70244 Slipportillg Evidellce-based Policies alld Implemelltatioll CAREER PREFERENCES OF MEDICAL AND NURSING STUDENTS IN UTTAR PRADESH' Shomikho Raha' , Peler Bcmtan:,Aarushi Bhatnagar" This note describes Ihe career preferences a/gradualing medical alld nursillg sludents ill Ullar Pradesh, with special reference to incenrives oJferedfor alld work altributes of emp!oymenr opporrunities in rural areas. Results illdicate rilal medical studenls prefer ro COllcentrate 011 'heir post-graduate education alld are 1/01 ille/illed to work ill rural areas while lIursing students have a grealer predilectioll to work ill public rural settings. The /lole dra ws attention 10 file fact that il is (J tougher challenge 10 increase 'he supply a/physicialls ill rural areas as compared 10 lIurses alld il/cel/lives offered to prospeclive hea"" workers wOl/ld be more effective ill the form of incentive packages. India, more specificall y the state of Uttar Pradesh (UP), cllr- package which could succeed is to understand how health rently faces a seriolls geographic mal-distribution of human workers perceive various job, remuneration, and location resources for health. Though the majority of the popUlation options. Planners designing new programs to increase recr- lives in rural areas, doctors in both thc pub lic and private uitment and retention for rural areas need to understand the sectors arc concentrated in urban areas. Doctor and nurse reasoning behind prospective health workers' preferences densities in cities are 3-4 times higher than rural areas.' for working in urban areas to detemline which incentives and other work attributes would attract health pcrsonnel to Government is trying to remedy these imbalances by rural service. This note reports on a study to understand recruiting and placing doctors and other health workers in perceptions of factors affecting employment choice among rural areas. Vacancies in the government health sector in the graduating medical and nurs ing students in UP. country are large: 40% of the medical officer posts in Primary Health Centres (PI-ICs) and 50% of the specialist HOW THE STUDY WAS CONDUCTED posts in Community Hea lth Centres (CHCs) arc vacant. One Medical and nursing schoo ls in Lucknow, Allahabad and result of the geographic imbalance in the health workforce is Gorakhpur were purposively chosen to represent a diversity that rural populations lack access to quality health services. of both academic reputation and geographic locations. Additional prob lems such as abscnteeism reduce access Except for one private institution located in Lucknow, all the further. medical coll eges were pub lic institutions. Within each Th e Union Government recently proposed one approach to medica l school, final year undergraduates and post- tack le this shortage of rural health workers by making the graduatesJ were purposively selected to capture a range of license to practice medicine or pursue further education geograph ic locations of their hometown. Focus group contingent on completion of one year rura l service after the di scussions (FGDs) and interviews were held with these undergraduate course (Times of India, 2006). But compul- medica l students as well as with first-year students at pub lic sory rural service is difficult to enforce! and not very popular nursing schoo ls and final-year stud en ts at pri vate among medical students. Gol is also providing significant institutions. 4 FGDs enabled a range of opinions and also new funding for recruitment of health personnel on contract allowed for cross-checking views students professed through the National Rural Health Mission . But can the individually and in group settings. A semi-structurcd government attract health workers to voluntaril y opt for questionnaire was used for in-depth int erviews and a simi lar rural service? A first step in fomlUlating an employment set of discussion topics was used for the FGDs. Students . Health workers in sufficient numbers, in the right places, and adequately trained, moti vated and supported are the backbone of an effecti ve, eq uitable, and efficient health care system . Success in creating and sustaining an effective health workforce in India to achieve national health goals wi ll require sound policy and creative and commined implementation. More and bener infomlation on human resources for hea lth in India is one clemem needed to achieve thi s. This note summarizes recent and ongoing work in support of India's health work force goals. Forthc full report, see Ralw. S. f'1 al "Career Preferences oJMedical and Nu rsing students in Utta r Pradesh: A Qualitalil'e Analysis" HRH Technical Report #3 al www.hrhilldia.org ! The World Bank, New Delhi , India; : The World Bank, Washington DC; •. The Public Health Foundation of India, New Delhi were asked about their plans upon graduation and their views were expressed about the choice between the public perspectives on work ing in the public and private sector and and private sector - swdents seemed more attracted to the in urban and rural areas. Both English and Hindi were used private sector but they also acknowledged that the public to communicate during the FGDs and in-depth interviews. sector offered severa l advantages. Post-graduate students, however, were much more inclined towards the pri vate KEY FINDINGS sector. When direc tly asked to choose betwee n a Th e Importa nce of Specialization and Timing Labor government job in an urban area and a private job in an Ma rkel Entrance: On graduation with their MBBS degree urban area, students preferred the former. This result was (Bachelors of Medicine),! 