Self-interested, Not Dodgy, Doctors

Rumi Ahmed.

Published in the Weekend Independent on 5 November 2010.

This piece argues that physicians must be given incentives to go rural.

Lately, Prime Minister Sheikh Hasina has been urging the physicians and surgeons to render health services to the people living in villages. However, all the persuasions and warnings of the Prime Minister and the health authorities fell on deaf ears. According to newspaper reports, on most surprise visits to rural centres by health officials since the warnings, they found a majority of the doctors to be absent. Despite repeated appeals and warnings from the highest authorities of the country, government physicians continue to remain absent from their workplaces in rural Bangladesh.

This is a puzzle. Even though there is an intense demand for government jobs amongst physicians in Bangladesh, oncethey get the job why do they not take it seriously?

It is thus important to at least try to understand our physicians’ aversion to remaining at the workplace in rural Bangladesh. Our authorities must understand that they cannot force physicians to stay at their rural postings unless they want to be at their job out of their own passion and interest. Unfortunately, this interest will never appear until some basic job requirements are fulfilled.

What does a young physician have in a remote rural god forsaken place? And if he or she has a family — what opportunities are being offered to the spouse and children? Does the spouse have a second job prospectand do the kids have good schooling? Forget community clinics or union sub centers, how many Upazilla health complexes have good residential quarters or even a decent working environment?

Physicians, like other professionals, are the brightest and the most able individuals in a society. How comparable are the perks of rural physicians against those of the government engineers working for WBD, PBD, PWD, Roads & Highways, Railway, LGED or bridge projects? Compared to their lavish bungalows, government transportation, servants, aides and tennis courts—a physician posted in a union sub center does not even have a table to sit on in most cases. They are trained professional physicians, not Mohandas Gandhis!

Yet, there is more to the story. At almost every rural bazaar in any remote corner of Bangladesh, there is at least one graduate physician doing private practice. So not wanting to work in rural areas definitely is not the main problem. Where does the problem lie?

When a physician works in a rural center, what is his or her future? Is there any guarantee from the employer that she/he will be given an opportunity to learn advanced medicine in a city based tertiary hospital if she / he works in the rural center sincerely? Is there any financial incentive like remote posting pay, or material incentive like those enjoyed by government engineers when they are posted in remote sites? Is there even any emotional incentive such as the work place being in the native upazilla of the physician? The answer is ‘no’ in almost all the cases.

What the government hospitals need to do is offer the same incentives that a local bazaar provides for a practitioner, like being from the community, enjoying the financial returns, having his family at a nearby commutable major district town, etc.

Implementing a major change in the government’s bureaucratic system is tough, but at least we can start thinking about the changes we can make to keep physicians interested and vested in their rural jobs. The current Health Ministeris definitely a very pragmatic person and there is no doubt that he will at least understand the need for change.

Physicians need to be preferentially posted near their native villages. There must be a system where a sincere, hardworking rural physician gets an automatic opportunity for advanced training if she/he wishes to pursue further training.

More over, there must be financial incentive for rural posting. Rather than having seventeen physicians posted in an Upazilla Health Complex, why not post six physicians and use the rest of the budget to give a monthly rural posting allowance? Additionally, like the way the government is thinking about letting medical college professors practice within the premises of the government hospital, the government should think of making similar well-supervised and accounted arrangements in rural health complexes.

Long term changes can include the government coming into partnerships with local practicing physicians. Why not have each local practitioner serve the government facility for 24 hours at a negotiated rate and thus have seven such private physicians covering the government center for the week?

Our policymakers must also think of the broader social factors that make it difficult to make a physician live at a rural workplace. Not so long ago, the district headquarters used to have a good, educated society comprised of all government administration officials, engineers, teachers, physician, and well-to-do businessmen. There used to be good schools and a great cultural environment to raise a family.

Those days are no more. Everyone is moving to Dhaka. Zilla school quality has declined considerably; all district level officials keep their family and children in Dhaka for English medium education. The cultural environment has altogether vanished.

All the warning and coaxing, even from the Prime Minister, has failed in keeping the physicians’ hearts at their rural jobs. There must be incentives instead of warnings. Physicians must be vested in rural health centres as eager partners of the government. Minor changes in the thought process and rule of procedures of the health ministry can go a long way to bring along this change.

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