attraction and retention of physicians and nurses in rural areas in india

7/29/2019 Attraction and Retention of Physicians and Nurses in Rural Areas in India

http://slidepdf.com/reader/full/attraction-and-retention-of-physicians-and-nurses-in-rural-areas-in-india 1/384

1

By

GANGARAM BISWAKARMA

Registration No. 18710176

UNDER THE GUIDANCE OF

DR. DEBA PRASAD PANDA

DEPARTMENT OF MANAGEMENT

SHRI JAGDISH PRASAD JHABARMAL TIBREWALA UNIVERSITY,

VIDYANAGARI, JHUNJHUNU, RAJASTHAN – 333001

2012



2

DECLARATION BY THE CANDIDATE

I declare that thesis entitled “AN EXPLORATORY STUDY ON

DISTRIBUTION, ATTRACTION AND RETENTION OF

PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA” is my

own work conducted under the supervision of Dr. Deba Prasad Panda,

Associated Professor of Commerce at Jawaharlal Nehru College,

Pasighat under Rajiv Gandhi University, Itanagar, Arunachal Pradesh.

I have put in more than 200 days of attendance with the supervisor

at the centre.

I further declare that to the best of my knowledge the thesis does

not contain any part of any work which has been submitted for award of

any degree either in this University or any other university/ deemed

university without proper citation.

Signature of Supervisor Signature of candidate

(with stamp)

Signature of the Head/Principal(with stamp)



3

CERTIFICATE OF SUPERVISOR

This is to certify that work entitled “AN EXPLORATORY

STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION

OF PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA” is

a piece of research work done by Shri Gangaram Biswakarma, under my

supervision for the degree of Doctor of Philosophy in Management of JJT

University, Jhunjhunu, Rajasthan, India. That the candidate has put

attendance of more than 200 days with me.

To the best of my knowledge and belief the thesis

1. Embodies the work of candidate himself

2. Has duly been completed

3. Fulfills the requirement of ordinance related to Ph.D. degree of the

University and

4. Is upto the standard both in respect of content and language for

being referred to the examiner.

Signature of the Supervisor

(with stamp)



4

###

This work is dedicated to my parents:

For their inspiration, support, prayers and

constant encouragement for accomplishing

my academic peak

###



5

ACKNOWLEDGEMENT

This is the part in the Thesis that I am very happy to write without any

boundation of pre-requisites, norms etc….. and overall with a very peaceful mind, not

just like writing the chapters in this thesis with tense mind.

First of all I would like to thank ‘GOD- the almighty’ for blessing me and

gave me the patience, tolerance and courage to complete my final ladder of my PhD

studies with this thesis and put me to the 50% part of the people who as per the study

of Kurup and Arora, the total number of students who enroll for a PhD only 50% end

up completing their thesis. I always believe in dream-‘a dream you dream alone is on

a dream, a dream you dream together is a reality’- JOHN LENNON . So, this thesiswould never have been completed without the dream of my father, mother, wife,

brother and my beloved sister and off-course my in-laws and their moral support

altogether.

In research study, as we know, choosing a good mentor/guide is the most

crucial factor in the successful outcome and timely completion of the thesis, on this

front, I made a perfect choice. I would like to express my gratitude to my supervisor

Dr. Deba Prasad Panda, Associate Professor, who was always equally passionate and

has shown amazing patience and diligence in assisting me to produce this thesis.

I would like to sincerely thank my Dad for immense morale support and

encouragement throughout my study period not only to complete my PhD but since

my first step to the school. “Yes DAD, I m proud of being your son”. Sincerely thanks

from core of my health to my younger brother ‘Pradeep’, who went to Qatar to earn

for the family as let me continue my PhD study behind. ‘I m proud to get you my

brother’. My sister ‘Bunu’ and MUM were always a supportive and encouraging

throughout the period of study.

At home, finally I would like to express my deep gratitude to my wife ‘Jun’. I

would never have been able to complete this work without her serenity, her

understanding and tolerance, and her sacrifices during the course of study. “Thank

you Jun, for the countless moments of encouragement and support during my lows in

study period and taking care of our little angle ‘ANWESHA’ in absence of me for

almost one and half year since her birth”. My Love for Anwesha, as she missed the



6

needed moments of tender love of a father in her infancy, because I could not be with

her side in period of study.

I would also like to thank all my in-laws especially father-in-law and elder

sister-in-law, who were always in my support throughout the period for my study. I

would also like to thank Kartu and his family to support and care for ANWESHA in

my absence.

This work would not have been possible without the responses I received to

both the questionnaire and the interviews. My thanks go to all the respondents who

contributed to the research especially those who agreed to be interviewed.

I would like to thank Dr. D.D. Agarwal, VC, Dr. Reecha Ranjan Singh & Dr.

Manish Sharma, Management Department from JJT University for their help and

valuable comments time to time to improve the quality of the thesis.

I would also like to thank Lakshminarayan Meena, Narshing Meena, Badri

Meena from Jaipur, Sandeep Agarwal from Noida, Rajita Goswami from Itanagar,

D.K. Dhir from IISASTR, Delhi, Jacob Mays from SPSSvideotutoral.com, Dr. Ali

Nasef from Tripoli University Lybia, Rabiu Ado, Research Scholar from Aberdeen

UK, Library Rajiv Gandhi University Itanagar, Library IBS Hyderabad, Library JJT

University and all DPMs of Arunachal Pradesh for their support and off course other

supporting staffs of JJT University who use to be cordial and always helpful in the

event of need during entire period of my stay in the University.

Though if I forget to note you down here, do not think that I m not thankful to

you, but it’s just a slip of mind. Thank you, thank you all for your constant support.

Gangaram Biswakarma



7

LIST OF FIGURES

Figure: 1: Total Physicians and nursing workforce in urban and rural areas- aglobal view

22

Figure: 2: Countries with a critical shortage of health service providers

(doctors, nurses and mid-wives)

23

Figure: 3: Density of health workers. Source: WHO Global Atlas of the

Health Workforce

24

Figure: 4: Different environments and location of decision-makers

associated with attraction and retention in the public sector

40

Figure: 5: Map of India 47

Figure: 6: Map of Arunachal Pradesh 47

Figure: 7: Number of Physicians (doctors), Nurses and Mid-wives in

Arunachal Pradesh

60

Figure: 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives

in Arunachal Pradesh

60

Figure: 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh 60

Figure: 10: District wise numbers of Physicians (doctors/ medical officers) in

Arunachal Pradesh

63

Figure: 11: District wise percentage share of Physicians (doctors/ medical

officers) in Arunachal Pradesh

64

Figure: 12: Graphical mapping of district wise number of Physicians (doctors/

medical officers) in Arunachal Pradesh

64

Figure: 13: District wise numbers of nurses in Arunachal Pradesh 66

Figure: 14: District wise share of nurses in Arunachal Pradesh 66

Figure: 15: Graphical mapping of district wise number of nurses in ArunachalPradesh 66

Figure: 16: District wise numbers of mid-wives in Arunachal Pradesh 68

Figure: 17: District wise share of nurses in Arunachal Pradesh 68

Figure: 18: Graphical mapping of district wise number of nurses in Arunachal

Pradesh

69

Figure: 19: Numbers of Physicians, nurses and mid-wives in rural and remote

areas in Arunachal Pradesh

69

Figure: 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives

in rural and remote area of Arunachal Pradesh

70

Figure: 21: Percentage Share of Nurses and Mid-wives in rural and remote

area in Arunachal Pradesh

70

Figure: 22: District wise numbers of Physicians (doctors/ medical officers) inArunachal Pradesh

72

Figure: 23: District wise percentage share of Physicians (doctors/ medicalofficers) in Arunachal Pradesh

72

Figure: 24: Graphical mapping of district wise number of Physicians (doctors/


73

Figure: 25: District wise numbers of nurses in rural and remote area

Arunachal Pradesh

74

Figure: 26: District wise share of nurses in rural and remote area Arunachal

Pradesh

75

Figure: 27: Graphical mapping of district wise number of nurses in rural and 75



8

remote area in Arunachal Pradesh

Figure: 28: District wise numbers of mid-wives in rural and remote area in

Arunachal Pradesh

77

Figure: 29: District wise share of mid-wives in rural and remote areaArunachal Pradesh

77

Figure: 30: Graphical mapping of district wise number of mid-wives in ruraland remote area in Arunachal Pradesh

77

Figure: 31: Urban-rural distribution of Physicians (doctors) in comparison to

urban – rural population in Arunachal Pradesh

78

Figure: 32: Urban-rural distribution of Nurses in comparison to urban – rural

population in Arunachal Pradesh

78

Figure: 33: Urban-rural distribution of Mid-wives in comparison to urban –

rural population in Arunachal Pradesh

79

Figure: 34: District wise urban-rural percentage distribution of Physicians

(doctors) in Arunachal Pradesh

80

Figure: 35: Graphical mapping of district wise rate of urban concentration of Physicians (doctors) in Arunachal Pradesh 80

Figure: 36: District wise urban-rural percentage distribution of nurses in

Arunachal Pradesh

81

Figure: 37: Graphical mapping of district wise rate of urban concentration of

nurses in Arunachal Pradesh

81

Figure: 38: District wise urban-rural percentage distribution of mid-wives inArunachal Pradesh

82

Figure: 39: Graphical mapping of district wise rate of urban concentration of

mid-wives in Arunachal Pradesh

82

Figure: 40: Percentage of migrating intention of the physicians, nurses and

mid wives

154

Figure: 41: Percentage of migrating intention of the physicians 155

Figure: 42: Percentage of migrating intention of the nurses 155

Figure: 43: Percentage of migrating intention of the mid-wives 155

Figure: 44: Percentage of migrating intention of the contract workforce

(Physicians, nurses and mid-wives)

156

Figure: 45: Percentage of migrating intention of the Permanent workforce(Physicians, nurses and mid-wives)

156



9

LIST OF TABLE:

Table : 1: Global health workforce by density 22

Table : 2: Estimated critical shortage of doctors, nurses and midwives 23

Table : 3: The areas falls under Urban areas in the state for this study 42

Table : 4: Demographic indicators Census 2011 and 2001 of ArunachalPradesh

45

Table : 5: Urban Rural comparison of demographic indicators of Arunachal Pradesh

46

Table : 6: Demographic characteristics of management representatives

respondents

54

Table : 7: Mean age and experience of management representatives

respondents

54

Table : 8: Demographic characteristics of employee respondents 55

Table : 9: Mean age and length of service of the respondents 55

Table : 10: Showing health infrastructure growth in rural areas of thestates

58

Table : 11: Distribution of Public Health Facilities in Arunachal Pradesh 58

Table : 12: Population covered by the health institutions in Arunachal

Pradesh

59

Table : 13: Numbers of Pediatricians, Anesthetist and Gynecologist in

Arunachal Pradesh (District Wise)

61

Table : 14: Numbers of Physicians (Medical Officer) in Arunachal

Pradesh district wise

62

Table : 15: Ranking of Density of Physicians (doctors) in Arunachal

Pradesh (District wise)

62

Table : 16: Numbers of Nurses in Arunachal Pradesh (District Wise) 65

Table : 17: District-wise ranking of density of Nurses in Arunachal

Pradesh

65

Table : 18: Numbers of Mid-Wives (ANM) in Arunachal Pradesh

(District Wise)

67

Table : 19: District-wise ranking of density of Mid-wives in Arunachal

Pradesh

67

Table : 20: District wise number of Physicians (Doctors) in Rural Area in

Arunachal Pradesh

71

Table : 21: District wise Doctor-Population ratio in Arunachal Pradesh 71

Table : 22: District wise number of Nurses in Rural Area in Arunachal

Pradesh

73

Table : 23: District wise Nurses –Population ratio in Rural Area in

Arunachal Pradesh

74

Table : 24: District wise number of Mid-wives in Rural Area in Arunachal

Pradesh

76

Table : 25: District wise number of Mid-wives-population ratio in Rural

Area in Arunachal Pradesh

76

Table : 26: Showing the trend in physicians and nurses in-position in 2005

& 2010

83

Table : 27: District wise requirement and shortfall of ANMS in ArunachalPradesh

84



10

Table : 28: District wise requirement and shortfall of Nurses in Arunachal

Pradesh

85

Table : 29: District wise requirement and shortfall of Physicians in

Arunachal Pradesh

85

Table : 30: District wise rural and remote area requirement and shortfall of

ANMs in Arunachal Pradesh

86


Nurses in Arunachal Pradesh

87


Physicians (doctors) in Arunachal Pradesh

87

Table : 33: Descriptive Statistics of the factors that attracted or placed the

Physicians, nurses and mid-wives in the current job in the ruraland remote area

90

Table : 34: Percentage selection of factors for attraction or placed by

Physicians, nurses and mid-wives

91


Physicians in the current job in the rural and remote area

92


contract Physicians in the current job in the rural and remote

area

93


permanent Physicians in the current job in the rural and remote

area

94

Table : 38: Percentage selection of factors for Attraction or placed by

Physicians

95


nurses in the current job in the rural and remote area

96


permanent nurses in the current job in the rural and remotearea

97


contract nurses in the current job in the rural and remote area

98

Table : 42: Percentage selection of factors for Attraction or placed by

nurses

98


mid-wives in the current job in the rural and remote area

99


contractual mid-wives in the current job in the rural andremote area

100


permanent mid-wives in the current job in the rural and remote

area

101

Table : 46: Percentage selection of factors for Attraction or placed by mid-

wives

102

Table : 47: Relationship between the factor for attraction or placement

with the demographic attributes of Physicians

106

Table : 48: Relationship between the factor for attraction or placement

with the demographic attributes of nurses

109

Table : 49: Relationship between the factor for attraction or placement 113



11

with the demographic attributes of mid-wives

Table : 50: Descriptive Statistics of the factors that may attract the

physicians, nurses and mid-wives in the rural and remote area

115

Table : 51: Percentage of factors that may attract physicians, nurses and

mid-wives in rural and remote areas

116

Table : 52: Descriptive Statistics of the factors that may attract the physicians

118

Table : 53: Percentage of factors that may attract physicians in rural andremote areas

119

Table : 54: Descriptive Statistics of the factors that may attracted thenurses

120

Table : 55: Percentage selection of Factor that may attract nurses 121

Table : 56: Descriptive Statistics of the factors that may attracted the Mid

wives

123

Table : 57: Percentage of factors that may attract mid-wives in rural and

remote areas

124

Table : 58: Analysis of Variance in factor that may attract the physicians,nurses and mid-wives

126

Table : 59: Percentage showing Job Satisfaction of physicians, nurses and

mid-wives in rural and remote area setting

129

Table : 60: Descriptive statistics of Job Satisfaction of Physicians, Nurses

and Mid-wives

130

Table : 61: Analysis of Variance in Job Satisfaction among the Physicians,

nurses and mid-wives

130

Table : 62: Percentage showing Job Satisfaction of contractual and

permanent physicians, nurses and mid-wives in rural and

remote area setting

130

Table : 63: Descriptive statistic of Job Satisfaction of contract and

permanent Physicians, nurses and mid-wives

131

Table : 64: Analysis of Variance (T-Test) of Job Satisfaction amongcontractual and permanent Physicians, nurses and mid-wives

131

Table : 65: Correlation between Job satisfaction and the demographic

attributes of the employees (Physicians, Nurses and Mid-

wives)

132


permanent Physicians.

133

Table : 67: Analysis of Variance (T-Test) of Job Satisfaction among

contractual and permanent Physicians.

133


attributes of Physicians

134


permanent nurses.

135

Table : 70: Analysis of Variance (T-Test) of Job Satisfaction amongcontractual and permanent nurses

135


attributes of Nurses

136


permanent mid-wives.

136



12

Table : 73: Analysis of Variance (T-Test) of Job Satisfaction among

contractual and permanent mid-wives

137


attributes of mid-wives

137

Table : 75: Descriptive Statistics of Factors contributed for job satisfaction

of the physicians, nurses and mid-wives

139

Table : 76: Regression Analysis of factors contributed for job satisfactionof the physicians, nurses and mid-wives.

140

Table : 77: Correlation matrix of overall job Satisfaction with factor of

job satisfaction for physicians, nurses and mid-wives

141

Table : 78: Descriptive Statistics on Factors contributed for job

satisfaction of the physicians.

142

Table : 79: Regression Analysis of factors contributed for job satisfaction

of the physicians.

143

Table : 80: Correlation matrix of Overall job Satisfaction with factor of

Job satisfaction of Physicians

143


satisfaction of the Nurses.

144

Table : 82: Regression Analysis of factors contributed for job satisfaction

of the nurses.

146

Table : 83: T-test results of factors contributed for job satisfaction of the

nurses.

146

Table : 84: Correlation matrix of Overall job Satisfaction with factor of Job satisfaction of Nurses

147


satisfaction of the Mid-wives.

148

Table : 86: Result of Regression Analysis of factors contributed for job

satisfaction of the mid-wives.

149

Table : 87: Correlation matrix of overall job Satisfaction with factor of job

satisfaction of Mid-wives

149

Table : 88: Descriptive Statistics for factors for job satisfaction of permanent Physicians, nurses and mid-wives

150

Table : 89: Descriptive Statistics for factors for job satisfaction of

contracts Physicians, nurses and mid-wives

151

Table : 90: Analysis of variance in factors of Job satisfaction of

Contractual and Permanent Physicians, nurses and mid-wives

in rural and remote area

152

Table : 91: Percentage showing the intention of migration of the physicians, nurses and mid wives

154

Table : 92: Percentage showing the intention of migration of the contract

and permanent workforce (physicians, nurses and mid wives)

156

Table : 93: Descriptive Statistics of contributing factor of likelihood of

retention of physicians, nurses and mid-wives

159

Table : 94: Descriptive statistics for contributing factor of likelihood of

retention of physicians

161


retention of permanent physicians

162

Table : 96: Descriptive statistics for contributing factor of likelihood of 163



13

retention of contract physicians


retention of nurses

164

Table : 98: Descriptive statistics contributing factor of likelihood of

retention of permanent nurses

165

Table : 99: Descriptive statistics for contributing factor of likelihood of retention of contract nurses

166

Table : 100: Descriptive statistics for contributing factor of likelihood of retention of Mid-wives

167

Table : 101: Descriptive statistics for contributing factor of likelihood of retention of Permanent Mid-wives

168


retention of contract Mid-wives

169

Table : 103: Descriptive statistics for contributing push factors for

physicians, nurses and mid-wives

171


physicians

172


permanent physicians

173

Table : 106: Descriptive statistics for contributing push factors for contract

physicians

174

Table : 107: Descriptive statistics for contributing push factors for nurses 175

Table : 108: Descriptive statistics for contributing push factors for regular

nurses

176


nurses

177

Table : 110: Descriptive statistics for contributing push factors for mid-wives

178


permanent mid-wives

179


mid-wives

180

Table : 113: Descriptive statistics of push factors for migration of

physicians, nurses and mid-wives to another rural area

181


physicians, nurses and mid-wives to rural to urban

183


physicians, nurses and mid-wives to other employer or outside

state

184

Table : 116: Relationship of demographic attributes to intention to migrate

in physicians, nurses and mid-wives

185


in physicians

185


in nurses

186


in mid-wives

186

Table : 120: Descriptive statistics of factors that may motivate the physicians, nurses and mid-wives to retain in current job in

188



14

rural and remote area

Table : 121: Descriptive statistics of factors that may motivate the

physicians to retain in current job in rural and remote area

189

Table : 122: Descriptive statistics of factors that may motivate the contract


190

Table : 123: Descriptive statistics of Factors that may motivate the permanent physicians to retain in current job in rural and

remote area

192

Table : 124: Descriptive statistics of factors that may motivate the nurses to

retain in current job in rural and remote area

193


nurses to retain in current job in rural and remote area

194

Table : 126: Descriptive statistics of factors that may motivate the permanent nurses to retain in current job in rural and remote

area

195

Table : 127: Descriptive statistics of Factors that may motivate the Mid-

wives to retain in current job in rural and remote area

196


Mid-wives to retain in current job in rural and remote area

198

Table : 129: Factors that may motivate the permanent Mid-wives to retain

in current job in rural and remote area

199

Table : 130: Gist of various training under NRHM for physicians, nurses

and mid-wives

214

Table : 131: Achievement cumulative Training for Maternal and Child

Health (March 2005-2012)

215

Table : 132: Categorization of rural and remote area for incentive scheme

for workforce

216

Table : 133: Information on new Constructions of infrastructure in the stateunder reform process

218

Table : 134: Information on Upgradations of infrastructure in the state

under reform process

218

Table : 135: New Constructions of infrastructure in the state under reform

process

218

Table : 136: Identified District Hospitals where New Residential Quarters

will be constructed

219

Table : 137: Identified List of facilities (PHCs) that are proposed for newconstruction of Residential Quarters:

219

Table : 138: Identified CHCs for Construction of Residential Quarters 219

Table : 139: Descriptive Statistics of views on health sector reform process

on HR by physicians, nurses and mid-wives

227


on HR by physicians

228


on HR by nurses

229


on HR by Mid-wives

230

Table : 143: Analysis of Variance of views on health sector reform process

on HR by physicians, nurses and mid-wives

231

Table : 144: Scale of satisfaction on Policies for planning, placement, 236



15

transfer and promotion by position of Respondents

Table : 145: Descriptive statistics on scale of satisfaction on policies for

planning, placement, transfer and promotion by position of

respondents

237

Table : 146: Analysis of Variance for scale of satisfaction on policies for

placement, transfer and promotion among the physicians,nurses and mid-wives among the group of respondents

237

Table : 147: Scale of satisfaction on Recruitment and selection process andPosition of Respondent

241

Table : 148: Descriptive statistics on scale of satisfaction on Recruitment

and selection process by position of respondents

242

Table : 149: Analysis of variance for Scale of satisfaction on Recruitment

and selection process among the group of respondents

242

Table : 150: Scale of satisfaction on fairness in HR Practice for placement,

transfer and promotion and Position of Respondent

243

Table : 151: Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position

of respondents

243

Table : 152: Analysis of Variance for the scale of satisfaction on fairness of

HR Practice for placement, transfer and promotion among the

group of respondents

243

Table : 153: Scale of satisfaction on Magnitude of management favouritism

and political interference in transfer and posting among the


244

Table : 154: Descriptive statistics on scale of satisfaction on magnitude of management favouritism and political interference in transfer

and posting by the position of respondents

244

Table : 155: Analysis of Variance for the scale of satisfaction on Magnitude

of management favouritism and political interference intransfer and posting among the group of respondents

244

Table : 156: Scale of satisfaction on response of

administration/management on your placement, transfer and promotional grievances

245

Table : 157: Descriptive statistics on scale of satisfaction on response of administration/ management on your placement, transfer and

promotional grievances by the position of respondents

245

Table : 158: Analysis of Variance for the scale of satisfaction on Response

of administration/management on your placement, transfer and promotional grievances among the group of respondents

245

Table : 159: Scale of satisfaction on Participation and involvement in the

decision making of your placement and transfer

246

Table : 160: Descriptive statistics on scale of satisfaction on participation

and involvement in the decision making of your placement and

transfer by the position of respondents

246

Table : 161: Analysis of variance for the scale of satisfaction on

Participation and involvement in the decision making of your

placement and transfer among the group of respondents

246

Table : 162: Scale of satisfaction of HR Practice for retentions –FinancialInterventions 247



16

Table : 163: Descriptive statistics on scale of satisfaction of HR Practice for

retentions –Financial Interventions by the position of respondents

247

Table : 164: Analysis of variance for the Scale of satisfaction of HR Practice for retentions –Financial Interventions among the


248

Table : 165: Scale of satisfaction of HR Practice for retentions –Non-

Financial Interventions

248

Table : 166: Descriptive statistics on scale of satisfaction of HR Practice for

retentions – Non Financial Interventions by the position of

respondents

248

Table : 167: Analysis of variance of Scale of satisfaction of HR Practice for

retentions – Non Financial Interventions among the workforce

among the group of respondents

248

Table : 168: Scale of Satisfaction of Training and Development 250

Table : 169: Descriptive statistics on scale of satisfaction of HR Practice of Training and Development by position of the respondents 250

Table : 170: Analysis of variance of Scale of Satisfaction of Training and

Development among the group of respondents

251

Table : 171: Level of satisfaction of employees on HR practice of planning,

recruitment and placement in respect of physicians, nurses and

mid-wives in rural and remote area in the state

251

Table : 172: Level of satisfaction of Contractual employees on HR practice

of planning, recruitment and placement in rural and remote

area in the state

251

Table : 173: Level of satisfaction of Permanent employees on HR practice

of planning, recruitment and placement in rural and remotearea in the state

251



17

ABBREVIATION

ANM- Auxiliary Nurse-Midwives

AYUSH- Ayurvedic, Yoga, Unani, Sidda, and HomeopathicBEmOC- Basic Emergency Obstetrics CareCEO-Chief Executive Officer

CHC-Community Health CentreCMOs- Chief Medical Officers

DH- District HospitalDMOs- District Medical Officers

DNA- Data Not Available

EmOC- Emergency Obstetrics Care

F-IMNCI- Facility based Integrated Management of Neonatal and Childhood Illness

GDP- Gross Domestic Product

GH- General HospitalGNM- General Nursing and Midwifery

GOAP –Government of Arunachal Pradesh

GoI- Govt. of India

HICs- High-income countries

HIV/AIDS- Human immunodeficiency virus infection / Acquired immunodeficiency

syndromeHQ- Head Quarter

HR- Human ResourcesHRD-Human Resource Development

HRH- Human Resource for Health

HRM- Human Resource ManagementIMNCI- Integrated Management of Neonatal and Childhood Illness

IPHS- Indian Public Health Standard

IUCD- intrauterine contraceptive device

LICs- Low income countries

LR- Labour Room

LSAS- Life Saving Anesthesia Skills

MBBS- Bachelor of Medicine, Bachelor of Surgery

MDG- Millennium Development Goals

MDGPs- Millennium Development Goals ProgrammesMiniLap- Mini Laparoscopic

MO- Medical Officer MoHFW- Ministry of Health and Family Welfare

MTP- Medical Termination of PregnancyMVA- Manual Vacuum Aspiration

NCHRH- National Council for Human Resources in Health

NE- North Eastern

NHP- National Health Policy

NRHM- National Rural Health Mission

NSSK- Navjaat Shishu Suraksha Karyakram

NSV- No Scalpel Vasectomy

PHC-Primary Health CentrePIP- Program Implementation Plan



18

PMU- Programme Management UnitRHS- Rural Health Statistics

RRWG- Rural and Remote Working Group.

RTI/STI – Reproductive Tract Infection /Sexually Transmitted Infection

SBA- Skill Birth Attendance

SC- Sub CentreSN- Staff Nurse

SPSS- Statistical package for the social sciences

TFR- Total Fertility Rate

UFWC- Urban Family Welfare Centre

UHC- Urban Health Centre

UN – United Nation

WHO- World Health OrganizationWHR- World Health Report



19

ABSTRACT

Background: In adopting the Millennium Declaration in the year 2000, the eight

Millennium Development Goals (MDGs) have been adopted by the international

community. To accomplish the MGDs no. 4, 5 and 6, related to Reduce Child

Mortality, Improve Maternal Health and Combat HIV/AIDS, malaria & other diseases

respectively, calls the strengthening of health care delivery system and improved

health care services. Healthcare is a service sector, depends highly on specially

trained professionals, which needs to produced, attract and retain at all level. Health

worker shortages are one of the main challenges internationally. The most concerning

issues on this is producing, attracting, recruiting, deploying and retaining them in

rural and remote areas. This study aimed at understanding the major HR issues in

distribution, attraction and retention of Physicians, nurses and mid-wives in Public

health care delivery system in rural areas in India with special reference to the state of

Arunachal Pradesh.

Method: The primary data required for the study was collected with the help of

interview schedule, survey questionnaire and observation. The primary data was

collected through questionnaire among 334 nos. (113 nos. of physicians, 98 nos. of

Nurses and 123 nos. of midwives) of physicians, nurses and mid-wives, to understand

their attitude towards working and living in rural areas and accepting the rural posting

and insight on the HR issues in the area of study. One management representatives

each from the 16 districts and one state level management representatives were picked

as a sample of management representatives and conducted the interview. The

interview materials were coded and quantitative data was analyzed with SPSS 19.

Results, discussion and conclusion: Over the last few decades the establishment of

health institutions in rural areas of the state is haphazard and not kept pace with

adhering to the norms and keeping view of the consequences of human resource

requirement. Consequently, many rural communities/areas are deprived of the

primary health care and desperately need the attention. The inequities in the

geographic distribution of Physicians, nurses and mid-wives, itself has meant too

many rural and remote areas with the shortage of Physicians, nurses and mid-wives.

The poor availability of Physicians, nurses and mid-wives co-exists and creating an

imbalance and a problem with debilitating health care delivery system in the regionalong with the absence of adequate training institutes for medical and nursing courses



20

results in low numbers of medics and paramedics produced for the state. Mal-

distribution, that is the distribution of health workforce is characterized by urban

concentration and rural deficits, but these imbalances are perhaps most disturbing

from within district perspective also. While 77% of the population lives in rural and

remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives are

serving in rural and remotes areas of the state. This creates urban and rural imbalance

in distribution. The phenomenon of urban skewness and mal-distribution among the

districts are there. In this study it is also found that the information on human resource

is in-consistence among the state and district level, while it is also found that the

inconsistency between the divisions of the health department.

While, the major issue on attraction, the study revealed that the workforces

who are presently working in the rural and remote areas of the state are altogether in

compulsion, either working to finish their minimum rural service tenure or on non-

transferable positions or Management and political pressure or demand. It is found

that 58% of the workforce is service in rural and remote areas in the compulsion.

Moreover, the other HR issues on attraction are –the lack of career development

opportunity, inactive recruitment strategy, lack of hospital infrastructure and resource

availability, poor working condition, lack of other cadres, team work and staff

relationship, the reward and recognition for the performance and achievement is not

there in the system which could attract the physicians, nurses and mid-wives in the

rural area service, poor use of financial means of attraction. The study also reveals a

limited scope of attraction due to training and development opportunities and Poor

supervision and mentoring is a hindrance for attraction.

While the HR issues on retention are in the issue of internal migration to urban

areas. The study reveals that only 19% of them want to continue with their present

rural posting place. 24% wants to shift to another rural health institute, 51% wants to

shift to another urban health institute and 6% wants to shift to another job in some

other State/sector in search of an alternative employer. The Factors that contributed

for migration of the physicians, nurses and mid-wives as a whole, from the present

rural area to other rural area, urban area or to leave the sector have two factors

significant that are the Lack of adequate financial incentives / rural

allowances/performance incentives, poor working condition, lack of Career

development opportunities and poor salary. The other retention measures of financial

and non-financial incentives area absent from the system that could retain the



21

workforce in rural and remote areas. It is also revealed that the factors that may

motivate the physicians, nurses and mid-wives to retain themselves in the present

rural area have four factors -financial incentives, improved living condition, career

development and Good reward and achievement recognition system. It is found in this

study that the intention of migration of physicians, nurses and mid-wives from a rural

area health institute to another rural health institute is propelled mainly by the factor

of team work and interpersonal relationship in the present place of work. This study

also revealed that the intention of migration of this workforce is related with the level

of job satisfaction of these groups of health workforce and propel them to migrate. So

forth, in addition to the other issues and concerns, there is a growing dissatisfaction

among the physicians, nurses and mid-wives in presently working in the rural and

remote areas.

While the reform initiatives in the sector are the emphasizing on contractual

employment, emphasizing on development of professional training institutes,

initiatives for comprehensive HR policy, decentralisation of HR activities to district

level, adoption of simplified way of recruitment and selection, emphasized on training

and development, emphasized on career development opportunities, shifting of view

towards the financial incentives, emphasizing of availability of essential equipments

for functionalising a health centre as per IPHS, development of supportive supervision

and emphasizing on infrastructure development initiatives including accommodation

facilities.

It is also found in respect of HR practice under reform process for distribution,

attraction and retention, that in the absence of appropriate and concrete human

resources policies on deployment, there is always a hindrance in managing people at

work as the entire district agreed to this. Along with, there is a major issue of HR

planning, recruitment and selection process, the common minimum tenures are not

followed along with the time bound promotions are not practices for several reasons

to these categories of staff, there is no use of provision of financial and non-financial

incentives for rural and remote area posting and retention, The reward and recognition

for the performance and achievement is also not there in the system, and there is no

random access of training needs, the planning of training and the execution of the

same have a random mismatch in the district and as well as in the state level.

Adequate human resources for health (HRH) are a key requirement for reaching

health goals, the study found that, the shortages of physicians, nurses and mid-wives



22

are an ongoing problem in the public health sector in Arunachal Pradesh with uneven

distribution. There is low job satisfaction in the workforce in the current job at rural

and remote areas. It is contributed by many of the factors including financial and non-

financial benefits. Attraction and retention of physicians, nurses and mid-wives in

remote and rural areas are determined by many factors including financial incentive,

career development opportunities, recognition etc. But, the factor of compulsion is the

main factor of stock in rural and remote areas, and rest of the factors have less

contribution, and the financial benefits along with non-financial benefits seems to be

migrating factors. The attraction, deployment and retention of physicians, nurses and

mid-wives in rural and remote areas are a real challenge and a difficult situation, and

affected by several factors ranging from organizational factors to external

environmental factors and to personal factors. However, the personal factors have less

affect on the situation. The massive poor living conditions in the rural and remotes

areas, poor working condition in health institutes, poor career development

opportunities with lack of financial benefits are some of the factors that contribute to

the reluctances of the physicians, nurses and mid-wives to serve the rural and remote

areas in the state. The sector has nothing to offer presently, to attract and retain and to

distribute rationally this workforce, which in result deteriorating the situation in the

rural and remote areas. Moreover, the reform process is doing less for the HRM

perspectives and the HR practices are not effective enough to solve the problems in

the state. it is clear that many factors affect the rational distribution, attraction and

retention of Physicians, nurses and mid-wives in the rural and remote area ranging

from environment issues, organisation issues as well as the personal issues, along with

the production issues, the facilities and basic amenities along with financial incentives

are determinant of manpower in rural areas of the state. It is also known that to solve

these HR issues, no individual interventions are not adequate, it need a pyramid of

interventions to ensure the minimization of the issues.

Moreover, a blend of initiatives is needed to address the problems of distribution,

attraction and retention of manpower in the state, there is a need of continue focus and

commitment on the part of government and as well as the political will to solve the

problem. In conclusion, efforts to strengthen health sector must address the HR issues

and a good Human Resource Management and a far sight in HR requirements are

needed.



23

LIST OF THE CONTENTS

Title Page No.

Declaration by the candidate i

Certificate of supervisor ii

Acknowledgement iv-v

List of figures vi-vii

List of table viii-xv

Abbreviation xvi-xvii

Abstract xviii-xxi

List of Contents xxii-xxvi

CHAPTER -1 INTRODUCTION 1-9

1.1. Introduction to research theme 1

1.2. Rationale behind the research 4

1.2.1. Why Physicians, nurses and mid-wives are selected for the study?

5

1.2.2. Why rural and remote areas selected for the study? 6

1.2.3. Why HR Practices (including distribution, attraction and

retention) selected for the study?

6

1.3. Objective of the study 7

1.4. Significance of the study 8

1.5. Outline of the thesis 9

CHAPTER -2 LITERATURE REVIEW 10-422.1. Introduction 11

2.2. Key HR issues in public health sector- in a global

perspective

11

2.3. Distributional issues of Health workforce- in global context

20

2.4. Attraction and retention of physicians and nurses in

rural areas- in a global context

24

2.5. Health Sector reform : the international and Indian

context 33

2.6. Gaps in the literature 34

2.7. Conceptual framework for the study 34

2.7.1. HRM in public health sector– a conceptual framework 34

2.7.2. Attraction and retention of health workers in rural areas

-Conceptual framework

38

2.7.3. Framework of urban area and rural area for this study 41

CHAPTER 3 RESEARCH METHODOLOGY 43-51

3.1. Research Methodology 44

3.1.1. Research Design 44

3.1.2. Objective of the study 44

3.1.3. The Study area 45



24

3.1.4. Map of the studied area 47

3.1.5. Data Collection methods and instruments 48

3.1.6. Sampling frame 49

3.1.7. Data Analysis 50

3.2. Limitation of research 503.3. Contribution of the research 51

CHAPTER -4 DATA ANALYSIS AND INTERPRETATION 52-

251

Section-1 Characterstics of respondents 53-55

4.1.1. Introduction 54

4.1.2. Characterstics of respondents 54

Section 2 Analysis of dimension of HR issues in Distribution of

Physicians, Nurses and Mid-wives in rural and

remote areas of the state

56-87

4.2.1. Introduction 574.2.2. Scenario of distribution of Health Institution in

Arunachal Pradesh

57

4.2.3. Scenario of distribution of physicians, nurses & mid-

wives in Arunachal Pradesh

59

4.2.3.1. District-wise Distribution pattern of Physicians

(Medical Officers) & Specialists (Paediatrics,

Anaesthetics and Gynaecologist):

61

4.2.3.2 Distributional pattern of Nurses (Staff Nurses & GNM)

district-wise

64

4.2.3.3. Distribution pattern of Mid-wives (ANM) district-wise 674.2.4. Scenario of distribution of physicians, nurses & mid-

wives in rural and remote areas in Arunachal Pradesh

69

4.2.4.1. Distribution pattern of Physicians (Medical Officers) in

rural & remote areas (district wise)

70

4.2.4.2. Distributional pattern of Nurses (Staff Nurses & GNM)in Rural and Remote area in Arunachal Pradesh district-

wise

73

4.2.4.3. Distributional pattern of Mid-wives (ANM) in Rural and

Remote area in Arunachal Pradesh district-wise

75

4.2.5. Urban-Rural distribution of physicians, nurses and mid-wives 78

4.2.5.1. District wise Urban-Rural distribution of Physicians


79

4.2.5.2. District wise Urban-Rural distribution of Nurses in

Arunachal Pradesh

80

4.2.5.3. District wise Urban-Rural distribution of Mid-wives

(ANM) in Arunachal Pradesh

82

4.2.6. Numerical inadequacy of physicians, nurses and mid-wives in Arunachal Pradesh

83

4.2.6.1 Requirement and shortfall of human resources in SCs,

PHCs and CHCs in the state according to IPHS norms.

84



25

Section 3 Analysis of the dimension of HR issues in attraction

of Physicians, Nurses and Mid-wives in rural and


88-

126


4.3.2. Factors that attracted or placed the physicians, nurses

and mid-wives in the current job in the rural and remotearea: current determinants of attraction and placements

89

4.3.2.1. Factors that attracted or placed the physicians in present


92

4.3.2.2. Factors that attracted or placed the nurses in present


95

4.3.2.3. Factors that attracted or placed the mid-wives in present


99

4.3.3. Relationship of factors of attraction and demographic

characteristics of physicians, nurses and midwives

102

4.3.3.1. Relationship of factors of attraction and demographiccharacteristics of physicians

103

4.3.3.2. Relationship of factors of attraction with thedemographic characteristics of nurses

107

4.3.3.3. Relationship of factors of attraction with the

demographic characteristics of mid-wives

110

4.3.4. Factors that may attract physicians, nurses and mid-

wives to rural area- choice of current physicians, nurses

and mid-wives

114

4.3.4.1. Factors that may attract physicians to rural area- Choice

of current Physicians

117

4.3.4.2. Analysis of the factors that may attract nurses to ruraland remote area- choice of current nurses

119

4.3.4.3. Analysis of the factors that may attract mid-wives to

rural and remote area- choice of current mid-wives

122

4.3.4.4. Variance in choice of factor that may attract the physicians, nurses and mid-wives

124

Section 4 Analysis of the dimension of HR issues in retention

of Physicians, nurses and mid-wives in Rural and


127-

199


4.4.2. Overall Job satisfaction of Physicians, nurses and mid-wives in Present rural and remote area and relationshipwith other demographic attributes

129

4.4.2.1. Job satisfaction of Physicians in rural and remote area

and relationship with other demographic attributes

132

4.4.2.2. Job satisfaction of Nurses in rural and remote area and

relationship with other demographic attributes

134

4.4.2.3. Job satisfaction of Mid-wives in rural and remote area

and relationship with other demographic attributes

136

4.4.3. Factors of job satisfaction of physicians, nurses and

mid-wives in rural and remote area

138

4.4.3.1. Factors of job satisfaction of physicians in rural and 141



26

remote area

4.4.3.2. Factors of job satisfaction of nurses in rural and remotearea

144

4.4.3.3. Factors of job satisfaction of mid-wives in rural and

remote area

147

4.4.3.4. Factors of job satisfaction of contractual and permanent physicians, nurses and mid-wives in rural and remote

area

150

4.4.4. Likelihood of migration of physicians, nurses and mid-

wives- choice to migrate

153

4.4.4.1. Contributing factor of likelihood of retention of

physicians, nurses and mid-wives- Choice to stay

159

4.4.4.2. Push factors of likelihood of migration of physicians,

nurses and mid-wives- Choice to migrate

170

4.4.4.3. Push factors of likelihood to migrate according to the

choice of place

181

4.4.4.4. Relationship of demographic and satisfaction attributes

with the major intention to migrate to urban areas

184

4.4.5. Factors that may motivate the physicians, nurses and

mid-wives to retain in current job in rural and remote

area- What is their choice?

187

4.4.5.1. Factors that may motivate the physicians to stay 188

4.4.5.2. Factors that may motivate the Nurses to stay 192

4.4.5.3. Factors that may motivate the Mid-wives to stay 196

Section 5 Analysis of the Reform initiatives for distribution,

attraction and retention of physicians, nurses andmid-wives

200-

232

4.5.1. Reform initiatives for recruitment and deployment(Distribution)

201

4.5.2. Reform initiatives for attraction and retention 213

4.5.3. Exploring the views on health sector reform from the perspective of physicians, nurses and mid-wives

220

Section 6 Analysis of the HR policies and practices on

attraction, distribution and retention of physicians,

nurses and mid-wives for rural and remote area in

the state

233-

251


4.6.2. Policies for HR Planning, recruitment (attracting),

placement, transfer and promotion

234

4.6.3. HR planning, recruitment and selection process 237

4.6.4. HR practice for placement, transfer and promotion 242

4.6.5. HR practice for retention - financial & non-financial

interventions

246

4.6.6. HR practice for retention - training and development 249

CHAPTER- 5 MAJOR FINDINGS, SUGGESTIONS AND

CONCLUSION

252

Section 1 Major HR issues in distribution of physicians, nurses 253-



27

and midwives in rural and remote areas 264


5.1.2. Major HR issues in distribution of physicians, nurses

and midwives

254

Section 2 Major HR issues in attraction of physicians, nurses

and midwives in rural and remote areas

265-277

5.2.1. Major HR issues in attraction of physicians, nurses and

midwives

266

Section 3 Major HR issues in retention of physicians, nurses

and midwives in rural and remote areas

278-

299

5.3.1. Major HR issues in retention of physicians, nurses and

midwives

279

Section 4 Major reform initiatives and issues thereon 300-

308

5.4.1. Major Reform initiatives and issues thereon 301

Section 5 Major issues in HR practice related to attraction,distribution and retention of physicians, nurses and

mid-wives

309-314

5.5.1. Major issues in HR practice for attraction, distribution

and retention of physicians, nurses and mid-wives

310

Section 6 Suggestion 315-323


5.6.2. Broad suggestions 318

Section 7 Conclusion 324-

3265.7.1. Conclusion 325

Reference 327-

343

Appendix – 1: Manpower Recommended under IPHS 344-346

Appendix 2: Questionnaire for physicians, nurses and

mid-wives

347-

353

Appendix 3: Interview schedule for State and District

management representatives

354-

356

Conference attended 357

Paper Published 358



28

Chapter -1

INTRODUCTION



29

1.1. INTRODUCTION TO RESEARCH THEME

It is apparent that the human element in an organisation is the most important

element in achieving the organisational goal. Focusing to the management of human

affairs within the organizations is the responsibility of human resources management

(HRM) in an organisation. Traditionally, management of this system has gained more

attention from service organizations than from manufacturing organizations

(Radcliffe, 2005).

The early decades of the 21st century considered as the era of human

resources for health sector. The public health sector is purely a service sector, the

human element is a critical element for it success and achievement of organizational

goals. In the health sector, a strong human infrastructure is fundamental to closingtoday’s gap between health promise and health reality and anticipating the health

challenges of the 21st century (WHO, 2006). The World Health Organization (WHO)

estimates the current HRH workforce at 59 million and its global shortage at 4.3

million. Both developed and developing countries are currently of Health worker

shortages. Such shortages are symptoms of a poorly managed health workforce and

health care system. The causes of the crisis are more complex with insufficient

production capacity, and overall with an inability to keep the workers in the places

where they are needed.

Despite of significant achievements after 64 years (1947-2011) of

Independence, public health sector in India is facing a critical challenge on several

fronts. While the country has made substantial strides in economic growth, its

performance in health has been less impressive. Despite an extensive network of

government funded clinics and hospitals providing low cost care, curative health

services, the country fails to address public health needs of the people. An important

reason for this is the inability of the health system to provide health care for all due to

inadequate infrastructure and human resource. Distortions in the area of human

resources in health sector are one of the significant issues in Indian public health

sector today. The country faces a shortage of qualified health workers with large

geographic variations in the health workforce, across states and rural and urban areas.

These issues are the important challenges in reforming Indian public health sector.

The public sector of the health system has been one of the main targets of the

national initiatives of reform for the public administrations, particularly because of the



30

magnitude of their expenses and the number of personnel employed (Roberto & Jose,

2003). Designers and implementers of decentralization and other reform measures

have focused much attention on financial and structural reform measures, but ignored

their human resource implications. Concern is mounting about the impact that the

reallocation of roles and responsibilities has had on the health workforce and its

management. (Kolehmainen-Aitken, 2004).

While to accomplish the ‘Millennium Development Goals’ (MDG) which was

adopted in the Millennium Declaration in the year 2000, the strengthening of health

care delivery system and improved health care services are utmost importance.

Healthcare is a service sector, depends highly on specially trained professionals and

technical human resources. Both developed and developing countries are currently

facing Health worker shortages along with attraction and retention problems.

At the same time, India is also struggling to accomplish the development goals

along with the rest of the developing world. For this, the human resource are needed

to developed and retain at all level. There is a need to respond and address the HR

issues and challenges and to mobilize a motivated human resource in particular the

technical workforce towards the accomplishment of targets of the organization.

In India, health worker shortages are one of the main challenges in achieving

population health goals. Adding more on this challenge the geographical distribution

of heath workforce is always a matter of concern, featured with urban attraction in the

country. More on the issue, the mostly concerned area in health sector are difficulty in

producing, recruiting and retaining health workforce in rural and remote areas.

Thus, the major challenge in the new millennium is the retention of health

workers, not only in poorer countries, but also within any country in remote and rural

areas (Bangdiwala et al., 2011). Therefore, this study aimed at understanding the HR

issues on distribution, attraction and retention of Physicians and Nurses including the

Mid-wives in Public health care delivery system in rural India with special reference

to the State of Arunachal Pradesh. This research process not only generated useful

contributions to the field of research, but that it also provided time for reflection and

learning for other people involved in the process as there is no literature on the topic

as on date in Arunachal Pradesh (as far as this researcher has been able to establish).



31

1.2 . RATIONALE BEHIND THE RESEARCH

Geographical mal-distribution of health care providers, especially physicians

and nurses including mid-wives, is a ubiquitous problem, affecting many countries

and reasons (Pong, 2008). While adopting the Millennium Declaration in the year 2000, the international community pledged to “spare no effort to free our fellow men,

women and children from the abject and dehumanizing conditions of extreme

poverty.” We are now more than halfway towards the target date – 2015 – by which

the Millennium Development Goals are to be achieved (MDG, Report 2008, UN).

The MDGs no. 4, 5 and 6 are related to Reduce Child Mortality, Improve Maternal

Health and Combat HIV/AIDS, malaria & other diseases respectively. To accomplish

these MGDs, the strengthening of health care delivery system and improved health

care services are utmost importance. Whereas, the healthcare is a service sector,

depends highly on specially trained professionals and technical human resources.

Both developed and developing countries are currently facing Health worker

shortages especially physicians and nurses along with their attraction and retention

problems. Efforts to overcome physicians and nurses shortage can be divided into two

major categories: attraction/recruitment and retention. Whereas the former is an effort

to get a doctor to set up practice in a community, the latter is an attempt to keep the

doctor there as long as possible (Pong, 2008). The causes of the crisis are complex,

with insufficient production capacity, but also with an inability to keep the workers

that are being produced in the places where they are mostly needed. The availability

of human resource is one of the important components for the efficient functioning of

public healthcare delivery system. Increase in health indicators needs increase in the

availability of health workers through improved health workforce attraction,

distribution and retention. Thus, the causes of the crisis are complex, with insufficient

production capacity, inability to keep the health workers that are being produced in

the places where they are mostly needed.

India is a vast country with a wide network of public health service with

diversified challenges in the achieving health goals, including health worker

shortages. The National Health Policy of India (2001) acknowledges the acute

shortage of healthcare professionals especially in rural areas. Such shortages are the

symptoms of a poorly managed health workforce and health care system. Several

issues which are foremost important are producing, distributing, attracting and their



32

retention rural and remote areas. India has about 1.4 million medical practitioners,

74% of whom live in urban areas where they serve only 28% of the population, while

the rural population remains largely underserved. (Sundararaman & Gupta, 2011).

The widespread poverty, illiteracy, malnutrition, absence of safe drinking water and

sanitary living conditions, poor maternal and child health services and ineffective

coverage of national health and nutritional services have been traced out in several

studies as possible contributing factors to dismal health conditions prevailing among

the tribal and rural population in India (Basu, 2000).

1.2.1. WHY PHYSICIANS, NURSES AND MID-WIVES ARE SELECTED

FOR THE STUDY?The rationale behind the selection of the physicians and the nurses from the

pool of professional workforce in the healthcare sector is due to the nature of these

categories of workforce. As, these healthcare categories of professionals require

special consideration, particularly to the availability, acquisition, retention,

development of their competence and meeting their professional needs and

expectations. The main skilled health workers in rural areas work in the public health

sector are these two categories of health workforce.

Moreover, according to the National Health Policy 2000, India is committed to

achieve the reduction in maternal and infant mortality rates set for National

Population Policy-2000. The Maternal Mortality in India continues to remain

unacceptably high, and there is enough evidence globally to demonstrate that an

effective package of obstetric and child health services provided within reach of the

communities and families can successfully reduce maternal and childhood mortality.

So, to operationalization of all Community Health Centers, Primary Health Centers

and Sub Health Centers for providing 24 hours x 7 days obstetric (maternal) and child

health services including the management of common obstetric complications,

emergency care of sick children and referrals round the clock, all seven days of the

week, in the public health setting, the services of Physicians, Nurses and Mid-wives

are the critical components besides the infrastructural development at all level.

Thus, the rationale behind the selection of the physicians and the nurses from

the pool of professional workforce in the healthcare sector is due to the nature of these

categories of workforce, as these healthcare categories of professionals require special

consideration, particularly to the availability, acquisition, retention, development of

their competence and meeting their professional needs and expectations.