90 percent of the undergraduate somewhat surprisin g given that the private sector cl earl y respondents intended to pursue a post-graduate course of seemed the pre ferred choice during discussion s and study. Post-graduate students arc much keener to get a job interviews. Some explanations for this result include: (i) once they obtain their degree, although there are also a few whi le the private sector is more attracti ve in the long-tenn, a who wou ld lik e to pursue super-spec ialty courses. All government job may be preferable as a first job to ga in medical students who parti cipated in this study placed great experience and as a stepping stone to private practi ce; and emphasis on specialization despite the fact that the number (ii) upon comparing the publ ic and private sector of post-graduate (PG) scats avai lable in a given year is a generically, students assumed that the public sector job third of the number of graduat ing MBBS studcnts (a nnual would be located in a ru ral area (and where students were reports of National Health Information, Government of likely to ha ve received their first posting) while the private India). Better career opportunities, the perception that sector was assumed to be in an urban arca since there are MBBS doctors have less slaws in society and the bel ief that fewer rural private practices). A private practice in a rural an M.BBS degree docs not sufficient ly qualify them to area was the least appealing option, most likel y because it practice medi ci ne dri ve them to pursue a PG degree. was not expected to be very lucrative. Through severa l atlempl"s at the PG-entrance examination, Though there was not a clear·cut prcference between the they also expressed a high level of confidcnee that they will public and private sectors. the medical students always undertake post-graduate studies despite the limited number preferred an urban job to one in a rural area. For medical of seats available. Finally, all students expressed a very low students location was the dominant factor in an idea l first preference fo r COlllmunity Medicine. Training in publ ic job. In contrast, for nurses the publ ic sector was always the health holds litt le attraction for the current batch of medical preferred oplion. As in the case of medi cal students, nurses students in UP today even though government poli cy also preferred an urban public job to an urban private job, statements continue to prioritize its importance. though by a much larger margin than did medical students. Sim ilar to undergraduate medical stlldents, the majority of Similarly in rural areas, a government job is again the pre- nursing students would like to pursue further education in fe rred choice. For nurses, rural pri vate is also the least lenns of a B.Sc. in nursing. About 65 percent of the nursing preferred option. However, there was an important differen- students expressed an inclination towards a postgraduate ce. Nursing students actually preferred a rural publi c job to course. However, since Ihey felt that the chance of gelling a an urban pri vate job, whereas for med ica l students it was the scat in a BSc course was extremely low, nursing sn ldents reverse. Therefore, for nursing students, the determining were much more amenable to entering the job market on factor was not the location but the Iype of enterprise: the comp letion of the General Nurse Midwife (GNM) dip loma public sec tor being the most appealing choice. than were medi cal students graduating with an MBBS. Views on Incentives for Rural Se rvice: Both medical and Moreover, unlike medical students, seeking a job abroad nursing students were presented with choices of different was much more popular among nurses as they believed that non-pecuniary incenti ves, for doing temporary service in there were good opportunities for them in countries such as the pub lic sector in rural areas. They included a 50% America, Australia and Canada. reservation in post-graduate courses upon completi on of Id eal Job Attributes Cit ed by Students: Even though rural practice, lega lized private practice, increased training many medical students, espec ially the undergraduates, did oppo rtunit ies. good housing, faste r promotions, a not intend to enter the job market in the ncar futu re, they had guaranteed urban transfer, and a rural posting ncar the a cl ear sense of the job attributes important to them. For student 's hometown. Each of these incent ives was most students, a respectab le sa lary, the opportunity to util ize presented by itse lf, in the absence of any other inducement . skill s, good liv ing conditions and a safe working environ- The most appea ling non-financia l incentive for both ment fi gured prominently as essential criteria for a first job. undergraduate and post-graduate medi ca l students was a Nurses also placed grea t emphasis on job security. Factors 50% reservati on in PG courses for students who had such as workload and furth er training opportunit ies were compl eted a stin t in a rural area fo llowing their M BBS least important when considering ajob upon graduation. degree. For example, over 80 percent of undergraduates Preferen ces for Urban or Rural Locations and Public or interv iewed were very attracted to rural service for 2-3 years Pr ivate Sector: For undergraduate medica l snldcnts, mixed with 50 percent PG reservation. This is not surprising given [\;[1I.\ [ II \[ [J [ iii \ J \(>[UI11<: I • ~Ul11hl'r (, ( \ugU'1 .:!