RESEARCH TOPIC

Study of Unavailability of Doctors In

the Rural Areas of District Lahore

1. INTRODUCTION
Background

CONTENTS

Rationale/significance of the study Research Objectives Research question

2. LITERATURE REVIEW 3. STUDY DESIGN AND METHODOLOGY

Research design Study site/location Sample size Sampling technique
Data collection techniques and instruments Data Analysis

INTRODUCTION
BACKGROUND
The health workforce has been identified as the key to effective health services. The provision of adequate, accessible, appropriate and affordable health is one of the fundamental rights, recognized by global leadership under banner of World Health Assemblies of 1978 and 1998. One of the biggest challenges to health systems is to, get the right workers with the right skills in the right place doing the right things. However, workforce shortages are the most commonly reported staff-related problem in health care, especially in resource-constrained countries. This picture is even more complex in rural areas due to imbalances between offered medical services and health care needs of the communities.

 Pakistan is facing similar situation in rural areas, where 66% of the population is residing. According to Economic Survey 2011-12 urban population has increased to 67.55 million from 65.3 million in 2010-11 while rural population has increased to 113.16 million from 111.82 million in 2010-11. In Pakistan, the utilization of rural public sector health facilities had been estimated to be as low as 27% As a result of inadequate infrastructure locally and poor compensation packages, a sizeable number of physicians, nurses and other health professionals migrate to developed countries in search of fulfilling and lucrative positions.

 The doctors and nurses who remain are reluctant to relocate to remote areas, including rural and remote locations, where communication with other regions is poor and amenities for health professionals and their families are lacking.

So the inequitable geographical distribution of healthcare

professionals is compounded by a concentration of medical professionals in urban areas. While access to medical may be readily available in cities, rural dwellers often have to travel considerable distances in order to obtain treatment. Pakistans urban areas are also more attractive to healthcare professionals due to the social, cultural and professional advantages of urban work.

 Rural and remote employment is usually regarded as having a low status, while urban positions are perceived as more prestigious. The basic health units in rural areas are not equipped enough to better the falling health of rural populace. If there are well equipped hospitals, the availability of doctors is not ensured. The unavailability of doctors and nurses in rural areas often leads to a delay in seeking health care until symptoms become unbearable and the disease is advanced. Transporting a seriously ill patient to an urban facility on poor roads may result in a delay, makes the difference between life and death.

DEFINITION
The term 'rural' invokes images of farms, villages, small towns, and open spaces. But there is no consensus on specific definition for these areas. The United Nations itself recognizes the difficulty of defining urban and rural areas globally, stating that, because of national differences in the characteristics that distinguish urban from rural areas, the distinction between urban and rural population is not amenable to a single definition that would be applicable to all countries (United Nations, 1998).

 The following definition is proposed:

'Rural areas' are considered to be those areas which are not urban in nature. An 'urban agglomeration' refers to the de facto population contained within the contours of a contiguous territory inhabited at urban density levels without regard to administrative boundaries. It usually incorporates the population in a city or town plus that in the suburban areas lying outside of - but being adjacent to - the city boundaries (United Nations, 2008).

RATIONALE/SIGNIFICANCE OF THE STUDY

In the context of the present study, little research has been conducted to investigate the causes of doctors unavailability in rural area in a developing country like Pakistan.
The findings of the study will help in understanding the current views and perceptions of health workers, about staying in or leaving rural health facilities. The study will contribute in formulation of a better health policy and management of doctors in the country.

RESEARCH OBJECTIVE
To identify factors influencing decisions and choices of doctors regarding their placements in rural areas.

RESEARCH QUESTION
Why doctors do not want to offer their services in rural areas.

LITERATURE REVIEW
From the literature, three main trends are observed in health workforce today: People are moving very strongly towards work-life balance models People are motivated by a complex structure of rewards, in which non-financial benefits play an increasingly important role People will move quickly to another job or place if their expectations are not met.

 The World Health Report 2006 estimated that the world lacks about 4 million health workers, if a minimum level of health outcomes is to be achieved (WHO 2006). The report identified 57 'crisis' countries as being the most affected by this dearth in health personnel, predominantly in Sub-Saharan Africa and Asia. In the majority of countries, rural and remote areas are usually lacking sufficient numbers of health workers. 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.

 Agboatwalla & Niazi in their TAP (Transparency & Accountability Project) survey assessed that as absenteeism in hospitals increases in the less fortunate areas, it is decreasing both quality and quantity of health services. Either the sanctioned posts are not filled by the respective staff or absenteeism of the staff is the primary reason for this unavailability. Both in urban and rural areas patients said that in nearly three quarter of the visits, the doctor was not present in the health facility. In rural areas, there was a much stronger possibility (86.4%) of the dispenser acting as doctor than in urban areas (42%). Patients are often misdiagnosed and have to return without treatment. Absenteeism was also higher (40%) in those facilities which lacked basic infra-structure and where availability of medicines and basic equipment were issues.

