy, Unani, Siddha andhomoeopathy (AYUSH) practitioners, 58.4% of nurses and midwives and 69.2%of health associates. By cadre, there were 3.3 qualified allopathic doctors and3.1 nurses and midwives per 10 000 population; this is around one quarter ofthe World Health Organization benchmark of 22.8 doctors, nurses and midwivesper 10 000 population. Out of all qualified workers, 77.4% were located in urbanareas, even though the urban population is only 31% of the total population of thecountry. This urban–rural difference was higher for allopathic doctors (density 11.4times higher in urban areas) compared to nurses and midwives (5.5 times higherin urban areas).Conclusion: The study highlights several areas of concern: overall low numbersof qualified health workers; a large presence of unqualified health workers,particularly in rural areas; and large urban–rural differences in the distribution ofqualified health workers