33

1.2.2. WHY RURAL AND REMOTE AREAS SELECTED FOR THE STUDY?In recent year, major initiatives have been launched to tackle health and

inequalities in access to health. The mal-distribution of personnel has its roots in

longstanding global inequalities. It is in this global context of accelerating inequities

that health-service policy makers and managers are searching for ways to improve the

attraction and retention of staff in remote and rural areas (Lehmann et al, 2008).

Recruiting and retaining highly qualified health workers in remotely located areas

presents an enormous challenge in both developed and developing countries (Chomitz

et al, 1998). In view of these quotes, the remarks are particularly for the rural and

remote areas. To talk of Asia as a whole, according to Chen. L., et al. in Joint

Learning Initiative (2004) Asia which has about half the world's population, has

access to only about thirty percent of the world's health professionals and has

confirmed that global inequities in the distribution of health personnel hit those

countries hardest which can least afford it. India is predominantly a rural area and the

Rural Health Care System forms an integral part of the National Health Care System.

Provision of Primary Health Care is the foundation of the rural health care system.

For developing vast public health infrastructure and human resources of the country,

accelerating the socio-economic development and attaining improved quality of life,

the Primary health care is accepted as one of the main instrument of action.

The studied area- the state of Arunachal Pradesh is a pre-dominantly a rural

and remote area. The rural population constitutes 77.33% whereas; the urban

population consists of only 22.67% of the total population of the state (Census 2011).

Thus, the importance of rural and remote areas argues for the selection.

1.2.3. WHY HR PRACTICES (INCLUDING DISTRIBUTION,

ATTRACTION AND RETENTION) SELECTED FOR THE STUDY?According to Infosys CEO, Narayana Murthy said “My employees seek

challenging opportunities, respect, dignity and opportunities to learn new things. I

keep telling them that my assets are not this building, the business or foreign

contacts, My assets – all 8,000 of them – walk out of the gate every evening and I wait

for them to come back to me the next morning” This is what has made Infosys one of

the best proactive HRD practicing company and also one of the first companies to

adopt an employee stock option and create additional wealth for its employees

(Ramani, 2003).



34

The increased attention paid to new HRM practices has been particularly

prevalent in the fields of strategic management, human resource management, and

increasingly, the economics of organization (Laursen & Foss, 2000). There are

significant relationship between human resources practice and organisational success.

This is well known that human beings are the most important resources of an

organisation especially in service sector organisation as they play a crucial role in its

growth and development and achievement of goals.

In the health sector, along with several HR issues, according to Lehmann et al,

2008, one of the most negative effects of severely weakened and under-resourced

health systems is the difficulty they face in producing, recruiting, and retaining health

professionals, particularly in rural and remote areas.

Efforts to overcome physician and nurse shortage can be divided into two

major categories: recruitment/attraction and retention. Whereas the former is an effort

to get a doctor to set up practice in a community, the latter is an attempt to keep the

doctor there as long as possible (Pong, 2008). Resulted in, the main challenges as

experienced to be the recruitment, distribution and retention of health workers.

Thus, keeping the synergies between the research problems, a look on at HR

issues regarding distribution, attraction and retention of physicians and nurses in

rural and remote areas are considered.

The discussion of attraction, distribution/placement and retention factors and

strategies falls within the broad scope Human Resource Management (HRM) as a

strategic and coherent approach to managing staff (with inclusions from Armstrong,

2007). These areas are equally important with a focus on rural and remote areas and

thus the order of discussion does not represent their relative importance.

1.3. OBJECTIVE OF THE STUDYAs the researcher could able to establish, that there is no academic literature

available as on date relating to the research topic in the state of Arunachal Pradesh. In

view of the above, this research study aims at exploring the issues on the distribution,

attraction and retention of Physicians and Nurses in Public health care delivery system

in rural area in the state of Arunachal Pradesh. The study is focused on physicians

(doctors) and nurses (Staff Nurse/GNM, ANM -the Mid-wives) only. The research

question puts for the study are that- What are the major HR issues on distribution,

attraction and retention of physicians and nurses in rural and remote areas in



35

Arunachal Pradesh? What are the major reform initiatives under reform process for

major issues on distribution, attraction and retention of physicians and nurses in

rural and remote areas in Arunachal Pradesh?

Rationally, the following objectives are place for the study:-

1. To explore the major HR issues on distribution, attraction and retention of

physicians and nurses in rural and remote areas in Arunachal Pradesh.

2. To explore the major reform initiatives under reform process for major issues on

distribution, attraction and retention of physicians and nurses in rural and remote

areas in Arunachal Pradesh.

3. To suggest some remedial measures to address the major issues.

1.4. SIGNIFICANCE OF THE STUDYThe early decades of the 21st century considered as the era of human

resources for health. This research work has brought out major issues and reform

initiatives of distribution, attract and retention of physicians and nurses in Public

Health sector of Arunachal Pradesh.

Among all factors of production, man is by far the most important. The

importance of human factor in any type of co-operative endeavour cannot be

overemphasized. It is a matter of common knowledge that every businessorganization depends for its effective functioning not so much on its material or

financial resources as on its pool of able and willing human resources. The human

resource becomes even more important in the service industry whose value is

delivered through information, personal interaction or group work (Tripathi, 2009). In

the health sector, a strong human infrastructure is fundamental to closing today’s gap

between health promise and health reality and anticipating the health challenges of

the 21st century (WHO, 2006). The health care sector is both labour-intensive and

labour-reliant, and the delivery of quality health care services is strongly dependent

on having enough well-trained health care workers to meet patient needs and

expectations. There is a growing awareness that human resource issues need to be

prioritized more effectively within reforms in order to secure an adequate health care

workforce to deliver services now and in the future (Lethbridge, 2004). Health

reforms that aims at increasing efficiency, quality and users' satisfaction need to take

into consideration human resource issues, because the health sector is labour intensive

and the performance of health systems depends on qualified and motivated workers



36

(Homedes and Ugalde, 2005). Health sector reform often focuses on changes in

financing or organisational structure, but neglects a key resource – ‘the staff’. This

may result in inappropriately skilled staff for new tasks, poorly motivated staff, or

even serious opposition to the reforms (Martineau & Buchan, 2000). There has been

several analysis of the successes and failures of health reforms in general. However,

relatively little attention has been paid to the critical part that human resources (HR),

which will play in determining the success or failure of health reforms(Martineau &

Buchan, 2000). Several studies have pointed out that human resource issues need to

be a primary consideration in reform design, suggesting that reforms can only be

implemented successfully where there is consensual participation on the part of the

workforce (Ssengooba et al, 2007).

Therefore, the importance of this research is due to : - FIRSTLY, the urgency

behind “ Health Care Delivery System Reform” emphasizes by Government of India,

and the human resource is always behind in thinking of Health Sector Reforms.

SECONDLY, Human resources management occupies a unique niche in our system

of health care and the importance of attraction and retention of physicians and nurses

in rural and remote areas in delivering health care services. THIRDLY, the need of

motivated and skilled workforce to deliver better and quality primary health care

services to the rural mass.

The urge about, how this aspect of issues in India, particularly in the state of

Arunachal Pradesh are and can be addressed, motivated the researcher to explore the

subject.

1.5. OUTLINE OF THE THESIS

The first chapter is on Introductory part includes the objective, rationale and

significance of the study. The succeeding chapters are organized as follows: Chapter-

2 is Literature review which summarizes the previous study and other related themes.

Chapter-3 presents the research methodology. Chapter-4 presents the data analysis

and interpretation. Chapter-5 summarizes the Major findings on HR Issues on

distribution, attraction and retention of the Physicians, Nurses and Mid-wives and it

also presents the suggestions and conclusion of the study. Thereafter, followed by the

Bibliography and Appendix.



37

Chapter -2

LITERATURE REVIEW



38

2.1. INTRODUCTIONIn the field of Human Resource Management, fortunately there is no dearth of

literature. Excellent researchers, academicians and practitioners have been devoting

considerable thought to the different aspects of HRM. However, comprehensive

studies covering HR in Health Sector in India or Arunachal Pradesh is limited. An

attempt is made here to explore the literature addressing issues of distribution,

attraction and retention of physicians and nurses in a global context, along with the

health sector reforms.

This chapter discussed the literature available on the study topic. It includes

key HR issues in public health sector in global context, gaps in literatures and

conceptual framework for the study.

2.2. KEY HR ISSUES IN PUBLIC HEALTH SECTOR- IN A

GLOBAL PERSPECTIVEWhile examining health care systems in a global context, several issues are

highlighted in the literature in context of the general human resources issues. Some of

the issues of greatest relevance in the literature are discussed in subsequent section.

Here in a nutshell, the literatures emphasize the variation of size, distribution and

composition within a county's health care workforce is of great concern. One of the

biggest concerns is critical shortages of Human Resource. The importance of health

workforce provision has gained significance and is now considered one of the most

pressing issues worldwide (Hawthorne and Anderson, 2009). The international

shortage of health care professionals exists in different severities and has different

root causes, depending on the particular health profession and the country of origin.

Health care priorities therefore change between countries: a universal health system

would invariably not provide the required health care efficiently to all those who need

it (Hawthorne and Anderson, 2009). At the global level, many countries are facing

critical HRH challenges including worker shortage, skill-mix imbalance, mal-

distribution, poor work environment, and weak knowledge base (Chen, 2004; Wyss,

2004). Health professionals are insufficiently committed to the present public health

system (Homedes & Ugalde, 2005), and that is of particularly nurses and physicians

(El-Jardali et al; 2007) and especially in critical areas like specialist dentists,

anaesthetists etc, (Ramadoss, 2007). The World Health Organization (WHO)

estimates the current HRH workforce at 59 million and its global shortage at 4.3



39

million (WHO, 2006). According to the WHO, there are currently 57 countries with

critical shortages of human resource for health (including India) equivalent to a global

deficit of 2.4 million doctors, nurses and midwives.

The general HR issues are highlighted below:

1. Shortage of skilled health workers: The functioning and growth of health

systems depends on the availability of human resources and on the time, effort and

skill mix provided by the workforce in the execution of its tasks (Ozcan et al, 1995,

Martínez et al, 1998- adapted from Gupta and Dal Poz, 2009). The severe shortage of

health workforce globally, especially in developing countries like African countries,

Pacific and Asian countries is a critical issue that must be addressed as an integral part

of strengthening health systems (Henderson and Tulloch, 2008). Factors that

contribute to the shortage of skilled health workers which was highlighted in the

studies of Henderson and Tulloch, 2008; Hawthorne and Anderson, 2009; Satpathy &

Venkatesh, 2006; Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; El-Jardali et

al, 2007; Kabene et al, 2006; Henderson and Tulloch, 2008; Dubois & McKee, 2006;

Management Science for Health, 2009; Institute for Public Health, 2007; WHO,

World Health Report, 2006; Bach, 2000; McCaffery, 2006; Martinez & Martineau,

1997; Mavalankar, 1999; Dussault and Dubois, 2003; Uneke et al 2008; Liu, et al.,

2006; Joaquin, 2009, Mutizwa, 1998, Mathauer and Imhoff, 2006, Brien and Gostin,

2009). The factors includes a lack of effective planning (Henderson and Tulloch,

2008; Martineau & Buchan, 2000; McCaffery, 2006; Mavalankar, 1999; Martínez &

Martineau , 1998; Uneke et al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al,

2007), limited health budgets (Henderson and Tulloch, 2008; Ssengooba et al, 2007;

Uneke et al 2008), migration of health workers (Henderson and Tulloch, 2008;

Dubois & McKee, 2006; Manafa et al, 2009; Martinez & Martineau, 2002;Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006;

Ssengooba et al, 2007), inadequate numbers of students entering and/or

completing professional training (Henderson and Tulloch, 2008; Dubois & McKee,

2006; Institute for Public Health, 2007; WHO, World Health Report, 2006; Martínez

& Martineau, 2002; Bach, 2000;McCaffery, 2006; Martinez & Martineau, 1997;

Dussault and Dubois, 2003; Kushwah, 2000, Brien and Gostin, 2009), limited

employment opportunities (Henderson and Tulloch, 2008), low Salaries (Homedes

& Ugalde, 2005; Kabene et al, 2006; Martínez & Martineau ,1998; El-Jardali et al,



40

2007; Henderson and Tulloch, 2008; Institute for Public Health, 2007; WHO, World

Health Report, 2006; Martínez & Martineau, 2002; Martineau & Buchan, 2000;

Mavalankar, 1999; Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009),

poor working conditions (Homedes & Ugalde, 2005; Chen, 2004 ; Wyss, 2004;

Henderson and Tulloch, 2008; Management Science for Health, 2009; El-Jardali et

al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar, 1999;

Uneke et al 2008; Kolehmainen-Aitken, 2004), weak support and Supervision

(Henderson and Tulloch, 2008; Institute for Public Health, 2007; McCaffery, 2006;

Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008; Dieleman et al, 2009) ,

and limited opportunities for professional Development (Henderson and Tulloch,

2008; Uneke et al 2008; Kolehmainen-Aitken, 2004; Dieleman et al, 2009). The

shortage of workers often results in inappropriate skill mixes in the health sector

(Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; Henderson and Tulloch, 2008;

Dubois & McKee, 2006; McCaffery, 2006; El-Jardali et al, 2007; Bach, 2000;

Martineau & Buchan, 2000; Mavalankar, 1999; Mathauer and Imhoff, 2006), as well

as gaps in the distribution of health workers (WHO, 2006; Homedes & Ugalde,

2005; Chen,2004 ; Wyss, 2004; Kabene et al, 2006 ; Martinez & Martineau, 1997;

El-Jardali et al, 2007; Henderson and Tulloch, 2008; Martinez & Martineau, 2002;

Bach, 2000; McCaffery, 2006; Mavalankar, 1999; Dussault and Dubois, 2003;

Martínez & Martineau , 1998; Kolehmainen-Aitken, 2004; Joaquin, 2009). Overall

staffing ‘shortages’ due to the inability to attract and retain sufficient numbers, or due

to financial constraints that may be externally imposed e.g. as part of structural

adjustment. Yet there may be an over concentration of staff in urban areas at the

expense of poorer, more remote, under-served areas where posts are left vacant

(Ghana, India, Bangladesh and many poor countries) (Martínez & Martineau, 2002).

This is especially so in rural and remote areas where the provision of services is

difficult because of limited health budgets and scattered populations living in isolated

villages or islands (Henderson and Tulloch, 2008). According to Bach, (2000),

shortages of personnel trained in disciplines such as primary health care, health

economics, public health, health communication, health education, nutrition, and

environmental engineering continue to severely limit the possibilities for improving

the quality and efficiency of the health care system, that is we can say deals with

number and the composition of health workforce (Kabene et al, 2006). Almost all

countries suffer from misdistribution characterized by urban concentration and rural



41

deficits, but these imbalances are perhaps most disturbing from a regional perspective

(WHO 2006). There is an over-concentration of qualified health personnel in urban

hospitals and urban centers, coupled with shortages in poor neighborhoods and rural

areas (Homedes & Ugalde, 2005). At the global level, many countries are facing mal-

distribution (Chen, 2004; Wyss, 2004; El-Jardali et al, 2007) and human resources

units are not adequately staffed (Homedes & Ugalde, 2005), distribution of health

care workers (Kabene et al, 2006 ) are not equally distributed, especially to manage

change in the health sector. Inequity in rural-urban distribution of human resources

for health (HRH) is a worldwide problem (Lexomboon, 2003). So, it may be

summaries that the regional differences of workforce is the major public health issues

and in the organization and delivery of public health services (Beaglehole and Dal

Poz, 2003).

2. Working conditions: Several researchers highlighted and summed up with

poor working condition for public health workforce in this sector. At the global level,

health workforce in the different countries are facing poor work environment which

was highlighted in the studies of Homedes & Ugalde, 2005; Chen, 2004 ; Wyss,

2004; Henderson and Tulloch, 2008; Management Science for Health, 2009; El-

Jardali et al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar,

1999; Uneke et al 2008; Kolehmainen-Aitken, 2004. After understaffing which was

the most commonly reported HR challenge; poor working conditions and staff

grievances (Management Science for Health, 2009) are the most viewed issues.

3. Compensations issues: The issue of low remuneration or inadequate salary

has attracted many research studies like Homedes & Ugalde, 2005; Kabene et al,

2006; Martínez & Martineau ,1998; El-Jardali et al, 2007; Henderson and Tulloch,

2008; Institute for Public Health, 2007; WHO, World Health Report, 2006;

Martínez & Martineau, 2002; Martineau & Buchan, 2000; Mavalankar, 1999;

Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009, Mathauer and Imhoff,

2006 and their studies concludes that, health workers in developing countries are

underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006). Under

production of health workforce, inability to pay higher salaries and benefits, inability

to sustain are other some of the issues pertaining to this, which is highlighted by

WHO, World Health Report, (2006).

4. Migration of health workforce: Even where there are an appropriate number

and mix of trained health workers, there may not be jobs available for them in their



42

country of origin, despite the population experiencing widespread unmet health needs

(Brien and Gostin, 2009). Another issue highlighted in the literatures is the migration

of health workforce from own place of origin to other part of the world in search of

better avenues. Many researchers have come across this key issue while studying on

HR issues. As poor compensation packages may be one of the reasons for the

migration of the health workforce. Silently the education opportunities for their

(workforce) children (Uneke et al 2008), the migration of workers are also there. In

addition to international migration there is also considerable in-country migration

between the public and private health sectors, between urban and rural areas and

between tertiary and primary health care delivery (Manafa et al, 2009). Many

countries lack the human resources needed to deliver essential health interventions

and migration of health workers within and across countries (Henderson and Tulloch,

2008; Dubois & McKee, 2006; Manafa et al, 2009; Martínez & Martineau, 2002;

Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006;

Ssengooba et al, 2007) is one of the main concern.

5. Retention and high attrition: Due to poor working conditions, low

compensation package and migration, it is very difficult for retention of these

workforce in a developing or an underdeveloped countries and make use of their

services in rural areas. Retention and high attrition issues have been highlighted by

many research including- Martínez & Martineau, 2002; McCaffery, 2006;

Mavalankar, 1999; Institute for Public Health, 2007.

6. Aging workforce: It is yet another issue confronting some of the countries

and these aging workforces cannot be utilized fully for health interventions. This is

highlighted in the study of El-Jardali et al; (2007).

7. Professional training and production issues: The issue of inadequate

professional training is in disparity as suggested by several studies. The regulation of

training institutions and conditions of practice is weak (Homedes & Ugalde, 2005).

Insufficient numbers of people trained in primary health care and public health related

fields and the training centers are unable to produce personnel to operate the reformed

health system (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Institute for

Public Health, 2007; WHO, World Health Report, 2006; Javier Martínez & Tim

Martineau, 2002; Bach, 2000; McCaffery, 2006; Martinez & Martineau, 1997;

Dussault and Dubois, 2003; Kushwah, 2000). So, there is a need of educational

reform (Chen- 2004; Wyss, 2004; Mavalankar, 1999; El-Jardali et al, 2007).



43

8. In-service-training issues: Besides insufficient numbers of health

professionals are produced, the in service-training of other health workforce is

inadequate. Health workforce education has been a low priority (Brien and Gostin,

2009). The training of health promoters and other auxiliary personnel such as dental

assistants, midwives, laboratory technicians, equipment maintenance and repair

technicians, and pharmacist is poor or non-existent (Homedes & Ugalde, 2005). At

the global level, many countries are facing critical weak knowledge base (Chen, 2004;

Wyss,2004). Workforce training is yet another important issue (Homedes & Ugalde,

2005; Kabene et al, 2006; Chen, 2004; Wyss, 2004; Kabene et al, 2006;

Management Science for Health, 2009; Mavalankar,1999; Martinez &

Martineau, 2002;; McCaffery, 2006; Martínez & Martineau , 1998; Kushwah, 2000;

Joaquin, 2009). It is essential that human resource personnel consider the composition

of the health workforce in terms of both skill categories and training levels. The

prevalence of inadequate training at various levels resulted in Limited opportunities

for professional development (Henderson and Tulloch, 2008; Uneke et al 2008;

Kolehmainen-Aitken, 2004; Dieleman et al, 2009) at the service period, which

adversely affect the professional life of the professional workforce in the health

sector.

9. Motivational issues: Health workers especially in underserved areas usually

have motivational problems at work which may be reflected and resulted in a variety

of circumstances like poor compensation packages, more opportunities for career and

educational advancement and unsatisfactory working conditions as mention above.

More to explore on the issue, Rewards are not linked to performance or the incentives

(Mavalankar, 1999; Martinez & Martineau, 2002; Martineau & Buchan, 2000,

Ssengooba et al, 2007; Martínez & Martineau , 1998; Dieleman et al, 2009), added to

the low morale and motivation of the workforce. Health workers in developing

countries are underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006;

Management Science for Health, 2009; Martinez & Martineau, 2002; McCaffery,

2006; Uneke et al 2008; Kolehmainen-Aitken, 2004). Lack of satisfaction is the most

commonly reported HR challenge, (Management Science for Health, 2009) resulted

from poor working conditions, workers’ health and well-being (Mavalankar, 1999;

McCaffery, 2006; El-Jardali et al, 2007) and staff grievances (Management Science

for Health, 2009). The motivations of health worker also affected by the Job security

(Ssengooba et al, 2007) in a great extend.



44

10. Human resource policy: The medical profession strongly dominated the

definition of health sector policies and the regulation of the conditions of practice of

all health professions (Homedes & Ugalde, 2005). Regional differences in the major

public health issues and in the organization and delivery of public health services

contribute to the need for public health human resource policy advice to be context-

specific, sustainable and in tune with the available resources. (Beaglehole and Dal

Poz, 2003). The formulation of national policies and plans in pursuit of health

workforce development objectives requires sound information and evidence. (Dubois

& McKee, 2006, adapted from Gupta and Dal Poz, 2006). Absence of appropriate

human resources policies (Beaglehole and Dal Poz, 2003; Homedes & Ugalde, 2005 ;

Dubois & McKee, 2006; Dussault and Dubois, 2003; Martínez & Martineau , 1998;

Kolehmainen-Aitken, 2004), chronic imbalance with multifaceted effects on the

health workforce: quantitative mismatch, qualitative disparity, unequal distribution

and a lack of coordination between HRM actions and health policy needs are the main

issues in HR in health sector. (Dussault and Dubois, 2003). In the absence of the

human resource policies, personnel decisions (hiring and promotion) were too often

guided by favoritism, political dictates, and nepotism (Homedes & Ugalde, 2005).

Recruitment, hiring and retention are the major problems highlighted in many studies

such as (Homedes & Ugalde, 2005; Bach, 2000; Martineau & Buchan, 2000; El-

Jardali et al, 2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007;

Martínez & Martineau , 1998).

11. Health human resource planning: Planning is most important in every

sectors including health sector especially in manpower recruitment and placing.

Health human resource planning (future needs) (Martineau & Buchan, 2000;

McCaffery, 2006; Mavalankar, 1999; Martínez & Martineau , 1998; Uneke et

al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al, 2007; Henderson and Tulloch,

2008) and human resource management skills generally do not exist at local,

peripheral levels in developing countries ( Kolehmainen-Aitken, 2004).

12. HR information, absence of database: Human resource planning can be

difficult in the absence of database on present human resource in the sector.

Moreover, mentioned earlier that, the formulation of national policies and plans in

pursuit of health workforce development objectives requires sound information and

evidence (Dubois & McKee, 2006). Very limited HR information, absence of

database or accurate information on staffing (Dubois & McKee, 2006; Bach, 2000;



45

McCaffery, 2006; Mavalankar, 1999; Martínez & Martineau , 1998; Uneke et al

2008; El-Jardali et al, 2007) is not in the system as suggested by many researchers is

affecting human resource management practices, sufficient attention to HR problem

of shortage, misdistribution, poor staff utilization, appropriate skills, recruitment,

performance management.

13. HRM systems: As a result of this circumstances of no access to tools and

information, Human resources management systems are weak (Homedes & Ugalde,

2005; Kolehmainen-Aitken, 2004; Management Science for Health, 2009; Martínez

& Martineau, 2002; Bach, 2000; Martineau & Buchan, 2000; McCaffery, 2006;

Dussault and Dubois, 2003; Ssengooba et al, 2007; Martínez & Martineau , 1998;

Uneke et al 2008; Joaquin, 2009), largely due to dispersal of accountability

(Homedes & Ugalde, 2005). Lack of management experts, especially experts in

insurance systems and contract managers (Homedes & Ugalde, 2005) is highlighted.

In most countries, managerial positions were traditionally given to physicians with

little or no management training (Homedes & Ugalde, 2005). Human resource

management skills generally do not exist at local, peripheral levels in developing

countries (Kolehmainen-Aitken, 2004). It comes out in light that, the lack of well-

trained human resource managers mirrors the region’s shortage of health care

professionals in general (Management Science for Health, 2009). Low pay and staff

motivation, unequal and inequitable distribution of the health workforce, and poor

staff performance and accountability, qualified staff move more freely among

countries, and even countries that can train and produce large numbers of health

workers are unable to retain them, Failure of existing performance management

systems, effective use of incentives in managing performance, weak HR capacity in

the health sector (Martínez & Martineau, 2002). Health workers with relatively high

professional and material expectations are working in a resource poor environment

with little support or supervision (Ferrinho & Lerberghe, 2000). As mentioned above,

Lack of management experts (Homedes & Ugalde, 2005), resulted in weak

supervision at all levels (Henderson and Tulloch, 2008; Institute for Public Health,

2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008;

Dieleman et al, 2009). Insufficiently/limited resourced and neglected health systems

(Henderson and Tulloch, 2008; Ssengooba et al, 2007; Uneke et al 2008), Centralized

planning (Mavalankar, 1999) often results in above situation in the health sector as

can be figured out of various literature review. Decentralization of HR management



46

systems (Martineau & Buchan, 2000; Martínez & Martineau , 1998; Dieleman et al,

2009) and capacity, staff performance management, designing/ implementing new

pay/ career structures, changing skill mix new roles for professions, HR planning in a

decentralized system., establishing new employment systems and conditions of

service, development of new types of incentives to support new ways of working

(Martineau & Buchan, 2000), which is absence in majority of the health sector.

14. Absenteeism: Absenteeism among health care workers is a obstacle to

successful health service deliverance and is caused by a number of factors. As figured

out above paragraphs, there is inadequate training, poor working conditions, low

compensation at various levels, so, resulted in lack of availability and accountability

of the staff (Homedes & Ugalde, 2005; Mavalankar,1999; Javier Martínez & Tim

Martineau, 2002), for example only 52% of the auxilliary nurse-midwives (ANM)

and 57% of the medical officers (MO) stay at their place of posting in India (ICMR,

1997). This system of working has not done much to develop a team spirit and

remains a very hierarchical and bureaucratic (Mavalankar,1999).

15. Performance of the workforce: Performance of the public health system

depends on multiple factors, among which human resources (HR) are one of the most

important components (Djibuti et al; 2008). In Latin America, the need to improve

the performance of the workforce had been pointed out in many health sector

assessments conducted in the 1970s and 1980s by the United States Agency for

International Development (USAID), the World Bank (WB). The training of health

personnel is poor or non-existent (Homedes & Ugalde, 2005), thus their performance

was poor (Homedes & Ugalde, 2005), with low productivity and efficiency (Homedes

& Ugalde, 2005), and resulted in poor utilization of the present workforce (Bach,

2000).

16. Equipment and supplies: Inadequate equipment (Homedes & Ugalde, 2005),

shortages of supplies and drugs (Homedes & Ugalde, 2005), workforce ill-equipped

(Institute for Public Health, 2007; Uneke et al 2008) were also highlighted in

literatures.

17. Duality of roles: Minimal supervision, high attrition rates of employees, Less-

qualified personnel, very low government salaries (Institute for Public Health, 2007),

often resulted in duality of roles, overburden and workload (Management Science for

Health, 2009; McCaffery, 2006; Uneke et al 2008, Martinez & Martineau, 2002) to



47

the present health human resources. Thus, there are two reasons for this duality of

roles: First, a shortage of staff, especially in rural areas, results in HRM

responsibilities being added to already over-burdened health care practitioners

(Management Science for Health, 2009).

So to sum up, old and new challenges threaten the human resources (HR)

responsible for health care planning and delivery in public sector funded national

health systems. Among the old challenges, low pay and staff motivation, unequal and

inequitable distribution of the health workforce, and poor staff performance and

accountability remain key obstacles to health sector development. Among the new

challenges, qualified staff move more freely among countries, and even countries that

can train and produce large numbers of health workers are unable to retain them

(Martínez & Martineau, 2002).

2.3. DISTRIBUTIONAL ISSUES OF HEALTH WORKFORCE- IN

GLOBAL CONTEXT Globally the problem of distribution of health workforce is a matter of

concern. The uneven distribution of health workforce is a global phenomenon. World

Health Organisation (WHO) estimates show a shortage of about 4 million health

workers, and this more than any other single factor may lead to failure of attaining the

Millennium Development Goals (MDGs) within the set timelines. It also suggests that

“in absolute terms, the greatest shortage occurs in South-East Asia, dominated by the

needs of Bangladesh, India and Indonesia. The largest relative need exists in Sub

Saharan Africa, where an increase of almost 140% is necessary” (WHO, 2006).

Unbalanced distribution of health personnel between and within countries is a

worldwide, longstanding and serious problem. All countries, rich and poor, report a

higher proportion of health personnel in urban and wealthier areas. (Dussault &

Franceschini, 2006). Shortage and mal-distribution of health workers in rural areas is

a concern in all countries. The central health care issue for many communities across

the nation is the inadequate supply of health care professionals and limited access of

residents to health services (Sultz & Young, 1999; Christianson & Moscovice, 1993).

The mal-distribution of health care professionals has left many areas underserved or

without health care services, while other areas deal with surpluses of health care

specialists and services. (LaSala, 2000). This contributes directly or indirectly to



48

increased inequalities of access to basic health care and therefore health outcomes

(Wafula et al, 2011).

Health workers are distributed unevenly across the globe (Speybroeck, et al,

2006). Within regions and countries, access to health workers is also unequal. In India

current ratios for doctors are 1 per 1507 and 1 per 1205 for nurses, the problem of

mal-distribution remains unchanged since independence (Sundararaman & Gupta,

2011). Similar variation prevails globally, Viet Nam averages just over one health

service provider per 1000 people, but the range is wide. 37 of Viet Nam’s 61

provinces fall below this national average, while some province have around four

health service providers per 1000 (Prasad, et al, 2006). In Nicaragua, around 50% of

the health personnel are concentrated in the capital, Managua, which comprises only

one-fifth of the country's population (Nigenda & Machado, 2000). In Mexico, it is

estimated that 15% of all physicians are unemployed, underemployed or inactive. Yet

despite this apparent surplus, rural posts remain unfilled (WHO, 2000). In Bangladesh

the metropolitan areas contain around 15% of the country's population but 35% of

doctors and 30% of nurses, in government positions. Since there are virtually no

doctors or nurses in the private sector outside the metropolitan areas, the geographical

concentration of these providers in the metropolitan areas is even greater (MoHFW,

Bangladesh, 1997). In Brazil in 1995, the number of physicians per 1000 population

by region varied from 0.52 and 0.66 in the poorer regions of the north and the

northeast to 1.75 and 2.05 in the states of São Paulo and Rio de Janeiro, in the richer

southeast region. The average for the whole country was 1.19. This gap in favour of

richer regions is smaller than it was 25 years earlier, thanks to efforts to expand the

coverage of the population by public services. But "the low incomes of the population

have discouraged the settlement of doctors" in the poorer regions(Machado, 1997). In

Ghana in 1997, 1087 of the 1247 (87.2%) general physicians worked in the urban

regions, although 66% of the population lives in the rural areas (WHO, 1997). Health

worker density is higher in urban areas globally (WHO, 2006). The distribution of

health workers is heavily skewed towards urban areas. The imbalanced distribution of

health personnel can contribute to great disparities in health outcomes between the

rural and urban population (Dussault & Franceschini, 2006). 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 (figure : 1). The nurse to population/patient ratio is low compared to other



49

countries. In 2004, the ratio was 1:2250 in India and 1:100-150 in Europe. This ratio

in African countries, Sri Lanka and Thailand is 1:1400, 1:1100 and 1:850,

respectively. Many States in India face a shortage of nurses and midwives. This

shortage is due to variety of reasons including: migration to well developed countries,

under production of health workforce, inability to pay higher salaries and benefits,

inability to sustain other measures to retain health workers in some countries, illness

and death and other factors that are uncontrollable. Estimates by WHO (2006), the

critical shortage are in 57 (fifty seven) countries, which includes India.

population.

Figure : 1 : Total Physicians and nursing workforce in urban and rural areas- a

global view

A clear-cut distinction between public health and clinical services is not

entirely realistic or practical (Beaglehole and Dal Poz, 2003). WHO estimates the

current full time health workforce to be 59.2 million. Out of this, health service

providers constitute about two third, whilst the remaining portion comprises of

management and supporting staffs (WHO, 2006). Based on the above estimates by

WHO (2006), the critical shortage are in 57 (fifty seven) countries, which includes

India. It is estimated that the deficit is 2.4 millions of doctors, nurses and midwives

globally. Sub-Saharan Africa region has the highest proportional shortfalls, and by

absolute numerical terms it is highest in deficiency in South-East Asian region due to

its vast population size. The global profile shows that there are more than 59 million

health workers in the world, distributed unequally between and within countries. They

are found predominantly in richer areas where health needs are less severe. Their

numbers remain woefully insufficient to meet health needs, with the total shortage

being in the order of 4.3 million workers (WHO, 2006). Table: 1 and 2 along withfigure 2 & 3 presented can highlight more on this situation.

50%

50%

62%

38%

76%

24%



50

Table 1 : Global health workforce by density

WHO Region Total Health Worker Health Service

Providers

Health management

and support workers

Number Density

(Per 1,000

population)

Number Percentage

of total

healthworkforce

Number Percentage

of total

healthworkforce

Africa 1640000 2.3 1360000 83 280000 17

Eastern

Mediterranean

2100000 4.0 1580000 75 520000 25

South East

Asia

7040000 4.3 4730000 67 2300000 33

WesternPacific

10070000 5.8 7810000 78 2260000 23

Europe 16630000 18.9 11540000 69 5090000 31

Americas 21740000 24.8 12460000 57 9280000 43

World 59220000 9.3 39470000 67 19750000 33Source: WHO, 2006, Pg- 5

Table 2: Estimated critical shortage of doctors, nurses and midwives

WHO Region Number of countries In countries with shortages

Total With

shortages

Total

Stock

Estimated

Shortage

Percentage

increase

required

Africa 46 36 590198 817992 139

Americas 35 5 93603 37886 40South East Asia 11 6 2332054 1164001 50

Europe 52 0 NA NA NA

Eastern

Mediterranean

21 7 312613 306031 98

Western Pacific 27 3 27260 32560 119

World 192 57 3355728 2358470 70

Source: WHO, 2006, Pg- 13

Figure 2: Countries with a critical shortage of health service providers (doctors,nurses and mid-wives) Source : WHO, 2006, Pg-12.



51

Figure 3 : Density of health workers. Source: WHO Global Atlas of the Health

Workforce (created on 4 July 2007) (adapted from Henderson & Tulloch, 2008).

2.4. ATTRACTION AND RETENTION OF PHYSICIANS AND

NURSES IN RURAL AREAS- IN A GLOBAL CONTEXT Attraction and Retention of physicians and nurses in rural areas is a challenge

globally, mostly related to attraction towards urban area and leaving the rural areasunderserved. This section of literature review explores the perspective of attraction

and retention of both physicians and nurses including mid-wives in rural areas, as

these groups of health workforce are the largest and the important workforce to cater

the need of maternal and child health services in the community. Due to the limited

documentation on retention in low-income countries (LICs), literature on high-income

countries (HICs) has also been included to explore whether lessons could be learnt

from experiences in them (Dieleman and Harnmeijer, 2006).

The issue of attraction and retention of rural physicians is a long-standing

problem globally. The hindrance of the countries in achieving the health objectives

and goals are of the reasons that the country’s inadequacy and mal-distribution in

health workforce (Snow et al (2011). Difficulty in production, recruitment and

retention of health professionals issues for severely weakened and under resourced

health sector (Lehmann et al, 2008) is a concern. WHO (2006), also emphasized on

the production issue of enough doctors, nurses and other key health workers. But,

only increase in production is not enough. Recent attempts at trying to solve the



52

problem of underserviced areas have resulted in much hostility and little achievement

(Jason & Alison, 1999). While the rural population has continued to grow, the

number of physicians in these areas has steadily declined. Urban areas are more

attractive to health care professionals for their comparative social, cultural and

professional advantages (Lerberghe, et al, 2002). This problem is not exclusive in

underdeveloped or developing counties but it in developed countries also, to name a

few are Canada, USA & Australia.

According to the study by Jason & Alison (1999) for physicians in Canada,

they explore the problem of physician recruitment and retention in rural areas in the

three main areas of physician needs – professional satisfaction, financial

remuneration, and lifestyle. They also emphasized on useful approach in defining the

solution is to examine it at all levels of a rural physician’s training and career. They

concluded that an integrated approach to problem solving requires not only

interventions at the high school, university, medical school, and residency levels, but

also the active participation and co-operation of the physicians, the communities in

which they practice, and the regional and provincial governments.

“Rural physicians' recruitment and retainment has traditionally been a

challenge for hospitals and rural communities (Full, 2001).” Several researches have

been done regarding the attraction/recruitment and retention of physicians and nurses

to stay in rural area service. There are different factors in different country setting that

make a physicians and nurses more likely to attract and retain themselves in rural

services. This section summarises findings of the literature review on factors

impacting on staff attraction and retention, with a focus on remote rural areas

(Lehmann, U. et al, 2008).

Individual factors may depend on a person's personal characteristics, such as

age, gender, marital status, etc. How they impact on an individual's decision-making

is often fluid and may change in a person's life and career cycle (Lehmann, U. et al,

2008). Research suggests that the ability to adapt to rural practice and, especially,

rural life is the key determinant of retention (LaRavia. D., et al., 2002). Health

workers have been reluctant to work in rural and remote areas because of little support

or supervision, a lack of material resources for health, poor working and living

conditions, and isolation from professional colleagues (Henderson & Tulloch, 2008).

Doctors and nurses are reluctant to relocate to remote islands and forest locations that

offer poor communications with the rest of the country and few amenities for health



53

professionals and their families (Chomitz, et al., 1998). It has been proposed that the

low numbers of physicians in rural area has more to do with retention than with

recruitment (Oreilly, 1997). Low wages, poor working conditions, lack of

supervision, lack of equipment and infrastructure as well as HIV and AIDS, all

contribute to the flight of health care personnel from remote areas (Lehmann, U. et al,

2008). Preferences of location may also depend on what kind of living conditions

health personnel are used to. The correlation between geographical origin of students

and their future choice of practice, i.e. whether students from under-served areas will

return to under-served areas to practise their profession, is much debated in the

literature. (Lehmann, U. et al, 2008).

Study of Snow et al (2011), an assessment of rural posting preferences by the

senior students of medical was considered. The responses were emphasized in three

orders, which are to provide career development incentives, to provide clear terms of

appointment with reliable endpoints and salary top-ups. Other responses included

were clinical infrastructure, adequate accommodation and provision of schooling of

children.

Witter et al. (2011) in his study suggested the order of importance of the

factors that encourage the doctors to work and stay in rural areas. His order of

importance of the factors are : Salary, working condition, training opportunities,

Allowances, Career development, Living condition, Supervision and management.

According to the study by Lagarde and Blaauw (2009), while they carried out

a literature review using discrete choice experiments to investigate the human

resources issues related to health workers, both in developed and developing

countries. They conclude with the salary variable as an important determinant of job

preferences. Beside salaries, the other attributions which were found are workload in

case of developed country, location characteristics, housing, and opportunity to

benefit for further education and drugs and equipments in the facilities in case of

developing countries.

In the study of Irene. A. A. (1999), following factors are identified of rural

area posting -lack of equipments, non-availability of electricity, safe water,

communication system and isolation. She also emphasized on method of selection of

community nurses, who often have an urban background and family ties and reluctant

to work in rural areas. Advocated on changing the process of selection to enable retain

trained nurses in rural areas.



54

Kristiansen & Forde (1992), has also suggested proper education facility for

workforce’s children as one of the priority requirements for rural posting of doctors

and staffs. He also emphasized on work load and suggested the overtime payments.

Navajo Area Indian Health Services (Kim C., 2000) study suggested lack of

housing, lack of health care and lack of schools for children are quoted internationally

as reasons why staff either do not join or leave health services in remote areas, they

were raised in research conducted among health care providers.

The importance of general living conditions, including staff accommodation,

schools and qualified teachers, good drinking water, electricity, roads and transport,

also features very prominently in a study conducted by Mensah, (2002), into factors

affecting retention in rural Ghana. (Lehmann, U. et al, 2008).

According to the study of Dormael et al, (2008), in which retention was

assessed for all 65 trainees between 2003 and 2007. Out of the 65 trained doctors

between 2003 and 2007, 55 were still engaged in rural practice end of 2007,

suggesting high retention for the Malian context. Participants viewed the training as

crucial to face technical and social problems related to rural practice. However, they

concluded that retention can however not be attributed solely to the training

intervention but first, incentives related to living and working conditions, which

influenced rural doctors' attraction, also contribute to retention. Second, other support

mechanisms known to foster retention are provided: mentoring, supervision, and

access to further rurally relevant continuous training sessions. While complementary

bundles of interventions indeed work better than isolated interventions, it is difficult

to disentangle their effects.

According to the recent study by Murthy et al., (2012) in Indian context,

covering a few parts of the country, in which the study examine what doctors expect

in order to work in rural areas. Doctors perceived that the current salaries were not

sufficient. They expected increase in salaries; some expected double the current

salaries or parity with private healthcare sector. Many doctors were demotivated by

the lack of infrastructure. Lack of quality education facilities for children in rural

areas was a big deterrent. Security, living facilities, connectivity and proximity to

family were among the prominent expectations of doctors to work in rural areas.

Better management, well-defined and transparent transfer policy and increased leaves

were seemed as important incentives by doctors to serve in rural areas.



55

In the study of Ebuehi & Campbell, (2010) in Nigeria, major rural motivators

included: assurances of better working conditions; effective and efficient support

systems; opportunities for career development; financial incentives; better living

conditions and family support systems. The main de-motivator was poor job

satisfaction resulting from inadequate infrastructure. Rural health workers were

particularly dissatisfied with career advancement opportunities.

Similarly, in a study in Nepal by Nick Simons Institute (2008), the key issues

identified as critical to the retention of Nepali MDGPs in rural areas were:

Career/promotion prospects, Status/recognition, financial incentives, working

conditions, Education for children, Continuing medical education and Political

stability and security.

Yet another study Shankar (2010), which was done for Nepal and wrote that

the recent introduction of mandatory rural service for scholarship students was aimed

to reduce the loss of medical graduates to developed nations. High tuition fees in

private medical schools and low Government wages prevent recent graduates from

taking up rural positions, and those who do face many challenges.

In the study of Glasser. M., (2010) in United States, most rural physicians in

this study decided to practise in rural areas because of family ties. The major reason

for deciding to practise in a rural location was family ties to the community, followed

by a loan or scholarship obligation. With respect to attributes positively impacting

practice satisfaction in the community, the most frequently mentioned was good

partners/call coverage, followed by good revenues/patient volume and

autonomy/freedom in the rural practice setting. Negative attributes of rural

professional practice were varied: the top three mentioned were lack of private paying

patients; hard work/long hours; and distance from specialists and medical testing.

In the study of Awofeso. N., (2010), in Nigeria, highlighted the factors as the

Spartan living standards in rural and remote areas (Open defecation, severely limited

access to electricity, primitive social amenities, chronic poverty, poor quality

educational or communication facilities, fragile health systems and the inadequacy of

potable water), Inadequate numbers of trained health staff and limited employment

capacity in the public sector, Inadequate remuneration, Sub-optimal mix and

distribution of healthcare worker, Burnout of staff (excessive workload, coupled with

relatively poor remuneration, inadequate clinical facilities and limited opportunities



56

for professional development, hinder efforts to recruit and retain skilled health staff in

rural and remote areas.

According to the study by Nestman, N. A., ( 1998), factors of retaining

physicians and nurses in rural areas of Canada emphasized on lack of time off and

working hours, frustrated with earnings, not valued by regulatory bodies, medical

schools, and government, reduced availability of acute care services and specialty

services and working conditions.

According to Ballance, D. et al., (2009), while “nature” or rural background is

a common factor in many physicians who choose rural practices, “nurture” or

programs that encourage and maintain rural affinity. Effective recruitment efforts that

highlight the positive aspects of rural life and address work-life balance are also

shown to attract providers and retain them in their rural practices.

In a study of doctors and medical students in Vietnam by Vujicic. M., (2010),

respondents positively value being located in an urban area, having adequate

equipment, higher official income, being offered skills development (short-term

training), long-term education (specialist training), and free housing.

In a cohort study of 145 doctors responded by Pagaiya. N., etal., (2011) under

International Health Policy Program, found in relation of their job preference, 6

attributes found to be statistically significant in the decision to choose a job in a rural

area: hospital size, location, salary, overtime work, specialty training opportunities

and career promotion.

In the study of King. B., (2006) of Health Professions Resource Center, Texas,

the reasons given for not wanting to practice in rural areas in Texas had less to do

with the amenities or social activities associated with urban areas than with the patient

base (large numbers of uninsured or poor people) or the quality of the facilities. They

ranked “competitive salaries” as “very important” to the retention of providers in rural

areas along with facilities in rural areas, long term service to patients, recognition of

efforts and updated equipment.

In the research paper of McDonald. J., (2002), factors that have been

identified as barriers include: professional isolation and lack of organisational

support, inadequate access to hospitals, unreasonable workloads, unsatisfactory levels

of procedural work, and the lack of availability of good social and cultural facilities.

Factors likely to attract medical graduates to rural areas include: childhood experience

of country life, and rural internship.



57

A study by Straume & Shaw (2010), the area of study was northern Norway

and they explore the issues of Lack of opportunities for professional development to

be the most common reason for leaving – more common than wage- and workload-

related factors. On the other hand, the enjoyable aspects of rural living and working

conditions were the most important reasons for staying.

According to the study of Kornik & Clark, (undated) on retention of doctors in

rural areas of South Africa, emphasizes on issues of professional isolation, Poor

management at facility and department level, poorly equipped hospitals, erratic salary.

The study of LaSala (2000), it is found that both rural and urban settings,

nursing administrators perceived salaries, lack of full-time positions for nurses, and a

competitive job market as barriers to both recruitment and retention. Rural

administrators also reported the local economy and unmet family needs as barriers.

The administrators in both areas indicated nurse relationships (with other nurses,

administration and physicians) and work related variables (benefits, working

conditions, and workload) were viewed as positive incentives for retention.

Geographic location, housing, and community amenities were not significant factors

in either the rural or urban settings.

Hegney, McCarthy, Rogers-Clark and Gorman (2002) conducted a cross-

sectional survey of 146 registered and enrolled nurses in rural Australia. The survey

asked nurses to rank 91 separate items on level of importance in relation to the

decision to remain in rural practice. The results suggest job satisfaction and being part

of a professional team are the most important predictors of remaining in rural practice

(Cited in Manahan, 2008).

Bilodeau and Leduc (2003), when discussing factors affecting retention of

health personnel in rural and remote areas, define three categories of factors affecting

health personnel's motivation to practise in these locations: personal (age, gender,

education, etc.), professional (specialization, working hours, incentives, etc.), and

contextual/ environmental (community amenities, quality of life, population's

educational level, etc). (Chomitz, et al., 1998).

Lea & Cruickshank (2007), the factor analyzed were-the ward culture,

workload and level of responsibility within rural healthcare facilities were of concern

for new graduates and influenced their retention within the rural nursing workforce.

While in Mullei et al. (2010) , investigated reasons for poor recruitment and

retention in rural areas of 345 nursing trainees in Kenya interviewed. The findings



58

were, positive aspects included lower costs of living and more autonomy at work.

Negative issues included poor infrastructure, inadequate education facilities and

opportunities, higher workloads, and inadequate supplies and supervision.

Bushy (2006), suggested to retain a highly skilled rural nursing workforce,

continuing education must be accessible to nurses.

The major inferences drawn from a study of Klaas (2007) is that nurses are

dissatisfied with lack of promotional opportunities, lack of professional support,

facing drastic responsibilities but with less income, tremendous workloads, emotional

demands and unrealistic salary package.

A study by Vujicic M., et al. (2010) of recruitment and retention of nurses and

certified midwives in rural areas of Liberia focused the six key job attributes-location,

total pay, conditions of equipment, availability of transportation, availability of

housing, and workload.

RRWG (2004), Identified the following issues or challenges as priorities

facing rural nursing in Nova Scotia are Quality of Work Life, Limited Work

Opportunities, Continuing Education.

In study of Reardon, (2010), significant differences were identified by

country. The rank ordered items for nurses from Australia and the United States

proved to be different, but emphasized the importance of a positive workplace, good

management, job satisfaction, and job security for nurses. Decisions to leave a rural

facility included, feeling unvalued, workplace morale/culture, and job satisfaction.

The findings indicated non-financial issues rated high as factors nurses considered

when leaving rural employment.

Incentives had a large impact on the willingness (Chomitz, 1998). Taking into

consideration of a study of running financial incentive program in Canada they argued

that only financial incentives cannot solve the rural accessibility of health workforce.

The programme fails to attend the objective of locating physicians in remote rural

areas of Ontario.

Anderson & Rosenberg (1990), emphasized on combination of compulsory

service and incentive, which is being used by various developed and developing

countries.

In Blaauw et al., 2010 study findings in Thailand, Kenya and South Africa,

suggested that financial incentives are very important in persuading health workers to

choose a rural posting, especially in poorer countries, but only if they are fairly large.



59

Non-financial strategies are just as important. Improved housing and accelerated

promotion were moderately effective, but preferential access to training and career

development opportunities were very powerful non-financial strategies.

Frehywot et al. (2010), put another dimension of retention of physicians. In

their study, they put emphasize on compulsory service programme for physicians in

rural areas. They found more than 70 (seventy) countries including India with

compulsory service programme as a strategy for physicians in rural areas. However,

the study emphasizes on compulsory service in rural but, opinion on that no

commitment for service could be seen in this circumstances.

According to the study of Matsumoto M, et al., (2010), they write about the

bound medical education program followed by obligatory rural service in Japan for

retention of the physicians in rural Japan. Free medical education in exchange for

obligatory rural service; and close, long-term cooperation of national and local

governments, and the medical school over the period from pre entrance selection to

completion of the nine-year obligation for each student.

Other than those of the factors highlighted, yet another issue is the migration

out of the country of the health workforce. While some countries, such as India,

Indonesia and the Philippines, have specifically trained health professionals for export

to developed countries, the unplanned loss of health workers can be extremely costly

due to their lengthy education programs, the high cost of teaching materials and

techniques, and the need to hire replacements that may lack appropriate skills,

languages or cultural sensitivity (WHO, 2004).