 In a research study of attraction and retention of qualified health workers to rural areas in Nigeria Ebuehi & Campbell (2011) findings revealed that working conditions career development opportunities and appropriate infrastructural issues are still core factors affecting an individuals motivation for rural work, regardless of the health workers geographic origin. This calls for an urgent and comprehensive review, and accommodation of issues related to staff motivation if the HMDGs are to be realized.

This would entail developing a comprehensive rural health work force improvement strategy which incorporates a coordinated intersectoral approach involving partnership among stakeholders in rural health development.

 In the report of three years rolling plan 2010-2013 district Lahore prepared by health department, It has been identified that the Health sector in Punjab is facing enormous health and service delivery problems. The society is passing through demographic and epidemiological transition. The service delivery/management problems are diverse in nature, and include shortage of technical human resource, capacity issues, lack of infrastructure and equipment. Shortage of human resource is due to: * Ban on permanent postings * Non availability of incentivized pay package and career structure * Medico-legal work for WMOs * Non sanctioning of posts according to MSDS

STUDY DESIGN AND METHODOLOGY

RESEARCH DESIGN

Descriptive research design is used for this study.

Employs a cross sectional methodology as a one-time survey with the description of the perceptions and opinions of doctors about the factors affecting their decision about staying in or leaving rural health facilities.

STUDY SITE/LOCATION
The study shall be conducted in rural areas of district Lahore. Lahore is the 5th largest city in South Asia. It is also the 2nd largest as well as 2nd most populous city of Pakistan. A Detail of physical infrastructure of public health facilities under the administrative control of EDO (health) in the district is given below.
Facility Type Number of Facility

Public hospitals RHCs BHUs MCH Centers

8 6 37 23

Data source: DHIS/EDOH office

 Two government hospitals Mayo and Lahore general hospital, three BHUs and three RHCs situated in rural areas within district Lahore are chosen as study sites. The rural areas selected include:
Manga Mandi Kahna Nau Burki Shamkay Bhattian Kamalian Jia Bagga
Source: Punjab Health Sector Reforms Programme

SAMPLE SIZE
20 doctors shall be selected from the above mention health facilities. The survey shall include both male and female doctors.

SAMPLING TECHNIQUE
Convenience sampling shall be used where doctors shall be selected on the basis of their availability and accessibility.

DATA COLLECTION TECHNIQUES AND INSTRUMENTS

Data will be collected between December 2012 and January 2013. A self-administered questionnaire is adapted from a data tool used in a previous study identified in the literature review. The parameters listed in the data tool includes respondents work experience, whether or not they liked their current job and reasons for this, reasons for assuming their current job, likelihood to leave their current job, and motivators and de-motivators regarding their willingness to work in rural settings.

DATA ANALYSIS

The collected data will be entered, processed and then analyzed using the computer software package SPSS (V-16). Decision on selection of statistical tests will base on the structure of questionnaire which is yet to be given a final touch.

REFERENCES
1. Mujib, M., Khan, & Abbas, M. (2007). Availability and utilization of primary health care services in
the rural areas of district Peshawar a case study. Sarhad J. Agric, 23(4), 1218-1219.

2. Ebuehi, OM., & Campbell, PC. (2011).Attraction and retention of qualified health
workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria. The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy, 11(515), 2-10. through improved retention.

3. WHO. (2009). Background paper: Increasing access to health workers in remote and rural areas 4. Farooq, U., Ghaffar, A., Narru, I.A., Khan, D., & Irshad, R. Doctors perception about staying in or
leaving rural health facilities in district Abbottabad. Global Forum for Health Research, WHO, Geneva, Health Services Academy, Islamabad.

5. Three years rolling plan 2012-2013 district, Lahore. 6. Johnson, J.C., Nakua, E., Dzodzomenyo, M., Baffour, P.A., Gyakobo, M., Asabir, K., Kwansah, J.,
Kotha, S.R., Snow, R.C. & Kruk, M.E. (2011). For money or service? A cross-sectional survey of preference for financial versus non-financial rural practice characteristics among Ghanaian medical students. Johnson et al. BMC Health Services Research, 11(300), 1472-6963.

7. Pakistan Economic Survey (2011-12). Economic Advisers Wing, Finance Division, Government of
Pakistan, Islamabad. [On line] Available http://www.einfopedia.com/health-care-in-pakistan.php [On line] Available http://www.phsrp.punjab.gov.pk/rhcs/Lahore.pdf [On line] Available http://www.phsrp.punjab.gov.pk/bhus/Lahore.pdf

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