()()lJ) the extreme competitiveness of admissions to post-graduate recent snldies in oth er countries such as Ethiopia6 support programs of study. this view. The results suggest cumu lati ve effects from Both undergraduate and post-graduate medical students comb ining improved incentives, both pecuniary and non- considered that good housing, on its own, and in the absence pecuniary, rather than improvingjust one job attribute. of any other facilities, was not of great significance in The importance of addressing mUltiple job attributes makes attracting students to public sector jobs in rural areas . the task of government planners to increase recruitment and Studen ts also felt that government accelcration of retention more difficult. They may need to address a mix of promotions for doctors serving in rural areas would not be attributes, some of which are within their control (e .g. particularly effective in recruit ing students to publ ic service access to trainings, preferences for location of postings) and thcre. Medical students wcre much more inclined to favor some of which arc not (post-graduate admissions, better government poli cy that attempted to post students near their salaries). hometown. They were, in general, wi ll ing to tolerate only a Third and most important, our findings suggest that staffing eertain di stance [rom their hometown even if posted in the rural health services won 't be merely a "nu mbers game" that same district. can be addressed by financing medical colleges to produce Nursing students' rcsponses were simi lar to those of many more doctors. Planners need to understand and medical students . Reservation in BSc eou rses for nurses address the preferences of the staff they want to recruit and who work in rural areas was considered an appealing retain. There already exists an active job market for doctors prospect. I-Iowever, for nurses, the most attractive option and nurses and young people entcring that market have was in fact a posting in a rural area near their hometown or choi ces. village. Once again the least appealing incentive was the promise ofsolcly good housing in rural areas. NEXT STEPS I. Cons ider implementing 50% preferential treatment in CONCLUSIONS AND POLICY IMPLICATIONS entrance to post-graduate stud ies for doctors who serve a This was a small and largely qualitative study, so one should fixed period (3 years) in a rura l posting of the pub lic be cautious abou t generalizations from the results. sector health care services. The preferential treatmcnt Nonet heless, the findings raise some difficult issues for may either be given as points added to the overall marks cu rrent government efforts through the National Rural of the applicant or through the allocation of scats Health Mission (NRHM) to provide marginal fiscal reserved for such applicants. Each state wi ll need to work incentives to recruit and retain doctors in rural areas. out the specifie formula most likcly to be successfu l in First, undergraduate mcdical students are most concerned the speci fic state context. about future postgraduate study. There is little likelihood in 2. The use of compulsory rural servi ce has internationall y UP of increasing the supply of MBBS doctors for govern- shown very mixed results and its effectiveness in ment jobs in the cxist ing condi ti ons at rural facilities. In providing rural health service in some states in India still contrast, even in the existing environment, increasing the unknown. The extent of sllceess such compu lsory number of nurses in the public sector is very feasible, given service has had in bringing rural health care in other their preference for government jobs. Medical students in countri es? and the measures needed for its successful UP arc largely not interested in rural public service and application and enforcement in the Indian context many cited familial opposition to such career choices. This warrant carefu l examination. is not just a personal preference, but also related to the 3. Examine alternat ives to posting MBBS doctors as head s eontrasti ng socia l and economic background of the students of primary level faci lities such as more empowered and and their fam ili es when compared to most rural comm- ski lled nurses and the creation of a managerial cadre of unities. In contrast, nursing students find public service nurse or AYUS H practitioners. attractive and may be more recept ive to rural servicc, espec iall y, if nearer their family homes. These findings 4. A successfu l package of incentives in drawing health suggest that a human resources in health (I-IR.1-I) strategy, workers, like doctors and nurses, requires better under- which focuses too much on increasing the supply of physic- standing of their preferences. More thorough studies in ians in rural areas, faces tougher challenges than one which different states analyzing such preferences should be emphasizes increasing the numbers and roles of nurses. initiated and such packages may also be quantified using Discrete Choi ce Experiments, as has be done to estimate Second, to attract medical students to take ajob in the public costs of incentive packages for doctors and nurses in sector health system, a package approach that has a bundle other country contexts. 