Literatures characterized health sector with shortage and poor availability of

physicians and nurses in rural areas globally. Health workforce is reluctant to be

posted in rural and remote areas. Several factors have been identified from monetary

to non-monetary, which affects the willingness or desire of physicians and nurses for

rural posting. The studies also suggested and encouraged a wide range of mixed

interventions for possibly solve the problem and let physicians and nurses to work for

the rural community by their own will or by compulsion. The international

experience shows that alone the monetary incentives could not change the picture and

blends of interventions are needed.



60

2.5. HEALTH SECTOR REFORM : THE INTERNATIONAL AND

INDIAN CONTEXT

Reform means to reorganize, to change the way in which things are being

done or to make something better. Reform in the Health Sector means to reorganize

the manner in which the system is run so that it can become a more efficient entity. It

is with this thought in mind that health policy makers around the world embarked on a

mission to find new and improved ways to make the health sector a vibrant and

productive organization that will meet the needs of its customers. (Gittens-Gilkes, _).

Infante (1999) describes health sector reform as a dynamic process employed by

governments and health authorities to improve efficiency and effectiveness in the

health sector. The goal is to provide equity in health care, increase productivity and

improvement in the general management of health systems.

Health sector reform became a worldwide phenomenon in the 1990s (Alwan

and Horny, 2002). As Kutzin (1995) pointed out, Health Sector Reform is not a new

development. In its broader sense, it has been happening for many years in many

countries. However, in its more recent usage, it is associated with a set of fairly

focused activities and objectives which are being considered or implemented by

countries across the developing world and the political spectrum. These are

particularly addressed to financing, resource allocation and management issues,

although the precise mix and emphasis of HSR policies varies (Standing, 2000).

Health sector reforms have been used as crutches to pretend one is changing the

system, but basically staying the course or even regressing (Bjorkman, 2010).

So, Health system reforms have been a regular occurrence in countries around

the world for several decades (Yepes et al, 2010). Since the late 1980s, many

developing countries have initiated efforts to improve their health systems.

(Dmytraczenko et al, 2003). Both developed and developing are undertaking health

sector reform in their respective countries. Philippines, Thailand, South Korea,

Malaysia, Indonesia, India and Pakistan are some of the developing countries and

underdeveloped countries like Nepal and Bangladesh in Asia-Pacific are taking

initiatives for health sector reform in their respective countries.

Although there are many useful ways to categorize reforms, in practice, many

health sector reforms cannot be grouped under a single heading because of the

complex and inter-related nature of the components of the health system (PAHO,2003). During the 1990s, the pace of reforms accelerated. In some countries, this



61

occurred in response to internal political changes, but in many others it was caused by

external pressures from international organizations. A common thread has been the

search for universality and efficiency, with most health reforms of the 1990s being

market-oriented. Decentralization has also been a strategy of many reforms, being

seen as effective in stimulating service delivery, better allocating resources according

to needs, and involving communities in decisions on priorities, so as to reduce

inequities. (Yepes et al, 2010).

The decade of the 1990s is seen as a marker for the beginning of health sector

reform in South Asia. These reforms are premised on four cardinal market principles

of Individual, charities and private organizations should be made responsible for

health care; Public funding must be restricted to health promotion and prevention of

disease; Central government’s role should be restricted to policy formulation and

technical guidance, with delivery of services left to the private sector and local

authorities; Private and non-governmental sector should be supported to become the

key providers of health and social services. It is these principles that guided the

design of health sector reforms across South Asia (South Asia includes India,

Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan) with the active support of

multilateral and bilateral agencies. Most of these countries initiated reforms in the

1990s and has been guided by a similar design for these reforms. (Baru, 2010).

Many other developing countries in the globe adopted Health Sector Reform

like Bolivia, Bamako, China , Chile, Czech Republic, Colombia, Egypt, Ghana,

Hungary, Kyrgyzstan Kenya, Poland, Senegal, South Africa, South Africa , Zambia,

Zimbabwe and other Central and Eastern European nations.

While literatures available on Indian context, though Government initiatives in

public health have recorded some noteworthy success over time, the Indian health

system is ranked 118 among 191 WHO member countries on overall health

performance. Health is a priority goal in its own right, as well as central input into

economic development and poverty reduction. India is well placed now to develop a

uniquely India set of health sector reforms to enable the health system in meeting the

increasing expectation of is users and staff (Ramani et al, 2005).

The health sector reforms in India were started way back in 1970s .The Govt.

of India identifies the need HSR and stated in the eighth five year plan. The Ninth

Five Year Plan (1997-2002) introduce more on health system reforms to enable the

population to obtain optimum care at affordable cost, increase the involvement of



62

voluntary, private organizations, self-help groups and Panchayati Raj Institutions

(PRI) in planning and monitoring of health programmes. The Tenth Five Year Plan

(2002-2007) touches upon reforms at primary, secondary and tertiary level.

(www.april24.info)

According to the study of Agarwal (2006), the importance of working on

sector reforms and the important elements of health sector reforms are paramount in

Indian context. India is one of the country which are less developed are reforming

their health systems in an effort to achieve public health goals more affordably and

effectively.

In India, the health sector reforms broadly cover the following areas:

Reorganisation and restructuring of existing government health care system

Involving Community in health service delivery and provision

Health Management Information System

Quality of care

2.6. GAPS IN THE LITERATURE

Although the research specific to rural physicians and nursing including mid-

wives is growing, it is still very limited in the side of academic literature. Research

specific to rural physicians and nurses including mid-wives-distribution, attraction

and retention needs to be replicated and elaborated in terms of remote rural area in

context of Indian scenario especially a state which is sharing international boundary

and predominately a tribal area in sector reform environment, which is scare at this

time of research.

2.7. CONCEPTURAL FRAMEWORK FOR THE STUDY

2.7.1.HRM IN PUBLIC HEALTH SECTOR– A CONCEPTUALFRAMEWORK

Human Resource Management today is not a conceptual revolution but a

revolutionary concept (Sharma, 2000). In general Human Resource Management

refers to the management of people within the organization, not to a specific function.

This is the management of people in an organization. This includes consideration of

the management of people at a strategic level within the organization (Hyde et al,

2006). HRM is the process of acquiring, training, appraising, and compensating

employees, and of attending to their labor relations, health and safety, and fairness



63

concerns (Dessler, 2008). HRM is a management function that helps manager recruit,

select, train and develops members for an organisation (Aswathappa, K., 2008).

According to Saiyadain (2009), HRM is a relative recent title for all the aspects of

managing people in an organization. It represents a broad based understanding of the

problems of people and their management in view of the development of behavioral

science knowledge. This is human resource approach; it is concerned with the growth

and development of people towards higher levels of competency, creativity, and

fulfillment, because people are the central resource in any organisation and any

society (Newstrom, 2007).

Conceptually, it may be defined as the art of procuring, developing and

maintaining competent workforce to achieve the goals of an organisation in an

effective and efficient manner.

In coming years there will be great demand for highly developed human

capital. This will require systematic and substantial investment in the development of

employees skills and knowledge. Firms will build portfolio of skills in the employee

base (Kodwani, 2003). To develop firm’s human capital more concerted effort is

necessary from every quarter. Further research by Gallup Organisation (Ramani,

2003); reveals that positive employee attitudes are likely to create 50 per cent more

customer loyalty to a company and are 44 per cent more likely to result in above

average productivity. The study also revealed that positive attitudes have a significant

impact on profits and turnover . The above views are self explanatory to the context of need

and importance of HRM.

The people in the health system carry the knowledge and skill that are the

important determinants of sustainable health in the society (Lexomboon, 2003).

Human resources play a critical role in delivering health services to the population.

Health planners and decision makers have to ensure that the right number of people,

with the right skills, is at the right place at the right time to deliver health services for

the population needs, at an affordable cost (Dreesch et al, 2005). More than any other

type of organization, health organizations are highly dependent on their workforce

(Dussault and Dubois, 2003). The health sector is a major employer in all countries.

The International Labour Organisation reckons that 35 million persons are currently

employed in the health sector worldwide (ILO, 1998). Also, HR account for a high

proportion of budgets assigned to the health sector (Narine L, 2000).



64

The performance of the health sector is the sum of the performance of

individual performers and groups of performers in each organization that comprise the

sector. Unlike the physical assets of an institution, human capital which is the

capability of the workforce and its willingness and commitment to work, is an asset

that, with the proper support, can appreciate. Human resources management in the

particular area of management in an organization explicitly charged with people needs

and the priorities of employees in the organization (Johnson, 2000).

Human Resource Management in health sector involves the different functions

involving planning, managing and supporting the professional development of the

health workforce within a health system (Esmail et al, 2007). Good human resource

management (HRM) is essential to retaining staff and maintaining a high overall level

of performance within a health organization and within many health care systems

worldwide, increased attention is being focused.

Human resource management in the health sector has to function with a

unique set of circumstances and characteristics. These include: A large and diverse

workforce; A workforce comprising separate occupations and professions, some with

sector-specific skills and others with more portable ones; Loyalty of those with sector-

specific skills (e.g. doctors and nurses) tends to be first to their profession and patients

rather than to their employer.; Access to health professional training and employment

is controlled by standards and entry requirements in many countries; The health sector

is a major recipient of public expenditure in many countries; Health care delivery is a

politicised process; Health is very labour-intensive and the proportion of the total

budget spent on staff is much greater than in manufacturing and many service

industries. (Buchan 2004).

A refocus on human resources management in health care and more research

are needed to develop new policies (Kabene et al, 2006). The health sector is

considered an atypical customer when it comes to the effective utilization of HRM

interventions and the ability to show sector-specific results or outcomes that can be

directly attributed to those interventions (Adano, 2006). Further, Human resources

management plays a significant role in the distribution of health care workers. With

those in more developed countries offering amenities otherwise unavailable, chances

are that professionals will be more enticed to relocate, thus increasing shortages in all

areas of health care (Kabene et al, 2006). Human resources management also played

an important role in investing in employee development. This case makes obvious the



65

important roles that human resources management can play in orchestrating

organizational change.

As discussed above, all health care is ultimately delivered by people, effective

human resources management will play a vital role in the success of health sector.

And a strong understanding of the human resources management issues is required to

ensure the success of any health care program. Here we have found that the

relationship between human resources management and health care is extremely

complex, particularly when selected literature reviews from a global perspective.

2.7.2. ATTRACTION AND RETENTION OF HEALTH WORKERS IN

RURAL AREAS -CONCEPTUAL FRAMEWORK

Health systems employ a large and growing number of medical professionals

(Fujisawa and Lafortune, 2008). Hence, it is important to attract and retain the health

workforce particularly in rural areas for achieving health goals.

The extent to which health workers can be attracted to and retained in rural

and remote areas depends on two interconnected sides: the factors which contribute to

health workers' decisions to accept and the stay in rural and remote areas and the

strategies employed by management to respond to such factors (under its control). It is

highlighted by the literature review above that the factors globally are mainly higher

salaries, better working conditions, better career opportunities or by compulsion. Both

push and pull factors impact on the individual who makes a decision about moving to,

leaving or staying in rural and remote area in many different ways. Attitudes towards

these factors by an individual physicians and nurses will be the result of adequacy of

physicians and nurses in rural and remote areas.

There are several theories supporting the mobility of workforce. One of them

is the Standard location theory has been used to predict and explain choices of

practice location by health professionals (Chomitz, et al., 1998). Location theory is

concerned with the geographic location of economic activity (Wikipedia.org). Such

that, the Neoclassic Wage Theory, suggest that the choice is driven largely by

financial motives (Boyle & Halfacree, 1998) and by the probability of finding

employment (Todaro, 1976). (Lehmann et al, 2008). Behavioural theories, such as

those developed by Maslow and Herzberg, show a more complex decision-making

process regarding the movement of labour with a particular emphasis on the

importance of job satisfaction (Lehmann et al, 2008).



66

Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for

turnover in general include dissatisfaction with work. The lower level of job

satisfaction, results in more intention to migrate of this workforce. Performance,

motivation and job satisfaction are closely related to each other: workforce satisfied

with their jobs remains in their posts and performs well (Dieleman and Harnmeijer,

2006). The term, job satisfaction, has been defined by Grieshaber, Parker, and

Deering (1995): “Job satisfaction has been measured in various ways: in terms of the

gratification of needs in the work place, a ratio of perceived inputs and outcomes, as

an emotional response, and more generally as an equivalent to job attitudes.

According to the Hughes et al., (2002), Job satisfaction is defined as “the extent to

which a person likes his or her job” and is related to a person’s attitudes and feelings

towards the tasks, salary, working conditions, training and career opportunities,

supportive working environment, etc. Various studies have demonstrated that there is

a clear link between job satisfaction and staff retention (Dieleman and Harnmeijer,

2006. Therefore, the job satisfaction component is included in the framework.

Riegel (2002) argues that turnover is the consequence of a complicated series

of dynamics, including job satisfaction, organisational commitment, and intent to

leave, that influence employee attitudes and ultimately affect employee behaviour.

Turnover models have been extensively studied, and scholars have provided strong

support for the proposition that behavioural intentions (intention to leave) are the most

immediate determinant of actual behaviour (turnover) (Igharia & Greenhaus, 1992;

Lee & Mowday, 1987). Scholars have recommended using intent to leave attitudes

rather than actual staying or leaving behavior because it is relatively less expensive to

collect data on turnover intentions than actual turnover (Udo etal., 1997). Prior

research also has reported a positive relationship between intention to leave and actual

turnover (Igharia & Greenhaus, 1992; Udo et al., 1997). (cited in – Guchait, 2007).

So, the intention of migration is also included in the framework.

According to Lehmann et al; 2008, there are different types of environment

surrounding the health workforce attraction and retention. The figure 4 is presenting

the different environments.



67

Figure 4: Different environments & Location of decision-makers associated with

attraction and retention in the public sector. (Source: Lehmann et al; 2008)

The factors in the international environment are mainly pull factors such as

higher salaries, better working conditions and better career opportunities in other

countries. The national environment comprises both push and pull factors such as the

general political climate, including the degree of political and social stability, war,

crime, etc., as well as general labour relations, the situation of the public service,

salary levels, career opportunities, etc. The local environment is primarily made up of

general living conditions and the social environment. The work environment again

encompass push and pull factors, such as local labour relations, management styles,

existence or lack of leadership, opportunities for continuing education, availability of

infrastructure, equipment and support. Lastly, there are a number of individual factors

which may impact on decisions, such as origin, age, gender and marital status. All

factors will be discussed in more detail below. (Lehmann et al; 2008).

To best suit for this study, analytical framework for exploring the HR Issues

will be two sided exploration, one from the side of Management Representative and

the other from the side of employee perceptions that is Physicians, Nurses & Mid-

wives with above framework of attraction and retention.



68

2.7.3. FRAMEWORK OF URBAN AREA AND RURAL AREA FOR THIS

STUDY

The identification of rural and urban area of the state for this study is done

within the framework of these definitions.

Rural settlement : The definition of a rural settlement depends on the country. In

some countries, a rural settlement is any settlement in the areas defined as rural by a

governmental office, e.g., by the national census bureau. This may include even rural

towns. In some others, rural settlements traditionally do not include towns.

(Wikipedia)

Urban Settlement: For the Census of India 2011, the definition of urban area is as

follows (Census, 2011, Data highlights):

1. All places with a municipality, corporation, cantonment board or notified townarea committee, etc.

2. All other places which satisfied the following criteria:

a. A minimum population of 5,000;

b. At least 75 per cent of the male main working population engaged in

non-agricultural pursuits; and

c. A density of population of at least 400 persons per sq. km.

Other criteria: Along with the considerations of above definitions, the inclusion

criteria of presence of a District or General Hospital within the health system structure

in the state are also looked into.

The framework of urban area and rural area for this study:

As highlighted by the above definition and other criteria, the following point

will be considered for filtering the urban area:

1. Presence of District Hospital/General Hospital in the location of town area will be

considered as Urban area

2. Further it will be filtered with population above the minimum criteria of 5000

3. Rest of the towns falls outside the point 1 & 2 will considered as rural town areas

4. Other areas of the above will be inclusively rural area.

5. The areas falls under urban area is tabulated in the table.3



69

Table 3: The areas falls under Urban areas in the state for this study

Sl.no.

District District HQ/DistrictHospital

location

Population DistrictHospital/General

Hospital

Consideration asUrban Area for thisstudy

1 Tawang Tawang 8376 1 Qualify as UrbanArea

2 West Kameng Bomdila 6693 1 Qualify as Urban

Area

3 East Kameng Seppa 15002 1 Qualify as UrbanArea

4 Papum Pare

includingCapitalComplex

Yupia

(Rural area)/Itanagar &

Naharlagun

----

35022 &27020

1 Qualify as UrbanArea

5 Lower Subansiri

Ziro 12384 1 Qualify as UrbanArea

6 Kurung Kumey Koloriang 4798 0 Not Qualify asUrban Area

7 Upper Subansiri

Daporijo 15756 1 Qualify as UrbanArea

8 West Siang Along 17033 1 Qualify as UrbanArea

9 East Siang Pasighat 21965 1 Qualify as Urban

Area

10 Upper Siang Yingkiong 5103 1 Qualify as UrbanArea

11 Lower Dibang

Valley

Roing 10107 1 Qualify as Urban

Area12 Dibang Valley Anini 4853 1 Not Qualify asUrban Area

Considered as RuralTown

13 Lohit Tezu 15015 1 Qualify as Urban

Area

14 Anjaw Hawai 3954 0 Not Qualify asUrban Area

15 Changlang Changlang 6469 1 Qualify as Urban

Area

16 Tirap Khonsa 9233 1 Qualify as Urban

Area



70

Chapter -3

RESEARCH

METHODOLOGY



71

3.1. RESEARCH METHODOLOGY

3.1.1. RESEARCH DESIGNBased on the research objectives, the study is analytical, exploratory and

descriptive on the major HR issues on distribution, attraction and retention of physicians and nurses in rural areas in India with special reference to the state of

Arunachal Pradesh. The study included both quantitative and qualitative data

collection and analyses. This research is primarily based on primary data with

inclusion of secondary data as well. Interview and questionnaire are the major

technique used in this research along with the technique of observation. Data

collection instruments like interview schedule and survey questionnaires were

developed with the help of wide literature review. The data as collected from the

respondents (physicians, nurses and the management representatives was analyzed

and present the findings with description on the topics. Subsequently, the

interpretations and commentaries were put on the line keeping in the view of

sequences of the respective objectives.

3.1.2. OBJECTIVE OF THE STUDY

The research question puts for the study are that- What are the major HR

issues on distribution, attraction and retention of physicians and nurses in rural and

remote areas in Arunachal Pradesh? What are the major reform initiatives under

reform process for major issues on distribution, attraction and retention of physicians

and nurses in rural and remote areas in Arunachal Pradesh?

Rationally, the following objectives are place for the study:-

4. To explore the major HR issues on distribution, attraction and retention of

physicians and nurses in rural and remote areas in Arunachal Pradesh.

5. To explore the major reform initiatives under reform process for major issues on

distribution, attraction and retention of physicians and nurses in rural and remote

areas in Arunachal Pradesh.

6. To suggest some remedial measures to address the major issues.



72

3.1.3. THE STUDY AREA For this study, the state of Arunachal Pradesh in India was selected. It is

situated in north-eastern most part of the country, sharing the international border of

1628 km with Bhutan to the West, China to the North and North-East and Myanmar

to the East. The referred state of Arunachal Pradesh is a pre-dominantly a rural and

remote area and one of the most splendid and variegated tribal area of the country. As

the researcher could able to establish, that there is no academic literature available as

on date relating to the research topic in the state of Arunachal Pradesh. This raises the

unexplored issues in context of tribal remote and rural areas and even if it is explored,

it is not in record in form of any literature. The health system in Arunachal Pradesh is

still in a poor state and this is traceable to several factors especially the gross under-

infrastructure of the health system and shortage of skilled medical personnel at the

primary health care level. Despite the vast improvement in the establishment of

primary health infrastructure in the state, several parts of the state continue to suffer

from lack of access to primary care services, particularly those in the poorer hilly

tribal regions in the absence of physicians and nurses to provide maternal and child

health services. Over the last decade, a series of reforms have been undertaken, in the

states. The urge about, how this aspect of issues in the state of Arunachal Pradesh are

and can be addressed, motivated me to explore the subject in this study area.

Demographic and socio economic feature: The state is situated at latitude of

90.360E to 97.30 E and longitude of 26.420 N to 29.300 N covering a total land area of

83,743 sq. km., the largest amongst NE States in India. It has a total population of

1,382,611 with an average population density per square kilometer of 17 persons. Due

to its peculiar topography and difficult terrain, there is widely dispersed settlement

pattern of the population that applies to both rural and urban areas. The rural

population constitutes 77.33% and the urban only 22.67 %.Sex ratio of the state is 920females per 1000 males. The total literacy rate of the state is 66.95% with a male

literacy rate of 73.69 % and female literacy rate of 59.57 %. (Source: Census 2011).

The district wise Population as per census 2011 is presented in table 4.

Table 4: Demographic indicators Census 2011 and 2001 of Arunachal Pradesh

Indicators 2011 (census) 2001 (census)

Population 1,382,611 1,097,968

Male 720,232 579,941

Female 662,379 518,027

Population Growth 25.92% 26.21%



73

Percentage of total Population 0.11% 0.11%

Sex Ratio 920 901

Child Sex Ratio 960 798

Density/km2 17 13

Density/mi2 43 34

Area km2 83,743 83,743Area mi2 32,333 32,333

Total Child Population (0-6 Age) 202,759 205,871

Male Population (0-6 Age) 103,430 104,833

Female Population (0-6 Age) 99,329 101,038

Literacy 66.95 % 54.34 %

Male Literacy 73.69 % 65.43 %

Female Literacy 59.57 % 40.23 %

Total Literate 789,943 484,785

Male Literate 454,532 303,281

Female Literate 335,411 181,504

Table 5 : Urban-Rural comparison of demographic indicators of Arunachal

Pradesh

Indicators Rural Urban

Population (%) 77.33 % 22.67 %

Total Population 1,069,165 313,446

Male Population 554,304 165,928

Female Population 514,861 147,518

Population Growth 22.88 % 37.55 %

Sex Ratio 929 889

Child Sex Ratio (0-6) 964 944Child Population (0-6) 164,617 38,142

Child Percentage (0-6) 15.40 % 12.17 %

Literates 557,105 232,838

Average Literacy 61.59 % 84.57 %

Male Literacy 68.79 % 89.45 %

Female Literacy 53.78 % 79.04 %

The administrative set up of Arunachal Pradesh and its changing district

boundaries correspond broadly to natural boundaries of river basin. Even the

boundaries of Sub-Divisions, Community Development Blocks and Administrative

Circles within the districts have also been directly affected by the terrain features.

There are 16 Districts, 37 sub-divisions, 155 circles, 17 towns, 69 blocks and

3862 villages (Source - Census: 2001) constituting an elaborate administrative

structure for diffusing developmental activities in the state.



74

3.1.4. MAP OF THE STUDIED AREA

Figure 5: Map of India (Source : www.Stayfinder.com)

Figure 6: Map of Arunachal Pradesh (Source : www.arunachalipr.gov.in)

Focused

Studied

Area



75

3.1.5. DATA COLLECTION METHODS AND INSTRUMENTS

PRIMARY DATA: The primary data required for the study was collected

with the help of interview schedule, survey questionnaire and observation. The

primary data was collected through questionnaire among sampled physicians, nurses

and mid-wives to understand their attitude towards working and living in rural areas

and accepting the rural posting and insight on the HR issues in the area of study. A

selected key informants from state and district health official in Arunachal Pradesh

was interviewed with the help of interview schedule. Further, the data required on

distribution pattern was collected with personal visits to department of health and

family welfare, Govt. of Arunachal Pradesh.

The survey questionnaire for physicians and nurses including mid-wives was

developed with literature review and it was done in two stages. Firstly, it was

developed and tested in a pilot survey to ensure that the survey instrument is free from

all errors and all inclusions. For the purpose a field visit was undertaken. The pilot

survey was done in a rural area Primary Health Centre named as Koronu PHC, Iduli

PHC and Parbuk CHC in the Lower Dibang Valley district of Arunachal Pradesh on

dated 7.9.2010 to 10.9.10, along with 3 nos. of Physicians, 1 no. of Nurse and 3 mid-

wives. Copies of the instrument in English was prepared for each of them and handed

to them personally along with the covering letter attached with the instrument. The

filled-in questionnaires were returned to the researcher with some suggestions in

about 20 minutes of time. The suggestions of the participants were well taken and

necessary suggestions were included and reviewed for a final copy of the survey

instrument. The finally developed questionnaire is displayed in Appendix. The

participants in pilot survey were again included in the fresh survey after necessary

corrections of the instrument. The interview schedule is place in Appendix.

SECONDARY DATA: A range of research articles, books and officialdocuments available in soft and hard copies were reviewed which were related to

distribution, attraction and retention of workforce in public health sector in rural areas

in India and specially referring to the study area. The Rural Health Statistics, 2010,

published by Ministry of Health and Family Welfare, Govt. of India was used for

exploring the issues in distribution of physicians and nurses in rural India and

Arunachal Pradesh. For other secondary data, the printed & online policy manuals of

government, printed journals, government publications, articles, research thesisand books was used for collecting relevant secondary information.



76

3.1.6. SAMPLING FRAME

Choosing a study sample is an important step in any research study, since it is

rarely practical, efficient or ethical to study whole population. In this study, the

multistage sampling, convenience sampling and simple random method was used to

frame the sample of physicians and nurses in rural areas in the study area. By

applying the sampling techniques, the total sixteen (16) districts were divided in four

equal zones comprises of four districts in each zone according to their geographical

location. Zone 1: (Tawang, West Kameng, East Kameng and Papumpare); Zone 2:

(Kurung Kumey, Lower Subansiri, Upper Subansiri and West Siang); Zone-3(Upper

Siang, East Siang, Dibang Valley and Lower Dibang Valley); Zone-4: (Lohit, Anjaw,

Changlang and Tirap). The simple random sampling was used to pick the sample of

physicians and nurses from each of the zone from selected health institutions through

convenience sampling.

According to the Rural Health Statistics (2010), there are 200 nos. of

physicians (doctors) and 688 nos. of nurses and mid-wives (395 nos. of mid-wives

and 293 nos. of nurses) in the rural public health system in Arunachal Pradesh.

Therefore, the sample size determined were 132 nos. of physicians and 247

nos. of midwives and nurses. The sample was determined with 95% of confidence

level, 5% margin of error with a response distribution of 50%.

According to the sample size determined, the survey questionnaires were

distributed and total of 353 nos. of questionnaires were returned to the researcher out

of which 334 nos. (113 nos. of physicians, 98 nos. of Nurses and 123 nos. of

midwives) of questionnaires were useable for the study. Henceforth the useable

response rate was 88% in total. Whereas the individual response rate for physicians

was 85% and mid-wives and nurses was 89%. To get the high response rate the use of

reminders (at-least 3 times) and questionnaire survey were used. The distribution of

questionnaire and collection of data was done within the period of 7.9.2010 to

25.03.2012.

One management representatives each from the 16 districts and one state level

management representatives were picked as a sample of management representatives

and conducted the interview.



77

3.1.7. DATA ANALYSIS

Possessing relevant information generated from the interviews,

questionnaires and observations are categorizes the interviewees point to the key

themes, into main themes of issues including the observational themes. It

includes analyzing by organizing the text from the individual interview

respondent and grouping the relevant issues and eliminating the answers which

seemed irrelevant to the topic. Once the data are organized, the next step

followed was the description i.e., the researcher described the various pertinent

aspects of the study including the setting, the individual being studied, the

purpose of any activities examined, the viewpoints of the participants, etc. Only

after data have organized and described, the final step of analysis process i.e.,

interpretation and commentary was done, which involves explaining the

findings. Subsequently, the interpretation and commentary was placed according

to the research questionnaire and the study objectives. Findings and results is

presented in the sequence of the research problems.

The information collected from both the primary and secondary sources

was classified, tabulated and subjected to analysis. SPSS software was used for

data entry, validation, cleaning and analysis. The statistical package for the social

sciences (SPSS for windows version 19) and Microsoft Excel 2007 was used to

analyse the quantitative data. The summaries of the data were undertaken which

includes percentage, mean, standard deviations. The statistical analysis used

included reliabilities, correlation, T-Test (one sample & paired), ANOVA, Chi-

square test, multiple & logistic regression etc.

3.2. LIMITATION OF RESEARCH To lineout the limitation of this study, it may not be free from some of the

limitations despite of maximum heed. Although the primary data was collected with

the assumption that it truly represented the character, and the views expressed by the

respondents and the possibility of personal bias of such respondents cannot be ruled

out. Further, analysis includes the researchers own views on the HR Issues and HRM

Practice in the health sector of Arunachal Pradesh, which may include personal

experience and bias. Moreover, to determine the major issues only pertinent to

Physicians and nurses from a wide range of technical professional occupations in

health sector was considered. Other service occupations in health sectors are not



78

considered here for the study, as it would have invited a huge area of study which is

not possible to sum up in the constraints of funding and timing.

3.3. CONTRIBUTION OF THE RESEARCH

It is mentioned in earlier sections that there is limited literature of the topic as

on date in Arunachal Pradesh, (so far as this researcher has been able to establish).

This research process would not only generate useful contributions to the field of

research, but that it would also provide time for reflection and learning for other

people involved in this sector. This research work definitely is useful, which has

brought out in the light of Human Resource issues and present HR practice in Public

Health sector in Arunachal Pradesh. That would I believe generate an atmosphere of

enhancing workforce management in the organization creating a WIN-WIN Situation.

It also may act as a resource book for future reference to know the HRM in the Public

Health Sector in Arunachal Pradesh in health organisation and other study purposes

also. In addition, a study such as this one, which focuses on the experiences and

views of healthcare workforce, provides useful information to policy-makers and

those responsible for the implementation and effectiveness of health sector reform

initiative in the state. It also tries to provide ideas for future improvements.



79

Chapter -4

DATA ANALYSIS AND

INTERPRETATION



80

SECTION-1

CHARACTERSTICS OF

RESPONDENTS



81

4.1.1. INTRODUCTION

This chapter is present, the detail data analysis of the questionnaire survey and

the interview followed by interpretation of all findings. The chapter is divided into six

sections and consist of : i) Demographic characteristics of respondents, ii) Dimensionon Distribution, iii) Dimension on attraction, iv) Dimension on retention, v)

Dimension in Reform initiatives and vi) Exploration of HR Practice in Reform

Process.

4.1.2. CHARACTERSTICS OF RESPONDENTS

Characteristics- management representatives: Seventeen (17) nos. of management

representatives were pooled from District (16 nos.) and State level (1 no.) for the

study. 88.2% of the respondents were male and 11.8% were female. The mean age

and management experience of the respondents are 44 years and 8 years (approx.)

respectively. Table 6 and 7 shows the sample descriptive.

Table 6 : Demographic characteristics of management representatives respondents

Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)1 Position Level State Level 1 5.9

District Level 16 94.1

2 Gender Male 15 88.2

Female 2 11.8

3 Age 35-40 2 11.841-45 9 52.9

46-50 6 35.3

4 Years of managementexperience

0-5 3 17.6

6-10 8 47.1

11-15 6 35.3

Table 7 : Mean age and experience of management representatives respondents

Sl. No. Attributes N Mean Std. Dev.

1 Age of the respondents 17 44.29 2.88

2 Management Experience of the respondents 17 7.88 3.47

Characteristics- employees: According to the data of RHS (2010), 200 numbers of

physicians (doctors) and 688 nos. of nurses and mid-wives are in the rural and remote

areas in the state. Among these physicians, nurses and mid-wives, 132 nos. of

physicians and 247 nos. of midwives and nurses were included in the sampling size.

Finally, 334 nos. of responses in completed form were selected and included in the

data analysis. Out of total 334 nos. of respondents, 113 nos. (33.8%) are Physicians,

98 (29.3%) nurses and 123 nos. (36.8%) of mid-wives. Out of the total respondents,

26.3% of the respondents were male and 73.7% were female. In individual groups of



82

these three employees 87 nos. (77%) were male and 26 nos. (23%) were female in

group of the Physicians and only 1 no. of male in group of nurses and mid-wives. 230

nos.(68.9%) of respondents had rural family Background and 104 nos. (31.1%) had

urban family background. 215 nos. (64.4%) of the respondents were married and 119

nos. (35.6%) were unmarried. The mean age and length of in-service were 31 years

(approx.) and 7 years (approx.) respectively. Out of the total respondents, 154 nos.

(46.1%) were contractual employees and 180 nos. (53.9%) were permanent

employees. At the time of study, 12 nos. (3.6%), 101 nos. (30.2%), 157 nos. (47.0%)

and 64 nos. (19.2%) of respondents were working in District Hospitals, CHCs, PHCs

and SCs respectively. Table 8 and 9 shows the employee demographic characteristics

in detail.

Table 8: Demographic characteristics of employee respondents

Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)

1 Position Physicians 113 33.8

Nurses 98 29.3

Mid-wives 123 36.8

2 Age 20-30 years 178 53.3

30-40 years 121 36.2

40-50 years 33 9.9

50-60 years 2 0.6

3 Sex Male 88 26.3

Female 246 73.7

4 Family Background Rural 230 68.9

Urban 104 31.1

5 Marital Status Married 215 64.4

Unmarried 119 35.6

6 Length of Service 0-5 years 172 51.5

5-10 years 96 28.7

10-15 years 43 12.9

15-20 years 16 4.8

20-25 years 7 2.1

7 Presently Working in DH 12 3.6

CHC 101 30.2

PHC 157 47.0

SC 64 19.2

8 Nature of Employment Contract 154 46.1

Permanent 180 53.9

Table 9: Mean age and length of service of the respondents

Sl. No. Attributes N Mean Std. Dev.

1 Age of the respondents 334 31.38 6.270

2 Length of service of the respondents 334 6.78 4.781



83

SECTION 2

ANALYSIS OF DIMENSION OF

HR ISSUES IN DISTRIBUTION OF

PHYSICIANS, NURSES AND MID-

WIVES IN RURAL AND REMOTE

AREAS OF THE STATE



84

4.2.1. INTRODUCTIONThis section of this chapter describes the dimensions of distributional issues of

the Physicians, Nurses and Mid-wives in the study area i.e., the state of Arunachal

Pradesh, focusing on the government health system where the problem is most severe.

The state public health delivery system is based on the three tiers that are in

primary, secondary and tertiary health care system. Public hospitals in Arunachal

Pradesh have to behave and function in accordance with the government's

administrative and financial laws issued by specific Government of India and

Government of Arunachal Pradesh. With the network of the public hospitals in the

state, the State government is responsible for managing and delivering health services,

including some aspects of prescription care, as well as planning, financing, and

evaluating hospital care provision and health care services.

The Public Health Services department that is the Department of Health and

Family Welfare is headed by Secretary H& FW and Director of Health Services and

the directorate has a separate branches headed by a Joint Directors. The planning

department undertakes the planning of new institutions which include creation of

posts for the new institutions as per the Govt. of India and state govt. norms. The

other respective National health programmes are handled by respective programme

officers, under the umbrella of National Rural Health Mission Programme which is

being headed by the Mission Director-NRHM in Directorate level.

4.2.2.SCENARIO OF DISTRIBUTION OF HEALTH

INSTITUTION IN ARUNACHAL PRADESHA widespread establishment of health institutions in the state was done across

the five year plans. According to the RHS, (2010), there is a sharp increase in the

health institutions in rural areas of the state. 55 SCs in sixth plan (1981-85) to 286

SCs in eleventh plan (2007-2012), not a single PHCs to 97 PHCs and not a single

CHCs to 48 CHCs in the region. There are 2 General Hospitals in the state, one at

Pasighat (the district headquarter of East Siang) and other at Naharlagun in the district

of PapumPare (the capital district).

Presently the state is having 468 nos. of sanctioned SCs, out of which only 286

SCs are functional due to one of other reasons of human resource inadequacy or

inadequacy of infrastructure. Above the hierarchy 119 nos. of sanctioned and

functional PHCs are functioning out of which 29 nos. of 24x7 PHCs and rest are non24x7 PHCs. Above that a wide network of sanctioned 49 nos. of CHCs are functional,



85

out of which only 1 no. of CHC is functioning as FRU. There are 2 General Hospitals

at Naharlagun and Pasighat, 13 District Hospitals at Tawang, Bomdila, Seppa, Ziro,

Daporijo, Along, Yingkiong, Roing, Anini, Tezu, Changlang, Khonsa and Hawai

(under-construction). The District/General Hospital covers an average of 98,758 nos.

of population. Similarly, Average population for CHC is 28,217 and for PHC is

11,619 and SC is 2,954. Table 11 puts detail lights of the individual districts.

Table 10: Showing health infrastructure growth in rural areas of the states

State

Sub Centres Primary Health Centres Community Health Centres6

th

7

th

8

th

9

th

10

th

11

th

6

th

7th

8

th

9

th

10

th

11

th

6

th

7

th

8

th

9

th

10

th

11

th

Arunachal

Pradesh 55 155 223 273 379 286 0 24 45 65 85 97 0 6 9 20 31 48

Source : RHS, 2010

Table 11: Distribution of Public Health Facilities in Arunachal Pradesh

No. of facilities

T o t a l

Name of the Districts

T a w a n g

W e s t K a m e n g

E a s t K a m e n g

P a p u m p a r e

L o w e r S u b a n s i r i

K u r u n g K u m e y

U p p e r S u b a n s i r i

W e s t S i a n g

E a s t S i a n g

U p p e r s i a n g

L o w e r D i b a n g V a l l e y

D i b a n g V a l l e y

L o h i t

A n j a w

C h a n g l a n g

T i r a p

Total no. of

sanctioned

sub centres

468 14 27 41 42 25 45 46 44 38 13 13 3 24 27 30 36

Total no. of

functional

sub centres

286 7 21 10 30 18 13 25 28 38 11 11 4 20 12 18 22

Total no. of

sanctioned

PHCs

119 6 4 9 8 7 10 11 15 15 2 6 1 8 2 8 7

Total no. of

24x7 PHC29 1 3 1 1 1 3 1 3 4 1 1 1 1 1 4 2

Total no. of

non 24x7

PHCs

90 5 1 8 7 6 7 10 12 11 1 5 0 7 1 4 5

Total no. of CHC

49 1 4 2 4 2 4 4 5 6 4 2 0 3 2 4 3

Total no. of

CHC

(FRUs)

1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0

Total no. of

CHC

which are

non-FRUs

48 1 4 1 4 2 4 4 5 5 4 2 0 3 2 4 3

Total

number of

District

Hospitals/

General

Hospital

14 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1



86

Table 12: Population covered by the health institutions in Arunachal PradeshSlNo

Name of District

Population

(Census

2011)

Number

of

DH/

GH

Population of

DH

No.Of

CHC

Population for

CHC*

No.Of

PHC

Population for

PHC

No.Of

HSC

Population

for

HSC

1 Tawang49,950

1 49,950 124,975

68,325

143,568

2 West

Kameng 87,013

1 87,013 4

21,753

4

21,753

27

3,223

3 East

Kameng 78,413

1 78,413 1

39,207

9

8,713

41

1,913

4 Papum

Pare 1,76,385

1 1,76,385 4

44,096

8

22,048

42

4,200

5 Lower

Subansiri 82,839

1 82,839 2

41,420

7

11,834

25

3,314

6 KurungKumey 89,717 0 0 4 22,429 10 8,972 45 1,994

7 Upper Subansiri 83,205

1 83,205 420,801

117,564

461,809

8 West

Siang 1,12,272

1 1,12,272 5

22,454

15

7,485

44

2,552

9 East

Siang 99,019

1 99,019 6

16,503

15

6,601

38

2,606

10 Upper

Siang 35,289

1 35,289 4

8,822

2

17,645

13

2,715

11 L/D/Vall

ey 53,986

1 53,986 2

26,993

6

8,998

13

4,15312 Dibang

Valley 7,948

1 7,948 0

-

1

1,590

3

2,649

13 Lohit

1,45,538

1 1,45,538 3

48,513

8

18,192

24

6,064

14 Anjaw

21,089

0 0 2

10,545

2

10,545

27

781

15 Changlang1,47,951 1 1,47,951 4 36,988 8

18,494

30

4,932

16 Tirap 1,11,997 1 1,11,997 3 37,332 7

16,000

36

3,111

Total 13,82,611 14 98,758 49 28,217 119 11,619 468 2,954

* Population covered by a single Health Institution in the districts are actual population covered by the HI and rest are average

4.2.3. SCENARIO OF DISTRIBUTION OF PHYSICIANS, NURSES

& MID-WIVES IN ARUNACHAL PRADESH

In Arunachal Pradesh, there is scarce on the data availability on distribution,

and trends in human resources in public health care sector has been observed by the

researcher. It is also a barrier to the effective human resource planning in the state.

According to the primary data collection from the field districts and state officials,



87

there are 449 nos. of physicians/Medical Officers, 390 nos. of nurses and 542 nos. of

Mid-wives (ANM) distributed across the health institutions in Arunachal Pradesh.

This accounted for 33% of doctors, 28% of nurses and 39% of mid-wives among this

pool of human resource. Among the nursing cadre 58% accounted Mid-Wives (ANM)

and 42 % accounted for Nurses (GNM/SN). The trend may be seen at figure 7, 8 & 9.

Figure 7: Number of Physicians (doctors), Nurses and Mid-wives in Arunachal

Pradesh

Figure 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives in

Arunachal Pradesh

Figure 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh



88

4.2.3.1. DISTRICT-WISE DISTRIBUTION PATTERN OF PHYSICIANS

(MEDICAL OFFICERS) & SPECIALISTS (PAEDIATRICS, ANAESTHETICS

AND GYNAECOLOGIST):

The Physicians are synonymously called doctors or Medical Officers in the

field. The distribution of the physicians is skewed and mal-distributed among thedistricts. They are more concentrated to the district which is with good access to

communication. The Specialist cadres, essential for the maternal and child like

Paediatrics, Anaesthetics and Gynaecologist are very scare and concentrated only to

the highest possible level of hospitals in urban area in the state. There are overall 11

nos. of Paediatrician, 13 nos. of Anaesthetist and 15 nos. Gynaecologist in the state.

Only 6 (37%) out of 16 districts have pediatrician. They are distributed as 3 nos. in

Papum Pare district, 2 nos. in Lower Subansiri district, 1 nos. in Upper Subansiri

district, 2 nos. in East Siang district, 2 nos. in Upper Siang and 1 no. in Lohit district.

Only 5 (31%) out of 16 districts have Anesthetist, 4 nos. in Papum Pare, 1 nos. in

Upper Subansiri, 5 nos. in East Siang, 2 nos. in Upper Siang and 1 no. Lohit Districts.

Only 8 out of 16 districts have Gynaecologist, 1 no. in West Kameng, 3 nos. in

Papum Pare, 2 nos. in L/Subansiri, 1 no. in U/Subansiri, 1 no. in West Siang, 4 nos. in

East Siang, 2 nos. in Upper Siang, and 1 no. in Lower Dibang Valley.

Table 13: Numbers of Pediatricians, Anesthetist and Gynecologist in

Arunachal Pradesh (District Wise)Sl. No. Name of District Paediatrician Anaesthetist Gynaecologist

1 Tawang 0 0 0

2 West Kameng 0 0 1

3 East Kameng 0 0 0

4 Papum Pare 3 4 3

5 L/Subansiri 2 0 2

6 Kurung Kumey 0 0 0

7 U/Subansiri 1 1 1

8 West Siang 0 0 1

9 East Siang 2 5 410 Upper Siang 2 2 2

11 L/D/Valley 0 0 1

12 Dibang Valley 0 0 0

13 Lohit 1 1 0

14 Anjaw 0 0 0

15 Changlang 0 0 0

16 Tirap 0 0 0

Total 11 13 15



89

There are 449 nos. of physicians/Medical Officers distributed across the health

institutions in Arunachal Pradesh having 1:3079 of doctor-population ratio against a

norm of 1:1000 by WHO, which deviates 68% of the norms. Comparing the

concentration of physicians across the districts the districts of Papum Pare (75), East

Siang (53) and West Siang (40) are three highest districts. These districts are featured

by good communication and other basic amenities in urban areas. The Doctor-

population ratio is good in comparing to other district in Anjaw district (1:1506) to the

worst scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in

Table: 15.

Table 14: Numbers of Physicians (Medical Officer) in Arunachal Pradesh

district wise

Sl. No. Name of District No. of MOs 1 Papum Pare 75

2 East Siang 53

3 West Siang 40

4 Lohit 33

5 L/Subansiri 32

6 Changlang 29

7 West Kameng 26

8 U/Subansiri 24

9 East Kameng 23

10 Upper Siang 23

11 Tirap 22

12 L/D/Valley 21

13 Tawang 19

14 Anjaw 14

15 Kurung Kumey 10

16 Dibang Valley 5

Total 449

Table 15: Ranking of Density of Physicians (doctors) in Arunachal Pradesh

(District wise)

Rank

District Population(2011

census)

No. of Physicians

Density of physicians

Differencefrom the

norm of

WHO

&GOI

%Difference

(norm -

actual)

1 Anjaw 21,089 14 1506 506 34%

2

Upper

Siang

35,289 23 1534

534 35%

3

Dibang

Valley

7,948

5

1590

590 37%

4 East Siang 99,019 53 1868 868 46%

5PapumPare

1,76,385 75 23521352 57%



90

6 L/D/Valley 53,986 21 2571 1571 61%

7 L/Subansiri 82,839 32 2589 1589 61%

8 Tawang 49,950 19 2629 1629 62%

9 West Siang 1,12,272 40 2807 1807 64%

10 WestKameng 87,013 26 3347 2347 70%

11

East

Kameng

78,413 23 3409

2409 71%

12 U/Subansiri 83,205 24 3467 2467 71%

13 Lohit 1,45,538 33 4410 3410 77%

14 Tirap 1,11,997 22 5091 4091 80%

15 Changlang 1,47,951 29 5102 4102 80%

16

Kurung

Kumey

89,717 10 8972

7972 89%

Total 13,82,611 449 3079 2079 68%

The distribution of the physicians in Arunachal Pradesh is concentrated to the

districts with good access to communication, semi-urban, rural towns and higher

health institutions. The number of physicians of 75 nos. (17%) is in Papum Pare the

capital district followed by East Siang 53 nos. (12%), West Siang 40 nos. (9%), Lohit

33 nos. (7%), L/Subansiri 32 nos. (7%), Changlang 29 nos.(6%), West Kameng

26nos.(6%), U/Subansiri 24 nos. (5%), Upper Siang 23 nos. (5%), East, Kameng 23

nos. (5%), Tirap 22 nos. (5%), L/D/Valley 21 nos. (5%), Tawang 19 nos. (4%),

Anjaw 14 nos. (3%), Kurung Kumey 10 nos (2%), Dibang Valley 5 nos. (1%). This

trend is presented graphically in figures 10, 11 and 12.

Figure 10: District wise numbers of Physicians (doctors/ medical officers) in

Arunachal Pradesh



91

Figure 11: District wise percentage share of Physicians (doctors/ medical officers)in Arunachal Pradesh

Figure 12: Graphical mapping of district wise number of Physicians (doctors/


4.2.3.2 DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES &

GNM) DISTRICT-WISE

The Nurses are synonymously called Staff Nurses and GNM in Arunachal

Pradesh. There are 390 nos. of Nurses across the geographical boundary of the state,

covering 3545 average population by a single Nurse against an expected norm of

1:500 by Govt. of India. Comparing the concentration of nurses across the districts the

districts of Papum Pare (90), East Siang (62) and West Siang (35) are three highest

districts. The density of Nurse-population ratio is good in comparison within the

districts in East Siang (1:1597) to the worst scenario in Kurung Kumey district

(1:9802). The district wise ratio is placed in table 17.



92

Table 16: Numbers of Nurses in Arunachal Pradesh (District Wise)

Sl.

No.

Name of District No of

Nurses

Sl.

No.

Name of District No of

Nurses

1 Papum Pare 90 9 West Kameng 16

2 East Siang 62 10 Upper Subansiri 14

3 West Siang 35 11 Upper Siang 124 Changlang 31 12 Tawang 11

5 Lohit 27 13 Kurung Kumey 11

6 Lower Subansiri 24 14 East Kameng 8

7 L/D/Valley 20 15 Anjaw 8

8 Tirap 19 16 Dibang Valley 2

Total 390

Table 17: District-wise ranking of density of Nurses in Arunachal Pradesh

Rank Name of District Population

(2011 census)

No of

Nurses

Density of

Nurses1 East Siang 99,019 62 1597

2 Papum Pare 1,76,385 90 1960

3 Anjaw 21,089 8 2636

4 L/D/Valley 53,986 20 2699

5 Upper Siang 35,289 12 2941

6 West Siang 1,12,272 35 3208

7 Lower Subansiri 82,839 24 3452

8 Dibang Valley 7,948 2 3974

9 Tawang 49,950 11 4541

10 Changlang 1,47,951 31 4773

11 Lohit 1,45,538 27 5390

12 West Kameng 87,013 16 5438

13 Tirap 1,11,997 19 5895

14 Upper Subansiri 83,205 14 5943

15 Kurung Kumey 89,717 11 8156

16 East Kameng 78,413 8 9802

Total 13,82,611 390 3545

As per the norms Nurses are placed in higher health institution than Sub-

Centres. The distributional pattern of the nurses in the state is also concentrated to the

districts with good access to communication and higher health institutions. The

number of nurses is concentrated to the districts are Papum Pare 90 nos. (23%), East

Siang 62 nos. (16%),West Siang 35 nos. (9%),Changlang 31 nos.(8%), Lohit 27 nos.

(7%), Lower Subansiri 24 nos. (6%), Lower Dibang Valley 20 nos. (5%), Tirap 19

nos. (5%),West Kameng 16 nos. (4%), Upper Subansiri 14 nos. (4%), Upper Siang

12 nos. (3%), Tawang 11nos. (3%), Kurung Kumey 11 nos. (3%), East Kameng 8

nos. (2%), Anjaw 8 nos. (2%), and Dibang Valley 2 nos. (1%). This trend is presented

graphically in figure 13, 14 and 15.



93

Figure 13: District wise numbers of nurses in Arunachal Pradesh

Figure 14: District wise share of nurses in Arunachal Pradesh

Figure 15: Graphical mapping of district wise number of nurses in ArunachalPradesh



94

4.2.3.3. DISTRIBUTION PATTERN OF MID-WIVES (ANM) DISTRICT-

WISE

The Mid-wives are synonymously called ANM in Arunachal Pradesh.

Generally as per norms ANMs are posted in Sub-Centre Level and if adequate are

placed in higher institutions as per norms. There are 542 nos. of ANMs are across the

geographical boundary of the state, covering 2551 average population by a single

Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The density of

Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison to other

districts to the worst scenario in Kurung Kumey district (1:4722). The district wise

ratio is placed in Table: 19.

Table 18: Numbers of Mid-Wives (ANM) in Arunachal Pradesh (District Wise)

Sl. No Name of District No of Midwives Sl. no Name of

District

No of

Midwives

1 Papum Pare65 9 Lower

Subansiri35

2 East Siang 55 10 L/D/Valley 32

3 West Siang 47 11 West Kameng 29

4 East Kameng

45 12 Kurung

Kumey

19

5 Changlang 43 13 Tawang 17

6 Upper Subansiri 41 14 Anjaw 16

7 Lohit 38 15 Upper Siang 15

8 Tirap 36 16 Dibang Valley 9Total 542

Table 19: District-wise ranking of density of Mid-wives in Arunachal Pradesh

Rank Name of District Population (2011

census)

No of

Midwives

Density

of Nurses

1 Dibang Valley 7,948 9 883

2 Anjaw 21,089 16 1318

3 Lower Dibang Valley 53,986 32 1687

4 East Kameng 78,413 45 1743

5 East Siang 99,019 55 1800

6 Upper Subansiri 83,205 41 2029

7 Upper Siang 35,289 15 2353

8 Lower Subansiri 82,839 35 2367

9 West Siang 1,12,272 47 2389

10 Papum Pare 1,76,385 65 2714

11 Tawang 49,950 17 2938

12 West Kameng 87,013 29 3000

13 Tirap 1,11,997 36 3111

14 Changlang 1,47,951 43 3441

15 Lohit 1,45,538 38 3830

16 Kurung Kumey 89,717 19 4722Total 13,82,611 542 2551



95

The distributional pattern of the ANMs in the state is also concentrated to the

districts with good access to communication and higher health institutions. The

number of mid-wives is concentrated to the districts as Papum Pare 65 nos. (12%),

East Siang 55 nos. (10%), West Siang 47 nos. (9%), East Kameng 45 nos. (8%),

Changlang 43 nos.(8%), Upper Subansiri 41 nos. (8%), Lohit 38 nos. (7%),Tirap 36

nos. (7%), Lower Subansiri 35 nos.(6%), Lower Dibang Valley 32 nos. (6%), West

Kameng 29 nos. (5%), Kurung Kumey 19 nos. (4%), Tawang 17 nos. (3%), Anjaw 16

nos. (3%), Upper Siang 15 nos. (3%) and Dibang Valley 9 nos.(2%). This trend is

presented graphically in figure 16, 17 and 18.

Figure 16: District wise numbers of mid-wives in Arunachal Pradesh

Figure 17: District wise share of nurses in Arunachal Pradesh



96

Figure 18: Graphical mapping of district wise number of nurses in Arunachal

Pradesh

4.2.4. SCENARIO OF DISTRIBUTION OF PHYSICIANS,

NURSES & MID-WIVES IN RURAL AND REMOTE AREAS IN

ARUNACHAL PRADESHAccording to the primary data collection, there are 283 nos. of

physicians/medical officers, 210 nos. of nurses and 390 nos. of Mid-wives (ANM)

distributed across the rural and remote health institutions in Arunachal Pradesh. This

accounted for 32% of doctors, 24% of nurses and 44% of mid-wives among this pool

of human resource. Among the nursing cadre 65% accounted Mid-wives (ANM) and

35% accounted for Nurses (GNM/SN). Figure 19, 20 and 21 represent the situation

graphically.

Figure 19: Numbers of Physicians, nurses and mid-wives in rural and remote

areas in Arunachal Pradesh



97

Figure 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives in

rural and remote area of Arunachal Pradesh

Figure 21: Percentage Share of Nurses and Mid-wives in rural and remote area


4.2.4.1. DISTRIBUTION PATTERN OF PHYSICIANS (MEDICAL

OFFICERS) IN RURAL & REMOTE AREAS (DISTRICT WISE)

There are 283 nos. of physicians/Medical Officers distributed across the rural

health institutions in Arunachal Pradesh having 1:3797 of doctor-rural population

ratio against a norm of 1:1000 by WHO, which deviates 74%. Comparing the

concentration of physicians across the districts the districts of Papum Pare (36), East

Siang (32) and West Siang (31) are three highest districts. The Doctor-population

ratio is good in comparing to other district in Anjaw district (1:1506) to the worst

scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in Table:

21.



98

Table 20: District wise number of Physicians (Doctors) in Rural Area in

Arunachal Pradesh

Sl.

NO

Name of District Physicians

(Doctors) inRural Area

Sl.

NO

Name of

District

Physicians

(Doctors) inRural Area

1 Papum Pare 36 9 Anjaw 14

2 West Siang 32 10 Tirap 13

3 East Siang 31 11 East Kameng 12

4 Changlang 25 12 L/D/Valley 12

5 Lohit 23 13 Tawang 11

6 Lower Subansiri 18 14 Kurung Kumey 10

7 West kameng 16 15 Upper Siang 10

8 Upper Subansiri 15 16 Dibang Valley 5

Total 283

Table 21: District wise Doctor-Population ratio in Arunachal Pradesh Name of

District

Physicians

(Doctors)

in Rural

Area

Rural

Population

(Census

2011)

Doctor

Populatio

n ratio

WHO

norms

Difference

from the

norm of

WHO

&GOI

%

Difference

(norm -

actual)

Anjaw 14 21089 1506 1000 506 34%

Dibang

Valley

5 7948 1590 1000 590 37%

Papum

Pare

36 79500 2208 1000 1208 55%

East Siang 31 71417 2304 1000 1304 57%

West

Siang

32 87311 2728 1000 1728 63%

Upper

Siang

10 28743 2874 1000 1874 65%

L/D/Valley 12 42601 3550 1000 2550 72%

Lower Subansiri

18 70029 3891 1000 2891 74%

Tawang 11 44323 4029 1000 3029 75%

West

Kameng

16 68654 4291 1000 3291 77%

Upper

Subansiri

15 69595 4640 1000 3640 78%

Lohit 23 113700 4943 1000 3943 80%

East

Kameng

12 60156 5013 1000 4013 80%

Changlang 25 128736 5149 1000 4149 81%

Tirap 13 91113 7009 1000 6009 86%

Kurung

Kumey

10 89717 8972 1000 7972 89%

Total 283 1074632 3797 1000 2797 74%



99

The distributional pattern of the physicians in rural & remote area in

Arunachal Pradesh is concentrated to the districts with easy to access of rural from the

urban areas. The number of physicians of Papum Pare 36 nos. (13%), West Siang 32

nos. (11%),East Siang 31 nos. (11%), Changlang 25 nos. (9%), Lohit 23 nos. (8%),

Lower Subansiri 18 nos. (6%), West Kameng 16 nos. (6%), Upper Subansiri 15 nos.

(5%), Anjaw 14 nos. (5%), Tirap 13 nos. (5%), L/D/Valley 12 nos. (4%), East

Kameng 12 nos. (4%), Tawang 11 nos. (4%), Upper Siang 10 nos. (4%), Kurung

Kumey 10 nos. (4%) and Dibang Valley 5 nos. (2%). This trend is presented


Figure 22: District wise numbers of Physicians (doctors/ medical officers) in

Arunachal Pradesh

Figure 23: District wise percentage share of Physicians (doctors/ medical officers)




100

Figure 24 : Graphical mapping of district wise number of Physicians (doctors/


4.2.4.2. DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES &

GNM) IN RURAL AND REMOTE AREA IN ARUNACHAL PRADESH

DISTRICT-WISE

There are 210 nos. of Nurses across the geographical boundary of the state,

covering 5117 average population by a single Nurse against an expected norm of

1:500 by Govt. of India. Comparing the concentration of nurses across the districts,

East Siang (33), Changlang (26) and West Siang (24) are three highest districts. The

density of Nurse-population ratio is good in comparison within the districts in East

Siang (1: 2164) to the worst scenario in East Kameng district (1: 15039). The district

wise ratio is placed in Table: 23.

Table 22: District wise number of Nurses in Rural Area in Arunachal Pradesh

Sl.

NO

Name of District Nurses in

Rural Area

Sl.

NO

Name of District Nurses in

Rural Area

1 East Siang 33 9 Upper Subansiri 102 Changlang 26 10 West Kameng 8

3 West Siang 24 11 L/D/Valley 8

4 Papum Pare 19 12 Anjaw 8

5 Lohit 19 13 Upper Siang 6

6 Lower Subansiri 16 14 Tawang 5

7 Kurung Kumey 11 15 East Kameng 4

8 Tirap 11 16 Dibang Valley 2

Total 210



101

Table 23: District wise Nurses –Population ratio in Rural Area in Arunachal

Pradesh

Name of

District

Nurses

inRural

Area

Rural

Population(Census

2011)

Nurse

Populationratio

WHO

norms

Difference

from thenorm of

WHO&GOI

ifference(norm -

actual)

East Siang 33 71417 2164 500 1664 77%

Anjaw 8 21089 2636 500 2136 81%

West Siang 24 87311 3638 500 3138 86%

Dibang Valley 2 7948 3974 500 3474 87%

Papum Pare 19 79500 4184 500 3684 88%

Lower Subansiri 16 70029 4377 500 3877 89%

Upper Siang 6 28743 4791 500 4291 90%

Changlang 26 128736 4951 500 4451 90%

L/D/Valley 8 42601 5325 500 4825 91%Lohit 19 113700 5984 500 5484 92%

Upper Subansiri 10 69595 6960 500 6460 93%

Kurung Kumey 11 89717 8156 500 7656 94%

Tirap 11 91113 8283 500 7783 94%

West Kameng 8 68654 8582 500 8082 94%

Tawang 5 44323 8865 500 8365 94%

East Kameng 4 60156 15039 500 14539 97%

Total 210 1074632 5117 500 4617 90%

The number of nurses as concentrated to the districts in ranking are East Siang

33 nos. (16%), Changlang 26 nos. (12%), West Siang 24 nos. (11%), Lohit 19 nos. (9%),

Papum Pare 19 nos. (9%), Lower Subansiri 16 nos. (8%), Tirap 11 nos. (5%), Kurung

Kumey 11 nos. (5%), Upper Subansiri 10 nos. (5%), Anjaw 8 nos. (4%), Lower Dibang

Valley 8 nos. (4%) , West Kameng 8 nos. (4%), Upper Siang 6 nos. (3%), Tawang 5 nos.

(2%), East Kameng 4 nos. (2%), Dibang Valley 2 nos. (1%). This trend is presented


Figure 25: District wise numbers of nurses in rural and remote area ArunachalPradesh



102

Figure 26: District wise share of nurses in rural and remote area Arunachal

Pradesh

Figure 27: Graphical mapping of district wise number of nurses in rural and

remote area in Arunachal Pradesh

4.2.4.3. DISTRIBUTIONAL PATTERN OF MID-WIVES (ANM) IN RURAL

AND REMOTE AREA IN ARUNACHAL PRADESH DISTRICT-WISE

Generally as per norms ANMs are posted in Sub-Centre Level. There are 390

nos. of ANMs in rural and remote area of the state, covering 2755 average population

by a single Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The

density of Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison

to other districts to the worst scenario in Tawang district (1: 6332). The district wise

ratio is placed in table 25.



103

Table 24: District wise number of Mid-wives in Rural Area in Arunachal

Pradesh

Sl.

No.

Name of District Mid-wives

in rural andremote area

Sl.

No.

Name of

District

Mid-wives

in rural andremote area

1 Tawang 7 9 L/D/Valley 262 Dibang Valley 9 10 Tirap 29

3 Upper Siang 14 11 East Kameng 30

4 Anjaw 16 12 Papum Pare 30

5 Kurung Kumey 19 13 Lohit 30

6 Lower Subansiri 23 14 West Siang 35

7 West Kameng 25 15 East Siang 35

8 Upper Subansiri 25 16 Changlang 37

Total 390

Table 25: District wise number of Mid-wives-population ratio in Rural Area

in Arunachal Pradesh Name of District Mid-

wives

in

Rural

Area

RuralPopulation

(Census

2011)

Mid-wives

Population

ratio

WHO

norms

Difference

from the

norm of

WHO

&GOI

%

Difference

(norm -

actual)

Dibang Valley 9 7948 883 500 383 43%

Anjaw 16 21089 1318 500 818 62%

L/D/Valley 26 42601 1639 500 1139 69%

East Kameng 30 60156 2005 500 1505 75%

East Siang 35 71417 2040 500 1540 75%

Upper Siang 14 28743 2053 500 1553 76%

West Siang 35 87311 2495 500 1995 80%

Papum Pare 30 79500 2650 500 2150 81%

West Kameng 25 68654 2746 500 2246 82%

Upper Subansiri 25 69595 2784 500 2284 82%

Lower Subansiri 23 70029 3045 500 2545 84%

Tirap 29 91113 3142 500 2642 84%

Changlang 37 128736 3479 500 2979 86%

Lohit 30 113700 3790 500 3290 87%

Kurung Kumey 19 89717 4722 500 4222 89%

Tawang 7 44323 6332 500 5832 92%Total 390 1074632 2755 500 2255 82%

The distributional pattern of the ANMs in rural & remote areas in the state is

also concentrated to the districts with good access to communication. The number of

nurses is concentrated to the districts are as Tawang 7nos. (2%), Dibang Valley 9 nos.

(2%), Upper Siang 14 nos. (4%), Anjaw 16 nos. (4%), Kurung Kumey 19 nos. (5%),

Lower Subansiri 23 nos. (6%),West Kameng 25 nos. (6%), Upper Subansiri 25 nos.

(6%), L/D/Valley 26 nos. (7%),Tirap 29 nos. (7%), East Kameng 30 nos. (8%),

Papum Pare 30nos. (8%), Lohit 30 nos. (8%), West Siang 35nos. (9%), East Siang 35



104

nos. (9%) and Changlang 37 nos. (9%). This trend is presented graphically in Figure

28, 29 and 30.

Figure 28: District wise numbers of mid-wives in rural and remote area

Arunachal Pradesh

Figure 29: District wise share of mid-wives in rural and remote area Arunachal

Pradesh

Figure 30: Graphical mapping of district wise number of mid-wives in rural andremote area in Arunachal Pradesh



105

4.2.5.URBAN-RURAL DISTRIBUTION OF PHYSICIANS,

NURSES AND MID-WIVESThe global problem of the unequal distribution of the health workforce

between urban and rural is also found in Arunachal Pradesh. The phenomenon of

workforce mal-distribution can be seen on the data analysed.

The percentage share of Physicians (Doctors) in urban and rural area is 37%

and 63% respectively, share of Nurses in urban and rural area is 46% and 54%

respectively, share of Mid-wives in urban and rural area is 28% and 72% respectively.

In comparison to 23% of the population is urban and 77% population is rural in the

state. Figure 31, 32 and 33 presents the situation graphically.

Figure 31: Urban-rural distribution of Physicians (doctors) in comparison to urban

– rural population in Arunachal Pradesh

Figure 32: Urban-rural distribution of Nurses in comparison to urban – rural




106

Figure 33: Urban-rural distribution of Mid-wives in comparison to urban – rural


4.2.5.1. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF PHYSICIANS

(DOCTORS) IN ARUNACHAL PRADESHThe percentage share of Physicians (Doctors) in urban and rural area is 37%

and 63% respectively in the state. When it is analysed district wise, the figures are

asymmetrical, Kurung Kumey, Dibang Valley and Anjaw Districts are predominantly

a rural area, the rest are having few numbers of health institute in urban area basically

the district hospital and general hospitals are in urban area. The figures range from

14% of urban concentration in Changlang district to 52% in Papumpare & 57% in

Upper Subansiri districts of physicians concentrated to the urban areas. However, as it

is mentioned only one institute per district are in urban areas, so in comparison it has

higher concentrations. The figures graphically of the entire district are presented in

figures 34 and 35.



107

Figure 34: District wise urban-rural percentage distribution of Physicians


Figure 35: Graphical mapping of district wise rate of urban concentration of


4.2.5.2. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF NURSES IN

ARUNACHAL PRADESH

The percentage share of Nurses in urban and rural area is 46% and 54%

respectively. When it is analysed district wise, the figures are asymmetrical

throughout the district and maximum of the nurses area concentrated to the urban

areas. It is already mentioned in earlier paragraphs that Kurung Kumey, Dibang

Valley and Anjaw Districts are predominantly a rural area, the rest are having few

numbers of health institute in urban area basically the district hospital and general



108

hospitals are in urban area. The figures range from the highest concentration of 79%

of Nurses in Urban area of Papum Pare District which is the capital complex of the

State, 60% of urban concentration in Lower Dibang Valley district to 55% in Tawang

districts. The lowest concentration of urban nurses is of 16% in Changlang district

besides the Kurung Kumey, Dibang Valley and Anjaw Districts. The figures of the

entire districts are presented in figures 36 and 37.

Figure 36: District wise urban-rural percentage distribution of nurses inArunachal Pradesh

Figure 37: Graphical mapping of district wise rate of urban concentration of

nurses in Arunachal Pradesh



109

4.2.5.3. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF MID-WIVES

(ANM) IN ARUNACHAL PRADESHThe percentage share of Mid-wives in urban and rural area is 28% and 72%,

which seems to be a good figure, however, Mid-wives are basically the category of

health workforce those are meant for Sub-centres and then to PHCs and CHCs. 54%

of ANM are concentrated in the capital complex urban area health institute in

Papumpare District. 59% in Tawang and the least in Upper Siang district (7%),

besides the predominate rural areas districts of Kurung Kumey, Dibang Valley and

Anjaw Districts. The figures of the entire district are presented in figures 38 and 39.

Figure 38: District wise urban-rural percentage distribution of mid-wives


Figure 39: Graphical mapping of district wise rate of urban concentration of mid-

wives in Arunachal Pradesh



110

4.2.6. NUMERICAL INADEQUACY OF PHYSICIANS, NURSES

AND MID-WIVES IN ARUNACHAL PRADESHAccording to RHS, 2010, the number of ANMs at Sub Centres and PHCs has

decreased from 454 in 2005 to 392 in 2010. The numbers of Nurses at PHCs and

CHCs has increased from 105 in 2005 to 293 in 2010. The Doctors at PHCs have

increased from 78 in 2005 to 92 in 2010. The number of Specialist doctors at CHCs

has increased from 0 in 2005 to 1 only in 2010, along with 108 General Duty Medical

Officers (GDMOs) is also available at CHCs.

However, as compared to requirement according to RHS, (2010), there was a

shortfall of 27 nos. of ANM at SCs taking into consideration of 286 SC in RHS, 2010,

whereas, the number of SCs without ANM out of 286 SCs were 56 SCs. There was

140 nos. of shortfall of Nurses in PHC/CHCs. The shortfall Doctors at PHCs were 5

in 2010 with PHCs without doctors were 10 out of 97 PHCs. There was a shortfall of

48 nos. of Obstetricians & Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs.

As per primary data available for this study, there are total no. of sanctioned

sub centres are 468, out of which only 301 have existing infrastructure, 222 No. of

SCs having only one ANM each, only 33 SCs have 2 nos. each ANMs. 22 nos. of

PHCs does not have Medical Officer i.e., the physician. 12 PHCs only have the full

strength of 3 staff nurses or 3 ANMs, none of the CHCs except are having fullcomplement of specialists i.e. Gynaecologist, Anaesthetist and Paediatrician.

It is also came to know from the interview of the management representative

that many of the health posts in the rural area are manned by the less skilled workers

like nursing assistant and other semi-skilled or unskilled fourth grade staffs, this

because of shortages in nurses and mid-wives or rather they are staying at urban areas.

The impact of this mal-distribution on health care delivery in rural areas is profound,

at times resulting in primary health care facilities being staffed mostly by other staffs.

Table 26: Showing the trend in physicians and nurses in-position in 2005 & 2010

State

SCS/PHCs ANM

CHCs/PHCs nurses

Physician

s (MO) inPHCs

Physicians

(MO)in CHCs

Specialistsin CHCs

2005 2010 2005 2010 2005 2010 2005 2010 2005 2010

Arunachal

Pradesh 454 395 105 293 78 92 NA 108 0 1

Source : RHS, 2010



111

4.2.6.1 REQUIREMENT AND SHORTFALL OF HUMAN RESOURCES IN

SCS, PHCS AND CHCS IN THE STATE ACCORDING TO IPHS NORMS.The availability of human resource is one of the vital prerequisite for the

competency in Rural Healthcare Delivery System in the state, where 77% population

(2011 census) lives in rural and remote areas.

The Government of India has developed the Indian Public Health Standards

(IPHS) and indicated the human resources requirements for SHC, PHC, CHC as well

as various Hospitals with bed strengths ranging from 31 to 500 beds. The estimation

is based on the HR data of the available health facilities as primarily collected by the

researcher, the requirement and shortfall of Physicians, nurses and mid-wives is

estimated on the basis of Indian Public Health Standards. For the estimation

requirement of physicians, nurse and mid-wives, the norms of IPHS for SHC, PHC,CHC , Hospital norms of 31-50 beds for District hospitals and Hospital norms for

101-200 beds for General Hospital has been adapted. The 31-50 beds norm for

District Hospital has been considered as most of the district hospitals in the state are

yet to attain the full requirement of First Referral Unit norms and lack one of other

infrastructural requirement of 51-100 beds. The detail norms of IPHS are presented in

Appendix.

There is an acute shortage of ANMs, Nurses and Physicians for the existing

health facilities (SHCs, PHCs, CHCs and District hospitals). There is a requirement of

570 more nos. of ANM and percentage of current shortfall is 51%. The requirement of

Nurses is 926 more nos. of nurses and percentage of current shortfall is 70%. The

requirement of Physicians (doctors) is 510 more nos. of nurses and percentage of

current shortfall is 53%. The critical human resources required for the entire health

institutes district wise in the state are as detailed below in table 27, 28 and 29.

Table: 27: District wise requirement and shortfall of ANM in ArunachalPradesh

Sl.

No Districts

ANMs

Requirement Available

Shortfall

(IPHS)

% of

Shortfall

1 Tawang 35 17 18 51%

2 West kameng 62 29 33 53%

3 East Kameng 93 45 48 52%

4 Papum Pare 100 65 35 35%

5 Lower Subansiri 59 35 24 41%

6 Kurung Kumey 104 19 85 82%

7 Upper Subansiri 107 41 66 62%8 West Siang 108 47 61 56%



112

9 East Siang 100 55 45 45%

10 Upper Siang 32 15 17 53%

11 L/D/Valley 34 32 2 6%

12 Dibang Valley 7 9 -2 -29%

13 Lohit 59 38 21 36%

14 Anjaw 58 16 42 72%15 Changlang 72 43 29 40%

16 Tirap 82 36 46 56%

Total 1112 542 570 51%

Table 28: District wise requirement and shortfall of Nurses in Arunachal

Pradesh

Sl.

No Districts

Nurses


Shortfall

(IPHS)

% of

Shortfall

1 Tawang 56 11 45 80%2 West Kameng 67 16 51 76%

3 East Kameng 78 8 70 90%

4 Papum Pare 143 90 53 37%


6 Kurung Kumey 78 11 67 86%

7 Upper Subansiri 102 14 88 86%

8 West Siang 129 35 94 73%

9 East Siang 185 62 123 66%

10 Upper Siang 57 12 45 79%

11 L/D/Valley 63 20 43 68%

12 Dibang Valley 24 2 22 92%13 Lohit 80 27 53 66%

14 Anjaw 24 8 16 67%

15 Changlang 87 31 56 64%

16 Tirap 75 19 56 75%

Total 1316 390 926 70%

Table 29: District wise requirement and shortfall of Physicians in Arunachal

Pradesh

Sl. No Districts

Physicians (Doctors)

Requirement AvailableShortfall(IPHS)

% of Shortfall

1 Tawang 40 19 21 53%

2 West kameng 53 26 27 51%

3 East Kameng 59 23 36 61%

4 Papum Pare 76 75 1 1%




8 West Siang 104 40 64 62%

9 East Siang 111 53 58 52%

10 Upper Siang 45 23 22 49%



113

11 Lower Dibang Valley 47 21 26 55%

12 Dibang Valley 13 5 8 62%

13 Lohit 62 33 29 47%

14 Anjaw 22 14 8 36%

15 Changlang 69 29 40 58%

16 Tirap 58 22 36 62%Total 959 449 510 53%

There is an acute shortage of ANMs, Nurses and Physicians for the existing

health facilities in rural areas (SHCs, PHCs, CHCs and District hospitals). There is a

requirement of 714 more nos. of ANM and percentage of current shortfall is 65%. The

requirement of Nurses is 747 more nos. of nurses and percentage of current shortfall

is 78%. The requirement of Physicians (doctors) is 545 more nos. of nurses and

percentage of current shortfall is 66%. The critical human resources required for the

entire health institutes in rural and remote area of district wise in the state are as

detailed below in table 30, 31 and 32.

Table 30: District wise rural and remote area requirement and shortfall of

ANMs in Arunachal Pradesh

Sl.

No Districts

ANMs


Shortfall

(IPHS)

% of

Shortfall

1 Tawang 35 7 28 80%

2 West Kameng 62 25 37 60%3 East Kameng 93 30 63 68%

4 Papum Pare 96 30 66 69%


6 Kurung Kumey 104 19 85 82%


8 West Siang 108 35 73 68%

9 East Siang 96 35 61 64%

10 Upper Siang 32 14 18 56%

11 L/D/Valley 34 26 8 24%

12 Dibang Valley 7 9 -2 -29%

13 Lohit 59 30 29 49%

14 Anjaw 58 16 42 72%

15 Changlang 72 37 35 49%

16 Tirap 82 29 53 65%

Total 1104 390 714 65%



114


Nurses in Arunachal Pradesh

Sl.

No Districts

Nurses


Shortfall

(IPHS)

% of

Shortfall

1 Tawang 37 5 32 86%

2 West Kameng 48 8 40 83%

3 East Kameng 59 4 55 93%

4 Papum Pare 68 19 49 72%




8 West Siang 110 24 86 78%

9 East Siang 110 33 77 70%

10 Upper Siang 38 6 32 84%

11 L/D/Valley 44 8 36 82%12 Dibang Valley 24 2 22 92%

13 Lohit 61 19 42 69%

14 Anjaw 24 8 16 67%

15 Changlang 68 26 42 62%

16 Tirap 56 11 45 80%

Total 957 210 747 78%



Sl.

No Districts

Physicians (Doctors)


Shortfall

(IPHS)

% of

Shortfall

1 Tawang 31 11 20 65%

2 West kameng 44 16 28 64%

3 East Kameng 50 12 38 76%

4 Papum Pare 60 36 24 40%




8 West Siang 95 32 63 66%

9 East Siang 95 31 64 67%

10 Upper Siang 36 10 26 72%

11 L/D/Valley 38 12 26 68%

12 Dibang Valley 13 5 8 62%

13 Lohit 53 23 30 57%

14 Anjaw 22 14 8 36%

15 Changlang 60 25 35 58%

16 Tirap 49 13 36 73%

Total 828 283 545 66%



115

SECTION 3

ANALYSIS OF THE DIMENSION

OF HR ISSUES IN ATTRACTION

OF PHYSICIANS, NURSES AND

MID-WIVES IN RURAL AND

REMOTE AREAS

OF THE STATE



116

4.3.1. INTRODUCTIONThis section of this chapter describes the dimensions of attraction of the

Physicians, nurses and mid-wives to the rural area services. An employee attitude

survey measured the employee attitudes towards the rural and remote area services

covering the factors that attracted them to the rural services. It is also attempted to

explore the factors that may attract them more to work in the rural and remote area.

Side by side this section of the chapter also presents where deem fit the management

perspective on the issue as well. The determination of the factor that majorly

attracted and may attract the physicians, nurses and mid-wives has considered on the

Mean factor which would be statistically significant at Mean Test value of (1.5), that

means the selection was done by the majority (more than half) of the respondents and

have an greater impact at large workforce. This helps in ascertain the most affected

factors for the current attraction and the factor that may attract the workforce.

4.3.2. FACTORS THAT ATTRACTED OR PLACED THE

PHYSICIANS, NURSES AND MID-WIVES IN THE CURRENT

JOB IN THE RURAL AND REMOTE AREA: CURRENT

DETERMINANTS OF ATTRACTION AND PLACEMENTS

Several previous studies have an outlook that the doctors and nurses are

reluctant to relocate to rural and remote areas. These workforces who are presently in

rural and remote areas are only due to compulsion or with their any other attraction

factors contribute to their location. So, in this section it is attempted to explore the

factors contributed regarding physicians, nurses and mid-wives for selection of their

current employment in the rural and remote area. Is the compulsion is only factor

which contributed to their attraction of rural area services, or the other factors do

contribute to it. The exploration is based on the sixteen (16) preset factors which were

included for the same. The determination of the factor that majorly attracted the

physicians, nurses and mid-wives has considered on the Mean factor which would be

statistically significant at Mean value of (1.5), that means the selection was done by

the majority (more than half) of the respondents and have an greater impact at large

workforce. This helps in ascertain the most affected factors presently.

The Reliability analysis was done for the present attraction factors consistency

of responses to items. The Cronbach alpha coefficient indicates the consistency of

responses to items in a measure (Foxcroft & Roodt, 2002). The Cronbach’s alpha

coefficient for the factor items is α =(-0.038) on item 16 and N=334, which is a



117

negative alpha and when the factor no 8: Compulsion (minimum rural service tenure

or non-transferable or Management or political pressure) has been dropped and the

Cronbach’s alpha coefficient comes to α =(0.534) on item 15 and N=334, which is

higher than 0.5.

As it can be derived from Table 33, the results indicated the factors of

attraction of the physicians, nurses and mid-wives as : Compulsion (minimum rural

service tenure or non-transferable or Management or political pressure) (1.58), Career

opportunity (1.25), Current health facility is closer to town or Closer to family and

friends (1.20), Continuing education/higher education Opportunities (1.20), Training

and skill development Opportunities (1.19), Flexible working hour with minimal

workload (1.13), Authority, independency and autonomy (1.09), Improved working

condition (1.09), Amenities like housing, conveyance provided (1.07), Availability of

equipment, drugs and supplies (1.05), Availability of good schools for children nearby

town (1.05), Safety at workplace (1.04), Teamwork and Interpersonal staffs

relationship (1.03), Reward and recognition system (1.00), Supportive supervision

and mentoring (1.00) and Financial incentives / Rural allowances/ Performance

incentives (1.00). Whereas the Compulsion (minimum rural service tenure or non-

transferable or Management or political pressure) having mean of 1.58 has the highest

mean and the factor item contributed the employee to be in rural and remote area but

it may resulted in non-commitment towards the service. Compulsion (minimum rural

service tenure or non-transferable or Management or political pressure) is statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)= 2.990 , p=

.003. The Percentage selection of Factor for Attraction or placed is presented in detail

in table 34.

Table 33: Descriptive Statistics of the factors that attracted or placed the

Physicians, nurses and mid-wives in the current job in the rural and remotearea

Factors

N MeanStd.Dev.

Test Value = 1.5

t df

Sig.

(2-tailed)

MeanDiff.

Compulsion 334 1.58 .494 2.990 333 .003 .081

Career development opportunity 334 1.25 .433 -10.620 333 .001 -.251

Current health facility is closer

to town or Closer to family and

friends

334 1.20 .403 -13.433 333 .001 -.296

Continuing education/higher education Opportunities

334 1.20 .401 -13.644 333 .001 -.299



118

Training and skill development

Opportunities

334 1.19 .394 -14.298 333 .001 -.308

Flexible working hour with

minimal workload

334 1.13 .332 -20.598 333 .001 -.374

Improved working condition 334 1.09 .291 -25.607 333 .001 -.407

Authority, independency andautonomy

334 1.09 .291 -25.607 333 .001 -.407

Amenities like housing,conveyance provided

334 1.07 .254 -31.070 333 .001 -.431

Availability of equipment,drugs and supplies

334 1.05 .226 -36.052 333 .001 -.446

Availability of good schools

for children nearby town

334 1.05 .214 -38.630 333 .001 -.452

Safety at workplace 334 1.04 .194 -43.503 333 .001 -.461

Teamwork and Interpersonal

staffs relationship

334 1.03 .171 -50.333 333 .001 -.470

Financial incentives / Rural

allowances/ Performance

incentives

334 1.00 .000

- - - -

Supportive supervision and

mentoring

334 1.00 .000- - - -

Reward and recognition system 334 1.00 .000 - - - -

Table 34: Percentage selection of factors for attraction by Physicians, nurses

and mid-wives

Factors n n%

Compulsion 194 58%

Career development opportunity 83 25%

Current health facility is closer to town or Closer to family and friends 68 20%

Continuing education/higher education Opportunities 67 20%

Training and skill development Opportunities 64 19%

Flexible working hour with minimal workload 42 13%

Improved working condition 31 9%

Authority, independency and autonomy 31 9%

Amenities like housing, conveyance provided 23 7%

Availability of equipment, drugs and supplies 18 5%

Availability of good schools for children nearby town 16 5%

Safety at workplace 13 4%

Teamwork and Interpersonal staffs relationship 10 3%

Financial incentives / Rural allowances/ Performance incentives 0 0%

Supportive supervision and mentoring 0 0%

Reward and recognition system 0 0%



119

4.3.2.1. FACTORS THAT ATTRACTED OR PLACED THE PHYSICIANS IN

PRESENT RURAL AND REMOTE AREA

As it can be derived from table 35, the factors of attraction of the physicians

in rural and remote area service are basically is Compulsion (minimum rural service

tenure or non-transferable or Management or political pressure) (1.66), beside the

factor of compulsion, the other attraction top five factors are-Continuing

education/higher education Opportunities (1.46), Career development opportunity

(1.23), Current health facility is closer to town or Closer to family and friends (1.20),

Authority, independency and autonomy (1.19) and Training and skill development

Opportunities (1.16). Only one factor that is the Compulsion is statistically significant

at Mean Test Value=1.5, 95%C.I, it is significant at t(113)=3.667 , p= .001. The

Percentage selection of Factor for Attraction or placed is presented in table 38.Table 35: Descriptive Statistics of the factors that attracted or placed the

Physicians in the current job in the rural and remote area

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

taile

d)

Mean

Diff.

Compulsion 113 1.66 .475 3.667 112 .001 .164

Continuing /higher education

Opportunity

113 1.46 .501 -.846 112 .400 -.040


Current health facility is closer to

town or Closer to family &friends

113 1.20 .404 -7.792 112 .001 -.296

Authority,independency&autonomy 113 1.19 .398 -8.160 112 .001 -.305


Opportunities

113 1.16 .368 -9.853 112 .001 -.341


Availability of equipment, drugs

and supplies

113 1.08 .272 -16.431 112 .001 -.420


minimal workload

113 1.08 .272 -16.431 112 .001 -.420


Amenities like housing,

conveyance provided

113 1.07 .258 -17.710 112 .001 -.429

Availability of good schools for

children nearby town

113 1.06 .242 -19.231 112 .001 -.438

Teamwork and Interpersonal staffs

relationship

113 1.04 .186 -26.609 112 .001 -.465

Financial / Rural allowances/

Performance incentives

113 1.00 .000- - - -

Supportive supervision & mentoring 113 1.00 .000 - - - -Reward and recognition system 113 1.00 .000 - - - -



120

When the group of physicians is further divided to contractual physicians, two

factors are significant and the factors are the Compulsion (minimum rural service

tenure or non-transferable or Management or political pressure) and Continuing

education/higher education is statistically significant at Mean Test Value=1.5, 95%

C.I, it is significant at t(34)= 3.064 , p= .004 and t(34)= 1.339 , p= .037. The

Percentage selection of Factor for Attraction or placed is presented in table 38.


contract Physicians in the current job in the rural and remote area

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.

Compulsion 34 1.74 .448 3.064 33 .004 .235

Continuing education/higher

education Opportunities

34 1.58 .500 1.339 33 .037 .029

Career development

opportunity

34 1.38 .493 -1.391 33 .174 -.118

Training and skilldevelopment Opportunities

34 1.21 .410 -4.179 33 .001 -.294

Current health facility is

closer to town or Closer to

family and friends

34 1.12 .327 -6.817 33 .001 -.382



minimal workload

34 1.06 .239 -10.771 33 .001 -.441



incentives

34 1.00 .000

- - - -

Availability of equipment,

drugs and supplies

34 1.00 .000- - - -

Authority, independency

and autonomy

34 1.00 .000- - - -


mentoring

34 1.00 .000- - - -


conveyance provided

34 1.00 .000- - - -

Reward and recognition

system

34 1.00 .000- - - -

Teamwork and

Interpersonal staffs

relationship

34 1.00 .000

- - - -

Safety at workplace 34 1.00 .000 - - - -



34 1.00 .000- - - -



121

When the group of permanent physicians is analysed separately, the same

factor, that is the Compulsion (minimum rural service tenure or non-transferable or

Management or political pressure) is statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(79)= 2.435 , p=.017. The Percentage selection of Factor

for Attraction or placed is presented in table 38.


permanent Physicians in the current job in the rural and remote area

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.

Compulsion 79 1.63 .485 2.435 78 .017 .133

Continuing

education/higher educationOpportunities

79 1.43 .498 -1.242 78 .218 -.070

Authority, independency

and autonomy

79 1.28 .451 -4.365 78 .001 -.222


closer to town or Closer tofamily and friends

79 1.24 .430 -5.362 78 .001 -.259

Career development

opportunity

79 1.16 .373 -7.990 78 .001 -.335

Training and skill

development Opportunities

79 1.14 .348 -9.203 78 .001 -.361

Improved working

condition

79 1.11 .320 -10.732 78 .001 -.386


drugs and supplies

79 1.11 .320 -10.732 78 .001 -.386



conveyance provided

79 1.10 .304 -11.673 78 .001 -.399

Flexible working hour withminimal workload

79 1.09 .286 -12.785 78 .001 -.411



79 1.09 .286 -12.785 78 .001 -.411

Teamwork and


relationship

79 1.05 .221 -18.102 78 .001 -.449



incentives

79 1.00 .000

- - - -


mentoring

79 1.00 .000- - - -


system

79 1.00 .000- - - -



122

Table 38: Percentage selection of factors for Attraction by Physicians

Factors Physicians

Contract

Physicians

Permanent

Physicians

n n % n n % n n %

Compulsion 75 66% 25 74% 50 63%Continuing /higher education Opportunities 52 46% 18 53% 34 43%

Career development opportunity 26 23% 13 38% 13 16%

Current health facility is closer to town or

Closer to family and friends

23 20% 4 12% 19 24%

Authority, independency and autonomy 22 19% 0 0% 22 28%

Training and skill developmentOpportunities

18 16% 7 21% 11 14%

Improved working condition 11 10% 2 6% 9 11%

Availability of equipment, drugs and

supplies

9 8% 0 0% 9 11%

Flexible working hour with minimal

workload

9 8% 2 6% 7 9%

Safety at workplace 9 8% 0 0% 9 11%

Amenities like housing, conveyance

provided

8 7% 0 0% 8 10%

Availability of good schools for children

nearby town

7 6% 0 0% 7 9%


relationship

4 4% 0 0% 4 5%

Financial incentives / Rural allowances/


0 0% 0 0% 0 0%

Supportive supervision and mentoring 0 0% 0 0% 0 0%

Reward and recognition system 0 0% 0 0% 0 0%

4.3.2.2. FACTORS THAT ATTRACTED OR PLACED THE NURSES IN

PRESENT RURAL AND REMOTE AREAThe factors that attracted or placed the nurses can be derived from table 39.

The results indicated the factors of Compulsion (minimum rural service tenure or non-

transferable or Management or political pressure) (1.59) have the highest Mean.

Beside the compulsion for the choice of the rural posting, the other top five factors of attraction for the nurses are- Current health facility is closer to town or Closer to

family and friends (1.26), Training and skill development Opportunities (1.26), Career

development opportunity (1.21), Flexible working hour with minimal workload (1.14)

and Improved working condition (1.08).

Thus, only one factor, that is the Compulsion (minimum rural service tenure or

non-transferable or Management or political pressure) is statistically significant at

Mean Test Value=1.5, 95% C.I, it is significant at t(97)=1.201, p=.041. The

Percentage selection of Factor for Attraction or presented is place in table 42.



123


nurses in the current job in the rural and remote area

Factors

N MeanStd.Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mea

nDiff.

Compulsion 98 1.59 .402 1.201 97 .041 .09


Opportunities

98 1.26 .438 -5.533 97 .001 -.245


town or Closer to family &

friends

98 1.26 .438 -5.533 97 .001 -.245


Flexible working hour withminimal workload

98 1.14 .352 -10.052 97 .001 -.357

Improved working condition 98 1.08 .275 -15.049 97 .001 -.418Amenities like housing,

conveyance provided

98 1.07 .259 -16.389 97 .001 -.429


drugs and supplies

98 1.05 .221 -20.096 97 .001 -.449



98 1.04 .199 -22.856 97 .001 -.459


staffs relationship

98 1.03 .173 -26.836 97 .001 -.469


Financial incentives / Ruralallowances/ Performance

incentives

98 1.00 .000- - - -

Authority, independency and

autonomy

98 1.00 .000- - - -


98 1.00 .000- - - -


mentoring

98 1.00 .000- - - -


When the data is analysed separately in the case of permanent nurses, it isfound that there is the combination of two factors of Compulsion (minimum rural

service tenure or non-transferable or Management or political pressure) and current

health facility is closer to town or to family are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(52)=2.442, p=.018 and t(52)=3.112,

p=.003. The Percentage selection of Factor for Attraction or placed is presented in

table 42.



124


permanent nurses in the current job in the rural and remote area

Factor

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.Compulsion 53 1.64 .578 2.442 52 .018 .160


to town or Closer to family andfriends

53 1.60 .563 3.112 52 .003 .198


53 1.21 .409 -5.200 52 .001 -.292


minimal workload

53 1.21 .409 -5.200 52 .001 -.292


conveyance provided

53 1.13 .342 -7.836 52 .001 -.368



Availability of equipment, drugs

and supplies

53 1.06 .233 -13.836 52 .001 -.443


staffs relationship

53 1.06 .233 -13.836 52 .001 -.443



53 1.06 .233 -13.836 52 .001 -.443



allowances/ Performanceincentives

53 1.00 .000

- - - -

Authority, independency andautonomy

53 1.00 .000- - - -



53 1.00 .000- - - -


mentoring

53 1.00 .000- - - -


While in the case of contract nurses, only one factors of Compulsion

(minimum rural service tenure or non-transferable or Management or political

pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant

at t(44)=3.090, p=.003. The Percentage selection of Factor for Attraction or

presented is place in table 42.



125

Table 41 : Descriptive Statistics of the factors that attracted or placed the

contract nurses in the current job in the rural and remote area

Factor

N MeanStd.Dev.

Test Value = 1.5

t df

Sig.

(2-tailed)

MeanDiff.

Compulsion 45 1.71 .458 3.090 44 .003 .211

Career development

opportunity

45 1.36 .484 -2.002 44 .052 -.144


45 1.31 .468 -2.706 44 .010 -.189



family and friends

45 1.16 .367 -6.304 44 .001 -.344



minimal workload

45 1.07 .252 -11.523 44 .001 -.433


drugs and supplies

45 1.04 .208 -14.663 44 .001 -.456



45 1.02 .149 -21.500 44 .001 -.478


allowances/ Performanceincentives

45 1.00 .000

- - - -


autonomy

45 1.00 .000- - - -



45 1.00 .000- - - -


mentoring

45 1.00 .000- - - -


45 1.00 .000- - - -


system

45 1.00 .000- - - -


staffs relationship

45 1.00 .000- - - -


Table 42: Percentage selection of factors for Attraction by nurses

Factors

Nurses

Contract

Nurses

Permanent

Nurses

n n% n n% n n%

Financial incentives / Rural allowances/


0 0% 0 0% 0 0%


Availability of equipment, drugs and supplies 5 5% 2 4% 3 6%

Authority, independency and autonomy 0 0% 0 0% 0 0%Career development opportunity 21 21% 16 36% 5 9%



126

Continuing education/higher educationOpportunities

0 0% 0 0% 0 0%

Training and skill development Opportunities 25 26% 14 31% 11 21%

Compulsion 48 49% 32 71% 16 30%

Flexible working hour with minimal workload 14 14% 3 7% 11 21%

Supportive supervision and mentoring 0 0% 0 0% 0 0%Amenities like housing, conveyance provided 7 7% 0 0% 7 13%


Teamwork and Interpersonal staffs relationship 3 3% 0 0% 3 6%


Availability of good schools for children

nearby town

4 4% 1 2% 3 6%

Current health facility is closer to town or Closer to family and friends

25 26% 7 16% 18 34%

4.3.2.3. FACTORS THAT ATTRACTED OR PLACED THE MID-WIVES INPRESENT RURAL AND REMOTE AREAThe factors that attract or placed the mid-wives towards rural and remote area

has also the factor of Compulsion (minimum rural service tenure or non-transferable

or Management or political pressure) (1.58), which have the highest mean, detail can

be derived from the table 43. Beside the compulsion, the other top five factors of

attraction for the nurses are- Career development opportunity (1.29), Training and

skill development Opportunities (1.17), Current health facility is closer to town or

Closer to family and friends (1.16), Flexible working hour with minimal workload(1.15) and Continuing education/higher education Opportunities (1.12). However,

only one factor that is the Compulsion (minimum rural service tenure or non-

transferable or Management or political pressure) is statistically significant at Mean

Test Value=1.5, 95% C.I, it is significant at t(122)=1.727, p=.047. The Percentage

selection of Factor for Attraction or placed is presented in table 46.


mid-wives in the current job in the rural and remote area

Factors

N MeanStd.Dev.

Test Value = 1.5

t df

Sig.

(2-tailed)

MeanDiff.

Compulsion 123 1.58 .496 1.727 122 .047 .077

Career developmentopportunity

123 1.29 .457 -5.033 122 .001 -.207

Training and skill


123 1.17 .378 -9.666 122 .001 -.329


closer to town or Closer tofamily and friends

123 1.16 .371 -10.099 122 .001 -.337



127


minimal workload

123 1.15 .363 -10.560 122 .001 -.346

Continuing

education/higher educationOpportunities

123 1.12 .329 -12.761 122 .001 -.378

Improved working condition 123 1.10 .298 -14.981 122 .001 -.402Authority, independency

and autonomy

123 1.07 .261 -18.104 122 .001 -.427


123 1.07 .248 -19.482 122 .001 -.435

Availability of good

schools for children nearby

town

123 1.04 .198 -25.692 122 .001 -.459


drugs and supplies

123 1.03 .178 -29.110 122 .001 -.467

Teamwork andInterpersonal staffs

relationship

123 1.02 .155 -34.055 122 .001 -.476




incentives

123 1.00 .000

- - - -

Supportive supervision andmentoring

123 1.00 .000- - - -


system

123 1.00 .000- - - -

When the data for the group of contractual mid-wives are separately analysed,

the same factor of Compulsion (minimum rural service tenure or non-transferable or

Management or political pressure) is statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(74)=5.616, p=.001. The Percentage selection of Factor

for Attraction or placed is presented in table 46.


contractual mid-wives in the current job in the rural and remote area

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.

Compulsion 75 1.77 .421 5.616 74 .001 .273

Career developmentopportunity

75 1.39 .490 -2.002 74 .049 -.113


75 1.15 .356 -8.592 74 .001 -.353



family and friends

75 1.09 .293 -12.026 74 .001 -.407




128



75 1.05 .226 -17.100 74 .001 -.447


minimal workload

75 1.04 .197 -20.193 74 .001 -.460


75 1.01 .115 -36.500 74 .001 -.487

Authority, independencyand autonomy

75 1.01 .115 -36.500 74 .001 -.487



75 1.01 .115 -36.500 74 .001 -.487



incentives

75 1.00 .000

- - - -


mentoring

75 1.00 .000- - - -


75 1.00 .000 - - - -

Reward and recognitionsystem

75 1.00 .000- - - -

Teamwork andInterpersonal staffs

relationship

75 1.00 .000- - - -


While in the case of permanent mid-wives, it is also found that the same factor

of Compulsion (minimum rural service tenure or non-transferable or Management or

political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is

significant at t(47)=2.424, p=.019. The Percentage selection of Factor for Attraction

or placed is presented in table 46.


permanent mid-wives in the current job in the rural and remote area

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.Compulsion 48 1.63 .576 2.424 47 .019 .167


minimal workload

48 1.27 .449 -3.535 47 .001 -.229


to town or Closer to family and

friends

48 1.27 .449 -3.535 47 .001 -.229



48 1.23 .425 -4.418 47 .001 -.271

Training & skill development

Opportunities

48 1.21 .410 -4.924 47 .001 -.292

Authority, independency &autonomy

48 1.17 .377 -6.132 47 .001 -.333



129


conveyance provided

48 1.17 .377 -6.132 47 .001 -.333





48 1.08 .279 -10.335 47 .001 -.417


drugs and supplies

48 1.06 .245 -12.391 47 .001 -.438


staffs relationship

48 1.06 .245 -12.391 47 .001 -.438


Financial incentives/Rural

allowances/Performance

incentives

48 1.00 .000

- - - -

Supportive supervision&mentori 48 1.00 .000 - - - -


Table 46: Percentage selection of factors for Attraction by mid-wives

Factors

Mid-

wives

Contract

mid-

wives

ermanent

id-wives

n n% n n% n n%

Compulsion 71 58% 58 77% 13 27%

Career development opportunity 36 9% 29 9% 7 15%

Training and skill development Opportunities 21 17% 11 15% 10 21%

Current health facility is closer to town or Closer to

family and friends

20 16% 7 9% 13 27%

Flexible working hour with minimal workload 19 15% 3 4% 16 33%

Continuing education/higher education Opportunities 15 12% 4 5% 11 23%


Authority, independency and autonomy 9 7% 1 1% 8 17%

Amenities like housing, conveyance provided 8 7% 0 0% 8 17%

Availability of good schools for children nearby town 5 4% 1 1% 4 8%

Availability of equipment, drugs and supplies 4 3% 1 1% 3 6%

Teamwork and Interpersonal staffs relationship 3 2% 0 0% 3 6%


Financial incentives / Rural allowances/ Performance

incentives

0 0% 0 0% 0 0%

Supportive supervision and mentoring 0 0% 0 0% 0 0%


4.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION AND

DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS,

NURSES AND MIDWIVES

The analysing of the relationship of factors of Attraction and the demographic

characteristics of physicians such as age, sex, family background, marital status,



130

length of service, place of work and nature of employment is presented in this

section. The three factors of attraction viz., Financial incentives / Rural allowances/

Performance incentives, Supportive supervision & mentoring and Reward and

recognition system, have at least one of the variables has zero variance and there is

only one variable in the analysis chi-square could not be computed for all pairs of

variables, henceforth it has been dropped from the analysis.

4.3.3.1. RELATIONSHIP OF FACTORS OF ATTRACTION AND

DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS

From the analysis of primary data at table 47, it is found that there is a

relationship between age group of the physicians and attraction factors like

availability of equipment, drugs and supplies { χ 2(3, N = 113) = 13.9, p = 0.003,

Cramer’s V=0.408} the higher age group (more than 30 years) of the physicians has

the tendency to attract by this factor; Authority, independency and autonomy { χ 2(3, N

= 113) = 34.43, p = 0.001, Cramer’s V=0.545} the higher age group (more than 30

years) of the physicians has the tendency to attract by this factor; Amenities like

housing & conveyance provided { χ 2(3, N = 113) = 8.79, p = 0.03, Cramer’s

V=0.267 } the higher age group (more than 30-50 years) of the physicians has the

tendency to attract by this factor; Safety at workplace { χ 2(3, N = 113) = 13.9, p =

0.003, Cramer’s V=0.408} the higher age group (more than 30-50 years) of the

physicians has the tendency to attract by this factor; and Current health facility is

closer to town or closer to family and friends { χ 2(3, N = 113) = 9.746, p = 0.021,

Cramer’s V=0.268} the higher age group (more than 30-50 years) of the physicians

has the tendency to attract by this factor.