8 of strategic incentives such as innovative linkages tuned to the ca reer-related preferenccs of snldents is probabl y more effect ive than an exclusive focus on a sing le incentive or bettering any particu lar job attribute to satisfactory levels. While we didn't yet test this hypothesis quantitatively, ['D[ \ [[I \L fl [ B[ \ J. \·O[Ullll' 1 • 'JumtK'1 (, ( \ug\l~l ::!OOlJ) Sec Note NO.3 in this volume for details on numbers and geographical distribution. Examples of the difficulties in ensuring compli ance from doctors and in implementation of compu lsory rural practice when a vibrant private sector and opportunities of migration exist have been noted Irom the experiences in Thailand, South Africa. Sec WHO (2009) for citations to more detailed relevant st udies. Anecdotal evidence from north-eastern states suggests similar experience in India. Post-graduate medical students refer to residents seeking a specialty degree. In public nursing schools in Uttar Pradesh there were only first-year nursing students due to recruitment of batches in 3 years cycles The undergraduate bachelors degree (MBBS) for medical students. including an internship year. is SY years. Specialist post-graduate z (PG) courses can take a further 2-3 years. For nursing students. the 'diploma' course of General Nursing and Midwifery (GNM) is a 3- year course. Nursing students can further enroll for a 'degree' course of Bachelors of Science in nursing or B.Sc (N). Lindclow, M. and P. Semecls (2006). "The perfomtance of health workers in Ethiopia : results from qualitative research." Soc Sci Mcd 62(9): 222S-2235. In Thailand. for instance, while compulsory rural service proved somc succcss in the late 1970s and early 1980s, the changing labor market for doctors to one resembling that of India today has led to doctors breaking thcir contracts. paying their fines for doing so, and then choosing to work in thc private sector (mainly urban practices). Internal brain drain also rcsulted with a peak of22% of new medica l graduates resigning from government servicc in 1997 according to recent studies. Sec WHO 2009 for dctails of studies. A discrete choicc experiment (DCE) is a quantitative technique for eliciting individual preferences. It allows policy makers to uncover how individuals value selected allributes of a program, product or job by asking them to statc their choicc over hypothetical alternatives. DCEs have becn applied to a range of health policy. planning and resource allocation decisions in high-income sellings. Comparatively fcw examples of DCEs have been used in developing countries. with recent cxamples of such work done in Ghana, Malawi. Ethiopia and Thailand. Sec Lemiere (2009). REFERENCES Chomitz. K. M. (1997). "What do doctors want? Dcveloping incentives for Doctors to Serve in Indonesia's Rural and Remote Arcas." Connell. J , P. Zurn, ct a1. (2007). "Sub-Saharan Africa: beyond the health worker migration crisis?"" Soc Sci Med 64(9): 1876- 1891. Di eleman. M.. P. Cuong. et a1. (2003). "Identifying factors lor job motivation of rural health workers in North Viet Nam." 1 ·IUln Resour Health 1( 1): 10-10. Doescher, M. P. , K. E. ElIsbury. et al. (2000). "The distribution of nITa I female generalist physicians in the United States." J Rural Health 16(2): 111-11 8. Dussault, G. and M. C. Franccschini (2006). '"Not enough therc, too many here: undcrstanding geographical imbalanccs in the di stribution of the health workforce." Hum Resour Hcalth 4: 12-12. Eley. D. and P. Baker (2006). "Docs recndtment lead to rctention?- Rural Clinical School training experiences and subsequent intern choices." Rural and Remote Health 6(511). Government of India. "Task Force on Medical Education for the National Rural Health Mision." Ministry of Health and Famil y Welfare Government of India (2006). "Bulletin on Rural Health Statistics in India 2006" Ministry of Health and Family Welfare. I·lanson K, McPake B. Nakamba P, Archard L. 2005. Preferences for hospital quality in Zambia: results from a discrete choice experiment. Health Economics 14: 687-701. Laven, G. and D. Wilkinson (2003). " Rural doctors and rural backgrounds: how strong is the evidence? A systematic review." Aust J Rural Health II (6): 277-284. Lehmann. U., M. Dieleman, et al. (2008). "Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention." BMC Health Serv Res 8: 19-19. Lemiere, C. (2009) Discrete Choice Experiment (DCE): a methodology for e licit ing hcalth workers preferences. Presentat ion at www.who.int/cntity/hrhlmigrat ionlhmr_expert_ meet ing_ lemiere.pd f Matsumoto, M., M. Okayama, et a1. (2005). "Factors associated with rural doctors intention to continue a mral career: A survey of3072 doctors in Japan." Australia n Journal of Rural Health 13(4): 219-225 . Scmpowski. I. P. (2004). " Effectiveness of financial incentives in exchange for mral and underscrviced area return-of-service commitments: systematic review of the literature." Can J Rural Mcd 9(2): 82-88. Serneels, P. , M. Lindelow, et al. (2007). "For public service or money: understanding geographical imbalances in the health workforce." Health Policy Plan. 22(3): 128-138. WHO. 2007. Not Enough Here ... Too Many Thcre - Health Workforce in India. World l'lealth Organization, Country Office for India. Editors: Gerard La Forgia, Lead Special ist, HNP Unit, The World Bank, New Delhi; and Kris hn a D. Rao, Public Health Foundation of India, New Delhi India Health Beal is produced by the Public Health Foundat ion of India and the World Bank's Health, Nutrition and Population unit located in Dclhi. The Notes arc a vehicle for disscminating policy-relevant rescarch, case studies and experiences pertinent to the Ind ian health system. We welcome submissions from Indian researchers and the donor community. Enquiries should be made to Nira Singh (nsingh2@worldbank.org). Disclaimer: The views, findings, interpretations and conclusions expressed in this policy note arc entirely of the authors and should not be auributed in any manner to the World Bank, ils affiliated organizations, members of its Board of Executi ve Directors. the countries they represent or to the Public l'leallh Foundation or India and its Board ofOirectors.