It is also found that the Marital Status of the physicians has relationship with

Authority independency and autonomy { χ 2(1, N = 113) = 16.16, p = 0.001, Cramer’s

V=0.378, 31% of married physicians against non of the unmarried physicians are

attracted by this reason; amenities like housing & conveyance provided { χ 2(1, N =

113) = 5.093, p = 0.024, Cramer’s V=0.212}, this factor has contributed as a factor

to 11.3% of married physicians against none of the unmarried; safety at workplace

{ χ 2(1, N = 113) = 5.785, p = 0.016, Cramer’s V=0.226 }, 12% of the married

physicians were attracted as one of the factor for attraction against none of the

unmarried physicians has attract due to this factor; and availability of good schools

for children nearby town { χ 2

(1, N = 113) = 4.414, p = 0.036, Cramer’s V=0.198}, it



131

is obvious that the married physicians were attracted of this reason, only 9.9% of

married physicians were attracted of this reason.

While, there is a relationship between Length of service of the physicians and

attraction from the availability of equipment, drugs and supplies { χ 2(4, N = 113) =

13.937, p = 0.007, Cramer’s V=0.351} the higher service length physicians 52% of

more than 10-20 years of service length of the physicians has shown the tendency to

attract by this factor; Authority, independency and autonomy { χ 2(4, N = 113) =

26.762, p = 0.001, Cramer’s V=0.487 } the higher age group (more than 10-25 years-

19% of 5-10 years, 43% of 10-15 years, 66% of 15-20 years and 100% of 20-25

years) of the physicians has shown the tendency to attract by this factor; Compulsion

(minimum rural service tenure or non-transferable or Management or political

pressure) { χ 2(4, N = 113) = 10.251, p = 0.036, Cramer’s V=0.301}, the physicians

with lower service length are serving in the rural area, 52% out of the service length

of 0-5 years and 33% out of the service length of 5-10 years are serving in

compulsion; Amenities like housing & conveyance provided{ χ 2(4, N = 113) =

16.454, p = 0.002, Cramer’s V=0.382} the physicians with medium and higher

service length are attracted by this factor, 6.3% out of the service length of 5-10

years, 24% out of the service length of 10-15 years and 33% of 15-20 years services

length are attracted of this; Teamwork and Interpersonal staffs relationship{ χ 2(4, N =

113) = 18.167, p = 0.001, Cramer’s V=0.401} only the 19% of physicians who have

10-15 years service length have considered this factor; Availability of good schools

for children nearby town { χ 2(4, N = 113) = 10.489, p = 0.033, Cramer’s V=0.305},

only 28% physicians with service length of 5-15 years has considered that this factor

has contributed to the attraction to rural areas, and Current health facility is closer to

town or closer to family and friends { χ 2(4, N = 113) = 14.217, p = 0.007, Cramer’s

V=0.355}, this factor has attracted almost all the physicians from 12% to 50% of

individual service length group, it is observed the attraction tendency is increasing as

the length of the services increases.

Similarly, it is found that there is a relationship between Nature of

Employment of physicians and attraction factors like Availability of equipment,

drugs and supplies { χ 2(3, N = 113) = 4.209, p = 0.04, Cramer’s V=0.193}, 12% of

the permanent physicians are more attracted of this factor than that of the contract

physicians but more of the both category were not agreed to this factor; Authority,

independency and autonomy { χ 2(3, N = 113) = 11.757, p = 0.001, Cramer’s



132

V=0.323} have 28% of the permanent physicians agreed that they were attracted but

more of the both category has not agreed to it; Career development opportunity { χ 2(3,

N = 113) = 6.365, p = 0.012, Cramer’s V=0.237 }-39% of contract and 16% of

permanent physicians are attracted of this factor; and Amenities like housing,

conveyance provided{ χ 2(3, N = 113) = 3.705, p = 0.05, Cramer’s V=0.181} have

more of the permanent physicians in comparison to contract employees attracted of

this factor.

Similarly, it is found that there is a significant relationship between the choice

of Place of work (rural health institution) by the physicians and Authority,

independency and autonomy at the place of posting { χ 2(3, N = 113) = 7.61, p = 0.05,

Cramer’s V=0.245} have physicians have more tendency to choice PHCs and CHCs

of this factor. Wherein, we did not found any relationship between the factors and sex

of the physicians and family background of the physicians has no relationship with

any other factors of attraction.



133

Table 47: Relationship between the factor for attraction or placement with the demographic attributes of Physicians

Factor of Attraction or

placement

With Age group With Sex With FamilyBackground

With MaritalStatus

With Length of service (group)

With Place of work

With nature of Employment

(χ 2) p

CV

(χ 2) p

CV (χ 2) p

CV (χ 2) p

CV

(χ 2) p

CV (χ 2) p

CV

(χ 2) p

CV

Improved working

condition

1.84

6

0.60

5

0.121 0.61 0.6

89

0.038 0.61

7

0.43

2

0.074 0.51

1

0.47

5

0.06

7

1.065 0.9 0.09

7

6.86

6

0.07

6

0.274 0 .821 0.365 0.085


supplies

13.9 0.003

0.408 2.922 0.087

0.161 1.253

0.263

0.105 2.843

0.092

0.159

13.937 0.007 0.351

2.989

0.393

0.166 4.209 0.04 0.193

Authority,

independency andautonomy

34.4

3

0.00

1

0.545 0.359 0.5

49

0.056 0.87

1

0.35

1

0.088 16.1

6

0.00

1

0.37

8

26.762 0.001 0.48

7

7.61 0.05 0.245 11.75

7

0.001 0.323

Career development

opportunity

3.26

4

0.35

3

0.166 0.272 0.6

02

0.049 5.29

2

0.22

1

0.216 2.38

1

0.12

3

0.14

5

4.603 0.331 0.20

2

4.77

8

0.18

9

0.204 6 .365 0.012 0.237

Continuing

education/higher

education

Opportunities

1.97

6

0.57

7

0.119 1.853 0.1

73

0.128 0.09

2

0.76

1

0.029 0.01

6

0.89

8

0.01

2

5.653 0.227 0.22

4

1.16

1

0.76

2

0.101 0 .938 0.333 0.091

Training and skill

development

Opportunities

3.44

3

0.32

8

0.178 0.275 0.6 0.049 4.95

8

0.42

6

0.209 0.02

7

0.86

9

0.01

5

2.535 0.638 0.15 0.48

4

0.92

2

0.054 0 .788 0.375 0.084

Compulsion 3.17

1

0.42

4

0.157 0.353 0.5

52

0.056 0.3 0.58

4

0.052 0.13 0.71

8

0.03

4

10.251 0.036 0.30

1

1.16

5

0.83

6

0.087 1 .116 0.291 0.099

Flexible working hour

with minimal

workload

3.91

4

0.27

1

0.21 0.588 0.4

43

0.072 0.12

1

0.72

8

0.033 0.22

2

0.63

8

0.04

4

5.01 0.286 0.21

1

1.13 0.77 0.076 0.288 0.592 0.05

Amenities like

housing, conveyance

provided

8.79 0.03 0.267 0.537 0.4

64

0.069 0.35

8

0.55 0.056 5.09

3

0.02

4

0.21

2

16.454 0.002 0.38

2

2.16 0.54 0.147 3.705 0.05 0.181

Teamwork and


relationship

5.75

2

0.12

4

0.244 1.239 0.2

66

0.105 0.96 0.32

7

0.092 2.45

3

0.11

7

0.14

7

18.167 0.001 0.40

1

8.11

7

0.04

4

0.268 1 .785 0.182 0.126

Safety at workplace 13.9

9

0.00

3

0.408 0.588 0.4

43

0.072 0.12

1

0.72

8

0.033 5.78

5

0.01

6

0.22

6

6.844 0.144 0.29

9

2.22

2

0.52

8

0.128 4.209 0.08 0.193


schools for children

nearby town

6.02

3

0.11

1

0.185 2.23 0.1

35

0.14 6.83

2

0.10

9

0.046 4.41

4

0.03

6

0.19

8

10.489 0.033 0.30

5

7.99

6

0.04

6

0.265 3 .212 0.073 0.169

Current health facility

is closer to town or

Closer to family and

friends

9.74

6

0.02

1

0.268 0.154 0.6

94

0.037 1.66

3

0.19

7

0.121 0.56

1

0.45

4

0.07 14.217 0.007 0.35

5

3.47

4

0.32

4

0.173 2.213 0.137 0.14

CV= Cramer’s V



134

4.3.3.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE

DEMOGRAPHIC CHARACTERISTICS OF NURSES

While analysing the relationship of factors of Attraction and the demographic

characteristics of the respondents such as age, family background, marital status,

length of service, place of work and nature of employment, wherein the sex

characteristic has been dropped as only one case of differentiation is there in the data.

The three factors of attraction viz., Financial incentives / Rural allowances/

Performance incentives, Supportive supervision & mentoring and Reward and

recognition system, have at least one of the variables has zero variance and there is

only one variable in the analysis chi-square could not be computed for all pairs of

variables, henceforth it has been dropped from the analysis.

According to the table 48, it is found that there is a relationship between agegroup of the nurses and Career development opportunity { χ 2(3, N = 98) = 2.443, p =

0.03, Cramer’s V=0.151} as lower age group nurses (20-30 yrs) has attraction of this

factor, Training and skill development Opportunities { χ 2(3, N = 98) = 3.928, p =

0.039, Cramer’s V=0.204} as lower age group nurses (20-40 yrs) has attraction of

this, and Compulsion (minimum rural service tenure or non-transferable or

Management or political pressure) { χ 2(3, N = 98) = 19.43, p = 0.001, Cramer’s

V=0.43} as lower age group nurses (20-40 yrs) has attraction of this.

Whereas, no association has been found of marital status and other attraction

factors, except the Compulsion has a relationship { χ 2(3, N = 98) = 4.665, p = 0.031,

Cramer’s V=0.218}, 62.5% married nurses has agreed that they are in rural services

on compulsion.

Similarly, the length of services (group) has the relationship to Career

development opportunity { χ 2(4, N = 98) = 9.288, p = 0.05, Cramer’s V=0.289} as

more of the lower group of the service length of 0-5 yrs has attracted for this reason,

Compulsion { χ 2(4, N = 98) = 24.473, p = 0.001, Cramer’s V=0.471} as more of the

lower group of the service length of 0-10 yrs has attracted for this reason, Amenities

like housing & conveyance provided { χ 2(4, N = 98) = 11.919, p = 0.018, Cramer’s

V=0.314}in which the group of 5-15 yrs of service length attracted due to this factor

and current health facility is closer to town or closer to family and friends { χ 2(4, N =

98) = 10.048, p = 0.040, Cramer’s V=0.331} as more of the higher group of the

service length of 10-20 yrs has attracted for this reason.



135

It is also found that the nature of employment has relationship with Career

development opportunity { χ 2(1, N = 98) = 9.863, p = 0.002, Cramer’s V=0.317 }

35.6% contract nurses has attracted in comparison to 9.4% permanent nurses attracted

of this factor; compulsion { χ 2(1, N = 98) = 16.309, p = 0.001, Cramer’s V=0.408}

have 66.7% contract nurses out of the total nurses opted for compulsion in

comparison to the permanent nurses; Flexible working hour with minimal workload

{ χ 2(1, N = 98) = 3.945, p = 0.047, Cramer’s V=0.201} as the permanent nurses are

more attracted, 78.6% permanent nurses opted for this against the 21.4% contract

nurses; Amenities like housing & conveyance provided { χ 2(1, N = 98) = 6.401, p =

0.011, Cramer’s V=0.256 } 13.2% of permanent nurses were attracted for this factor

to the rural services and non of the contract nurses; and Current health facility is


Cramer’s V=0.210} this factor has attracted 34% of permanent nurses against 15% of

contract nurses.

However, we found no association between Place of work and other attraction

factors other than the Availability of equipment, drugs and supplies { χ 2(3, N = 98) =

4.665, p = 0.031, Cramer’s V=0.218}.

Wherein, we did not found any relationship between the family backgrounds

of the nurses with any other factors of attraction.



136

Table 48: Relationship between the factor for attraction or placement with the demographic attributes of nurses

Factor of Attraction

With Age group With Family Background With Marital Status With Length of service

(group)

With Place of work With nature of

Employment

(2) p CV (2) p CV (2) p CV (2) p CV (2) p CV (2) p CV

Improved working

condition

0.704 0.872 0.081 1.609 0.205 0.128 0.432 0.511 0.066 2.127 0.712 0.148 3.144 0.208 0.234 0.058 0.809 0.024


drugs and supplies

0.342 0.958 0.056 0.384 0.536 0.063 0.151 0.698 0.03 9 3.853 0.505 0.184 10.509 0.005 0.366 0.074 0.785 0.028

Career development

opportunity

2.443 0.03 0.151 4 .731 0 .486 0.22 3.137 0.077 0.179 9.288 0.05 0.289 4.205 0.122 0.206 9.863 0.002 0.317

Training and skill

development

Opportunities

3.928 0.039 0.204 2 .443 0 .118 0.158 1.2 0.273 0.111 3.723 0.445 0.19 0.689 0.709 0.089 1.374 0.241 0.118

Compulsion 19.43 0.001 0.43 1.005 0.316 0.101 4.665 0.031 0.218 24.473 0.001 0.471 0.197 0.906 0.045 16.30

9

0.001 0.408

Flexible working hour

with minimal workload

6.128 0.106 0.249 2.235 0.135 0.151 1.44 0.23 0.121 8.479 0.076 0.316 1.583 0.453 0.151 3.945 0.047 0.201


conveyance provided

4.245 0.236 0.201 0.057 0.811 0.024 0.665 0.415 0.08 2 11.919 0.018 0.314 0.934 0.627 0.091 6.401 0.011 0.256

Teamwork and


relationship

6.468 0.091 0.289 1.62 8 0.202 0.129 1.177 0.278 0.11 7.148 0.128 321 0.24 0.88 7 0.043 2.628 0.105 0.164

Safety at workplace 4.109 0.25 0.26 0.49 0.484 0.071 0.384 0.535 0.063 6.661 0.155 0.4 92 1.757 0.415 0.12 0.858 0.354 0.094

Availability of goodschools for children

nearby town

1.133 0.769 0.106 0.111 0.739 0.034 1.586 0.208 0.127 7.261 0.123 0.281 0.736 0.692 0.08 0.735 0.391 0.087



family and friends

5.743 0.125 0.244 2.443 0.118 0.158 2.243 0.134 0.151 10.048 0.04 0.331 1.577 0.455 0.106 4.339 0.037 0.21

CV= Cramer’s V



137

4.3.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE

DEMOGRAPHIC CHARACTERISTICS OF MID-WIVES


characteristics of the respondents such as age, family background, marital status,

length of service, place of work and nature of employment, wherein the sex

characteristic has been dropped as no case of differentiation is there in the data. The

three factors of attraction viz., Financial incentives / Rural allowances/ Performance

incentives, Supportive supervision & mentoring and Reward and recognition system,

have at least one of the variables has zero variance and there is only one variable in

the analysis chi-square could not be computed for all pairs of variables, henceforth it

has been dropped from the analysis.

According to the table 49, it is found that there is a relationship between age

group of the nurses and Improved working condition { χ 2(2, N = 123) = 9.745, p =

0.008, Cramer’s V=0.300}(the lower age group of 20-30 years of the mid-wives has

attracted, 75% of the agreed nurses are of this category); Availability of equipment,

drugs and supplies{ χ 2(2, N = 123) = 7.688, p = 0.021, Cramer’s V=0.359}(about 25-

50% of the age group which has agreed upon it); Training and skill development

Opportunities { χ 2(2, N = 123) = 1.788, p = 0.049, Cramer’s V=0..127 }(about 66%

of age group of 20-30 years attracted due to this factor); Compulsion { χ

2

(2, N = 123)= 26.462, p = 0.001, Cramer’s V=0.455} (57% of mid-wives being placed of this);

Flexible working hour with minimal workload { χ 2(2, N = 123) = 14.072, p = 0.001,

Cramer’s V=0.375} (the higher age group of 57% agreed on this factor); Amenities

like housing & conveyance provided { χ 2(2, N = 123) = 17.693, p = 0.001, Cramer’s

V=0.448} (as the age group of higher mid-wives) and Teamwork and Interpersonal

staffs relationship { χ 2(2, N = 123) = 11.696, p = 0.003, Cramer’s V=0.431}(the

higher age group has attraction due to this factor).

Similarly, we found relationship between Marital status of Mid-wives and

Amenities like housing & conveyance provided { χ 2(1, N = 123) = 5.861, p = 0.015,

Cramer’s V=0.218} (more married mid-wives are attracted of this factor);

Availability of good schools for children nearby town { χ 2(1, N = 123) = 3.570, p =

0.050, Cramer’s V=0.170} (more married mid-wives are attracted of this factor); and

Current health facility is closer to town or Closer to family and friends { χ 2(1, N =

123) = 4.222, p = 0.040, Cramer’s V=0.185} (28% of married mid-wives and 12% of

unmarried Mid-wives attracted due to this factor); while the Compulsion { χ 2(1, N =



138

123) = 7.036, p = 0.008, Cramer’s V=0.239}(72% of unmarried and 48% of married

mid-wives are in the rural health institute in compulsion).

It is also found that the length of service has a relationship with factor of

Availability of equipment, drugs and supplies{ χ 2(4, N = 123) = 9.724, p = 0.045,

Cramer’s V=0.358}(18-25% of 10-15 and 15-20 years of service years mid-wives

were attracted); Continuing education/higher education Opportunities { χ 2(4, N =

123) = 13.940, p = 0.007, Cramer’s V=0.368}(5% to 45% of 0-15 years of service

length mid-wives have attracted); Training and skill development Opportunities { χ 2(4,

N = 123) = 6.601, p = 0.050, Cramer’s V=0.236 }(11% to 36% of 0-20 years of

service length has attracted); Flexible working hour with minimal workload { χ 2(4, N

= 123) = 23.991, p = 0.001, Cramer’s V=0.464}(25% to 100% of mid-wives who

have service length of 5-25 years attracted to this factor); Amenities like housing,

conveyance provided { χ 2(4, N = 123) = 9.527, p = 0.049, Cramer’s V=0.285}(12%

to 25% of 5-20 years of service length mid-wives have attracted by this factor);

Availability of good schools for children nearby town { χ 2(4, N = 123) = 11.478, p =

0.022, Cramer’s V=0.303}(about 20% of 5-15 years of service length has been

attracted from this factor); Current health facility is closer to town or closer to family

and friends { χ 2(4, N = 123) = 14.758, p = 0.005, Cramer’s V=0.360} (27% to 100%

of the higher age groups were attracted to this factor); besides these Compulsion

{ χ 2(4, N = 123) = 28.792, p = 0.001, Cramer’s V=0.474} also have the relationship.

Meanwhile, it is also found that the Place of work and the factors of attraction

of Authority, independency and autonomy { χ 2(3, N = 123) = 12.719, p = 0.005,

Cramer’s V=0.274}(15% of mid-wives presently posted in SCs have agreed to the

point); Amenities like housing & conveyance provided { χ 2(3, N = 123) = 23.766, p =

0.001, Cramer’s V=0.536 }; Teamwork and Interpersonal staffs relationship { χ 2(3, N

= 123) = 10.417, p = 0.015, Cramer’s V=0.304} (10% to 20% of the mid-wives in

CHCs and DHs have agreed that this factor also contributed), Current health facility is


Cramer’s V=0.240} (20%-40% of mid-wives at CHCs and DHs have agreed on this

factor); and besides these the Compulsion { χ 2(3, N = 123) = 13.904, p = 0.003,

Cramer’s V=0.332} is the factor of placement in rural areas.

Meanwhile, it is also found that the nature of employment also have

relationship with the factors of attraction like Authority, independency and autonomy

{ χ 2(1, N = 123) = 10.147, p = 0.001, Cramer’s V=0.287 } (17% permanent mid-wives



139

are more attracted of this factor); Career development opportunity { χ 2(1, N = 123) =

8.200, p = 0.004, Cramer’s V=0.258} (contract mid-wives (40%) to 14% of

permanent mid-wives have attracted); Continuing education/higher education

opportunities { χ 2(1, N = 123) = 8.451, p = 0.004, Cramer’s V=0.262}(23% of

permanent mid-wives, while 5% of contract mid-wives has attracted); Flexible

working hour with minimal workload { χ 2(1, N = 123) = 19.282, p = 0.001, Cramer’s

V=0.396 }(33% of permanent mid-wives and 4% contract mid-wives); Amenities like

housing, conveyance provided { χ 2(1, N = 123) = 13.370, p = 0.001, Cramer’s

V=0.330}(17% of permanent mid-wives were attracted due to this factor); Teamwork

and Interpersonal staffs relationship { χ 2(1, N = 123) = 4.085, p = 0.028, Cramer’s

V=0.198}(7% of permanent mid-wives were attracted due to this factor); Current

health facility is closer to town or closer to family and friends { χ 2(1, N = 123) =

6.772, p = 0.009, Cramer’s V=0.235}(27% of permanent and 9% contract mid-

wives); besides the above factor Compulsion { χ 2(1, N = 123) = 30.284, p = 0.001,

Cramer’s V=0.496 } also contribute to factor relationship.

However, we found no association between Family Background and other

attraction factors.



140

Table 49: Relationship between the factor for attraction or placement with the demographic attributes of mid-wives

Factor of Attraction

With Age group With FamilyBackground

With Marital Status With Length of service(group)

With Place of work With nature of Employment

(2) p CV (2) p CV (2) p CV (2) p CV (2) p CV (2) p CV

Improved working condition 9.745 0.008 0.3 0.507 0.476 0.064 0.295 0.587 0.049 6.59 0.159 0.304 3.636 0.304 0.186 0.673 0.412 0.074

Availability of equipment, drugs andsupplies

7.688 0.021 0.359 0.107 0.744 0.029 0.42 0.517 0.058 9.724 0.045 0.358 6.788 0.079 0.211 2.2249 0.134 0.135


autonomy

4.707 0.06 0.214 0.629 0.428 0.072 6.651 0.11 0.233 3.888 0.421 0.19 12.719 0.005 0.274 10.147 0.001 0.287

Career development opportunity 5.204 0.074 0.163 1.312 0.252 0.103 0.911 0.34 0.086 3.78 0.437 0.175 0.528 0.913 0.065 8.2 0.004 0.258


8.124 0.017 0.284 0.267 0.606 0.047 5.284 0.122 0.207 13.94 0.007 0.368 3.324 0.344 0.164 8.451 0.004 0.262


1.788 0.049 0.127 3.837 0.059 0.177 2.977 0.084 0.156 6.601 0.05 0.236 1.405 0.704 0.104 0.411 0.522 0.08

Compulsion (minimum rural servicetenure or non-transferable or Management or political pressure)

26.462 0.001 0.455 0.544 0.457 0.067 7.036 0.008 0.239 28.792 0.001 0.474 13.904 0.003 0.332 30.284 0.001 0.496

Flexible working hour with minimalworkload

14.072 0.001 0.375 0.394 0.53 0.057 3.577 0.059 0.171 23.991 0.001 0.464 0.872 0.832 0.085 19.282 0.001 0.396

Amenities like housing, conveyance provided

17.693 0.001 0.448 0.097 0.756 0.028 5.861 0.015 0.218 9.527 0.049 0.285 23.766 0.001 0.536 13.37 0.001 0.33

Teamwork and Interpersonal staffsrelationship

11.696 0.003 0.431 0.001 0.976 0.003 2.106 0.147 0.131 8.746 0.068 0.321 10.417 0.015 0.304 4.085 0.028 0.198

Safety at workplace 3.254 0.196 0.207 0.001 0.976 0.003 2.106 0.147 0.131 8 .877 0.064 0.332 7.555 0.056 0.246 4.805 0.128 0.198

Availability of good schools for children nearby town

1.846 0.397 0.124 0.372 0.542 0.055 3.57 0.05 0.17 11.478 0.022 0.303 2.251 0.522 0.103 3.677 0.055 0.173


town or Closer to family and friends

5.458 0.047 0.223 0.616 0.433 0.071 4.222 0.04 0.185 14.758 0.005 0.36 7.515 0.05 0.24 6.772 0.009 0.235

CV= Carmer’s V



141

4.3.4. FACTORS THAT MAY ATTRACT PHYSICIANS, NURSES

AND MID-WIVES TO RURAL AREA- CHOICE OF CURRENT

PHYSICIANS, NURSES AND MID-WIVES

This part of the section has attempted to explore the factors that may attract

physicians, nurses and mid-wives to rural area. Eighteen (18) factors were included

for the same. The determination of the factor that may majorly attract the physicians,

nurses and mid-wives has considered on the Mean factor which would be statistically

significant at Mean test value of (1.5), that means the selection was done by the

majority (more than half) of the respondents and have an greater impact at large

workforce. This helps in ascertaining the factors that may attract the larger part of the

workforce.

The Reliability analysis was done for the attraction factors consistency of

responses to items. The Cronbach’s alpha coefficient for the factor items is

α =(0.542) on item 18 and N=334.

The top 10 factor that may attract the physicians, nurses and mid-wives can be

derived from Table 50 are: 1) Higher Salary package in compare to urban posting

(1.80), 2) Conducive working condition (1.74), 3) Training and skill development

Opportunities (1.74), 4) Access to amenities like housing & conveyance (1.69), 5)

Financial incentives / Rural allowances/ Performance incentives (1.68), 6) Safety atworkplace (1.61), 7) Rotational Posting after completing minimum rural service

tenure (1.59), 8) Career development opportunities (1.58), 9) Availability of good

schools for children (1.40), 10) Good reward and recognition system (1.40).

The lowest mean factors are: Current health facility is closer to town or

Closer to family and friends (1.01), Flexible working hours with minimal workload

(1.07), Opportunity for authority, independency and autonomy (1.07), Supportive

supervision and mentoring (1.25) and Availability of equipment, drugs and

supplies (1.28).

The factors that may attract physicians, nurses and mid-wives for rural and

remote services has the following percentage of selection from these health

workforces: Higher Salary package in compare to urban posting-268 (80%);

Conducive working condition -247 (74%); Training and skill development

Opportunities-246 (74%); Access to amenities like housing & conveyance-231

(69%); The Financial incentives / Rural allowances/ Performance incentives-227

(68%); Safety at workplace -204 (61%); Rotational Posting after completing



142

minimum rural service tenure -196 (59%) and Career development opportunities -195

(58%); Availability of good schools for children -135 (40%); Good reward and

recognition system -134 (40%); Continuing education/higher education Opportunities

-131 (39%); Better teamwork and good interpersonal staffs relationship -128 (38%);

Job security-120 (36%); Availability of equipment, drugs and supplies -92 (28%);

Supportive supervision and mentoring -84 (25%);Opportunity for authority,

independency and autonomy-25 (7%); Flexible working hours with minimal

workload -24 (7%); Current health facility is closer to town or Closer to family and

friends -5 (1%). The detail percentage comparison is presented in table 51.

While the Mean Test value reveals the following factors statistically

significant- Higher Salary package in compare to urban posting, Conducive working

condition, Training and skill development opportunities, Access to amenities like

housing & conveyance, Financial incentives / Rural allowances/ Performance

incentives, Safety at workplace, Rotational Posting after completing minimum rural

service tenure and Career development opportunities. These factors are statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)=13.858, p=

.001, t(333)=9.959, p= .001, t(333)=9.798, p= .001, t(333)=7.571, p= .001,

t(333)=7.025, p= .001, t(333)=4.146, p= .001, t(333)=3.218, p= .001 and

t(333)=3.104, p= .002 respectively.

Table 50: Descriptive Statistics of the factors that may attract the physicians,

nurses and mid-wives in the rural and remote area

Factor

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.

Higher Salary package in

compare to urban posting

334 1.80 .399 13.858 333 .001 .302

Conducive working conditio 334 1.74 .440 9.959 333 .001 .240Training and skill


334 1.74 .441 9.798 333 .001 .237

Access to amenities like

housing & conveyance

334 1.69 .463 7.571 333 .001 .192



incentives

334 1.68 .467 7.025 333 .001 .180

Safety at workplace 334 1.61 .488 4.146 333 .001 .111

Rotational Posting after completing minimum rural

service tenure

334 1.59 .493 3.218 333 .001 .087



143

Career development

opportunities

334 1.58 .494 3.104 333 .002 .084


schools for children

334 1.40 .491 -3.563 333 .001 -.096

Good reward and

recognition system

334 1.40 .491 -3.678 333 .001 -.099

Continuing

education/higher education

Opportunities

334 1.39 .489 -4.028 333 .001 -.108

Better teamwork and good

interpersonal staffs

relationship

334 1.38 .487 -4.383 333 .001 -.117

Job security 334 1.36 .481 -5.352 333 .001 -.141


drugs and supplies

334 1.28 .447 -9.172 333 .001 -.225

Supportive supervision andmentoring 334 1.25 .435 -10.452 333 .001 -.249

Opportunity for authority,independency and

autonomy

334 1.07 .264 -29.482 333 .001 -.425

Flexible working hours

with minimal workload

334 1.07 .259 -30.253 333 .001 -.428



family and friends

334 1.01 .122 -72.888 333 .001 -.485

Table 51: Percentage of factors that may attract physicians, nurses and mid-wives in rural and remote areas

Factors n [n(%)]

Higher Salary package in compare to urban posting 268 (80%)

Conducive working condition 247 (74%)

Training and skill development Opportunities 246 (74%)

Access to amenities like housing & conveyance 231 (69%)

Financial incentives / Rural allowances/ Performance incentives 227 (68%)

Safety at workplace 204 (61%)

Rotational Posting after completing minimum rural service tenure 196 (59%)

Career development opportunities 195 (58%)Availability of good schools for children 135 (40%)

Good reward and recognition system 134 (40%)

Continuing education/higher education Opportunities 131 (39%)

Better teamwork and good interpersonal staffs relationship 128 (38%)

Job security 120 (36%)

Availability of equipment, drugs and supplies 92 (28%)

Supportive supervision and mentoring 84 (25%)

Opportunity for authority, independency and autonomy 25 (7%)

Flexible working hours with minimal workload 24 (7%)

Current health facility is closer to town or Closer to family & friends 5 (1%)



144

4.3.4.1. FACTORS THAT MAY ATTRACT PHYSICIANS TO RURAL AREA-CHOICE OF CURRENT PHYSICIANS

As it can be derived from Table 52, the results indicated the top 10 factors

that may attract the physicians are: 1) Training and skill development opportunities

(1.81), 2) Access to amenities like housing & conveyance (1.78), 3) Career

development opportunities (1.72), 4) Financial incentives / Rural allowances/

Performance incentives (1.71), 5) Rotational Posting after completing minimum rural

service tenure (1.69), 6) Conducive working condition, (1.65), 7) Good reward and

recognition system (1.64), 8) Higher Salary package in compare to urban posting

(1.63), 9) Continuing education/higher education Opportunities (1.51) and 10) Safety

at workplace (1.50).

The lowest mean factors are: 1) Current health facility is closer to town or

Closer to family and friends (1.03), 2) Flexible working hours with minimal

workload (1.13), 3) Opportunity for authority, independency and autonomy (1.14),

4) Job security (1.21), 5) Availability of equipment, drugs and supplies (1.30), 6)

Supportive supervision and mentoring (1.34), 7) Availability of good schools for

children (1.35) and 8) Better teamwork and good interpersonal staffs relationship

(1.38).

While the Mean Test value reveals the following factors significant- Trainingand skill development Opportunities, Access to amenities like housing & conveyance,

Career development opportunities, Financial incentives / Rural allowances/

Performance incentives, Rotational Posting after completing minimum rural service

tenure, Conducive working condition, Good reward and recognition system, Higher

Salary package in compare to urban posting and Continuing education/higher

education opportunities. These factors are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(112)=8.547, p=.001, t(112)=7.107, p= .001,

t(112)=5.093, p= .001, t(112)=4.840, p= .001, t(112)=4.355, p= .001, t(112)=3.447,

p= .001, t(112)=3.019, p= .003, t(112)=2.810, p= .006 and t(112)=1.281, p= .009

respectively. The Percentage selection of Factor is presented in table 53.



145

Table 52: Descriptive Statistics of the factors that may attract the physicians

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

taile

d)

Mean

Diff.


Opportunities

113 1.81 .391 8.547 112 .001 .314



113 1.78 .417 7.107 112 .001 .279

Career development opportunity 113 1.72 .453 5.093 112 .001 .217


allowances/Performance incentive

113 1.71 .457 4.840 112 .001 .208

Rotational Posting after

completing minimum rural

service tenure

113 1.69 .464 4.355 112 .001 .190

Conducive working condition 113 1.65 .478 3.447 112 .001 .155

Good reward and recognition

system

113 1.64 .483 3.019 112 .003 .137



113 1.63 .485 2.810 112 .006 .128



113 1.61 .479 1.281 112 .009 .113

Safety at workplace 113 1.50 .502 .094 112 .926 .004

Better teamwork and goodinterpersonal staffs relationship

113 1.38 .488 -2.604 112 .010 -.119

Availability of good schoolsfor children

113 1.35 .480 -3.231 112 .002 -.146


mentoring

113 1.34 .475 -3.667 112 .001 -.164


drugs and supplies

113 1.30 .461 -4.595 112 .001 -.199

Job security 113 1.21 .411 -7.442 112 .001 -.288

Opportunity for authority,

independency and autonomy

113 1.14 .350 -10.880 112 .001 -.358

Flexible working hours with

minimal workload

113 1.13 .341 -11.455 112 .001 -.367


to town or Closer to family andfriends

113 1.03 .161 -31.168 112 .001 -.473

The factor that may attract physicians for rural and remote services has the

following percentage of selection from the physicians: Training and skill

development Opportunities (81%), Access to amenities like housing & conveyance

(78%), Career development opportunities (72%), Financial incentives / Rural

allowances/ Performance incentives (71%), Rotational Posting after completing

minimum rural service tenure (69%), Conducive working condition (65%), Good



146

reward and recognition system (64%), Higher Salary package in compare to urban

posting (63%), Continuing education/higher education Opportunities (51%), Safety at

workplace (50%), Better teamwork and good interpersonal staffs relationship (38%),

Availability of good schools for children (35%), Supportive supervision and

mentoring (34%), Availability of equipment, drugs and supplies (30%), Job security

(21%), Opportunity for authority, independency and autonomy (14%), Flexible

working hours with minimal workload (13%), Current health facility is closer to town

or Closer to family and friends (3%).

Table 53: Percentage of factors that may attract physicians in rural and remote

areas

Factors may attract

Physicians

n n%Training and skill development Opportunities 92 81%

Access to amenities like housing & conveyance 88 78%

Career development opportunities 81 72%


Rotational Posting after completing minimum rural service tenure 78 69%

Conducive working condition 74 65%

Good reward and recognition system 72 64%

Higher Salary package in compare to urban posting 71 63%


Safety at workplace 57 50%Better teamwork and good interpersonal staffs relationship 43 38%

Availability of good schools for children 40 35%


Availability of equipment, drugs and supplies 34 30%

Job security 24 21%

Opportunity for authority, independency and autonomy 16 14%

Flexible working hours with minimal workload 15 13%


4.3.4.2. ANALYSIS OF THE FACTORS THAT MAY ATTRACT NURSES TORURAL AND REMOTE AREA- CHOICE OF CURRENT NURSES

In this section, it is attempted to explore the factors that may attract nurses to

rural area. The sixteen (18) point factors were included for the same.

As it can be derived from table 54, the results indicated the top 10 factors that

may attraction the nurses are: Higher Salary package in compare to urban posting

(1.89), Conducive working condition (1.82), Access to amenities like housing &

conveyance (1.79), Training and skill development Opportunities (1.74), Financial

incentives / Rural allowances/ Performance incentives (1.69), Good reward and



147

recognition system (1.63), Safety at workplace (1.56), Career development

opportunities (1.46), Rotational Posting after completing minimum rural service

tenure (1.40) and Better teamwork and good interpersonal staffs relationship (1.40).

The lowest mean factors are: Availability of good schools for children (1.37),

Job security (1.35), Continuing education/higher education Opportunities (1.32),

Availability of equipment, drugs and supplies (1.26), Supportive supervision and

mentoring (1.20), Flexible working hours with minimal workload (1.08), opportunity

for authority, independency and autonomy (1.04), Current health facility is closer to

town or Closer to family and friends (1.01).

It is found that the combination of seven factors are having statistically

significant at Mean Test Value=1.5, 95% C.I, and the factors : Higher Salary package

in compare to urban posting, Conducive working condition Access to amenities like

housing & conveyance, Training and skill development Opportunities, Financial

incentives / rural allowances/ Performance incentives, Good reward and recognition

system and Safety at workplace. These factors are significant at t(97)=12.098, p=

.001, t(97)=8.046, p= .001, t(97)=6.858, p= .001, t(97)=5.533, p= .001, t(97)=4.143,

p= .001, t(97)=2.710, p= .008 and t(97)=1.201, p= .041 respectively. The Percentage

selection of factor for Attraction or placed is place in table 55.

Table 54 : Descriptive Statistics of the factors that may attracted the nurses

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.



98 1.89 .317 12.098 97 .001 .388




98 1.79 .412 6.858 97 .001 .286


Opportunities

98 1.74 .438 5.533 97 .001 .245



incentives

98 1.69 .463 4.143 97 .001 .194

Good reward and recognition

system

98 1.63 .485 2.710 97 .008 .133


Career development opportunity 98 1.46 .501 -.807 97 .422 -.041

Rotational Posting after

completing minimum ruralservice tenure

98 1.40 .492 -2.053 97 .043 -.102



148


interpersonal staffs relationship

98 1.40 .492 -2.053 97 .043 -.102


children

98 1.37 .485 -2.710 97 .008 -.133

Job security 98 1.35 .478 -3.167 97 .002 -.153


98 1.32 .467 -3.890 97 .001 -.184


98 1.26 .438 -5.533 97 .001 -.245

Supportive supervision andmentoring

98 1.20 .405 -7.231 97 .001 -.296


minimal workload

98 1.08 .275 -15.049 97 .001 -.418



98 1.04 .199 -22.856 97 .001 -.459


town or Closer to family & friend

98 1.01 .101 -48.000 97 .001 -.490

The factor that may attract nurses for rural and remote services has the

following percentage of selection: Higher Salary package in compare to urban

posting (89%), Conducive working condition (82%), Access to amenities like

housing & conveyance (74%), Training and skill development Opportunities (79%),

Financial incentives / Rural allowances/ Performance incentives (63%), Good reward

and recognition system (69%), Safety at workplace (46%), Career development

opportunities (51%), Rotational Posting after completing minimum rural service

tenure (40%), Better teamwork and good interpersonal staffs relationship (35%),

Availability of good schools for children (32%), Job security (40%), Continuing

education/higher education Opportunities (37%), Availability of equipment, drugs

and supplies (26%), Supportive supervision and mentoring (20%), Flexible

working hours with minimal workload (4%), Opportunity for authority,

independency and autonomy (8%) and Current health facility is closer to town or

Closer to family and friends (1%)

Table 55: Percentage selection of Factor that may attract nurses

Factors may attract

Nurses

n n%




Training and skill development Opportunities 77 79%


Good reward and recognition system 68 69%Safety at workplace 45 46%



149



Better teamwork and good interpersonal staffs relationship 34 35%


Job security 39 40%

Continuing education/higher education Opportunities 36 37%Availability of equipment, drugs and supplies 25 26%





4.3.4.3. ANALYSIS OF THE FACTORS THAT MAY ATTRACT MID-WIVESTO RURAL AND REMOTE AREA- CHOICE OF CURRENT MID-WIVES

When the group of mid-wives is analysed, it is found that the top 10 factors

can be derived from table 56 are: Higher Salary package in compare to urban posting

(1.81), Access to amenities like housing & conveyance (1.78), Conducive working

condition (1.72), Training and skill development Opportunities (1.71), Good

reward and recognition system (1.69), Rotational Posting after completing

minimum rural service tenure (1.65), Financial incentives / Rural allowances/

Performance incentives (1.64), Continuing education/higher education Opportunities

(1.63), Career development opportunities (1.61), Safety at workplace (1.60).

The lowest mean factors are: Better teamwork and good interpersonal staffs

relationship (1.38), Availability of good schools for children (1.35), Supportive

supervision and mentoring (1.34), Availability of equipment, drugs and supplies

(1.30), Job security (1.21), Opportunity for authority, independency and autonomy

(1.14), Flexible working hours with minimal workload (1.13) and Current health

facility is closer to town or Closer to family and friends (1.03).

While the combination of ten factors are having statistically significant at

Mean Test Value=1.5, 95% C.I, and they are : Higher Salary package in compare to

urban posting, Access to amenities like housing & conveyance, Conducive working

condition, Training and skill development Opportunities, Good reward and

recognition system, Rotational Posting after completing minimum rural service

tenure, Financial incentives / Rural allowances/ Performance incentives, Continuing

education/higher education Opportunities, Career development opportunities and

Safety at workplace. These factors are significant at t(112)=8.547, p=.001,

t(112)=7.107, p= .001, t(112)=5.093, p= .001, t(112)=4.840, p=.001, t(112)=4.355,

p= .001, t(112)=3.447, p=.001, t(112)=3.019, p=.003, t(112)=2.810, p=.006,



150

t(112)=1.281, p=.009 and t(112)=1.094, p=.026 respectively. The Percentage

selection of Factor for Attraction or placed is presented in table 57.

Table 56: Descriptive Statistics of the factors that may attracted the Mid-

wives

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.



113 1.81 .391 8.547 112 .001 .314



113 1.78 .417 7.107 112 .001 .279


Training and skill


113 1.71 .457 4.840 112 .001 .208

Good reward and

recognition system

113 1.69 .464 4.355 112 .001 .190

Rotational Posting after completing minimum rural

service tenure

113 1.65 .478 3.447 112 .001 .155


allowances/Performance

incentives

113 1.64 .483 3.019 112 .003 .137



113 1.63 .485 2.810 112 .006 .128

Career development opportun 113 1.61 .479 1.281 112 .009 .113



interpersonal staffs

relationship

113 1.38 .488 -2.604 112 .010 -.119


for children

113 1.35 .480 -3.231 112 .002 -.146


mentoring

113 1.34 .475 -3.667 112 .001 -.164


drugs and supplies

113 1.30 .461 -4.595 112 .001 -.199

Job security 113 1.21 .411 -7.442 112 .001 -.288



113 1.14 .350 -10.880 112 .001 -.358


minimal workload

113 1.13 .341 -11.455 112 .001 -.367



family and friends

113 1.03 .161 -31.168 112 .001 -.473



151

The factor that may attract mid-wives for rural and remote services has the

following percentage of selection: Higher Salary package in compare to urban posting

(82%), Access to amenities like housing & conveyance (76%), Conducive working

condition (66%), Training and skill development Opportunities (67%), Good reward

and recognition system (63%), Rotational Posting after completing minimum rural

service tenure (64%), Financial incentives / Rural allowances/ Performance incentives

(59%), Continuing education/higher education Opportunities (52%), Career

development opportunities (46%), Safety at workplace (23%), Better teamwork and

good interpersonal staffs relationship (34%), Availability of good schools for children

(37%), Supportive supervision and mentoring (49%), Availability of equipment, drugs

and supplies (27%), Job security (21%), Opportunity for authority, independency and

autonomy (4%), Flexible working hours with minimal workload (1%) and Current

health facility is closer to town or Closer to family and friends (1%).

Table 57: Percentage of factors that may attract mid-wives in rural and remote

areas

Factors may attract

Mid-wives

n n%




Training and skill development Opportunities 83 67%Good reward and recognition system 77 63%





Safety at workplace 28 23%

Better teamwork and good interpersonal staffs relationship 42 34%



Availability of equipment, drugs and supplies 33 27%Job security 26 21%




4.3.4.4. VARIANCE IN CHOICE OF FACTOR THAT MAY ATTRACT THE


While analysing the variance in the choice of the factors that may attract the

physicians, nurses and mid-wives, it is found that there is difference in the groups in

the view of factors that may attract to the rural and rural areas services. It is found



152

that the physicians may be attracted to the rural and remote when they found there is

scope of training and skill development, a good working environment,

accommodation facilities, incentives and recognition system with a competitive

salary that is more than that of urban areas. It meant that the physicians first look at

self development by training and development, living condition and to the monetary

factors. While, the nurses and mid-wives have attraction of higher salary first, good

work environment, accommodation training and development, recognition and

Safety at workplace. It meant that the group of nurses and mid-wives are more

attracted to financial benefits and then they look after the work and living condition

and off-course to the Safety at workplace. Thus, it meant that the preference is not in

the same order and the factor cannot be generalised for all the three groups.

However, it is statistically found that the three groups differ in their choices in the

following factors:- Higher Salary package in compare to urban posting at F(2,

331)=3.210 , p= .042, Financial / rural/ Performance incentives at F(2, 331)=5.706 ,

p= .004, Improved working condition at F(2, 331)=3.740 , p= .025, Opportunity for

authority, independency & autonomy at F(2, 331)=5.629 , p= .004, Career

development opportunities at F(2, 331)=6.409 , p= .002, Continuing

education/higher education Opportunities at F(2, 331)=5.448 , p= .005, Training and

skill development Opportunities at F(2, 331) = 3.750 , p= .025, Rotational Posting at

F(2, 331)=5.952 , p= .003, Job security at F(2, 331)=10.231 , p= .001, Flexible

working hours with minimal workload at F(2, 331)=7.193 , p= .001, Supportive

supervision & mentoring at F(2, 331)=3.304 , p= .038, Access to amenities like

housing & conveyance at F(2, 331)=3.914 , p= .021, Safety at workplace at F(2,

331)=4.445 , p= .012, Good reward & recognition system at F(2, 331)=24.334 , p=

.001. Detail analysis of variance is presented in table 58.



153

Table 58 : Analysis of Variance in factor that may attract the physicians, nurses

and mid-wives

Factors df F Sig.

Higher Salary package in compare to urban

posting

Between Groups 2 3.210 .042

Within Groups 331

Financial incentives / Rural allowances/Performance incentives

Between Groups 2 5.706 .004Within Groups 331

Improved working condition Between Groups 2 3.740 .025

Within Groups 331


supplies

Between Groups 2 .298 .742

Within Groups 331

Opportunity for authority, independency

and autonomy


Within Groups 331

Career development opportunities Between Groups 2 6.409 .002

Within Groups 331

Continuing education/higher educationOpportunities Between Groups 2 5.448 .005Within Groups 331


Opportunities


Within Groups 331

Rotational Posting after completing

minimum rural service tenure


Within Groups 331

Job security Between Groups 2 10.231 .001

Within Groups 331

Flexible working hours with minimal

workload


Within Groups 331

Supportive supervision and mentoring Between Groups 2 3.304 .038

Within Groups 331

Access to amenities like housing &conveyance


Within Groups 331

Better teamwork and good interpersonal

staffs relationship


Within Groups 331

Safety at workplace Between Groups 2 4.445 .012

Within Groups 331

Good reward and recognition system Between Groups 2 24.334 .001

Within Groups 331

Availability of good schools for children Between Groups 2 1.264 .284

Within Groups 331Current health facility is closer to town or

Closer to family and friends


Within Groups 331



154

SECTION 4

ANALYSIS OF THE DIMENSION

OF HR ISSUES IN RETENTION OF


WIVES IN RURAL AND REMOTE

AREAS OF THE STATE



155

4.4.1. INTRODUCTION

This part of the chapter describes the dimensions of retention of the

Physicians, Nurses and Mid-wives in the rural and remote areas. An employee attitude

survey measured the employee attitudes towards their job satisfaction, intention to

migrate and what would motivate them to stand back in present rural and remote

place. There are two propositions concerning the satisfaction and performance

relationship. The first proposition which is based on the traditional view is that,

satisfaction caused performance. The second proposition is that satisfaction is the

effect rather than the cause of performance. This proposition says that effort in a job

leads to rewards, which result in a certain level of satisfaction. In another proposition,

both satisfaction and performance are considered to be functions of rewards (Sharma,

2000). Job satisfaction therefore is a function of satisfaction with different aspects of

the job, such as, nature of job, promotional avenues, supervisors, co-workers role etc.

and the particular importance one attaches to these respective components and it

affects the retention and performance.

Therefore, the exploration of the issues in retention of Physicians, Nurses and

Mid-wives from the perspective of employees itself are presented in five sub-parts of:

i) level of job satisfaction of current job in rural and remote area with individual

contributing factors of level of satisfaction, ii) the intention to continue the present

rural area service for at least another 3-5 years, iii) retention factors for continuing the

rural service, iv) contributing push factors and iv) factors that may motivate them to

retain the current job in rural and remote area.

The determination of the factor that majorly attracted the physicians, nurses

and mid-wives has considered on the Mean factor which would be statistically

significant at Mean Test value of (1.5), that means the selection was done by the

majority (more than half) of the respondents and have an greater impact at large

workforce. This helps in ascertain the most relevant factors for the issue.

Along with the employee perspectives, the management perspective is also

presented in the following section.



156

4.4.2. OVERALL JOB SATISFACTION OF PHYSICIANS,

NURSES AND MID-WIVES IN PRESENT RURAL AND REMOTE

AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC

ATTRIBUTES

Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for turnover in general include dissatisfaction with work. The job satisfaction of the

Physicians, Nurses and Mid-wives was measured on a scale of 1 to 5 with their

present job in rural and remote area. The scale denotes 1 (one) as the highly

dissatisfied to 5 (five) as highly satisfied.

The mean of overall scale of job satisfaction of these employees is 2.26

(N=334), which shows an average lower scale of satisfaction. In the group

comparison, the Physicians (2.53, N=113), Nurses (2.32, N=98) and Mid-wives (1.98, N=123) means respectively. The analysis shows that the groups of Mid-wives have

the lowest scale of job satisfaction, followed by the group of nurses and the

physicians.

21.2% of physicians are satisfied against 1.8% of them is highly satisfied and

3.5% have high dissatisfaction along with 64.6% of dissatisfied. In the counterpart the

nurses have 16.3% satisfied and 64.3% are dissatisfied along with 10.2% highly

dissatisfied. While, Mid-wives have 5.7% of satisfied group, 14.6% highly

dissatisfied and 78.9% has dissatisfied. It seems that most of the groups are

dissatisfied with the present job in rural and remote area.

Table 59: Percentage showing Job Satisfaction of physicians, nurses and mid-wives in rural and remote area setting

Category of

Respondents

Scale of overall job satisfaction

Total

H i g h l y

D i s s a t i s f i e d


N e

i t h e r

S a t i s f i e d N o r


S a t i s f i e d

H i g h l y

S a t i s f i e d

Physician 4 (3.5%) 73 (64.6%) 10 (8.8%) 24 (21.2%) 2 (1.8%) 113

Nurse 10 (10.2%) 63 (64.3%) 9 (9.2%) 16 (16.%) 0 (0%) 98

Mid-Wife 18 (14.6%) 97 (78.9%) 1 (0.8%) 7 (5.70%) 0 (0%) 123

Total 32 (9.6%) 233 (69.8%) 20 (6%) 47 (14.1%) 2 (0.6%) 334

While the analysis of variance shows that there is difference in the scale of job

satisfaction among the three groups, the values of F(2, 331)=14.197 , p =.001.



157

Table 60: Descriptive statistics of Job Satisfaction of Physicians, Nurses and

Mid-wives

Category of Respondents N Mean

Std.

Deviation

Std.

Error Min Max

Physician 113 2.53 .927 .087 1 5

Nurse 98 2.32 .869 .088 1 4Mid-Wife 123 1.98 .620 .056 1 4

Total 334 2.26 .840 .046 1 5

Table 61: Analysis of Variance in Job Satisfaction among the Physicians,


Sum of Squares df Mean Square F Sig.

Between Groups 18.552 2 9.276 14.197 .001

Within Groups 216.262 331 .653

Total 234.814 333

In the group comparison as per the Nature of Employment, the means of contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. This

interprets as the contractual employees have lower job satisfaction in comparison to

the permanent employees.

If we analysed the situation in categorizing the workforce in nature of

employment, we found that contract workforce are more dissatisfied than the

permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2%

are satisfied in the group of the contracts. Whereas, the permanent employees have9.6% are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only

0.6% are highly satisfied.

Table 62: Percentage showing Job Satisfaction of contractual and permanentphysicians, nurses and mid-wives in rural and remote area setting

Nature of

Employment

Scale of overall job satisfaction

T o t a l

H i g h

l y



N e i t h e r S

a t i s f i e d

N o r D i s s a t i s f i e d

S a t i s f i e d

H i g h l y S a t i s f i e d

Contract 27(17.5%) 110 (71.4%) 9 (5.8%) 8 (5.2%) 0(0.0%) 154

Permanent 5 (2.8%) 123 (68.3%) 11 (6.1%) 39 (21.7%) 2(1.1%) 180

Total 32 (9.6%) 233 (69.8%) 20 (6.0%) 47 (14.1%) 2(0.6%) 334

Two sample T-Test shows that it is statistical significant, the values are: t(332)

= -5.835, p=.001. There is a difference in the job satisfaction between the groups. The

mean difference is -.513 between the contractual and permanent employees.



158

Table 63: Descriptive statistic of Job Satisfaction of contract and permanent


Nature of Employment N Mean Std. Deviation

Std. Error

Mean

Contract 154 1.99 .667 .054

Permanent 180 2.50 .900 .067

The Medical professions like doctor and nurses has been long among the most

attractive and satisfied profession in the society, but when it is analysed in the context

of rural and remote area services, the results suggests that these group of employees

are increasingly getting dissatisfied with their jobs in rural and remote areas.

The next topic of analysis and interpretation is on how the demographicattributes effect the job satisfaction of these groups in rural and remote area service

setting.

It is well known that the job satisfaction is effected by the demographic

attributes of the employees. To explore the relationship of the Job satisfaction of

Physicians, nurses and mid-wives in rural and remote area services with other

demographic attributes like age, family background, marital status, length of service,

place of posting and nature of employment, the statistical analysis has been done and

interpreted. The variable, (sex) has been drooped from analysing for the relationship

because there are male and female classification is only in the Physicians group,

where as the nurses and mid-wives does not have the classification of male and

female, except 1 (one) no. of male in the nurse group of employee.

Correlation (Pearson’s ratio or Spearman Correlation), paired sample T-Test

were used to identify the attributes significantly related with job satisfaction. The p-

values of 0.05 were used as the level of significance.

Table 64: Analysis of Variance of Job Satisfaction among contractual and

permanent Physicians, nurses and mid-wivesLevene's Testfor Equality of

Variances t-test for Equality of Means

F Sig. t df

Sig.

MeanDifference

Std. Error Difference

(2-tailed)

Equal variances

assumed

54.929 .001 -5.835 332 0 -0.513 0.088

Equal variances

not assumed

-5.969 325.5

41

0 -0.513 0.086



159

It is statistically significant that there is a positive relationship of job

satisfaction with the age r(334)=.282, p=.001, length of service r(334)=.224,

p=.001, place of posting r(334)=.053, p=.004 and nature of employment

r(334) = .305, p=.001. However, the relationship is not strong between the variables

because the association is under minimum values. Thus, it signifies that as higher

age employee has higher job satisfaction, higher length of service has higher job

satisfaction, employee posted at the higher level of health institute has higher job

satisfaction and permanent employees have the higher job satisfaction than the

contractual employees.

There is negative relationship and statistically significant as well between the

variables. The correlation between the marital status and job satisfaction is

r(334)=(-).159, p=.004. Thus, in marital status it signifies that married employees

has less job satisfaction. Wherein, it signifies that the more married employees the

less satisfaction level in rural setting.

There is no relationship between family background and job satisfaction of

employees in rural setting. The correlation between the variables is not statistically

significant r(334)=.028, p=.613. Thus, there is no effect of family background on

job satisfaction of the employees.

To sum up, statistically it seems that age, length of service, place of posting

and nature of employment have the positive impact on job satisfaction in the rural

setting.

Table 65: Correlation between Job satisfaction and the demographic attributes

of the employees (Physicians, Nurses and Mid-wives)

4.4.2.1. JOB SATISFACTION OF PHYSICIANS IN RURAL AND REMOTE


ATTRIBUTESThe job satisfaction of the physicians has been measured on a scale of 1 to 5

with their present job in rural and remote area. The scale denotes 1 (one) as the highly


Sl. No. Attributes Correlation coefficient P-Value

1. Age 0.282 0.001

2. Family Background 0.028 0.613

3. Marital Status -0.159 0.004

4. Length of Service 0.224 0.001

5. Nature of Employment 0.305 0.001

6. Place of Posting 0.053 0.004



160

The mean of overall scale of job satisfaction of physician is (2.53, N=113),

which shows an average low scale of satisfaction. In the group comparison, the

contractual physicians (2.24, N=34), permanent physicians (2.66, N=79).

The analysis shows that the contractual physicians have the lowest scale of job

satisfaction in comparison to the permanent physicians.

Two sample T-Test (Paired) shows that it is statistical significant, the values

are: t(111) = -2.266, p =0.025. It signifies that there is a difference in the job

satisfaction between the groups. The mean difference is -.423 between the contractual

and permanent physicians.

Table 66 : Descriptive statistic of Job Satisfaction of contract and permanent

Physicians.

Category N Mean Std. Dev. Std. Error Min MaxContract 34 2.24 .741 .127 1 4

Permanent 79 2.66 .973 .109 1 5

Total 113 2.53 .927 .087 1 5


permanent Physicians.Levene's Test

for Equalityof Variances t-test for Equality of Means

F Sig. t df Sig.

(2-tailed)

Mean

Diff.

Std.

Error Diff.

Equal variances assumed 14.522 .001 -2.266 111 0.025 -0.423 0.187

Equal variances not assume -2.522 81.191 0.014 -0.423 0.168

To explore the relationship of the Job satisfaction of Physicians in rural and

remote area services with other demographic attributes like age, sex, family

background, marital status, length of service and nature of employment, the

statistical analysis has been done and interpreted. The variable place of posting is

not considered for the aforesaid test, because the variable has fewer cases of

different groups.

Correlation (Pearson’s) or paired sample T-Test was used to identify the

attributes significantly related with job satisfaction. The p-values of 0.05 were used

as the level of significance.


satisfaction with the age r(113)=.213, p=.024, length of service r(113)=.223,

p=.018, and nature of employment r(113) = .210, p = .025. However, therelationship is not strong between the variables because the association is under



161

minimum positive values. Thus, it signifies that as higher age employee has higher

job satisfaction, higher length of service has higher job satisfaction and permanent

employees have the higher job satisfaction than the contractual employees.

There is negative relationship and statistically significant as well between the

variables. The correlation between the sex and job satisfaction is negative

r(113)=(-).178, p=.05 and the marital status is r(113)=(-).185, p=.05. Thus, it

signifies that males (77%) out-numbered the female (23%) employees and the job

satisfaction diminishes as the male employees goes up and male physicians have less

job satisfaction in rural setting. Moreover, the negative relationship in marital

signifies that married employees has less job satisfaction and it is statistically

signifies. The married physicians (63%) are out-numbered the unmarried physicians

(37%), and as the married physicians out-numbered, the satisfaction level will go

down in rural setting.

It is found that, there is no relationship between family background and job

satisfaction of employees in rural setting. The correlation between the variables is

not statistically significant r(113)=.042, p=.656. Thus, there is no effect of family

background on job satisfaction of the employees.

To sum up, statistically it seems that age, length of service and nature of

employment have positive relationship with the job satisfaction of the Physicians.

Table 68 : Correlation between Job satisfaction and the demographic attributes

of Physicians

4.4.2.2. JOB SATISFACTION OF NURSES IN RURAL AND REMOTE AREA

AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTESThe job satisfaction of the Nurses has been measured on a scale of 1 to 5 with

their present job in rural and remote area. The scale denotes 1 (one) as the highly


The mean of overall scale of job satisfaction of Nurses is (2.32, N=98), which

shows an average lower scale of satisfaction. In the group comparison, the contractual

nurses (2.02, N=45), permanent nurses (2.57, N=53).


1. Age 0.213 0.024

2. Sex -0.178 0.050







162

The analysis shows that the contractual nurses have the lowest scale of job

satisfaction in comparison to the permanent nurses.


are: t(96) = -3.236, p =0.002. It signifies that there is a difference in the job


and permanent nurses.


nurses.

N Mean Std. Dev. Std. Error Min Max

Contract 45 2.02 .723 .108 1 4

Permanent 53 2.57 .910 .125 1 4

Total 98 2.32 .869 .088 1 4

Table 70 : Analysis of Variance of Job Satisfaction among contractual and

permanent nursesLevene's Testfor Equality of

Variances t-test for Equality of Means

F Sig. t df Sig. (2-tailed)

MeanDiff.

Std. Error Diff.

Equal variances assumed 13.959 .001 -3.236 96 .002 -.544 .168

Equal variances not assum -3.297 95.608 .001 -.544 .165

To explore the relationship of the Job satisfaction of Nurses in rural and

remote area services with other demographic attributes like age, family background,

marital status, length of service and nature of employment, the statistical analysis has

been done and interpreted. The variable place of posting and sex is not considered

for the aforesaid test, because the variable has fewer cases of different groups.

Correlation (Pearson’s) or paired sample T-Test was used to identify the




satisfaction with the age r(98)=.225, p=.026 , length of service r(98)=.227, p=.025,

and nature of employment r(98) = .314, p = .002.

However, the relationship is not strong between the variables because the

association is under minimum positive values. Thus, it signifies that as higher age

nurses has higher job satisfaction, higher length of service has higher job satisfaction

and permanent nurses have the higher job satisfaction than the contractual nurses.



163

The correlation between the marital status and job satisfaction is negative and

statistically not significant r(98)=(-).173, p=.089. Also, there is no relationship

between family background and job satisfaction of nurses in rural setting

r(98)=.0.047, p=.644. Thus, there is no relationship of Marital Status and family

background and Job Satisfaction in Nurses.

To sum up, statistically it seems that age, length of service and nature of

employment have positive effect on the job satisfaction of the Nurses.

4.4.2.3. JOB SATISFACTION OF MID-WIVES IN RURAL AND REMOTE


ATTRIBUTESThe job satisfaction of the Mid-wives has been measured on a scale of 1 to 5

with their present job in rural and remote area. The scale denotes 1 (one) as the highly


The mean of overall scale of job satisfaction of Nurses is (1.98, N=123),

which shows a lower scale of satisfaction. In the group comparison, the contractual

nurses (1.85, N=75), permanent nurses (2.17, N=48).

The analysis shows that the contractual mid-wives have the lowest scale of job

satisfaction in comparison to the permanent mid-wives.


are: t(121) = -2.809, p= .006. It signifies that there is a difference in the job


and permanent mid-wives.


mid-wives.

Category N Mean Std. Deviation Std. Error Min Max

Contract 75 1.85 .562 .065 1 4

Permanent 48 2.17 .663 .096 1 4

Total 123 1.98 .620 .056 1 4

Table 71: Correlation between Job satisfaction and the demographic

attributes of Nurses


1. Age 0.225 0.026


3. Marital Status -0.173 0.0894. Length of Service 0.227 0.025




164


permanent mid-wives Levene's

Test t-test for Equality of Means

F Sig. t df Sig. (2-tailed) MeanDiff.

Std.

Error Diff.

Equal variances assumed .042 .839 -2.809 121 .006 -.313 .112

Equal variances not assumed -2.709 88.315 .008 -.313 .116

To explore the relationship of the Job satisfaction of Mid-wives in rural and

remote area services with other demographic attributes like age, family background,

marital status, length of service and nature of employment, the statistical analysis has

been done and interpreted. The variable place of posting and sex is not considered

for the aforesaid test, because the variable has fewer cases of different groups.Correlation (Pearson’s) or paired sample T-Test was used to identify the




satisfaction with the age r(123)=.183, p=.043 and nature of employment r(123) =

.247, p = .006

However, the relationship is not strong between the variables because the

association is under minimum positive values. Thus, it signifies that as higher age

mid-wives has higher job satisfaction and permanent mid-wives have the higher job

satisfaction than the contractual mid-wives.

The correlation between the length of service r(123)=.158, p=.081, marital

status r(123)=(-).101, p=.265 and family background r(123)=.0.140, p=.123 with

job satisfaction is statistically not significant, thus there is no relationship between

these separate variables and job satisfaction of mid-wives in rural setting.

To sum up, statistically it seems that age and nature of employment have

positive effect on the job satisfaction of the Mid-wives.

Table 74 : Correlation between Job satisfaction and the demographic attributes

of mid-wives


1. Age 0.183 0.043







165

4.4.3. FACTORS OF JOB SATISFACTION OF PHYSICIANS,

NURSES AND MID-WIVES IN RURAL AND REMOTE AREAMany managers subscribe to the belief that a satisfied worker is necessarily a

good worker. In other words, if management could keep all the workers “happy”,

good performance would automatically follow. Job satisfaction in relation to workers

and organisation has been a fascinating area of scientific enduring right from the day

of Taylor and his pessimistic philosophy that the workers are essentially “stupid and

phlegmatic” and satisfied only with more economic return to a more realistic and

complex approach to job satisfaction. It has come a long way. The studies of Hoppock

(1935) and Samantray (1997) to mention some of the studies have added new

dimensions of knowledge on job satisfaction. The studies in the Indian context

between 1951 to 1983 as reviewed by Sayadain (2009) reveal that the economic

factors play a significant role in job satisfaction of Indian workers followed by job

security, fringe benefits and relationship with boss in that order. So, it is attempted to

explore the dimension of factors of job satisfaction in this study. As it is mentioned

job satisfaction is a composite of several variables that contributed to the overall

satisfaction from the job. These variables contribute to the job satisfaction in different

manner. One aspect or the variable can contribute to the job satisfaction and other

may not be. So, the analysis of factors of job satisfaction is necessities here.In this study, job satisfaction among physicians, nurses and mid-wives is

found to be at lower scale of satisfaction. Specifically in overall the mid-wives has the

lowest satisfaction level and the contractual physicians, nurses and mid-wives have

the lowest satisfaction level than the permanent employees of the same category.

Therefore, in this section of the study, it is attempted to explore the factors

contributed for job satisfaction of the physicians, nurses and mid-wives. The factors

of job satisfaction of the physicians, nurses and mid-wives have been measured on 18

items related to the current job in the rural area setting. The items attempted to

explore the contributing factors for job satisfaction of physicians, nurses and mid-

wives from the current job in rural and remote area setting.

The Cronbach’s alpha coefficient for this factor items is α =0.556 on item 18

and N=334, which is higher than 0.5.

The analysed results indicated in table 75 shows that the factor means at - a)

Social recognition and opportunities of public services/ care to patients (1.80) and b)

Better Job Prospects in future (1.80), which is the highest with mean among the factor



166

list that contributed for job satisfaction of the physicians, nurses and mid-wives. The

top 10 listed factor according to the compared mean out of the 18 point factors of job

satisfaction are: i) Social recognition and opportunities of public services/ care to

patients, ii) Better Job Prospects in future, iii) Training and skill development

Opportunities, iv) Matching of skills and tasks, v) Support, supervision, management

and mentoring, vi) Job security, vii) Teamwork and Interpersonal staffs relationship

viii) Salary, ix) Appropriate Work load and x) Career development opportunities.

The lowest mean factors are : Financial incentives linked to rural posting

(1.00), Reward system and recognition (1.00), Non-financial benefits/allowances

linked to rural posting (1.08), Safety at the workplace from external environment

(1.10), Work environment (1.19), Access to free accommodation (Housing) (1.20),

Adequacy of equipment, drugs and supplies (1.20), Opportunities of continuing

education/higher education (1.25), Career development opportunities (1.26),

Appropriate Work load (1.43)

Table 75: Descriptive Statistics of Factors contributed for job satisfaction of the


Factors

N Mean

Std.

Dev.

Better Job Prospects in future 334 1.8 0.403

Social recognition and opportunities of public services/ care

to patients

334 1.8 0.399

Training and skill development Opportunities 334 1.74 0.44

Matching of skills and tasks 334 1.73 0.444

Support, supervision, management and mentoring 334 1.66 0.473

Job security 334 1.59 0.493

Teamwork and Interpersonal staffs relationship 334 1.55 0.498

Salary 334 1.52 0.5

Appropriate Work load 334 1.43 0.496

Career development opportunities 334 1.26 0.441

Opportunities of continuing education/higher education 334 1.25 0.433Adequacy of equipment, drugs and supplies 334 1.2 0.399

Access to free accommodation (Housing) 334 1.2 0.399

Work environment 334 1.19 0.396

Safety at the workplace from external environment 334 1.1 0.295

Non-financial benefits/allowances linked to rural posting 334 1.08 0.273

A simultaneous multiple linear regression analysis was conducted to find

significant predictor at current time for the job satisfaction of physicians, nurses and

mid-wives altogether in rural and remote area setting. The factor variables of job

satisfaction explained about 17% of the variance in job satisfaction, F(16, 317)=



167

4.95; p < .05. As in table 76 shows, the factor model included 18 factors. The

following variables are constants or have missing correlations, financial incentives

linked to rural posting, Reward system and recognition, thus, they were deleted for

the analysis.

An examination of the T-Value indicates that Salary and Training & Skill

development opportunities are the main contributors to Job satisfaction in current

time of physicians, nurses and mid-wives altogether in rural and remote area setting.

Salary found to be significant at (b=.324, t=4.508; p= .001) and Training and skill

development opportunities found to be significant at (b=.108, t=2.017; p= .004).

Table 76: Result of Regression Analysis of factors contributed for job

satisfaction of the physicians, nurses and mid-wives.

Factors b t p-

value

(Constant) .419 .675

Salary .324 4.508 .001

Better Job Prospects in future -.033 -.639 .523

Job security .018 .278 .781

Career development opportunities .059 1.054 .293

Opportunities of continuing education/higher education -.035 -.595 .552

Training and skill development Opportunities .108 2.017 .044

Work environment .053 .970 .333Adequacy of equipment, drugs and supplies .065 1.199 .231

Non-financial benefits/allowances linked to rural posting .023 .434 .665

Appropriate Work load -.081 -1.435 .152

Matching of skills and tasks .060 1.092 .276

Support, supervision, management and mentoring .014 .263 .793


to patients

.086 1.629 .104

Teamwork and Interpersonal staffs relationship -.010 -.154 .878

Safety at the workplace from external environment .017 .320 .749

Access to free accommodation (Housing) .050 .919 .359

R R SquareAdjusted R

SquareStd. Error of the Estimate

.415 .172 .131 .783

The correlation matrix at table 77, indicates a positive relationship between

Overall job satisfaction with Salary, Job security, Career development opportunities,

Opportunities of continuing education/higher education, Training and skill

development Opportunities, Matching of skills and tasks, Social recognition and

opportunities of public services/ care to patients, Teamwork and Interpersonal staffs

relationship, Access to free accommodation (Housing).



168

Table 77: Correlation matrix of overall job Satisfaction with factor of job

satisfaction for physicians, nurses and mid-wives

Correlation p-value

Salary .350 .001

Better Job Prospects in future -.018 .737

Job security .213 .001Career development opportunities .169 .002

Opportunities of continuing education/higher education .133 .015

Training and skill development Opportunities .089** .005

Work environment .089 .104

Adequacy of equipment, drugs and supplies .086 .116

Financial incentives linked to rural posting .a -

Non-financial benefits/allowances linked to rural posting .090 .100

Appropriate Work load -.028 .605

Matching of skills and tasks .126 .021

Support, supervision, management and mentoring -.011 .837Reward system and recognition .a .

Social recognition and opportunities of public services/ care to

patients

.129 .018

Teamwork and Interpersonal staffs relationship .212 .001

Safety at the workplace from external environment .043 .430

Access to free accommodation (Housing) .158 .004(**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). a. Cannot be

computed because at least one of the variables is constant.)

4.4.3.1. FACTORS OF JOB SATISFACTION OF PHYSICIANS IN RURAL

AND REMOTE AREAWhen we look into separately the factors that impact on job satisfaction of

physicians at table 78, the 1) Social recognition and opportunities of public services/

care to patients (1.89) is the highest mean factor and Financial incentives linked to

rural posting (1.00) is the lowest mean factor. The top 10 factors area : 1) Social

recognition and opportunities of public services/ care to patients (1.89), 2) Better Job

Prospects in future (1.81), 3)Training and skill development Opportunities (1.77), 4)

Job security (1.75), 5) Matching of skills and tasks (1.72), 6) Salary (1.69), 7)

Teamwork and Interpersonal staffs relationship (1.66), 8) Support, supervision,

management and mentoring (1.65), 9) Opportunities of continuing education/higher

education (1.50), 10) Career development opportunities (1.39), and the lowest mean

factors are Financial incentives linked to rural posting (1.00), Reward system and

recognition (1.00), Non-financial benefits/allowances linked to rural posting (1.14),

Safety at the workplace from external environment (1.14), Work environment (1.22),

Adequacy of equipment, drugs and supplies (1.23), Access to free accommodation

(Housing) (1.23), Appropriate Work load (1.24).



169

Table 78: Descriptive Statistics on Factors contributed for job satisfaction of

the physicians. Sl.

No.Factors

N Min Max MeanStd.Dev.

1 Social recognition and opportunities of public

services/ care to patients

113 1 2 1.89 .309

2 Better Job Prospects in future 113 1 2 1.81 .398

3 Training and skill development Opportunities 113 1 2 1.77 .423

4 Job security 113 1 2 1.75 .434

5 Matching of skills and tasks 113 1 2 1.72 .453

6 Salary 113 1 2 1.69 .464

7 Teamwork and Interpersonal staffs

relationship

113 1 2 1.66 .475

8 Support, supervision, management and

mentoring

113 1 2 1.65 .478

9 Opportunities of continuing education/higher education

113 1 2 1.50 .502

10 Career development opportunities 113 1 2 1.39 .490

11 Appropriate Work load 113 1 2 1.24 .428

12 Access to free accommodation (Housing) 113 1 2 1.23 .423

13 Adequacy of equipment, drugs and supplies 113 1 2 1.23 .423

14 Work environment 113 1 2 1.22 .417

15 Safety at the workplace from external

environment

113 1 2 1.14 .350

16 Non-financial benefits/allowances linked to

rural posting

113 1 2 1.14 .350

17 Reward system and recognition 113 1 1 1.00 .00018 Financial incentives linked to rural posting 113 1 1 1.00 .000


significant predictor at current time for the job satisfaction of physicians in rural and

remote area setting. The factor variables of job satisfaction explained about 22% of

the variance in physicians job satisfaction, F(16, 96)= 1.726; p < .05. As in table 79,

the 18 factors were included. The following variables are constants or have missing

correlations, financial incentives linked to rural posting, Reward system and

recognition, thus, they were deleted for the analysis. An examination of the T-Value

indicates that Salary, Training & skill development Opportunities and Safety at the

workplace from external environment are the main contributors to the prediction of

Job satisfaction in current time of physicians in rural and remote area setting. Salary

found to be significant at (b=.364, t=2.839; p=.006), Training and skill development

opportunities found to be significant at (b=.186, t=1.926; p=.05) and Safety at the

workplace from external environment found to be significant at (b=.232, t=2.441; p=

.016)



170

Table 79: Result of Regression Analysis of factors contributed for job

satisfaction of the physicians.

Factors b t P

(Constant) -.340 .734

Salary .364 2.839 .006

Better Job Prospects in future .004 .038 .970Job security -.032 -.319 .751

Career development opportunities .024 .237 .813



Work environment .143 1.383 .170

Adequacy of equipment, drugs and supplies .101 .961 .339

Non-financial benefits/allowances linked to rural posting -.065 -.700 .486

Appropriate Work load -.166 -1.647 .103

Matching of skills and tasks .001 .012 .991

Support, supervision, management and mentoring .042 .439 .662Social recognition & opportunities of public services .069 .706 .482

Teamwork and Interpersonal staffs relationship -.006 -.053 .958

Safety at the workplace from external environment .232 2.441 .016


R R Square

Adjusted R

Square

Std. Error of

the Estimate

.473 .223 .094 .882

The correlation matrix at table 80, indicates a positive and strong relationship

between Overall job satisfaction with Salary (r=.282), Training and skill development

Opportunities (r=.110) and Safety at the workplace from external environment

(r= .262).

Table 80: Correlation matrix of overall job Satisfaction with factor of Job

satisfaction of Physicians

Factors r p

Salary .282 .002

Better Job Prospects in future .041 .668

Job security .019 .839

Career development opportunities .111 .242

Opportunities of continuing education/higher education .091 .339Training and skill development Opportunities .110* .048



Non-financial benefits/allowances linked to rural posting -.041 .665



Support, supervision, management and mentoring .055 .565

Social recognition and opportunities of public services/ care to patients .043 .653



Access to free accommodation (Housing) .118 .212**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).



171

4.4.3.2. FACTORS OF JOB SATISFACTION OF NURSES IN RURAL AND

REMOTE AREA

The factors that impact on job satisfaction of nurses can be seen at table 81,

such that- 1) Social recognition and opportunities of public services/ care to patients

(1.89) is the highest mean factor and Financial incentives linked to rural posting

(1.00) is the lowest mean factor.

The top 10 factors are: Social recognition and opportunities of public

services/ care to patients (1.91), Matching of skills and tasks (1.89), Better Job

Prospects in future (1.82), Training and skill development Opportunities (1.72),

Appropriate Work load (1.69), Support, supervision, management and mentoring

(1.65), Teamwork and Interpersonal staffs relationship (1.61), Job security (1.60)

Salary (1.53) and Career development opportunities (1.24).

Work environment (1.23), Access to free accommodation (Housing) (1.21),

Adequacy of equipment, drugs and supplies (1.17), Opportunities of continuing

education/higher education (1.06), Non-financial benefits/allowances linked to rural

posting (1.05), Safety at the workplace from external environment (1.04), Reward

system and recognition (1.00) and Financial incentives linked to rural posting (1.00)

are the main factors which have the lowest scores and contributes to the less job

satisfaction of the nurses.

Table 81: Descriptive Statistics on factors contributed for job satisfaction of

the Nurses.

Sl.

No.Factors

N Min Max Mean

Std.

Dev.

1 Social recognition and opportunities of public


98 1 2 1.91 .290

2 Matching of skills and tasks 98 1 2 1.89 .317

3 Better Job Prospects in future 98 1 2 1.82 .389

4 Training and skill development Opportunities 98 1 2 1.72 .449

5 Appropriate Work load 98 1 2 1.69 .4636 Support, supervision, management and mentoring 98 1 2 1.65 .478

7 Teamwork and Interpersonal staffs relationship 98 1 2 1.61 .490

8 Job security 98 1 2 1.60 .492

9 Salary 98 1 2 1.53 .502

10 Career development opportunities 98 1 2 1.24 .432

11 Work environment 98 1 2 1.23 .426

12 Access to free accommodation (Housing) 98 1 2 1.21 .412

13 Adequacy of equipment, drugs and supplies 98 1 2 1.17 .381

14 Opportunities of continuing education/higher

education

98 1 2 1.06 .241



172

15 Non-financial benefits/allowances linked to rural

posting

98 1 2 1.05 .221

16 Safety at the workplace from external

environment

98 1 2 1.04 .199

17 Reward system and recognition 98 1 1 1.00 .000

18 Financial incentives linked to rural posting 98 1 1 1.00 .000


significant predictor at current time for the job satisfaction of nurses in rural and


the variance in nurses job satisfaction, F(16, 81)= 1.403; p > .05. However, it is

statistically not significant, the p value is 0.161.

As table 82 shows, the factor included 18 factors. The following variables are

constants or have missing correlations, financial incentives linked to rural posting,

Reward system and recognition, thus, they were deleted for the analysis. An

examination of the T-Value indicates that no factors contribute to the prediction of

Job satisfaction in current time of nurses in rural and remote area setting. None of the

value found to be statistically significant.

However, the one sample T-test at table 83 shows that the following factors

have the Mean more than 1.5 and statistically significant in selection of factor of

satisfaction according to the responses. Social recognition and opportunities of public

services/ care to patients [t(97) = 13.920 p= .001], Matching of skills and tasks

[t(97) = 12.098 p= .001], Better Job Prospects in future [t(97) = 8.046 p= .001],

Training and skill development Opportunities t(97) = 4.949 p= .001,

Appropriate Work load [t(97) = 4.143 p= .001], Support, supervision, management

and mentoring [t(97) = 3.167 p=.002], Teamwork and Interpersonal staffs

relationship [t(97) = 2.269 p= .025] and Job security [t(97) = 2.053 p= .043]



173

Table 82: Regression Analysis of factors contributed for job satisfaction of the

nurses.

Factors b t Sig.

(Constant) 1.378 .172

Salary .209 1.354 .179

Better Job Prospects in future -.130 -1.228 .223Job security -.004 -.031 .975

Career development opportunities -.024 -.203 .840


Training and skill development Opportunities -.008 -.075 .941

Work environment -.031 -.281 .780

Adequacy of equipment, drugs and supplies .087 .780 .438

Non-financial benefits/allowances linked to rural posting .162 1.489 .140

Appropriate Work load -.097 -.862 .391


Support, supervision, management and mentoring .051 .474 .637

Social recognition and opportunities of public services/ careto patients

-.016 -.148 .883

Teamwork and Interpersonal staffs relationship .085 .635 .527

Safety at the workplace from external environment -.155 -1.445 .152


R R Square

Adjusted R

Square

Std. Error of

the Estimate

.466 .217 .062 .841

Table 83: T-test results of factors contributed for job satisfaction of the nurses.

Factors Test Value = 1.5

t df Sig.(2-

tailed)

Mean

Diff.

Salary 0.604 97 0.547 0.031

Better Job Prospects in future 8.046 97 0.001 0.316

Job security 2.053 97 0.043 0.102

Career development opportunities -5.843 97 0.001 -0.255

Opportunities of continuing/higher education -18.025 97 0.001 -0.439

Training & skill development Opportunities 4.949 97 0.001 0.224

Work environment -6.165 97 0.001 -0.265

Adequacy of equipment, drugs and supplies -8.493 97 0.001 -0.327 Non-financial benefits/allowances linked to rural

posting

-20.096 97 0.001 -0.449

Appropriate Work load 4.143 97 0.001 0.194

Matching of skills and tasks 12.098 97 0.001 0.388

Support, supervision, management and mentoring 3.167 97 0.002 0.153

Social recognition and opportunities of public


13.92 97 0.001 0.408

Teamwork and Interpersonal staffs relationship 2.269 97 0.025 0.112

Safety at the workplace from external environment -22.856 97 0.001 -0.459

Access to free accommodation (Housing) -6.858 97 0.001 -0.286



174


between overall job satisfaction with Salary (r= .321), Teamwork and Interpersonal

staffs relationship (r=.267) and Access to free accommodation (Housing) (r= .240),

while the weakest relationship was found between Training and skill development

Opportunities (r=.012).

Table 84: Correlation matrix of overall job Satisfaction with factor of Job

satisfaction of Nurses

Factors

Correlation

with job

satisfaction

P

Salary .321 .001




Opportunities of continuing education/higher education -.044 .665

Training and skill development Opportunities .012** .006



Financial incentives linked to rural posting .a .




Support, supervision, management and mentoring .044 .670

Reward system and recognition .a .Social recognition and opportunities of public services/ care to

patients

.047 .645



Access to free accommodation (Housing) .240 .017**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one

of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).

4.4.3.3. FACTORS OF JOB SATISFACTION OF MID-WIVES IN RURAL

AND REMOTE AREA

The factors that have impact on job satisfaction of mid-wives have the highest

mean of the factors like- Training and skill development Opportunities (1.72),

Support, supervision and management mentoring (1.68) and Better Job Prospects in

future (1.64) which may be seen at table 85.

The top 10 factors are: Training and skill development Opportunities (1.72),

Support, supervision and management mentoring (1.68), Better Job Prospects in

future (1.64), Social recognition and opportunities of public services/ care to patients

(1.63), Matching of skills and tasks (1.62), Job security (1.42), Appropriate Work



175

load (1.40), Teamwork and Interpersonal staffs relationship (1.40), Salary (1.37) and

Adequacy of equipment drugs and supplies (1.19).

Career development opportunities (1.16), Opportunities of continuing

education/higher education (1.16), Access to free accommodation (Housing) (1.15),

Work environment (1.14), Safety at the workplace from external environment

(1.10), Non-financial benefits/allowances linked to rural posting (1.05), Reward

system and recognition (1.00), and Financial incentives linked to rural posting (1.00)

have the lowest scores.

Table 85: Descriptive Statistics on factors contributed for job satisfaction of

the Mid-wives.

Factors N Min Max Mean

Std.

Dev.

Training and skill development Opportunities 123 1 2 1.72 .449

Support, supervision and management mentoring 123 1 2 1.68 .467

Better Job Prospects in future 123 1 2 1.64 .483



123 1 2 1.63 .484

Matching of skills and tasks 123 1 2 1.62 .488

Job security 123 1 2 1.42 .496

Appropriate Work load 123 1 2 1.40 .492

Teamwork and Interpersonal staffs relationship 123 1 2 1.40 .492

Salary 123 1 2 1.37 .484

Adequacy of equipment, drugs and supplies 123 1 2 1.19 .391Career development opportunities 123 1 2 1.16 .371

Opportunities of continuing education/higher education123 1 2 1.16 .371

Access to free accommodation (Housing) 123 1 2 1.15 .363

Work environment 123 1 2 1.14 .347

Safety at the workplace from external environment 123 1 2 1.10 .298

Non-financial benefits linked to rural posting 123 1 2 1.05 .216

Reward system and recognition 123 1 1 1.00 .000

Financial incentives linked to rural posting 123 1 1 1.00 .000


significant predictor at current time for the job satisfaction of nurses in rural and


the variance in mid-wives job satisfaction, F(16, 106)= 2.1; p < .05. It is statistically

significant, the p value is 0.013. As in table 86 shows, this included 18 factors. The

following variables are constants or have missing correlations, financial incentives

linked to rural posting, Reward system and recognition, thus, they were deleted for

the analysis. An examination of the T-Value indicates that Salary and Training &

skill development Opportunities and Safety at the workplace from external



176

environment are the main contributors to the prediction of Job satisfaction in current

time of mid-wives in rural and remote area setting. Salary found to be significant at

(b=.245, t=2.040; p= .044) and Training and skill development opportunities found to

be significant at (b=.230, t=2.508; p= .014).

Table 86: Regression Analysis of factors contributed for job satisfaction of the

mid-wives.

Factors b t Sig.

(Constant) 2.464 .015

Salary .245 2.040 .044

Better Job Prospects in future -.055 -.620 .537

Job security .241 1.973 .051

Career development opportunities .019 .204 .838



Work environment .113 1.187 .238

Adequacy of equipment, drugs and supplies -.049 -.551 .583

Non-financial benefits/allowances linked to rural posting .083 .884 .379

Appropriate Work load .013 .127 .899


Support, supervision, management and mentoring -.172 -1.766 .080


to patients

.097 1.110 .269

Teamwork and Interpersonal staffs relationship -.160 -1.395 .166

Safety at the workplace from external environment -.182 -1.910 .059

Access to free accommodation (Housing) -.096 -1.017 .311

R R Square

Adjusted R

Square

Std. Error of

the Estimate

.491a

.241 .126 .580


between overall job satisfaction with Salary (r=.303), Job security (r=.274) and while

the weakest relationship was found between Access to free accommodation (Housing)

(r= .053) and current job satisfaction.

Table 87: Correlation matrix of overall job Satisfaction with factor of job

satisfaction of Mid-wives

Factors r p

Salary .303 .001




Opportunities of continuing education/higher education .089 .329

Training and skill development Opportunities .152 .093


Adequacy of equipment, drugs and supplies -.015 .871Financial incentives linked to rural posting .

a.



177


Appropriate Work load .086 .345


Support, supervision, management and mentoring -.140 .122

Reward system and recognition .a .

Social recognition & opportunities of public services/ care to patients .134 .140Teamwork and Interpersonal staffs relationship .086 .345

Safety at the workplace from external environment -.120 .186

Access to free accommodation (Housing) .053* .048**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant.

*. Correlation is significant at the 0.05 level (2-tailed).

4.4.3.4. FACTORS OF JOB SATISFACTION OF CONTRACTUAL AND

PERMANENT PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND

REMOTE AREA

The past one decade has seen a growing tendency of contractual employment

in the public health sector in the country and as well in the state, toward a

fundamental restructuring for addressing the inadequacy issue. This section of the

chapter explores the factors of job satisfaction of contractual and permanent

physicians, nurses and mid-wives. A comparison of contractual and permanent job

satisfaction factors significantly shows a difference in between the two groups of

employees. As it is explored above that the contractual and permanent physicians,

nurses and mid-wives have different level of job satisfaction, in which contractual

have less job satisfaction level than that of the permanent physicians, nurses and mid-

wives. In the group comparison as per the Nature of Employment, the means of

contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. T-

Test shows that it is statistical significant, the values are: t(332) = -5.835, p =.001.

There is a difference in the job satisfaction between the groups. The mean difference

is -.513 between the contractual and permanent employees.

While exploring to the factors of job satisfaction in between the contractual

and permanent physicians, nurses and mid-wives, it is found as per table 88 and 89,

with Salary (1.92), Job security (1.88), Social recognition and opportunities of public

services/ care to patients (1.86), Teamwork and Interpersonal staffs relationship

(1.84) and Better Job Prospects in future (1.80) are the five most influential factors

for job satisfaction of permanent physicians, nurses and mid-wives. Whereas the

factors like Training and skill development Opportunities (1.80), Better Job Prospects

in future (1.79), Social recognition and opportunities of public services/ care to

patients (1.73), Matching of skills and tasks (1.69), and Support, supervision,management mentoring (1.66) are for the contractual.



178

Table 88 : Descriptive Statistics for factors for job satisfaction of permanent


Factors N in Max Mea

Std.

Dev.

Salary 180 1 2 1.92 .277

Job security 180 1 2 1.88 .322Social recognition and opportunities of public services/

care to patients

180 1 2 1.86 .347

Teamwork and Interpersonal staffs relationship 180 1 2 1.84 .369




Support, supervision, management and mentoring 180 1 2 1.64 .480


Opportunities of continuing education/higher education 180 1 2 1.42 .495

Career development opportunities 180 1 2 1.39 .490Access to free accommodation (Housing) 180 1 2 1.31 .462

Adequacy of equipment, drugs and supplies 180 1 2 1.22 .413


Non-financial benefits/allowances linked to rural posting 180 1 2 1.12 .322




Table 89: Descriptive Statistics for factors for job satisfaction of contracts


Factors N Min Max Mean

Std.Dev.





154 1 2 1.73 .443


Support, supervision, management and mentoring 154 1 2 1.66 .474


Job security 154 1 2 1.24 .429

Teamwork and Interpersonal staffs relationship 154 1 2 1.21 .412Adequacy of equipment, drugs and supplies 154 1 2 1.18 .381


Career development opportunities 154 1 2 1.11 .314


Access to free accommodation (Housing) 154 1 2 1.07 .258

Salary 154 1 2 1.06 .247

Opportunities of continuing /higher education 154 1 2 1.05 .209

Non-financial allowances linked to rural posting 154 1 2 1.04 .194





179

While exploring to the variance of factors of job satisfaction in between the

contractual and permanent physicians, nurses and mid-wives, it is observed in table

90, that the following have statistically significant difference between the two groups

of employees: Salary t(332) = -29.416, p= .001, Job security t(332) = -15.627, p=

.001, Career development opportunities t(332) = -6.185, p= .001, Opportunities of

continuing education/higher education t(332) = -8.793, p= .001, Training and skill

development Opportunities t(332) = 2.290, p= .023, Non-financial

benefits/allowances linked to rural posting t(332) = -2.616, p= .009, Matching of

skills and tasks t(332) = -2.617, p= .009, Social recognition and opportunities of

public services/ care to patients t(332) = -2.942, p= .003, Teamwork and

Interpersonal staffs relationship t(332) = -14.625, p= .001 and Access to free

accommodation (Housing) t(332) = -5.586, p= .001. However, it is found that there

is no significant difference of the following factors between the two groups: Better

Job Prospects in future, t(332)= -.176 p= .861, Work environment t(332)= -.822 p=

.412, Adequacy of equipment, drugs and supplies t(332)= -.944 p= .346, Appropriate

Work load t(332)= -.308 p=.758, Support, supervision, management and mentoring

t(332)=.845 p= .399,and Safety at the workplace from external environment t(332)=

-.653 p= .514.

Table 90: Analysis of variance in factors of Job satisfaction of Contractual and

Permanent Physicians, nurses and mid-wives in rural and remote area

Factors

t-test for Equality of Means

t df

Sig.(2-

tailed)

Mean

Diff.

Std.Error

Diff.

Salary -29.416 332 .001 -.852 .029

Better Job Prospects in future -.176 332 .861 -.008 .044

Job security -15.627 332 .001 -.643 .041

Career development opportunities -6.185 332 .001 -.284 .046

Opportunities of continuingeducation/higher education

-8.793 332 .001 -.377 .043


Opportunities

2.290 332 .023 .110 .048

Work environment -.822 332 .412 -.036 .044

Adequacy of equipment, drugs and supplies -.944 332 .346 -.041 .044

Non-financial benefits/allowances linked to

rural posting

-2.616 332 .009 -.078 .030

Appropriate Work load -.308 332 .758 -.017 .055

Matching of skills and tasks -2.617 332 .009 -.127 .048

Support, supervision, management andmentoring

.845 332 .399 .044 .052



180

Social recognition and opportunities of

public services/ care to patients

-2.942 332 .003 -.127 .043


relationship

-14.625 332 .001 -.625 .043

Safety at the workplace from external

environment

-.653 332 .514 -.021 .032

Access to free accommodation (Housing) -5.586 332 .001 -.234 .042

4.4.4. LIKELIHOOD OF MIGRATION OF PHYSICIANS, NURSES

AND MID-WIVES- CHOICE TO MIGRATE

Employees are the most valuable assets of organizations. Organisations need

to retain them, as it would benefit them in many ways. Employees who serve the

longest are best bets to win prizes for being the most productive and most reliable.

Long service employees are often the ones that carry the company and account for adisproportionate share of its success. No doubt, turnover arising because of super-

annuation and fusion of fresh blood in organizations is unavoidable and welcomed.

But constant change and flux in the labour force is wasteful. (Raju, 2003).

Therefore the intention of the physicians, nurses and the mid-wives to leave

the current job place or the job was explored with keeping the pay (salary) component

at constant. The dimension of migration was preset - to continue for atleast 3-5 years

in the present rural area posting or to shift to another rural health institute or to shift to

another urban health institute or to shift to another job in some other State/sector.

As per the position of the employees, the descriptive analysis in table 91,

shows that 41.6% of Physicians willing to shift to urban area, 24.8% physicians

willing to shift to other rural area health institute and only 26.5% wants to retain in

the present health institution in rural area, while 7.1% Physicians wants to leave the

public health service of the state. While, 50% of nurses willing to shift to urban area,

19.4% nurses willing to shift to other rural area health institute and only 25.5% wants

to retain in the present health institution in rural area and 5.1% nurses wants to leave

the public health service of the state. Similarly, 59.3% of mid-wives willing to shift to

urban area, 27.6% mid-wives willing to shift to other rural area health institute and

only 6.5% wants to retain in the present health institution in rural area and 6.5%

nurses wants to leave the public health service of the state. Thus, we can interpret that

more mid-wives are willing to shift to urban areas followed by nurses and physicians.

Figure 40 and 43 represent the situation graphically.



181

Management represenatatives have the concensus that there is lack of supply

of equipments, drugs and other supplies at the health institutes and the working

conditions are not conducive in the absence of adequate funding at all level. With

minimun resource the planning is very difficult and almost as doing nothing with plan

and the execution.

“For planning we need brain, discussion and laptop with a printer, but for

execution of plan we need money the fund, which is not adequate; funding is

needed for equipments, drugs and other supplies and infrastructure

development at the rural and remote areas in the districts. Contributing factors

are more, nothing is in its place, all mashed up. The workforce are not getting

conducive environment to work on, and overall personal factors are also there

which affects the turnover from the rural areas”.-A management representative

from the district. “the enviorment is good in urban areas, wiith schools, good

market and career development oppurtunites are there, on need the growth inthe professional life, not just dumping itself in the rural areas, this reasoncould be the out flux of the physicians, nurses and mid-wives.”-A management

representative from the district.

Table 91: Percentage showing the intention of migration of the physicians,

nurses and mid wives

Migrating Destination

Position of Respondent Total

Physician Nurse Mid-Wife

N N % N N % N N % N N %

To continue at least 3-5 years more in

the present rural area posting

30 26.5% 25 25.5% 8 6.5% 63 19%

To shift to another rural health institute 28 24.8% 19 19.4% 34 27.6% 81 24%

To shift to another urban health

institute

47 41.6% 49 50.0% 73 59.3% 169 51%

To shift to another job in some other

State/sector

8 7.1% 5 5.1% 8 6.5% 21 6%

Figure 40: Percentage of migrating intention of the physicians, nurses and midwives



182

Figure 41: Percentage of migrating intention of the physicians

Figure 42: Percentage of migrating intention of the nurses

Figure 43: Percentage of migrating intention of the mid-wives



183

Table 92: Percentage showing the intention of migration of the contract and

permanent workforce (physicians, nurses and mid wives)

Migrating Destination Nature of Employment

Contract Permanent

N N % N N %

To continue at least 3-5 years more in the present rural 16 10.4% 47 26.1%To shift to another rural health institute 38 24.7% 43 23.9%

To shift to another urban health institute 79 51.3% 90 50.0%

To shift to another job in some other State/sector 21 13.6% 0 .0%

Similarly in table 92, 51.3% of contract physicians, nurses and mid-wives are

willing to migrate to another urban health institution, whereas, only 50% of the

permanent physicians, nurses and mid-wives have the intention to leave for urban

area. More of the permanent employees are willing to continue the rural service in the

same posting place rather than the contract counterpart. While none of the permanent

employee are willing to shift to another job than that of 13.6% of contracts. Figure 44

and 45 represent the situation graphically.

Figure 44: Percentage of migrating intention of the contract workforce

(Physicians, nurses and mid-wives)

Figure 45: Percentage of migrating intention of the Permanent workforce(Physicians, nurses and mid-wives)



184

It is the job satisfaction of the employees which propel them to migrate. While

analysed, it is known that the job satisfaction has impact on the migration decision of

the employees.

Job satisfaction and decision to stay: With Logistic regression analysis it is tried to

explore the impact of job satisfaction as a predictor for stay at present posting rural

area. The variable job satisfaction significant at p<.001, has an impact and predictive

power for the decision of employees to stay at the present rural place of posting. By

measuring job satisfaction we can predict with 97.6% accuracy of the decision of

employees to stay at the present rural place of posting. A test of the full model against

a constant was statistically significant, indicating that a set reliably distinguished

between, in our case model chi square has 1 degrees of freedom, a value of 254.046and a probability of p<0.001. Thus, the indication is that the predictors do have a

significant effect. Here it is indicating that 53.3% of the variation in the decision to

stay is explained by the logistic model. Nagelkerke R Square is .859, so, it is

indicating a moderately strong relationship of 85.9% between the job satisfaction and

the choice to stay. While, The Wald criterion demonstrated it has 1 degrees of

freedom, a value of 56.505 and a probability of p<0.001 and signifies that job

satisfaction contributed significantly to the prediction of decision of stay at the present

job in rural and remote area of posting. EXP(B) value associated with Job satisfaction

is 79.527. Hence when job satisfaction is raised by one scale the odds ratio is 79 times

as large and therefore employees are 79 more times likely to stay.

Job satisfaction and shift to another rural area: With Logistic regression analysis

it is tried to explore the impact of job satisfaction as a predictor for employee shifting

to another rural area from presently posted rural area. As the variable is not

statistically significant, the p>.05, and if included would not have the predictive

power and not able to contribute to the prediction. Hence, it is statistically proved that

there is no significant relationship of job satisfaction and shifting of employee from

one rural area to another rural area.

Job satisfaction and shift to urban area: With Logistic regression analysis it is tried

to explore the impact of job satisfaction as a predictor for employee shifting to urban

area from presently posted rural area. The variable job satisfaction significant at

p<.001, has an impact and predictive power for the decision of employees to urban



185

migration. By measuring job satisfaction we can predict with 71% accuracy of the

decision of employees to migrate to urban area. A test of the full model against a

constant was statistically significant, in our case model chi square has 1 degrees of

freedom, a value of 75.551 and a probability of p<0.001. Thus, the indication is that

the predictors do have a significant effect. Here it is indicating that 20.2% of the

variation in the decision to migrate to urban area is explained by the logistic model.

Nagelkerke R Square is .270, so, it is indicating a low relationship of 27% between

the job satisfactions and migrates to urban area. While, The Wald criterion

demonstrated it has 1 degrees of freedom, a value of 41.434 and a probability of

p<0.001 and signifies that job satisfaction contributed significantly to the prediction

of decision. EXP(B) value associated with Job satisfaction is .221. Hence when the

figure is less that 1, any increase in the job satisfaction will leads to a drop in outcome

occurring that migration to urban area.

Job satisfaction and shift to other sector or state: With Logistic regression analysis

it is tried to explore the impact of job satisfaction as a predictor for employee shifting

out of the sector or the state. The variable job satisfaction significant at p<.001, has an

impact and predictive power for the decision of employees to out sector or state

migration. By measuring job satisfaction we can predict with 93.1% accuracy of the

decision of employees to this migration. A test of the full model against a constant

was statistically significant, in our case model chi square has 1 degrees of freedom, a

value of 50.076 and a probability of p<0.001. Thus, the indication is that the

predictors do have a significant effect. Here it is indicating that 13.9% of the variation

in the decision to migrate to other sector or state is explained by the logistic model.

Nagelkerke R Square is .172, so, it is indicating a low relationship of 17% between

the job satisfactions and migrates to other sector or state. While, The Wald criterion

demonstrated it has 1 degrees of freedom, a value of 38.758 and a probability of

p<0.001 and signifies that job satisfaction contributed significantly to the prediction

of decision. EXP(B) value associated with Job satisfaction is .039. Hence when job

satisfaction is raised by one scale, employees are more times stopped migrating to

other sector or state. However, migrating to other state or sector has low relationship

of 17% only.

Thus, the level of job satisfaction has a relationship and act as a predictor for

pushing the physicians, nurses and mid-wives from rural areas to urban and to other



186

sector. Whereas, it is not statically found that there is any association of job

satisfaction and rural to rural migration. However, the other pushing factors also act

as contributor for retention and migration of the workplace that too have an effect on

job satisfaction. So, coming section explores the factor for retention and migration of

this workforce.

4.4.4.1. CONTRIBUTING FACTOR OF LIKELIHOOD OF RETENTION OFPHYSICIANS, NURSES AND MID-WIVES- CHOICE TO STAY

In this section, it is attempted to explore the factors that contributed for the

decision of this workforce to stay back in same health institution at the rural area. The

eighteen (18) preset factors were included for the same.

The Cronbach’s alpha coefficient for the factor items is α =(0.559) on item 18

and N=63.

Factor of likelihood of retention of Physicians, nurses and mid-wives: The factor

that contributed to stay at the place of posting for more 3-5 years for both contract and

permanent physicians, nurses and mid-wives for rural and remote services has the

following top 10 selections: 1) Scope for training and skill development (1.71), 2)

Career development opportunities (1.56), 3) Job Security (1.40),4) Improved working

condition (1.33), 5) Satisfied with salary (1.32), 6) Scope for continuing

education/higher education (1.29), 7) Anticipation of obtaining a regular position after

contractual position (1.25), 8) More autonomy in current place of posting (1.24), 9)

Adequate drugs/equipment at the rural health centre (1.22) and 10) Improved support,

supervision and mentoring (1.17). Out of which, only one factor that is the Scope for

training and skill development is statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(62)= 3.735 , p=.001. However, the selection is made

only by 19% of the employee who wants to stay at the present posting place.Table 93: Descriptive Statistics of contributing factor of likelihood of retention

of physicians, nurses and mid-wives

Factors

N Mean

Test Value = 1.5

t df

Sig.

(2-

tailed

)

Mean

Diff.

Scope for training and skill development 63 1.71 3.735 62 .001 .214

Career development opportunities 63 1.56 .880 62 .382 .056

Job Security 63 1.35 -2.491 62 .015 -.151Improved working condition 63 1.33 -2.784 62 .007 -.167



187

Satisfied with salary 63 1.32 -3.088 62 .003 -.183

Scope for continuing /higher education 63 1.29 -3.735 62 .001 -.214

Anticipation of obtaining a regular position

after contractual position

63 1.25 -4.451 62 .001 -.246

More autonomy in current place of posting 63 1.24 -4.842 62 .001 -.262

Adequate drugs/equipment at the ruralhealth centre

63 1.22 -5.261 62 .001 -.278

Improved support, supervision and

mentoring

63 1.17 -6.749 62 .001 -.325

Adequate living conditions 63 1.13 -8.821 62 .001 -.373

Good schools for children/ education

prospects of children

63 1.13 -8.821 62 .001 -.373

Strong Teamwork and interpersonal

relationship

63 1.08 -12.253 62 .001 -.421

Flexible working hours with minimalworkload

63 1.06 -14.095 62 .001 -.437

Geographical affinities(Hometown near)andfamilial associations

63 1.06 -14.095 62 .001 -.437

Opportunity for both spouses to work and

live in the same location

63 1.05 -16.726 62 .001 -.452

Getting adequate financial incentives/ Rural

allowances/performance incentives

63 1.02 -30.500 62 .001 -.484

Physicians: While, analysing the factors to stay at the place of posting for more 3-5

years by the categories of employee i.e., Physicians, nurses and mid-wives. The

following 10 top factors for retention have been found for Physicians: 1)Scope for

training and skill development (1.83), 2) Career development opportunities (1.60),

3)Satisfied with salary (1.53), 4) Scope for continuing education/higher education

(1.43), 5) Improved working condition (1.40), 6) Job Security (1.40), 7) More

autonomy in current place of posting (1.40), 8) Adequate living conditions (access to

amenities like housing, water, electricity, conveyance and communication) (1.27), 9)

Opportunity for both spouses to work and live in the same location (1.20), and 10)

Anticipation of obtaining a regular position after contractual position (1.17). Out of

which, only one factor that is the Scope for training and skill development is

statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(29)=

4.817 , p=.001.



188

Table 94: Descriptive statistics for contributing factor of likelihood of

retention of physicians

Factors

NMea

nStd.Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mea

nDiff.

Scope for training and skilldevelopment

30 1.83 .379 4.817 29 .001 .333

Career development opportunities 30 1.60 .498 1.099 29 .281 .100

Satisfied with salary 30 1.53 .507 .360 29 .722 .033

Scope for continuing


30 1.43 .504 -.724 29 .475 -.067


Job Security 30 1.40 .498 -1.099 29 .281 -.100

More autonomy in current placeof posting 30 1.40 .498 -1.099 29 .281 -.100

Adequate drugs/equipment at the

rural health centre

30 1.27 .450 -2.841 29 .008 -.233

Adequate living conditions 30 1.20 .407 -4.039 29 .001 -.300

Anticipation of obtaining a

regular position after contractual

position

30 1.17 .379 -4.817 29 .001 -.333

Improved support, supervision

and mentoring

30 1.13 .346 -5.809 29 .001 -.367

Good schools for children/

education prospects of children

30 1.13 .346 -5.809 29 .001 -.367

Geographical

affinities(Hometown near)and

familial associations

30 1.10 .305 -7.180 29 .001 -.400

Opportunity for both spouses to

work and live in the same

location

30 1.10 .305 -7.180 29 .001 -.400


minimal workload

30 1.07 .254 -9.355 29 .001 -.433

Strong Teamwork and

interpersonal relationship

30 1.07 .254 -9.355 29 .001 -.433

Getting adequate financial

incentives/ Rural

allowances/performance

incentives

30 1.00 .000 - - - -

Achievement is recognized and

rewarded

30 1.00 .000 - - - -

Permanent physicians: While, the permanent physicians have the following top 10

factors for retention: 1) Scope for training and skill development (1.80), 2) Satisfied

with salary (1.64), 3) Career development opportunities (1.52), 4) Improved working

condition (1.48), 5) More autonomy in current place of posting (1.44), 6) Scope for



189

continuing education/higher education (1.32), 7) Job Security (1.32), 8) Adequate

drugs/equipment at the rural health centre (1.32), 9) Adequate living conditions

(access to amenities like housing, water, electricity, conveyance and communication)

(1.24). Out of which, only one factor that is the Scope for training and skill

development is statistically significant at Mean Test Value=1.5, 95% C.I, it is

significant at t(24)= 3.674 , p=.001.


retention of permanent physicians

Factors

N Mea

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mea

n

Diff.

Scope for training & skill development 25 1.80 .408 3.674 24 .001 .300

Satisfied with salary 25 1.64 .490 1.429 24 .166 .140

Career development opportunities 25 1.52 .510 .196 24 .846 .020

Improved working condition 25 1.48 .510 -.196 24 .846 -.020

More autonomy in current place of

posting

25 1.44 .507 -.592 24 .559 -.060

Adequate drugs/equipment at the

rural health centre

25 1.32 .476 -1.890 24 .071 -.180

Scope for continuing /higher education 25 1.32 .476 -1.890 24 .071 -.180

Job Security 25 1.32 .476 -1.890 24 .071 -.180


Geographical affinities(Hometownnear)and familial associations

25 1.12 .332 -5.729 24 .001 -.380



25 1.12 .332 -5.729 24 .001 -.380

Opportunity for both spouses to work

and live in the same location

25 1.12 .332 -5.729 24 .001 -.380


workload

25 1.08 .277 -7.584 24 .001 -.420


mentoring

25 1.08 .277 -7.584 24 .001 -.420


relationship

25 1.08 .277 -7.584 24 .001 -.420

Getting adequate financial / Ruralallowances/performance incentives

25 1.00 .000 - - - -

Anticipation of obtaining a regular

position after contractual position

25 1.00 .000 - - - -

Achievement is recognized &rewarded 25 1.00 .000 - - - -

Contract physicians: Likewise, the contract physicians have the following 8 factors

found to relevant for retention: 1) Scope for training and skill development (2.00), 2)

Anticipation of obtaining a regular position after contractual position (1.95), 3) Scope



190

for continuing education/higher education (1.86), 4) Career development

opportunities (1.81), 5) Improved support, supervision and mentoring (1.80), 6)

More autonomy in current place of posting (1.40), 7) Job Security (1.20), and 8)

Good schools for children/ education prospects of children (1.20). Out of which, only

two factors that is the Scope for training and skill development and Anticipation of

obtaining permanent post is statistically significant at Mean Test Value=1.5, 95% C.I,

it is significant at t(4)= 4.568 , p=.001 and t(4)= 2.500 , p= .001.


retention of contract physicians

Factors

Mean

Std.Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

MeanDiff.

Scope for training and skill development 5 2.00 .000 4.568 4 .001 .500



5 1.95 .218 2.500 4 .001 .452

Scope for continuing /higher education 5 1.86 .359 1.564 4 .100 .357


Job Security 5 1.80 .447 1.500 4 .208 .300


mentoring

5 1.40 .548 -.408 4 .704 -.100



5 1.20 .447 -1.500 4 .208 -.300

More autonomy in current place of postin 5 1.20 .447 -1.500 4 .208 -.300

Satisfied with salary 5 1.00 .000 - - - -

Getting adequate financial/ Rural


5 1.00 .000 - - - -

Improved working condition 5 1.00 .000 - - - -

Adequate drugs/equipment at the rural

health centre

5 1.00 .000 - - - -

Flexible working hours with minimalworkload

5 1.00 .000 - - - -

Strong Teamwork and interpersonalrelationship

5 1.00 .000 - - - -

Adequate living conditions 5 1.00 .000 - - - -


Geographical affinities(Hometown

near)and familial associations

5 1.00 .000 - - - -



5 1.00 .000 - - - -

Nurses: While, analysing the factors to stay at the place of posting for more 3-5 years

of the nurses. The following 10 top factors for retention have been found: 1) Scope



191

for training and skill development (1.64), 2) Career development opportunities

(1.48), 3) Anticipation of obtaining a regular position after contractual position

(1.32), 4) Job Security (1.32), 5) Improved working condition (1.28), 6) Improved

support, supervision and mentoring (1.20), 7) Adequate drugs/equipment at the rural

health centre (1.16), 8) Strong Teamwork and interpersonal relationship (1.12),

Satisfied with salary (1.12) and 9) Good schools for children/ education prospects

of children (1.12). Out of which, only one factor that is the Scope for training and

skill development and Anticipation of obtaining permanent post is statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(24)= 1.429 ,

p=.006.

Table 97: Descriptive statistics for contributing factor of likelihood of retention

of nurses

Factors

N ean

Std.

Dev.

Test Value = 1.5

t df Sig.

(2-tailed)

Mean

Diff.


Career development opportunities 25 1.48 .510 -.196 24 .846 -.020

Job Security 25 1.32 .476 -1.890 24 .071 -.180



25 1.32 .476 -1.890 24 .071 -.180


Improved support,supervision &mentorin 25 1.20 .408 -3.674 24 .001 -.300Adequate drugs/equipment at the rural

health centre

25 1.16 .374 -4.543 24 .001 -.340

Satisfied with salary 25 1.12 .332 -5.729 24 .001 -.380


relationship

25 1.12 .332 -5.729 24 .001 -.380



25 1.12 .332 -5.729 24 .001 -.380

Scope for continuing education/higher

education

25 1.08 .277 -7.584 24 .001 -.420


workload

25 1.08 .277 -7.584 24 .001 -.420




25 1.04 .200 -11.50 24 .001 -.460

Getting adequate financial incentives/

Rural allowances/performance incentives

25 1.00 .000 - - - -

Achievement is recognized & rewarded 25 1.00 .000

Opportunity for both spouses to work and live in the same location

25 1.00 .000 - - - -


posting

25 1.00 .000 - - - -



192

Permanent Nurses: While, analysing the factors to stay at the present place of

posting, the following 10 top factors for retention have been found in case of

permanent nurses: 1) Scope for training and skill development (1.53), 2) Career

development opportunities (1.29), 3) Improved working condition (1.24),

4) Adequate drugs/equipment at the rural health centre (1.18), 5) Satisfied with salary

(1.18), 6) Adequate living conditions (access to amenities like housing, water,

electricity, conveyance and communication) (1.12), 7) Strong Teamwork and

interpersonal relationship (1.12), 8) Job Security (1.12), 9) Geographical

affinities(Hometown near)and familial associations (1.06) and 10) Scope for

continuing education/higher education (1.06). Out of which, only one factor that is

the Scope for training and skill development is statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(16)=1 .236 , p= .017.

Table 98: Descriptive statistics contributing factor of likelihood of retention of

permanent nurses- Choice to stay in present rural area

Factors

NMean

Std.Dev.

Test Value = 1.5

t df Sig.

(2-tailed

MeanDiff.

Scope for training & skill development 17 1.53 .514 1.236 16 .017 .029

Career development opportunities 17 1.29 .470 -1.807 16 .090 -.206


Satisfied with salary 17 1.18 .393 -3.395 16 .004 -.324Adequate drugs/equipment at the rural

health centre

17 1.18 .393 -3.395 16 .004 -.324

Job Security 17 1.12 .332 -4.747 16 .001 -.382


relationship

17 1.12 .332 -4.747 16 .001 -.382




workload

17 1.06 .243 -7.500 16 .001 -.441

Improved support,supervision &mentori 17 1.06 .243 -7.500 16 .001 -.441

Geographical affinities(Hometownnear)and familial associations

17 1.06 .243 -7.500 16 .001 -.441



17 1.06 .243 -7.500 16 .001 -.441

Getting adequate financial / Rural


17 1.00 .000 - - - -



17 1.00 .000 - - - -

Achievement is recognized& rewarded 17 1.00 .000 - - - -



17 1.00 .000 - - - -

More autonomy in current placeof postin 17 1.00 .000 - - - -



193

Contract nurses: While, analysing the factors to stay at the present place of posting

for more 3-5 years, the following 10 top factors for retention have been found in case

of contract nurses: 1) Anticipation of obtaining a regular position after contractual

position (2.00), 2) Scope for training and skill development (1.88), 3) Career

development opportunities (1.88), 4) Improved support, supervision and mentoring

(1.75), 5) Improved working condition (1.50), 6) Good schools for children/

education prospects of children (1.38), 7) Strong Teamwork and interpersonal

relationship (1.25), 8) Flexible working hours with minimal workload (1.13), 9)

Scope for continuing education/higher education (1.13) and 10) Adequate

drugs/equipment at the rural health centre (1.13). Out of which, three factors that is

the Scope for training and skill development, Anticipation of obtaining permanent

post and Career development opportunities are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(7)=5.342, p=.001. t(7)=3.000, p=.020 and

t(7)=3.000, p=.020 respectively.


of contract nurses

Factors

N

Mea

n

Std.

Dev

.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.Anticipation of obtaining a regular


8 2.00 .000 5.342 7 .001 .500



Job Security 8 1.75 .463 1.528 7 .170 .250


mentoring

8 1.50 .535 .000 7 1.000 .000

Improved working condition 8 1.38 .518 -.683 7 .516 -.125



8 1.25 .463 -1.528 7 .170 -.250


8 1.13 .354 -3.000 7 .020 -.375



workload

8 1.13 .354 -3.000 7 .020 -.375

Strong Teamwork and interpersonalrelationship

8 1.13 .354 -3.000 7 .020 -.375



Rural allowances/performance

incentives

8 1.00 .000 - - - -




194

Achievement is recognized andrewarded

8 1.00 .000 - - - -



8 1.00 .000 - - - -



8 1.00 .000 - - - -


posting

8 1.00 .000 - - - -

Mid-wives: While, analysing the factors to stay at the present place of posting for

more 3-5 years, the following 10 top factors for retention have been found in case of

nurses: Scope for training and skill development (1.63), Anticipation of obtaining a

regular position after contractual position (1.61), Scope for continuing

education/higher education (1.38), Career development opportunities (1.38),

More autonomy in current place of posting (1.38), Improved working condition

(1.25), Adequate drugs/equipment at the rural health centre (1.25), Job Security

(1.25), Improved support, supervision and mentoring (1.25), Satisfied with salary

(1.13). Out of which, two factors that is the Scope for training and skill development,

Anticipation of obtaining permanent post are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(7)=.683, p=.016 and t(7)=.100, p=.043

respectively.


retention of Mid-wives

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

ig. (2

ailed)

Mean

Diff.

Scope for training & skill development 8 1.63 .518 .683 7 .016 .125

Anticipation of obtaining a regular position after contractual position

8 1.61 .535 .100 7 .043 .11

Scope for continuing /higher

education

8 1.38 .518 -.683 7 .516 -.125



posting

8 1.38 .518 -.683 7 .516 -.125



health centre

8 1.25 .463 -1.528 7 .170 -.250

Job Security 8 1.25 .463 -1.528 7 .170 -.250


mentoring

8 1.25 .463 - - - -


Getting adequate financial /Ruralallowances/performance incentives

8 1.13 .354 -3.000 7 .020 -.375



195

Good schools for children/ education prospects of children

8 1.13 .354 -3.000 7 .020 -.375


workload

8 1.00 .000 -1.528 7 .170 -.250


relationship

8 1.00 .000 - - - -





8 1.00 .000 - - - -



8 1.00 .000 - - - -

Permanent Mid-wives: While, analysing the factors to stay at the present place of

posting for more 3-5 years, the following 10 top factors for retention have been

found in case of permanent mid-wives: 1) Scope for training and skill development

(1.60), 2)Career development opportunities (1.40), 3) Job Security (1.40), 4) More

autonomy in current place of posting (1.40), 5) Improved working condition (1.40),

6) Scope for continuing education/higher education (1.20), 7) Good schools for

children/ education prospects of children (1.20), 8) Improved support, supervision

and mentoring (1.20), 9) Adequate drugs/equipment at the rural health centre (1.20)

and 10) Opportunity for both spouses to work and live in the same location (1.20).

Out of which, only one factor that is the Scope for training and skill development, is

statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at

t(4)=1.408, p= .004.


of Permanent Mid-wives

Factors

ean

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mean

Diff.

Scope for training and skilldevelopment

5 1.60 .548 1.408 4 .004 .100


Job Security 5 1.40 .548 -.408 4 .704 -.100


posting

5 1.40 .548 -.408 4 .704 -.100



Rural allowances/performanceincentives

5 1.20 .447 -1.500 4 .208 -.300


5 1.20 .447 -1.500 4 .208 -.300



196

Scope for continuing education/higher education

5 1.20 .447 -1.500 4 .208 -.300


Improved support, supervision andmentoring

5 1.20 .447 -1.500 4 .208 -.300


5 1.20 .447 -1.500 4 .208 -.300


workload

5 1.00 .000 - - - -


relationship

5 1.00 .000 - - - -

Anticipation of obtaining a regular position after contractual position

5 1.00 .000 - - - -

Adequate living 5 1.00 .000 - - - -

Achievement is recognized andrewarded

5 1.00 .000 - - - -



5 1.00 .000 - - - -



5 1.00 .000 - - - -

Contract Mid-wives: While, analysing the factors to stay at the present place of

posting for more 3-5 years, the following 7 factors for retention have been found

relevant mean in case of contract mid-wives: 1) Anticipation of obtaining a regular

position after contractual position (2.00), 2) Scope for training and skill development

(2.00), 3) Career development opportunities (2.00), 4) Scope for continuing

education/higher education (1.67), 5) More autonomy in current place of posting

(1.33), 6) Improved support, supervision and mentoring (1.33) and 7) Adequate

drugs/equipment at the rural health centre (1.33). Out of which, only two factors that

is the Anticipation of obtaining a regular position after contractual position and

Scope for training and skill development, are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(2)=.386, p=.001 and t(2)=.386, p=.001

respectively.


retention of contract Mid-wives

Factors

N Mean

Std.

Dev

.

Test Value = 1.5

t

d

f

Sig.

(2-

taile

d)

Mea

n

Diff.



3 2.00 .000 .386 2 .001 .000

Scope for training and skill development 3 2.00 .000 .386 2 .001 .000



197

Career development opportunities 3 1.67 .577 .500 2 .667 .167

Scope for continuing /higher education 3 1.67 .577 .500 2 .667 .167


health centre

3 1.33 .577 -

.500

2 .667 -.167


mentoring

3 1.33 .577 -

.500

2 .667 -.167


posting

3 1.33 .577 -

.500

2 .667 -.167


Getting adequate financial incentives/Rural allowances/performance incentives

3 1.00 .000 - - - -

Improved working condition 3 1.00 .000 - - - -

Job Security 3 1.00 .000 - - - -


workload

3 1.00 .000 - - - -


relationship

3 1.00 .000 - - - -


Achievement is recognized and rewarded 3 1.00 .000 - - - -



3 1.00 .000 - - - -


3 1.00 .000 - - - -

Opportunity for both spouses to work and live in the same location

3 1.00 .000 - - - -

4.4.4.2. PUSH FACTORS OF LIKELIHOOD OF MIGRATION OFPHYSICIANS, NURSES AND MID-WIVES- CHOICE TO MIGRATE

In this section, it is attempted to explore the push factors that contributed for

the decision to migrate from the present rural area health institution of the employees.

The eighteen (16) preset factors were included for the same.

The Cronbach’s alpha coefficient for the factor items is α =(0.607) on item 16

and N=271.

Push factors for migration of Physicians, Nurses and Mid-wives: It is analysed

and found that the top 10 factors that contributed for intention for migration of the

physicians, nurses and mid-wives from the present rural area to other rural area, urban

area or to leave the sector are: 1) Lack of adequate financial incentives/ Rural

allowances/performance incentive (1.57), 2) Poor working condition (1.54), 3) Poor

salaries (1.45), 4) Inadequate drugs/equipment (1.28), 5) Lack of Career development

opportunities (1.24), 6) Inadequate living conditions (access to amenities like

housing, water, electricity, conveyance and communication) (1.18), 7) Lack of scope



198

for continuing education/higher education (1.13), 8) Lack of others cadres,

teamwork and interpersonal relationship (1.07), 9) Lack of Job security (1.07) and 10)

Poor support, supervision and mentoring (1.04). Out of which, two factors that is the

Lack of adequate financial incentives / Rural allowances/performance incentives and

poor working condition is statistically significant at Mean Test Value=1.5, 95% C.I, it

is significant at t(270)= 2.265 , p=.024 and t(270)=1.400, p=.036.

Table 103: Descriptive statistics for contributing push factors for physicians,


Factors

N

Mea

n

Std.

Dev

.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mea

n

Diff.

Lack of adequate financial

incentives/ Ruralallowances/performance

incentives

271 1.57 .496 2.265 270 .024 .068

Poor working condition 271 1.54 .499 1.400 270 .036 .042

Poor salaries 271 1.45 .498 -1.769 270 .078 -.054

Inadequate drugs/equipment 271 1.28 .450 -8.031 270 .001 -.220

Lack of Career development

opportunities

271 1.24 .428 -10.011 270 .001 -.260

Inadequate living conditions 271 1.18 .389 -13.365 270 .001 -.315

Lack of scope for continuing


271 1.13 .340 -17.775 270 .001 -.367

Lack of others cadres,

teamwork and interpersonal

relationship

271 1.07 .256 -27.665 270 .001 -.430

Lack of Job security 271 1.07 .249 -28.610 270 .001 -.434

Poor support, supervision and

mentoring

271 1.04 .206 -36.401 270 .001 -.456

Limited or no good schools for

children/ education prospects of

children

271 1.04 .198 -38.253 270 .001 -.459

Achievement not recognized 271 1.03 .170 -45.674 270 .001 -.470

Limited opportunity of trainingand skill development

271 1.02 .147 -53.365 270 .001 -.478

Unusual working hours and

excess work load

271 1.02 .147 -53.365 270 .001 -.478

Lack of safety at workplace 271 1.02 .147 -53.365 270 .001 -.478

Lack of Autonomy 271 1.02 .147 -53.365 270 .001 -.478

Push factors for migration of Physicians: While analysing the responses, the top 10

factors found contributing for intention of migration of the physicians from the

present rural area to other rural area, urban area or to leave the sector are: 1) Lack of

adequate financial incentives/ Rural allowances/performance incentive (1.61), 2) Poor



199

working condition (1.51), 3) Lack of Career development opportunities (1.34), 4)

Inadequate drugs/equipment (1.31), 5) Poor salaries (1.29), 6) Lack of scope for

continuing education/higher education (1.23), 7), Inadequate living conditions


(1.22), 8) Lack of Job security (1.08), 9) Lack of Autonomy(1.05),10) Limited or no

good schools for children/ education prospects of children (1.05). Out of which, only

one factor that is the Lack of adequate financial incentives / Rural

allowances/performance incentives is statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(82)= 2.129 , p=.036. However, the poor working

condition also seems to be one of the factors that influencing with Mean of 1.51.

Table 104: Descriptive statistics for contributing push factor for physicians

Push factors for migration of permanent Physicians: While analysing further

breaking down to nature of employment as permanent physicians, it is found that thefollowing factors contributed for intention of migration of the permanent physicians

Factors

NMea

nStd.Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mea

nDiff.

Lack of adequate financial incentives/


incentives

83 1.61 .490 2.129 82 .036 .114

Poor working condition 83 1.51 .503 .109 82 .913 .006

Lack of Career development opportunit 83 1.34 .476 -3.115 82 .003 -.163

Inadequate drugs/equipment 83 1.31 .467 -3.646 82 .001 -.187Poor salaries 83 1.29 .456 -4.211 82 .001 -.211

Lack of scope for continuingeducation/higher education

83 1.23 .423 -5.843 82 .001 -.271



Lack of others cadres, teamwork and


83 1.05 .215 -19.103 82 .001 -.452

Limited or no good schools for childre

/education prospects of children

83 1.05 .215 -19.103 82 .001 -.452

Lack of Autonomy 83 1.05 .215 -19.103 82 .001 -.452

Unusual working hours and excess

work load

83 1.04 .188 -22.504 82 .001 -.464

Poor support, supervision & mentoring 83 1.04 .188 -22.504 82 .001 -.464


Limited opportunity of training and

skill development

83 1.02 .154 -28.103 82 .001 -.476




200

from the present rural area to other rural area, urban area or to leave the sector: 1)

Lack of adequate financial incentives/ Rural allowances/performance incentives

(1.68), 2) Poor working condition (1.47), 3) Inadequate drugs/equipment (1.28), 4)

Lack of Career development opportunities (1.11), 5) Inadequate living conditions


(1.11), 6) Lack of scope for continuing education/higher education (1.08), 7) Lack of

Autonomy (1.06), 8) Lack of others cadres, teamwork and interpersonal

relationship (1.06), 9) Unusual working hours and excess work load (1.06) and

10) Limited or no good schools for children/ education prospects of children (1.02).

Out of which, only one factor that is the Lack of adequate financial incentives / Rural

allowances/performance incentives is statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(52)= 1.243 , p=.020.

Table 105: Descriptive statistics for contributing push factor for permanent

physicians

Factors

N

Mea

n

Std.

Dev.

Test Value = 1.5

t df

Sig.

(2-

tailed)

Mea

n

Diff.

Lack of adequate financial incentives/Rural allowances/performance

incentives

53 1.68 .497 1.243 52 .020 .085

Poor working condition 53 1.47 .504 -.409 52 .684 -.028


Lack of Career development opportunitie 53 1.11 .320 -8.803 52 .001 -.387



53 1.08 .267 -11.589 52 .001 -.425

Unusual working hours/excess work load 53 1.06 .233 -13.836 52 .001 -.443



53 1.06 .233 -13.836 52 .001 -.443

Lack of Autonomy 53 1.06 .233 -13.836 52 .001 -.443Limited opportunity of trng.& skill dev. 53 1.02 .137 -25.500 52 .001 -.481

Poor support, supervision and mentoring 53 1.02 .137 -25.500 52 .001 -.481

Limited or no good schools for children/


53 1.02 .137 -25.500 52 .001 -.481

Poor salaries 53 1.00 .000 - - - -

Lack of Job security 53 1.00 .000 - - - -

Achievement not recognized 53 1.00 .000 - - - -

Lack of safety at workplace 53 1.00 .000 - - - -

Push factors for migration of contract Physicians: While analysing the responses

of contract physicians, it is found that these factors contributed for intention of



201

migration of the contract physicians from the present rural area to other rural area,

urban area or to leave the sector are: 1) Poor salaries (1.80), 2) Lack of adequate

financial incentives/ Rural allowances/performance incentives (1.77), 3) Lack of

Career development opportunities (1.73), 4) Poor working condition (1.57), 5) Lack

of scope for continuing education/higher education (1.50), 6) Inadequate living

conditions (access to amenities like housing, water, electricity, conveyance and

communication)(1.40), 7) Inadequate drugs/equipment (1.37), 8) Lack of Job security

(1.23), 9) Limited or no good schools for children/ education prospects of children

(1.10) and 10)Achievement not recognized (1.10). Out of which, three factors that

are the Poor salaries, lack of adequate financial incentives/ Rural

allowances/performance incentives and lack of Career development opportunities are


4.039 , p= .001, t(29)= 1.904 , p=.037 and t(29)= 2.841 , p=.008 respectively.

Table 106: Descriptive statistics for contributing push factor for contract

physicians

Factors

N Mean

Std.

Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.

Poor salaries 30 1.80 .407 4.039 29 .001 .300



incentives

30 1.77 .479 1.904 29 .037 .167


opportunities

30 1.73 .450 2.841 29 .008 .233

Poor working condition 30 1.57 .504 .724 29 .475 .067


30 1.50 .509 .000 29 1.00 .000




Achievement not recognized 30 1.10 .305 -7.180 29 .001 -.400Limited or no good schools for children


30 1.10 .305 -7.180 29 .001 -.400


mentoring

30 1.07 .254 -9.355 29 .001 -.433


Limited opportunity of training &skill

development

30 1.03 .183 -14.00 29 .001 -.467



30 1.03 .183 -14.00 29 .001 -.467

Lack of Autonomy 30 1.03 .183 -14.00 29 .001 -.467

Unusual working hours and excess

work load

30 1.00 .000 - - - -



202

Push factors for migration of Nurses: From the responses of the nurses, it is found

that these factors contributed for intention of migration of the nurses from the present

rural area to other rural area, urban area or to leave the sector are: 1) Lack of adequate

financial incentives/ Rural allowances/performance incentives (1.62), 2) Poor working

condition (1.62), 3) Poor salaries (1.48), 4) Inadequate drugs/equipment (1.26), 5)



(1.16), 7) Lack of scope for continuing education/higher education (1.08), 8)Lack of

others cadres, teamwork and interpersonal relationship (1.05), 9) Lack of Job security

(1.05) and 10) Limited opportunity of training and skill development (1.05). Out of

which, two factors, the Lack of adequate financial incentives/ Rural

allowances/performance incentives and Poor working condition are statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(72)= 2.032 , p= .046

both.

Table 107: Descriptive statistics for contributing push factor for nurses

N

Mea

n

Std.

Dev

Test Value = 1.5

t df

Sig.(2-

tailed

)

Mean

Diff.Lack of adequate financial incentives/


73 1.62 .490 2.032 72 .046 .116


Poor salaries 73 1.48 .503 -.349 72 .728 -.021


Lack of Career development opportunities 73 1.18 .385 -7.140 72 .001 -.322




73 1.08 .277 -12.908 72 .001 -.418

Limited opportunity of training and skill

development

73 1.05 .229 -16.600 72 .001 -.445


Lack of others cadres, teamwork andinterpersonal relationship

73 1.05 .229 -16.600 72 .001 -.445




73 1.04 .200 -19.616 72 .001 -.459


Unusual working hours and excess work load

73 1.01 .117 -35.500 72 .001 -.486

Lack of safety at workplace 73 1.01 .117 -35.500 72 .001 -.486Lack of Autonomy 73 1.00 .000 - - - -



203

Push factors for migration of permanent nurses: While analysing further breaking

down to nature of employment of nurses as permanent nurses, it is found from the

responses, the following factors contributed for intention of migration of the

permanent nurses from the present rural area to other rural area, urban area or to leave

the sector: 1) Lack of adequate financial incentives/ Rural allowances/performance

incentives (1.64), 2) Poor working condition (1.61), 3) Inadequate drugs/equipment

(1.22), 4) Inadequate living conditions (access to amenities like housing, water,

electricity, conveyance and communication) (1.08), 5) Lack of others cadres,

teamwork and interpersonal relationship (1.06), 6) Limited or no good schools for

children/ education prospects of children (1.06), 7) Limited opportunity of training

and skill development (1.06), 8) Poor support, supervision and mentoring (1.03), 9)

Lack of Career development opportunities (1.03) and 10) Unusual working hours

and excess work load (1.03). Out of which, only one factor that is the Lack of

adequate financial incentives / Rural allowances/performance incentives is


1.711 , p=.046. However, poor working condition also has seems contributing to the

intention with Mean of 1.61.

Table 108: Descriptive statistics for contributing push factor for regular nurses

N

Mea

n

Std.

Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

Mea

n

Diff.

Lack of adequate financial incentives/ Rural


36 1.64 .487 1.711 35 .046 .139




Limited opportunity of training and skill dev. 36 1.06 .232 -11.479 35 .001 -.444



36 1.06 .232 -11.479 35 .001 -.444



36 1.06 .232 -11.479 35 .001 -.444


Unusual working hours and excess work load 36 1.03 .167 -17.000 35 .001 -.472

Poor support, supervision & mentoring 36 1.03 .167 -17.000 35 .001 -.472

Poor salaries 36 1.00 .000 - - - -

Lack of scope for continuing /higher education36 1.00 .000

Lack of Job security 36 1.00 .000


Lack of safety at workplace 36 1.00 .000 - - - -Lack of Autonomy 36 1.00 .000 - - - -



204

Push factors for migration of contract nurses: While analysing the responses of

contract nurses, it is found that the following factors contributed for migration of the

contract nurses from the present rural area to other rural area, urban area or to leave

the sector: 1) Poor salaries (1.95), 2) Lack of adequate financial incentives/ Rural

allowances/performance incentives (1.62), 3) Poor working condition (1.59), 4) Lack

of Career development opportunities (1.32), 5) Inadequate drugs/equipment (1.30), 6)

Inadequate living conditions (access to amenities like housing, water, electricity,

conveyance and communication) (1.24), 7) Lack of scope for continuing

education/higher education (1.16), 8) Lack of Job security (1.11), 9) Achievement

not recognized (1.05) and 10) Lack of others cadres, teamwork and interpersonal

relationship (1.05). Out of which, two factors that is the Poor salary and Lack of

adequate financial incentives / Rural allowances/performance incentives are


11.833 , p= .001 and t(36)= 1.505 , p=.041 respectively.

Table 109: Descriptive statistics for contributing push factor for contract

nurses

Factors

N

Mea

n

Std

Dev

Test Value = 1.5

t df

Sig(2-

taile

d)

ean

Diff.Poor salaries 7 1.95 .229 11.833 36 .001 .446

Lack of adequate financial incentives/ Rural


7 1.62 .492 1.505 36 .041 .122


Lack of Career development opportunities 7 1.32 .475 -2.25236 .031 -.176

Inadequate drugs/equipment 7 1.30 .463 -2.66136 .012 -.203

Inadequate living conditions 7 1.24 .435 -3.59136 .001 -.257



7 1.16 .374 -5.49936 .001 -.338

Lack of Job security 7 1.11 .315 -7.57236 .001 -.392

Limited opportunity of training and skilldevelopment

7 1.05 .229 -11.83336 .001 -.446

Poor support, supervision and mentoring 7 1.05 .229 -11.83336 .001 -.446



7 1.05 .229 -11.83336 .001 -.446

Achievement not recognized 7 1.05 .229 -11.83336 .001 -.446

Lack of safety at workplace 7 1.03 .164 -17.50036 .001 -.473

Limited or no good schools for children/education prospects of children

7 1.03 .164 -17.50036 .001 -.473

Unusual working hours and excess work

load

7 1.00 .000 - - - -

Lack of Autonomy 7 1.00 .000 - - - -



205

Push factors for migration of Mid-Wives: While analysing for the group of Mid-

wives, it is found that the following factors contributed for migration from the present

rural area to other rural area, urban area or to leave the sector: 1) Poor salaries (1.74),

2) Poor working condition (1.64), 3) Lack of adequate financial incentives/ Rural

allowances/performance incentives (1.50), 4) Inadequate drugs/equipment (1.27), 5)




others cadres, teamwork and interpersonal relationship (1.10), 9) Lack of Job security

(1.06) and 10) Poor support, supervision and mentoring (1.05). Out of which, two

factors that is the Poor salaries, and Poor working condition are statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(114)= 1.838 , p=

.044 and t(114)= 1.465 , p=.050 respectively.

Table 110: Descriptive statistics for contributing push factor for mid-wives

N MeanStd.Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

MeanDiff.

Poor salaries 1151.74 .601 1.838 114 .044 .239

Poor working condition 1151.64 .502 1.465 114 .050 .142

Lack of adequate financial incentives/ Ruralallowances/performance incentives

1151.50 .402 .093 114 .926 .004

Inadequate drugs/equipment 1151.27 .446 -5.545 114 .001 -.230

Lack of Career development opportunities 1151.21 .408 -7.654 114 .001 -.291

Inadequate living conditions 1151.17 .381 -9.186 114 .001 -.326

Lack of scope for continuing /higher education 1151.10 .295 14.679 114 .001 -.404



1151.10 .295 14.679 114 .001 -.404

Lack of Job security 1151.06 .240 19.610 114 .001 -.439

Poor support, supervision and mentoring 1151.05 .223 21.502 114 .001 -.448

Limited or no good schools for children/education prospects of children 1151.03 .184 27.109 114 .001 -.465

Achievement not recognized 1151.03 .160 31.745 114 .001 -.474

Lack of safety at workplace 1151.03 .160 31.745 114 .001 -.474

Unusual working hours and excess work load 1151.02 .131 39.418 114 .001 -.483

Lack of Autonomy 1151.02 .131 39.418 114 .001 -.483


development

1151.00 .000 - - - -

Push factors for migration of Permanent Mid-Wives: While analysing further

breaking down from the bunch of Mid-wives, to nature of employment as permanent

Mid-wives, it is found that the following 8 factors have valid mean and contributed



206

for migration of the permanent mid-wives from the present rural area to other rural

area, urban area or to leave the sector: 1) Lack of adequate financial incentives/ Rural

allowances/performance incentives (1.65), 2) Poor working condition (1.63), 3)

Inadequate drugs/equipment (1.16), 4) Inadequate living conditions (access to


Lack of others cadres, teamwork and interpersonal relationship (1.05), 6) Lack of

Autonomy (1.02), 7) Limited or no good schools for children/ education prospects of

children (1.02) and 8) Lack of Career development opportunities (1.02). Out of which,

two factors that is the Lack of adequate financial incentives/ Rural

allowances/performance incentives and Poor working condition are statistically

significant at Mean Test Value=1.5, 95% C.I, it is significant at t(42)= 2.055 , p=.036

and t(42)= 1.715 , p=.044 respectively.

Table 111: Descriptive statistics for contributing push factor for permanent

mid-wives

Factors

N MeanStd.Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

MeanDiff.



43 1.65 .482 2.05542 .036 .151

Poor working condition 43 1.63 .489 1.71542 .044 .128

Inadequate drugs/equipment 43 1.16 .374 -5.92042 .001 -.337Inadequate living conditions 43 1.09 .294 -9.08042 .001 -.407



43 1.05 .213 -13.95642 .001 -.453

Lack of Career development opportunities 43 1.02 .152 -20.50042 .001 -.477



43 1.02 .152 -20.50042 .001 -.477

Lack of Autonomy 43 1.02 .152 -20.50042 .001 -.477

Poor salaries 43 1.00 .000 - - - -



43 1.00 .000- - - -


development

43 1.00 .000- - - -


Unusual working hours and excess work load 43 1.00 .000 - - - -

Poor support, supervision and mentoring 43 1.00 .000 - - - -



Push factors for migration of Contract Mid-Wives: While analysing further

breaking down from the bunch of Mid-wives, to nature of employment as contract

Mid-wives, it is found that the following top 10 factors contributed for migration of



207

the contract mid-wives from the present rural area to other rural area, urban area or to

leave the sector: 1) Poor salaries (1.86), 2) Poor working condition (1.77), 3) Lack of

adequate financial incentives/ Rural allowances/performance incentives (1.42), 4)

Inadequate drugs/equipment (1.33), 5) Lack of Career development opportunities

(1.32), 6) Inadequate living conditions (access to amenities like housing, water,

electricity, conveyance and communication) (1.22), 7) Lack of scope for continuing

education/higher education (1.15), 8) Lack of others cadres, teamwork and

interpersonal relationship (1.12), 9) Lack of Job security (1.10) and 10) Poor

support, supervision and mentoring (1.08). Out of which, two factors that is poor

salaries and Poor working condition are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(71)= 8.798 , p= .001 and t(71)= 1.705 , p=

.048 respectively.

Table 112: Descriptive statistics for contributing push factor for contract mid-wives

Test Value = 1.5

Factors N Mean

Std.Dev t df

Sig.(2-

tailed)

MeanDiff.

Poor salaries 72 1.86 .348 8.798 71 .001 .361




72 1.42 .496 -1.424 71 .159 -.083






72 1.15 .362 -8.132 71 .001 -.347



72 1.13 .333 -9.554 71 .001 -.375



Achievement not recognized 72 1.04 .201 - - - -Lack of safety at workplace 72 1.04 .201 -19.327 71 .001 -.458



72 1.04 .201 -19.327 71 .001 -.458

Unusual working hours & excess workload 72 1.03 .165 -24.213 71 .001 -.472

Lack of Autonomy 72 1.01 .118 -35.000 71 .001 -.486


development

72 1.00 .000

- - - -



208

4.4.4.3. PUSH FACTORS OF LIKELIHOOD TO MIGRATE ACCORDING TOTHE CHOICE OF PLACE

The above section tells us in detail the migration intention of the physicians,

nurses and mid-wives according to the category and nature of employment. In this

section it is aimed to explore the issue of intention to migrate according to the place of

choice. The exploration is based on finding the issue that, why the employees have the

choice for either vertical or the horizontal movements that is from rural to rural areas,

from rural to urban and migrates to other sector or to other places outside the state.

This effort is needed to track the issues of these health workforce migration

and understanding of factors contributing to it and may perhaps have these health

workforce retained in rural and remote areas of Arunachal Pradesh or country at large.

Migrating from rural area to another rural area: This section explores the

intention of migration of physicians, nurses and mid-wives from the present rural

health institute to any other rural health institute. The exploration of the preset factors

from the responses is presented below in table 113.

The top 10 factors that contributed to the intention of the migration of another

rural health institute of these employees are: 1) Lack of others cadres, teamwork and

interpersonal relationship (1.65), 2) Lack of Autonomy (1.59), 3) Poor support,

supervision and mentoring (1.07), 4) Poor working condition (1.05), 5) Unusual

working hours and excess work load (1.05), 6) Lack of adequate financial incentives/

Rural allowances/performance incentives (1.04), 7) Inadequate living conditions



safety at workplace (1.02) and 10) Inadequate drugs/equipment (1.02). Out of which,

two factors, the lack of others cadres, teamwork and interpersonal relationship, lack of

Autonomy are statistically significant at Mean Test Value=1.5, 95% C.I, it is

significant at t(80)= 4.238 , p= .001 and t(71)= 3.546 , p= .001 respectively.

Table 113: Descriptive statistics of push factors for migration of physicians,nurses and mid-wives to another rural area

Factors N Mean

Std.Dev.

Test Value = 1.5

t df Sig. (2-

tailed)

MeanDiff.



81 1.65 .331 4.238 80 .001 .151

Lack of Autonomy 81 1.59 .264 3.546 80 .001 .090

Poor salaries 81 1.31 .465 -3.705 80 .001 -.191



209

Limited opportunity of training andskill development

81 1.05 .218 -18.602 80 .001 -.451


mentoring

81 1.05 .218 -18.602 80 .001 -.451


Rural allowances/performanceincentives

81 1.04 .190 -21.926 80 .001 -.463

Unusual working hours and excesswork load

81 1.04 .190 -21.926 80 .001 -.463


opportunities

81 1.02 .156 -27.395 80 .001 -.475



81 1.02 .156 -27.395 80 .001 -.475


Poor working condition 81 1.01 .111 -39.500 80 .001 -.488





Limited or no good schools for

children/ education prospects of children

81 1.00 .000 - - - -

Migrating from rural area to urban area: This section explores the intention of

migration of physicians, nurses and mid-wives from the present rural health institute

to any other urban area health institute. The exploration of the preset factors from the

responses is presented below in table 114. The top 10 factors that contributed to the

intention of the migration of urban area health institute of these employees are: 1)

Poor working condition (1.83), 2) Lack of adequate financial incentives/ Rural

allowances/performance incentives (1.79), 3) Poor salaries (1.45), 4) Inadequate

drugs/equipment (1.38), 5) Inadequate living conditions (access to amenities like

housing, water, electricity, conveyance and communication) (1.28), 6) Lack of Career

development opportunities (1.25), 7) Lack of scope for continuing education/higher education (1.11), 8) Limited or no good schools for children/ education prospects of

children (1.07), 9) Lack of others cadres, teamwork and interpersonal relationship

(1.05) and 10) Poor support, supervision and mentoring (1.05). Out of which, two

factors, the Poor working condition and Lack of adequate financial incentives/ Rural

allowances/performance incentives are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(168)= 11.290 , p= .001 and t(168)= 9.369 ,

p= .001 respectively.



210

Table 114: Descriptive statistics of push factors for migration of physicians,

nurses and mid-wives to rural to urban

N MeanStd.Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

MeanDiff.




169 1.79 .406 9.369 168 .001 .293

Poor salaries 169 1.45 .499 -1.310 168 .192 -.050




opportunities

169 1.25 .433 -7.543 168 .001 -.251



169 1.11 .309 -16.53 168 .001 -.393

Limited or no good schools for children/education prospects of children

169 1.07 .247 -22.852 168 .001 -.435



169 1.05 .225 -25.788 168 .001 -.447



Unusual working hours & excess workload 169 1.02 .132 -47.337 168 .001 -.482

Limited opportunity of training and skilldevelopment

169 1.01 .108 -58.511 168 .001 -.488



Lack of Autonomy 169 1.00 .000 - - - -

Migrating to other sector or outside state: This section explores the intention of

migration of physicians, nurses and mid-wives from the present rural health institute

to any other sector or outside the state. The exploration of the preset factors from the

responses is presented below in table 115. The top 8 factors found to be with valid

mean that contributed to the intention of the migration to other sectors or outside state

are: 1) Lack of Career development opportunities (2.00), 2) Poor salaries (1.95), 3)

Lack of Job security (1.86), 4) Lack of adequate financial incentives/ Rural

allowances/performance incentives (1.81), 5) Lack of scope for continuing

education/higher education (1.76), 6) Inadequate drugs/equipment (1.52), 7)

Achievement not recognized (1.38) and 8) Poor working condition (1.29). Out of

which, five factors, the Lack of Career development opportunities, Poor salaries, Lack

of Job security, Lack of adequate financial incentives/ Rural allowances/performance

incentives and Lack of scope for continuing education/higher education are




211

11.568 , p= .001, t(20)= 9.5 , p= .001, t(20)= 4.564 , p= .001, t(20)= 3.525 , p= .002

and t(20)= 2.750 , p= .012 respectively.

Table: 115: Descriptive statistics of push factors for migration of physicians,

nurses and mid-wives to other employer or outside state

N Mean

Std.

Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.


opportunities

21 2.00 .000 11.568 20 .001 .500

Poor salaries 21 1.95 .218 9.500 20 .001 .452

Lack of Job security 21 1.86 .359 4.564 20 .001 .357



21 1.81 .402 3.525 20 .002 .310



21 1.76 .436 2.750 20 .012 .262

Inadequate drugs/equipment 21 1.52 .512 .213 20 .833 .024


Poor working condition 21 1.29 .463 -2.121 20 .047 -.214


development

21 1.00 .000 - - - -

Unusual working hours & excess workload21 1.00 .000 - - - -

Poor support, supervision and mentoring 21 1.00 .000 - - - -



21 1.00 .000 - - - -

Inadequate living conditions 21 1.00 .000 - - - -Lack of safety at workplace 21 1.00 .000 - - - -



21 1.00 .000 - - - -

Lack of Autonomy 21 1.00 .000 - - - -

4.4.4.4. RELATIONSHIP OF DEMOGRAPHIC AND SATISFACTION

ATTRIBUTES WITH THE MAJOR INTENTION TO MIGRATE TO URBANAREAS

It is known from the study that the intention to migrate is having relationship

with job satisfaction. Hence, the exploration is attempted along with the exploration

with demographic attributes like age, sex, family background, marital status, length

of service, hierarchy level of place of posting and nature of employment of the

employees on intention to migrate to urban areas. The variable –(sex) has been

drooped from interpretation for the relationship because there are few cases of male

and female classification in the data, and classification is only in the Physicians

group, where as the nurses and mid-wives does not have the classification of male

and female, except 1 (one) no. of male in the nurse group of employee.



212

From the study, it is found that there is no relationship exists between the

demographic attributes of age (2=1.523, p=.677), family background (2=0.008,

p=.929), marital status (2=0.927, p=.336), nature of employment (2=0.056,

p=.813), and place of posting (2=0.820, p=.845) with urban migration. Only theattribute of length of service (2=10.825, p=.029), is significant and revealed the

relationship with the migration to urban areas. And job satisfaction has been

statistically significance relationship at (2=84.930), p=.001), with the intention of

migration to urban area.

Table 116: Relationship of demographic attributes to intention to migrate in


Sl.

No.

Demographic and Satisfaction Attributes Chi-Square (2) P

1 Age 1.523 .6772 Family Background 0.008 .929

3 Marital Status 0.927 .3364 Length of Service 10.825 .0295 Hierarchy level of Health institutes-place of 0.820 .8456 Nature of Employment 0.056 .8137 Job Satisfaction 84.930 .001

While analysing by separating the positions of the workforce as Physicians, it

is found that there is no relationship exists between the demographic attributes of age

(2=3.729, p=.292), Sex (2=0.007, p=.933), family background (2=1.299,

p=.245), marital status (2=0.337, p=.562), nature of employment (2=0.598,

p=.439), and place of posting (2=1.981, p=.576), length of service (2=4.062, p=

.398), except job satisfaction has statistically significance relationship at

(2=33.227), p< .001), with the intention of migration to urban area.


physiciansSl. No Demographic and Satisfaction Attributes Chi-Square (2) P

1 Age 3.729 .2922 Sex 0.007 .9333 Famil Back round 1.299 .2544 Marital Status .337 .5625 Length of Service 4.062 .3986 Hierarchy level of Health institutes-place of 1.981 .576

7 Nature of Em lo ment .598 .4398 Job Satisfaction 33.227 .001

While analysing separating the positions of the workforce as Nurses, it isfound that there is no relationship exists between the demographic attributes of age



213

(2=1.341, p=.719), family background (2=.001, p=1.00), marital status (2=.051,

p=.821), nature of employment (2=.041, p=.839), and place of posting (2=4.668,

p=.097), length of service (2=5.384, p=.250), except job satisfaction has statistically

significance relationship at (2=33.797), p< .001), with the intention of migration to

urban area.


nurses

Sl. No Demographic and Satisfaction Attributes Chi-Square (2) P

1 Age 1.341 .719

2 Famil Back round .001 13 Marital Status .051 .8214 Len th of Service 5.384 .250

5 Hierarchy level of Health institutes-place of posting

4.668 .097

6 Nature of Employment .041 .8397 Job Satisfaction 33.797 .001

While analysing separating the positions of the workforce as Mid-wives, it is

found that there is no relationship exists between the demographic attributes of family

background (2=1.153, p=.238), marital status (2=1.886, p=.176), nature of

employment (2=1.747, p=.186), and place of posting (2=2.334, p=.506) with urban

migration and significant relationship has been found with age (2=9.110, p=.011)

and length of service (2=10.552, p=.032). And job satisfaction has statistically

significance relationship at (2=13.048), p=.005), with the intention of migration to

urban area.


mid-wives

Sl.

No

Demographic and Satisfaction Attributes Chi-Square

(2)

P

1 Age 9.110 .011

2 Family Background 1.153 .238

3 Marital Status 1.886 .176

4 Length of Service 10.552 .032

5 Hierarchy level of Health institutes-place of posting 2.334 .506

6 Nature of Employment 1.747 .1867 Job Satisfaction 13.048 .005



214

4.4.5. FACTORS THAT MAY MOTIVATE THE PHYSICIANS,

NURSES AND MID-WIVES TO RETAIN IN CURRENT JOB IN

RURAL AND REMOTE AREA- WHAT IS THEIR CHOICE?

The use of financial incentives as important motivators has been over

emphasised in the recent past. However, research in human relations and behaviour

sciences has shown that “where as money incentive had not proved effective, psychic

rewards worked” (Gellerman, 1963). Later research by Herzberg (1968) & Lawler

(1971) confirmed the fact that pay has very little to do with motivation. However,

several research studies in India have indicated the positive relationships between pay

and employee performance (Dwivedi, 1980). Therefore, the need is to understand the

various factors which motivate physicians, nurses and mid-wives to retain themselves

in the present rural posting. Taking all these factors into consideration, financial as

well as non-financial incentives can be planned.

So forth, in this section, it is attempted to explore the preset factors that may

motivate the physicians, nurses and mid-wives to retain themselves in the present

rural area health institution. The responses of these employees reveal the motivational

factors for retain themselves for the rural services. However, this section is based on

all responses of 334 health workforce and the eighteen (19) preset factors were

included in the section of the questionnaire.The Cronbach’s alpha coefficient for the factor items is α =(0.603) on item 19

and N=334.

Factors that may motivate the physicians, nurses and mid-wives : While

exploring the motivational factors that may motivate the physicians, nurses and mid-

wives to retain themselves in the present rural area health institution. The responses of

these employees reveal the following top 10 motivational factors for retain themselves

for the rural services: 1) Financial incentives for rural posting/ Rural

allowances/performance incentives (1.93), 2) Improve living conditions (Access to


Career development opportunities (1.63), 4) Good reward and achievement

recognition system (1.55), 5) Training and skill development Opportunities (1.53),

6) Improved working condition (1.49), 7) Adequacy of equipment, drugs and supplies

at Health centre (1.48), 8) Increase salary by half (1.34), 9) Opportunities of

continuing education/higher education (support for further education) (1.33) and 10)

Job Security (1.32). Out of which, four factors, financial incentives/ Rural



215

allowances/performance incentives, improved living condition, career development

and Good reward and achievement recognition system are statistically significant at

Mean Test Value=1.5, 95% C.I, it is significant at t(334)= 31.938 , p= .001,

t(334)=20.598, p= .001 and t(334)= 4.984 , p= .001 and t(334)= 2.867 , p= .043

respectively.

4.4.5.1. FACTORS THAT MAY MOTIVATE THE PHYSICIANS TO STAY

Getting a more refined picture, the analysis was done according to the

category of these groups of health workforce. While, exploring the motivational

factors that may motivate the physicians to retain themselves in the present rural area

health institution, the responses of these employees reveal the following top 10motivational factors for retain themselves for the rural services: 1) Financial

Table 120 : Descriptive statistics of factors that may motivate the physicians,

nurses and mid-wives to retain in current job in rural and remote area

Factors

N MeanStd.Dev.

Test Value = 1.5

t df

Sig.(2-

tailed)

MeanDiff.

Financial incentives for rural posting/ Rural


3341.93 .248 31.938 333.001 .434

Improve living conditions 3341.87 .332 20.598 333.001 .374

Career development opportunities 3341.63 .483 4.984 333.001 .132Good reward & achievement recognition

system

3341.61 .489 2.867 333.043 .111

Training & skill development Opportunities 334 1.53 .500 .985 333.325 .027

Improved working condition 3341.49 .501 -.437 333.662 -.012

Adequacy of equipment, drugs and suppliesat Health centre

3341.48 .506 -.865 333.388 -.024

Increase salary by half 3341.34 .474 -6.236 333.001 -.162

Opportunities of continuing

education/higher education (support for

further education)

3341.33 .470 -6.758 333.001 -.174

Job Security 3341.32 .466 -7.160 333.001 -.183

Good teamwork and good interpersonal

staffs relationship

3341.30 .457 -8.135 333.001 -.204

Security & Safety at workplace 3341.23 .420 -11.859 333.001 -.272

Supportive supervision, management &

mentoring

3341.19 .389 -14.755 333.001 -.314

Adequate patients/clients at current facility 3341.16 .366 -17.047 333.001 -.341

Increase salary by double 3341.12 .329 -20.978 333.001 -.377

Rotational posting 3341.11 .314 -22.630 333.001 -.389

Availability of good schools for children 334 1.11 .314 -22.630 333.001 -.389

Opportunity of autonomy 3341.03 .171 -50.333 333.001 -.470Flexible working hours with minimal workloa 3341.01 .122 -72.888 333.001 -.485



216

incentives for rural posting/ Rural allowances/performance incentives (1.90), 2)

Improve living conditions (Access to amenities like housing, water, electricity,

conveyance and communication) (1.79), 3) Career development opportunities (1.73),

4) Improved working condition (1.66), 5) Good reward and achievement recognition

system (1.65), 6) Training and skill development Opportunities (1.53), 7) Adequacy

of equipment, drugs and supplies at Health centre (1.50), 8) Opportunities of

continuing education/higher education (support for further education) (1.46), 9) Good

teamwork and good interpersonal staffs relationship (1.38) and 10) Adequate

patients/clients at current facility (1.36). Out of which, five factors, Financial

incentives for rural posting/ rural allowances/performance incentives, Improve living

conditions (Access to amenities like housing, water, electricity, conveyance and

communication), Career development opportunities, 4) Improved working condition

and Good reward and achievement recognition system are statistically significant at

Mean Test Value=1.5, 95% C.I, it is significant at t(112)= 14.376 , p= .001, t(112)

7.442, p= .001, t(112)= 5.620 , p= .001, t(112)= 3.667 , p= .001 and t(112)= 2.035 ,


Table 121: Descriptive statistics of factors that may motivate the physicians to


Factors

N MeanStd.Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

MeanDiff.

Financial incentives for rural posting/


1131.90 .298 14.376 112 .001 .403

Improve living conditions 1131.79 .411 7.442 112 .001 .288

Career development opportunities 1131.73 .444 5.620 112 .001 .235

Improved working condition 1131.66 .475 3.667 112 .001 .164

Good reward and achievement recognition

system

1131.65 .490 2.035 112 .030 .159

Training & skill development Opportunity 1131.53 .501 .657 112 .513 .031

Adequacy of equipment, drugs andsupplies at Health centre

1131.50 .502 .094 112 .926 .004

Opportunities of continuing /higher

education

1131.46 .501 -.846 112 .400 -.040

Good teamwork and good interpersonalstaffs relationship

1131.38 .488 -2.604 112 .010 -.119

Adequate patients/clients at current facility 1131.36 .483 -3.019 112 .003 -.137

Supportive supervision,management&ment 1131.22 .417 -7.107 112 .001 -.279

Increase salary by half 1131.21 .411 -7.442 112 .001 -.288

Job Security 1131.20 .404 -7.792 112 .001 -.296

Availability of good schools for children 1131.11 .309 -13.528 112 .001 -.394Rotational posting 1131.10 .298 -14.376 112 .001 -.403



217

Security & Safety at workplace 1131.10 .298 -14.376 112 .001 -.403

Increase salary by double 1131.09 .285 -15.334 112 .001 -.412

Opportunity of autonomy 1131.06 .242 -19.231 112 .001 -.438


work load

1131.00 .000 - - - -

Factors that may motivate the contract physicians: Getting a more refined picture,

the analysis was done according to the nature of employment inside the category of

groups of Physicians. While, exploring the motivational factors that may motivate the

contract physicians to retain themselves in the present rural area health institution, the

responses of these employees reveal the following top 10 motivational factors for

retain themselves for the rural services: 1) Career development opportunities (2.00),

2) Opportunities of continuing education/higher education (support for further

education) (1.97), 3) Financial incentives for rural posting/ Rural



Increase salary by half (1.71), 6) Job Security (1.68), 7) Training and skill

development Opportunities (1.62), 8) Improved working condition (1.59),

9)Adequacy of equipment, drugs and supplies at Health centre (1.53) and 10)

Good teamwork and good interpersonal staffs relationship (1.50). Out of which, six

factors, Career development opportunities, Opportunities of continuing

education/higher education (support for further education), Financial incentives for

rural posting/ Rural allowances/performance incentives , Improve living conditions

(Access to amenities like housing, water, electricity, conveyance and

communication), Increase salary by half and Job Security are statistically significant

at Mean Test Value=1.5, 95% C.I, it is significant at t(33)= 18.00 , p= .001, t(33)=

16.00 , p= .001, t(33)= 4.875 , p= .001, t(33)= 3.585 , p= .001, t(33)= 2.596 , p= .014,

and t(33)= 2.167 , p= .038, respectively.

Table 122: Descriptive statistics of factors that may motivate the contract


Factors

N ean

Std.

Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.


Opportunities of continuing education/higher

education (support for further education)

34 1.97 .171 16.000 33 .001 .471

Financial incentives for rural posting/ Ruralallowances/performance incentives 34 1.82 .387 4.875 33 .001 .324



218

Improve living conditions 34 1.76 .431 3.585 33 .001 .265

Increase salary by half 34 1.71 .462 2.596 33 .014 .206

Job Security 34 1.68 .475 2.167 33 .038 .176

Training and skill development Opportunities 34 1.62 .493 1.391 33 .174 .118

Improved working condition 34 1.59 .500 1.030 33 .311 .088

Adequacy of equipment, drugs and suppliesat Health centre

34 1.53 .507 .339 33 .737 .029


staffs relationship

34 1.50 .508 .000 33 1.00 .000

Good reward &achievement recognition system34 1.44 .504 -.681 33 .501-.059

Adequate patients/clients at current facility 34 1.32 .475 -2.167 33 .038-.176

Increase salary by double 34 1.29 .462 -2.596 33 .014-.206

Security & Safety at workplace 34 1.29 .462 -2.596 33 .014-.206

Supportive supervision, management and

mentoring

34 1.26 .448 -3.064 33 .004 -.235

Availability of good schools for children 34 1.18 .387 -4.875 33 .001-.324Rotational posting 34 1.09 .288 -8.340 33 .001-.412

Opportunity of autonomy 34 1.09 .288 -8.340 33 .001-.412

Flexible working hours with minimal workload 34 1.00 .000 - - - -

Factors that may motivate the permanent physicians: Similarly, while exploring

the motivational factors that may motivate the permanent physicians to retain

themselves in the present rural area health institution, the responses of these

employees reveal the following top 10 motivational factors for retain themselves for

the rural services: 1) Financial incentives for rural posting/ Rural


amenities like housing, water, electricity, conveyance and communication) (1.80),

3) Improved working condition (1.70), 4) Career development opportunities

(1.62), 5) Good reward and achievement recognition system (1.62), 6) Training and

skill development Opportunities (1.52), 7) Adequacy of equipment, drugs and

supplies at Health centre (1.49), 8) Adequate patients/clients at current facility (1.38),

9) Good teamwork and good interpersonal staffs relationship (1.33),and 10) Opportunities of continuing education/higher education (support for further

education) (1.24). Out of which, five factors, Financial incentives for rural posting/

Rural allowances/performance incentives, Improve living conditions (Access to

amenities like housing, water, electricity, conveyance and communication), Improved

working condition, Career development opportunities and Good reward and

achievement recognition system are statistically significant at Mean Test Value=1.5,

95% C.I, it is significant at t(78)= 15.840 , p= .001, t(78)= 6.537 , p= .001, t(78)=

3.768 , p= .001 , t(78)= 2.188 , p= .032 and t(78)= 2.188 , p= .032 respectively.



219

Table 123: Descriptive statistics of Factors that may motivate the permanent


Factors

N MeanStd.Dev

Test Value = 1.5

t df Sig

-tailed)

MeanDif.

Financial incentives for rural posting/ Ruralallowances/performance incentives

79 1.94 .245 15.840 78 .001 .437


Improved working condition 79 1.70 .463 3.768 78 .001 .196


Good reward &achievement recognition system79 1.62 .488 2.188 78 .032 .120

Training and skill development Opportunities 79 1.52 .503 .336 78 .738 .019

Adequacy of equipment, drugs and supplies at

Health centre

79 1.49 .503 -.112 78 .911 -.006

Adequate patients/clients at current facility 79 1.38 .488 -2.188 78 .032 -.120

Good teamwork and good interpersonal staffsrelationship 79 1.33 .473 -3.212 78 .002 -.171



79 1.24 .430 -5.362 78 .001 -.259


mentoring

79 1.20 .404 -6.537 78 .001 -.297

Rotational posting 79 1.10 .304 -11.67 78 .001 -.399

Availability of good schools for children 79 1.08 .267 -14.13 78 .001 -.424

Opportunity of autonomy 79 1.05 .221 -18.10 78 .001 -.449

Security & Safety at workplace 79 1.01 .113 -38.500 78 .000 -.487

Increase salary by half 79 1.00 .000 - - - -

Increase salary by double 79 1.00 .000 - - - -Job Security 79 1.00 .000 - - - -

Flexible working hours with minimal workload 79 1.00 .000 - - - -

4.4.5.2. FACTORS THAT MAY MOTIVATE THE NURSES TO STAY

Getting a more refined picture, the analysis was done for the group of the

nurses. While, exploring the motivational factors that may motivate the nurses to

retain themselves in the present rural area health institution, the responses of these





Career development opportunities (1.71), 4) Training and skill development

Opportunities (1.53), 5) Good reward and achievement recognition system (1.48), 6)

Adequacy of equipment, drugs and supplies at Health centre (1.47), 7) Improved

working condition (1.46), 8) Increase salary by half (1.35), 9) Job Security



220

(1.34) and 10) Good teamwork and good interpersonal staffs relationship (1.33). Out

of which, three factors, Financial incentives for rural posting/ Rural

allowances/performance incentives, Improve living conditions (Access to amenities

like housing, water, electricity, conveyance and communication) and Career

development opportunities are statistically significant at Mean Test Value=1.5, 95%

C.I, it is significant at t(97)= 16.389 , p= .001, t(97)= 11.344 , p= .001, t(97)= 4.672 ,


Table 124 : Descriptive statistics of factors that may motivate the nurses to


Factors

N MeanStd.Dev

Test Value = 1.5

tdf

Sig.(2-

tailed)

MeanDiff.


98 1.93 .259 16.38997 .001 .429

Improve living conditions 98 1.88 .329 11.34497 .001 .378

Career development opportunities 98 1.71 .454 4.67297 .001 .214

Training and skill development Opportunities 98 1.53 .502 .60497 .547 .031

Good reward& achievement recognition syste 98 1.48 .502 -.40297 .688 -.020

Adequacy of equipment, drugs and supplies

at Health centre

98 1.47 .522 -.58197 .563 -.031

Improved working condition 98 1.46 .501 -.80797 .422 -.041

Increase salary by half 98 1.35 .478 -3.16797 .002 -.153

Job Security 98 1.34 .475 -3.40297 .001 -.163Good teamwork and good interpersonal

staffs relationship

98 1.33 .471 -3.64397 .001 -.173

Security & Safety at workplace 98 1.23 .426 -6.16597 .001 -.265



98 1.20 .405 -7.23197 .001 -.296

Supportive supervision,management&mentori 98 1.19 .397 -7.62697 .001 -.306

Availability of good schools for children 98 1.14 .352 -10.05297 .001 -.357

Increase salary by double 98 1.11 .317 -12.09897 .001 -.388

Rotational posting 98 1.10 .304 -12.94897 .001 -.398

Adequate patients/clients at current facility 98 1.08 .275 -15.04997 .001 -.418

Flexible working hours with minimal work load

98 1.03 .173 -26.83697 .001 -.469

Opportunity of autonomy 98 1.01 .101 -48.00097 .001 -.490

Factors that may motivate the Contract Nurses: Getting a more refined picture

within the group of nurses, the analysis was done for the group of the contract nurses.

While, exploring the motivational factors that may motivate the contract nurses to

retain themselves in the present rural area health institution, the responses of these





221



3)Career development opportunities (1.93), 4) Increase salary by half (1.76), 5) Job

Security (1.73), 6) Training and skill development Opportunities (1.56), 7) Adequacy

of equipment, drugs and supplies at Health centre (1.56), 8) Improved working

condition (1.56), 9) Good reward and achievement recognition system (1.51) and 10)

Good teamwork and good interpersonal staffs relationship (1.42). Out of which, five

factors, Financial incentives for rural posting/ Rural allowances/performance

incentives, Improve living conditions (Access to amenities like housing, water,

electricity, conveyance and communication), Career development opportunities ,

Increase salary by half and Job Security are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(44)=12.543 , p= .001, t(44)=12.543 , p= .001,

t(44)=11.523 , p= .001, t(44)=3.944 , p= .001 and t(44)=3.500 , p= .001, respectively.

Table 125: Descriptive statistics of factors that may motivate the contract


Factors

N Mean

Std.

Dev

Test Value = 1.5

t df Sig

(2-taile

Mean

Diff.



45 2.00 .000 12.54344 .001 .500

Improve living conditions 45 2.00 .000 12.54344 .001 0.5

Career development opportunities 45 1.93 .252 11.52344 .001 .433

Increase salary by half 45 1.76 .435 3.94444 .001 .256

Job Security 45 1.73 .447 3.50044 .001 .233

Improved working condition 45 1.56 .503 .74244 .462 .056


Health centre

45 1.56 .503 .74244 .462 .056

Training and skill development Opportunities 45 1.56 .503 .74244 .462 .056

Good reward & achievement recognition

system

45 1.51 .506 .14744 .883 .011

Good teamwork and good interpersonal staffs

relationship

45 1.42 .499 -1.04544 .302 -.078




45 1.31 .468 -2.70644 .010 -.189

Increase salary by double 45 1.24 .435 -3.94444 .001 -.256


Supportive supervision,management& mentori 45 1.22 .420 -4.43244 .001 -.278



Flexible working hours with minimal workload 45 1.02 .149 -21.50044 .001 -.478

Opportunity of autonomy 45 1.00 .000 - - - -



222

Factors that may motivate the Permanent Nurses: Getting a more refined picture

within the group of nurses, the analysis was also done for the group of the permanent

nurses. While, exploring the motivational factors that may motivate the permanent

nurses to retain themselves in the present rural area health institution, the responses of


for the rural services: Financial incentives for rural posting/ Rural

allowances/performance incentives (1.87), Improve living conditions (Access to


Good reward and achievement recognition system (1.63), Training and skill

development Opportunities (1.51), Career development opportunities (1.45),

Adequacy of equipment, drugs and supplies at Health centre (1.40), Improved

working condition (1.38), Good teamwork and good interpersonal staffs relationship

(1.25), Supportive supervision, management and mentoring (1.17) and Security &

Safety at workplace(1.15). Out of which, three factors, Financial incentives for rural

posting/ Rural allowances/performance incentives, Improve living conditions (Access

to amenities like housing, water, electricity, conveyance and communication), Good

reward and achievement recognition system are statistically significant at Mean Test

Value=1.5, 95% C.I, it is significant at t(52)= 7.836 , p= .001, t(52)= 4.715 p= .001

and t(52)= 2.409 , p= .044 respectively.

Table 126: Descriptive statistics of factors that may motivate the permanent


Factors

N Mean

Std.

Dev

Test Value = 1.5

t df

Sig.(2-

tailed)

Mean

Diff.



53 1.87 .342 7.836 52 .001 .368


Good reward and achievement recognition

system

53 1.63 .504 2.409 52 .044 .130


Opportunities

53 1.51 .505 .136 52 .892 .009



53 1.40 .531 -1.422 52 .161 -.104



staffs relationship

53 1.25 .434 -4.269 52 .001 -.255


mentoring

53 1.17 .379 -6.342 52 .001 -.330

Security & Safety at workplace 53 1.15 .361 -7.031 52 .001 -.349



223

Opportunities of continuing

education/higher education (support for further education)

53 1.11 .320 -8.803 52 .001 -.387


Rotational posting 53 1.09 .295 10.008 52 .001 -.406

Availability of good schools for children 53 1.06 .233 13.836 52 .001 -.443Flexible working hours with minimal work

load

53 1.04 .192 17.493 52 .001 -.462

Opportunity of autonomy 53 1.02 .137 25.500 52 .001 -.481


Increase salary by double 53 1.00 .000 - - - -

Job Security 53 1.00 .000 - - - -

4.4.5.3. FACTORS THAT MAY MOTIVATE THE MID-WIVES TO STAY

Getting a more refined picture, the analysis was done for the group of the Mid-

wives also. While, exploring the motivational factors that may motivate the mid-

wives to retain themselves in the present rural area health institution, the responses of


for the rural services: 1) Financial incentives for rural posting/ Rural



Good reward and achievement recognition system (1.63), 4) Training and skill

development Opportunities (1.50), 5) Career development opportunities (1.47), 6)

Adequacy of equipment, drugs and supplies at Health centre (1.46), 7) Increase salary

by half (1.45), 8) Job Security (1.41), 9) Improved working condition (1.35) and 10)

Security & Safety at workplace (1.34). Out of which, three factors, Financial

incentives for rural posting/ Rural allowances/performance incentives, Improve living


communication) and Good reward and achievement recognition system are


29.110 , p= .001, t(122)= 23.137 p= .001 and t(122)= 2.877 , p= .005 respectively.

Table 127 : Descriptive statistics of Factors that may motivate the Mid-wives

to retain in current job in rural and remote area

Factors

N MeanStd

Dev.

Test Value = 1.5

t df Sig.-tailed)

eanDif.



1231.97 .178 29.110 122.001 .467

Improve living conditions 1231.95 .216 23.137 122.001 .451



224

Good reward and achievement recognitionsystem

1231.63 .486 2.877 122.005 .126


Opportunities

1231.50 .502 .090 122.929 .004

Career development opportunities 1231.47 .501 -.630 122.530 -.028


1231.46 .500 -.992 122.323 -.045

Increase salary by half 1231.45 .499 -1.174 122.243 -.053

Job Security 1231.41 .493 -2.102 122.038 -.093

Improved working condition 1231.35 .479 -3.484 122.001 -.150

Security & Safety at workplace 1231.34 .476 -3.693 122.001 -.159

Opportunities of continuing /higher


1231.30 .460 -4.797 122.001 -.199


staffs relationship

1231.20 .398 -8.497 122.001 -.305

Increase salary by double 1231.16 .371 -10.099 122.001 -.337

Supportive supervision, management andmentoring

1231.15 .355 -11.052 122.001 -.354

Rotational posting 1231.13 .338 -12.146 122.001 -.370

Availability of good schools for children 1231.09 .287 -15.892 122.001 -.411

Adequate patients/clients at current facility 1231.03 .178 -29.110 122.001 -.467

Opportunity of autonomy 1231.02 .127 -42.246 122.001 -.484

Flexible working hours with minimal work

load

1231.02 .127 -42.246 122.001 -.484

Factors that may motivate the Contract mid-wives: Getting a more refined picture

within the group of mid-wives, the motivational factors that may motivate the contract

mid-wives to retain themselves in the present rural area health institution, the

responses of these employees reveal the following top 10 motivational factors for

retain themselves for the rural service: 1) Financial incentives for rural posting/ Rural



3) Increase salary by half (1.73), 4) Job Security (1.67), 5) Good reward and

achievement recognition system (1.65), 6) Career development opportunities (1.61),

7) Training and skill development Opportunities (1.57), 8) Security & Safety at

workplace (1.53), 9) Adequacy of equipment, drugs and supplies at Health centre

(1.44) and 10) Opportunities of continuing education/higher education (support for

further education) (1.43). Out of which, six factors, Financial incentives for rural

posting/ Rural allowances/performance incentives, Improve living conditions (Access

to amenities like housing, water, electricity, conveyance and communication),

Increase salary by half, Job Security, Good reward and achievement recognitionsystem and Career development opportunities are statistically significant at Mean Test



225

Value=1.5, 95% C.I, it is significant at t(74)= 10.534 , p= .001, t(74)= 10.534 , p=

.001, t(74)= 4.539 , p= .001, t(74)= 3.041 , p= .003, t(74)= 2.772 , p= .007 and t(74)=

2.002 , p= .049 respectively.

Table 128: Descriptive statistics of factors that may motivate the contract Mid-wives to retain in current job in rural and remote area

Factors N Mean Std.

Dev.

Test Value = 1.5

t df Sig.(2-

tailed)

MeanDiff.


75 2.00 .000 10.534 74 .001 .500


Increase salary by half 75 1.73 .445 4.539 74 .001 .233

Job Security 75 1.67 .475 3.041 74 .003 .167

Good reward and achievement recognition system 75 1.65 .479 2.772 74 .007 .153Career development opportunities 75 1.61 .490 2.002 74 .049 .113

Training and skill development Opportunities 75 1.57 .498 1.275 74 .206 .073

Security & Safety at workplace 75 1.53 .502 .575 74 .567 .033


Health centre

75 1.44 .500 -1.040 74 .302 -.060



75 1.43 .498 -1.275 74 .206 -.073


Increase salary by double 75 1.27 .445 -4.539 74 .001 -.233

Rotational posting 75 1.20 .403 -6.452 74 .001 -.300

Good teamwork & good interpersonal staffs

relationship

75 1.19 .392 -6.918 74 .001 -.313

Supportive supervision, management &mentoring 75 1.12 .327 -10.059 74 .001 -.380

Availability of good schools for children 75 1.08 .273 -13.318 74 .001 -.420


Opportunity of autonomy 75 1.01 .115 -36.500 74 .001 -.487

Flexible working hours with minimal work load 75 1.00 .000 - - - -

Factors that may motivate the permanent mid-wives: Similarly, exploring the

motivational factors that may motivate the permanent mid-wives to retain themselvesin the present rural area, the responses of these employees reveal the following top 10

motivational factors for retain themselves for the rural service: 1) Financial incentives

for rural posting/performance incentives (1.92), 2) Improve living conditions (1.88),

3) Good reward and achievement recognition system (1.78), 4) Adequacy of

equipment, drugs and supplies at Health centre (1.48), 5) Training and skill

development Opportunities (1.40), 6) Improved working condition (1.31), 7) Career

development opportunities (1.25), 8) Good teamwork and good interpersonal staffs

relationship (1.21), 9) Supportive supervision, management and mentoring (1.21) and



226

10) Availability of good schools for children (1.19). Out of which, three factors,

Financial incentives for rural posting/ Rural allowances/performance incentives,

Improve living conditions and Good reward and achievement recognition system are

statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at

t(47)=10.335 , p= .001, t(47)= 7.774 , p= .001 and t(47)=3.159 , p=.022 respectively.

Table 129: Factors that may motivate the permanent Mid-wives to retain in

current job in rural and remote area

Factors N Mean Std.

Dev

Test Value = 1.5

t df Sig(2-

tailed)

Mean

Diff.



48 1.92 .279 10.33547 .001 .417

Improve living conditions 48 1.88 .334 7.77447 .001 .375Good reward & achievement recognitionsystem

48 1.78 .398 3.15947 .022 .283


Health centre

48 1.48 .505 -.28647 .776 -.021

Training and skill development Opportunities 48 1.40 .494 -1.46047 .151 -.104

Improved working condition 48 1.31 .468 -2.77347 .008 -.188

Career development opportunities 48 1.25 .438 -3.95847 .001 -.250

Good teamwork & good interpersonal staffsrelationship

48 1.21 .410 -4.92447 .001 -.292

Supportive supervision, management

&mentoring

48 1.19 .394 -5.48947 .001 -.313

Opportunities of continuing /higher education 48 1.10 .309 -8.88347 .001 -.396


Flexible working hours with minimal workload 48 1.04 .202 -15.72547 .001 -.458



Opportunity of autonomy 48 1.02 .144 -23.00047 .001 -.479



Increase salary by double 48 1.00 .000 - - - -

Job Security 48 1.00 .000 - - - -



227

SECTION 5

ANALYSIS OF THE REFORMINITIATIVES FOR DISTRIBUTION,

ATTRACTION AND RETENTION

OF PHYSICIANS, NURSES AND

MID-WIVES



228

4.5.1. REFORM INITIATIVES FOR RECRUITMENT AND

DEPLOYMENT (DISTRIBUTION)This section of the chapter addresses the descriptive finding of reform

initiatives in respect of the human resources in the public health sector, specifically

the initiatives related to distribution, attraction and retention of physicians, nurses and

mid-wives in the rural and remote areas for ensuring primary health care with especial

emphasize on maternal and child health. This part of the descriptive analysis also

presents the views of physicians, nurses and mid-wives on reform initiatives.

4.5.1.1. REFORM INITIATIVES TO ADDRESS THE ISSUE OF NUMERICAL

INADEQUACY OF HEALTH WORKFORCE (PHYSICIANS, NURSES &

MIDWIVES) IN THE STATE

a) Emphasized on contractual appointments for rural and remote area: While it

is true that human resource is one of the biggest challenges in Indian public health

sector, Government of India has brought the thrust on human resource in centre stage.

The serious issue in human resource management is huge gaps in critical health

manpower in government health institutions, particularly in rural areas, that provide

healthcare to the poorer segments of population. A large number of vacant posts of

physicians, nurses and mid-wives are reported at the primary level in government

hospitals. Also, almost all of the specialist positions in government hospitals in rural

areas in the state are lying vacant. Most of the management representatives have

pointed out for the difficulty in getting physicians, Nurses for the health posts. The

management representatives pointed out the crisis is more for the GNMs and the

physicians for rural and remote areas. It is may be due to lower graduates of

medicines and nursing candidates. They also revealed that they have many post lying

vacant in search of the GNMs (Nurses) and some of them are even personally

arranging these cadres for the rural health services. It is also pointed out by the

management representatives that in the light of very limited candidates for the posts

they have to compromise on the technical expertise and experience of the candidates

and have to appoint them for the rural and remote areas which obviously affect the

quality of the services in the rural and remote areas.

The situation at the secondary and tertiary level is somewhat better, as doctors

generally prefer to reside in urban areas.



229

“Increasing the number of health worker is a major challenge in improving

the health system, to address the issue of numerical adequacy with cost effectiveness

is contracting the human resource”-State Level Official.

The past one decade has seen a growing tendency of contractual employment

in the public health sector in the state, toward a fundamental restructuring for

addressing the inadequacy issue under National Rural Health Mission (NRHM). A

significant change in placement of human resource has been seen since 2005 in the

country. Several measures were initiated to fill the wide gaps of health workforce

shortage in the state under the Reform process in human resource for health sector.

Within the scope of this flagship programme one of the measures that have

been adapted by the state with vis-à-vis to the national policy is of recruiting the

health workforce is in contract appointment. This process has involved recruiting the

health workforce to minimize the gaps of numerical inadequacy and supported the

tremendous growth in contract employment in this sector in Arunachal Pradesh along

with rest of the states in the country. In the last seven years of Government of India

flagship programme National Rural Health Mission in the state has tried reforms with

resources available. Measures were initiated to fill the vacant posts of Medical

officers, Nurses and Mid-wives in the state with higher preference to rural and remote

areas. The NRHM division of the state undertakes the recruitment and placement of

Physicians including the Specialist cadres, Nurses and Mid-wives.

According to the statistics of MoHFW, Govt. of India and Govt. of Arunachal

Pradesh, 1 no. of Specialist , 57 nos. of Doctors , 21 nos. AYUSH Doctors , 15 Dental

Surgeons, 196 nos. of Staff Nurses and 158 nos. of ANM have been appointment by

the State Govt. on contract for the health institutes in Arunachal Pradesh. Similarly, in

the country an addition of total numbers of 2460 Specialist, 8624 MBBS doctors,

7692 Ayush Doctors, 26793 Staff Nurses, 46690 ANM and 14490 other Para Medics

have been recruited in contract employment.

Management Perspective: Pros and cons of recruiting in contract

I. Pros :

i) Cost Effectiveness: “The contractual employees are cheaper than the permanent

employees, it cost the department in much less than permanent employees, as

there are no provision of other financial benefits other than a consolidated

salary”.- Management Representative from the state. The remuneration structure



230

is affected through the department using the services of a contractual employee.

Thus, there is no burden upon the government for benefits like-insurance, medical,

leave encashment and retirement benefits etc. as it is given to the permanent

employee. It is also a viable alternative to the sector as long as

downsizing/restructuring is concern. Using the contract employees the health

department gets the ability to grow in size to meet the demand in large scale

without large scale effect on financial burdens.

ii) Flexibility: To a large extent the provision of contractual employee is a resource

balancing exercise of the sector. Fitting the human resource requirement in

existing resource pool of salary structure, when a permanent employment in

respect of higher rate pay is a problematic.

iii) Availability of manpower for higher days –Less employees on long leaves:

“No burden for paying benefits to these employees”- District Management

Representative. This group of employees is not entitled to all range of leaves as it

is entitled to the permanent employees. This group gets very short term leaves

and not entitled to long term leaves and thus ensures the availability of manpower

for higher days in a year.

iv) Simplified way of recruitment and reduce cost on recruitment and selection

process: “The contractual employees are recruited by walk-in-interview process

in the state, which reduces the cost of recruitment process”-Management

Representative from the state. In the state of Arunachal Pradesh, all the vacancies

under NRHM, both new and recurring are immediately filled up through open

advertisement in the local newspapers at the district level. In order to ensure

rational deployment of contractual manpower, recruitment is done at district level

and appointments are made for specific health centres without provision of

transfer. The appointments are district and facility specific and non transferable.

However, intra district relocation is allowed in certain exceptions.

v) Reduce unemployment percentage: “ All the contractual staff under NRHM is

normally employed for the entire NRHM period, subject to renewal of annual

contract based on performance, unless otherwise terminated on grounds of

breach of contract” ”-Management Representative from the state. By engaging a

huge numbers of employees in contract has reduce the unemployment percentage.

It has to an extent solved the unemployment problem, though it is a temporary

arrangement and valuable to the current short-term development.



231

II. Cons :

i) Investment on training and development of contractual employees: Under this

programme in public health sector, huge investments in the employees are done in

the form of training and development opportunities. In the terms of stability of the

trained employee is less, as the employees are contractual and may leave the

sector in order to ensure their stability in other work/job. In order to ensure a

return on those investments, it is the public health sector that stands at instability.

“Under NRHM different types of skill up-gradation training such at Skill Birth

Training, Medical Termination of Pregnancy, Life Saving Anesthesia Training,

Emergency Obstetrics Care, Neo-natal care etc. which are provided irrespective

of contract or permanent employee”- ”-Management Representative from the

state.

ii) Performance: The issue of the performance of the contract employees was

divided into two different opinions of the management representatives. The

opinion on performance cannot be generalizing the two groups of employees –

contract and permanent. Those favored the best performance by contract

employee is due to the fear of non renewal of contract and compulsion to show the

performance. Those who support the worst performance by contract employees

had echoed the comments that due to the insecurity of job, discrimination as a

contract employee in pays and perks may be one of the reasons the productivity

issue could be compromised.

iii) Employee Turnover or attrition: “Some contract employees had left contract

jobs over dissatisfaction with the low pay and lack of benefits”- comment by a

state level management representative. In the interests of stability of employment,

contractual employees may shift their job to other sector who offers employment

stability and to take steps to reduce turnover and re-filling of vacant position may

cost the department. However, there is no concrete data on attrition; the

management representatives estimate it to 05-10% attrition per year.

iv) Short –term arrangement (Less long-term feasibility): The contractual

arrangement of employees in public health sector only provides a short-term

solution for the inadequacy in human resource. The management representatives

also favor the statement, as it is time bound specific program for architectural

correction of health delivery system and it only provides the short term solution of

the problem unless the employees are made a permanent employee in the sector.



232

The contract employees felt no attachment to their employers' long-term strategies

because they are on short-term contracts.

Employee Perspective: view on contracting the pros and cons

Almost all of those interviewed were positive about their experience at this

sector, only in positivity in thinking in future they will be turned out to be a

permanent employee in the sector and they come up at par to the other existing

permanent employees. The following section focuses on findings of interaction and

questionnaire responses with the physicians, nurses and mid-wives).

I. Pros:

i) Solved unemployment problem of the employee: The contractual employment

has solved the unemployment problem of this group of peoples and now they areengaged in employment activity to earn their livelihood and atleast solved

financial hardship.

ii) Access to simplified process of recruitment process- “Walk-in-interviews”:

Most of the contractual employees those who were part of the study were

appointed through walk-in-interview. Some of them were appointed through

double stage of recruitment and selection process of written examination and

interview process. It is observed that major portion of the employees were

appointed in contract were simple process of Walk-in-interview. This process of

recruitment and selection process takes less time and efforts in respect of the

prospect candidates to be appointed on contract.

iii) Flexibility in job shifting/ Easy on job shifting: The existing norms for leaving

the job are very simple for the contractual employees. Giving one month advance

notice to the employer or in lieu of one month salary a contractual employee can

terminate the contract and leave the job. “The job shifting is easy in terms of

contract norms. I can easily leave the job if I get a new job that lead to an offer to

be brought on board full-time as a regular”.- A physician.

iv) Training opportunity: Majority of contract employees stated in response to the

questionnaire that they are getting full opportunity for skill up-gradation trainings

from the department. There is no discrimination regarding the status of

employment for proving various skill up-gradation training. Availability of

training opportunities can be seen as a factor of attraction and retention of the

contractual employees. They are getting opportunity for skill acquisition and have



233

the access to all type of training in the department as per their eligibility. They are

provided with a wide variety of training opportunity and provide exposure to

different type skill up-gradation of their related work and techniques. It can also

be developmental in a wider sense of developing both technical and professional

skills.

v) Contracting jobs may ultimately lead to a permanent offer : The physicians

and nurses generally expected employer will give them permanent offer. This is

one of the advantage and retention factor. “Number of the earlier contract

physician and nurses were offered and regularized from the contract pool to the

state govt. permanent posts”- A Physician. Most of the respondents believed that

they will be significantly regularized if they remain in government service.

II. Cons:

i) Provides a short-term and temporary solution: This is a temporary solution to

their employment needs. Contract employees shared that they are going to be

short-term tend to be invisible as per the health program in which they are

appointed. “There is a huge contractual employee in the state, which may be

difficult for the government to regularize us in a short period of time, they tend to

be treated by many as just not really there”-A Nurse.

ii) Feeling of job in-security: Security issues were important for many contract

physicians, nurses and mid-wives. They commented on the lack of security and

less reliable working arrangement for them. It doesn’t provide the security and

benefits of full-time employment. Thus, the level of security that employment

offers insecurity arose as an issue.

iii) Financial and other Pay: Different pay scale is followed for a contract which is

not at par with the permanent employee. They are paid less than those of

permanent employees performing the same tasks and they were without other

employment benefits, pension contribution/retirement benefits/plans, medical

benefits, life insurance, paid vacation, educational reimbursement etc. and

opportunities for employment. One of the respondent shared-“the bank is not

going to loan you money because I am a contract employee. This puts additional

stress factors in their lives that are absent in permanent employees' lives. Contract

employees were less satisfied with certain aspects of their jobs, such as

compensation and benefits at par with the existing contract employees. Different

set of pay and conditions can create an environment where conflict is possible.



234

One of the example of agitation in India is from Rajasthan –“No other benefits

Strike by Rajasthan contractual employee under NRHM” for other benefits.

iv) Lack of opportunity for career advancement: The ladder of career is absence in

the scenario of contract employment. “Career advancement and promotion avenue

are almost absent for contract employees”- A Mid-wive. The respondents stated

that they do not have the avenues for career advancement and promotional ladder

unless and until they are regularized in the department.

v) Lack of coordination and discrimination as in contract between Regular &

Contractual employee: The contract employee respondents stated that permanent

employee may not invite them in to their “inner circle” or share as much

information. “There is always a discrimination of being contract workers in the

middle of the circle of permanent employee”- A nurse. In addition to individual

level problems with perceived inequity, group level problems have also been

identified. It is observed that the contract employees are treated differently in the

workplace by employer, by management, by human resource policies, and by

permanent coworkers.

vi) Lack of loyalty, commitment and lack of motivation: They also stated that they

have less commitment towards their employer. The commitment is less and they

felt no attachment to their employer’s long-term or short-term strategies. Their

short-term contract meant they probably would not be employed long enough to

see long-term objectives achieved. A hard feeling among contract employees has

been observed. All contract employees admitted suffering stress connected to

contract employment and less motivation.

4.5.1.2. EMPHASIZING ON PROFESSIONAL TRAINING INSTITUTES FOR

ENHACING THE NUMBERS OF TECHNICAL HUMAN RESOURCE IN

THE STATE

Enhancing the pool of physicians, nurses and mid-wives within the state is a

alarming issue. It has not been kept pace with the need, especially with the physicians,

nurses and mid-wives. Absence of adequate training institutes for medical and nursing

courses results in low numbers of medics and paramedics produced for the state. Till

today, there is no medical college in public sector or in private sector for Allopathic

disciplines besides a Homeopathy Medical College in private sector. Yearly a fixed

numbers of students according to the Govt. of India quota seats, are placed in various

Medical colleges all over India. 32 seats in First nomination 2010 and 34 seats in first



235

nomination 2011 has been allotted to the students for the MBBS course in various

Medical Colleges in India (DHTE, 2010 & DHTE, 2011). For the training of nursing

personnel, the state runs a lone Nursing School for ANMs at General Hospital,

Pasighat, East Siang District of Arunachal Pradesh. The institute runs training

programs on midwifery (ANM) nursing courses. There are no fix numbers of ANM

admission seats per year in this ANM School, in the year 2009-10, the number was

70, a year before in 2008-09, it was 47. The variation depends on Government of

Arunachal Pradesh continuing changing policy. In the state there is a chronic and

serious shortage of GNMs, as there is no GNM training school in govt. sector in

Arunachal Pradesh. A few number of GNMs are produced in GNM School at

Ramakrishna Mission Hospital, Itanagar. With this inadequacy in teaching schools,

insufficient numbers of professionally trained personnel to compensate the situation.

Under the reform process the state government is keen to address this issue,

and at this moment one nursing school at Daporijo, the Headquarter of Upper

Subansiri District and 3 ANM schools at Tawang at Tawang District, Aalo (Along) at

West Siang District and Namsai at Lohit District are on project execution level and

expected to be completed in 2013-14.

“The Govt of India has recently released first instalment fund for

establishment of one GNM school in Upper Subansiri district. As per the civil works

norms framed by the Indian Nursing Council, the construction projects are being

undertaken through Works department of the state government. The construction is

going on. The projects are expected to take 1 year for completion and the nursing

schools will start functioning from the financial year 2013-14. This is expected to

augment the supply of nurses and reduce the deficiency confronted by the State health

sector presently”. “The HRTC at Pasighat is the lone institute in the entire State for

the training of para medical staff which is fully functional. The institute trains ANM

and Health Assistants. GoI has sanctioned 3 Para medic schools during 2010-11. The

constructions are going on at Tawang, Aalo and Namsai (ANM School)”.

(Source : SPIP, 12-13).

Regarding medical education in the state, Arunachal Pradesh Government, in

the month of September 2011, signed a tripartite memorandum of understanding

(MOU) with Union Health Ministry and Hospital Services Consultancy Cooperation

(HSCC) India Limited, for strengthening and up-gradation of Arunachal State

Hospital at Naharlagun. The health and family welfare ministry, Govt. of India is



236

supporting the up-gradation of the 140 bedded hospitals to a 300 bedded multi-

disciplinary hospital. MoHFW had sanctioned the Rs. 185 crore 300-bedded hospital

projects on priority with a target time of 24 months for its upgrading to a medical

college subsequently. (With inputs from Arunachal Times, 23rd

Sept’ 2011).

However, it will take a couple of years to completely established Medical College,

after fulfilment of several formalities.

The State level training Centre is under implementation through funding

support from GoI at a cost of Rs 2 Crores. The construction work of the training

centre is presently in full swing. Once completed, this is expected to reduce the

dependence of the health department on other department for conducting training

activities. Comprehensive training course materials, training methods and equipment

in place to ensure quality of training. (SPIP, 2012-13)

Most of the management representatives have pointed out for the difficulty in

getting physicians, Nurses for the health posts. The management representatives

pointed out the crisis is more for the GNMs and then the physicians for rural and

remote areas. It is may be due to lower graduates of medicines and nursing

candidates. They also revealed that they have many post lying vacant in search of the

GNMs (Nurses) and some of them are even personally arranging these cadres for the

rural health services.

4.5.1.3. INITIATIVES FOR HR POLICIES FOR RECRUITMENT AND

DEPLOYMENT OF DOCTORS, NURSES AND MID-WIVES:

There is no comprehensive HR Policy in Public health sector in Arunachal

Pradesh. There are recruitment rules for different category of health workforce. The

recruitment and other service conditions for staff in health services of the state

government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The

regular doctors and specialist cadre comes under the purview of service rule of APHS.The State health department has in place a concrete system for career progression for

physicians, nurses and mid-wives, where all have promotional avenues as per

seniority and availability of vacancies. The recruitment rules are the specific

instrument of the state govt. for recruitment, classification, method of

recruitment/promotion including constitution of departmental promotion committee,

salary etc. However, there is no specific HR Policy for contractual physicians, nurses

and midwives and other health workers.



237

The state Govt. is preparing a 5 year strategies and policy document for

augmentation and maximization of Human Resources. This includes sustainable HRD

and policy reform from restructuring/ rationalization of HR deployment. The vibrant

HR policy includes terms of recruitment / filling up of vacancies, rationalising

posting, specific tenure of posting, career progression and incentives. The policy is

focussing on improving maternal and child health indicators through posting of

required manpower for maximising performance at identified functional facilities.

(SPIP-NRHM Arunachal Pradesh, 2012-13).

In order to ensure rational deployment of contractual physicians, nurses and

mid-wives, recruitment is done at district level and appointments are made for

specific health centres without provision of transfer. The contractual position is on

facility based need and recruitment is only for that facility other than district health

society. The appointments are district and facility specific and non transferable.

However, intra district relocation is allowed in certain exceptions.

The state is also contemplating rational transfer of permanent physicians and

nurses & mid-wives on rotation after completion of atleast 3 years in a particular

posting place. The measures include compulsory rural posting for certain period,

earmarking certain percentage of postgraduate seats for doctors who have served in

rural areas, and provision of rural service allowance, etc.

Thus, the state Govt. is preparing a 5 year strategies and policy document for


and policy reform from restructuring/ rationalization of HR deployment. The HRD

issues related to contractual manpower under NRHM is in placed that include the

following:

1. The contractual manpower has been put in place following gap analysis through

facility survey report.

2. All the contractual appointments are decentralized to the District Health Society.

3. The recruitment process is done transparently through advertisement in the

newspaper.

4. The process of selection is based on the performance of the candidate in the walk

in interview.

5. The contractual position is on facility based need and recruitment is only for that

facility other than district health society.

6. The appointment is only for a period ending in the 31st

year of the year.



238

7. The appointment is purely temporality and non transferable. However, intra

district rational relocation as required by the District Health Society is allowed in

exceptional cases.

8. The extension of contractual services is subject to good performance and

recommendation by the appraisal board.

9. An undertaking is sign by the contractual appointee to abide by the appointee for

the period of appointment.

10. A new indicators based appraisal format is being used for ANM for further

extension of the services.

11. Monthly appraisal of all the PMSU staff is in place for regular monthly appraisal.

12. In term of carrier progression/incentive, the State Govt. is regularizing their job

into the state health services especially for technical manpower from time to time.

13. Further improvement in the working condition and careers progression will be put

in place during 2012-13 and years to come.

4.5.1.4. DECENTRALIZATION OF HR ACTIVITIES UNDER REFORM

PROCESS

Health service decentralization is being pursued by Government of India under

National Rural Health Mission at all levels, decentralization of authority,

responsibility, and resources for personnel functions is delegated in a decentralized

way in reform process. It is important to achieve effective human resource

management and to improve staff performance. However, decentralization itself

entails large-scale development of capacity at the local level for health planning,

financing, allocation and accounting for resources, and HR management functions

including staff recruitment, payroll and allowance documentation, and maintenance of

personnel records. The Human Resource Management functions including

recruitment and deployment are decentralized to the districts level. The recruitment

transfer and posting of manpower are done at the District level. The District is

ensuring rationality, appropriate placing of manpower to the facilities to make

functional. As per the District requirement, manpower is sanctioned from the state

level and District are recruiting & posting as per the guidelines and requirement. The

recruitment reform process is only for the contractual workforce with non-transferable

and district specific and with their performance appraisal.

Though decentralization is used as an ornamental word into the reform process, the actual implementation in the view of low capacity at the lower level is a



239

concern. The new decentralized organizational structures mean that the role of district

authority as employer is transferred from state level, but to configure the new

structure of decentralized environment there is no provision reform process for HRM

system and HRM personnel in the organisation at state or the district level, that to

strategically support the initiation. The transfer of human resources functions from

State level to district level without a comprehensive design and structure is quite a big

challenge for the district administration. Over all in the absence of an appropriate HR

policy at state and district level on human resource, is still provide a big deal of

challenge for the district authority. Decentralization brings considerable new skill

needs, particularly in management competencies. District managers’ capacity to

respond to these and other performance gaps through training is, however, there is a

budget constraint. The new structures of administration, new budgeting style and

reporting mechanisms, under reform process is the side of decentralization, but the

local capacity of absorptions is always a matter of concern. District health managers

have a range of new responsibilities, depending on the powers that have been

decentralized to them. Decentralization makes district health managers responsible for

improving the way health services are targeted to meet priority health needs,

organized, and managed within the available budget. To do this, they need a

workforce whose staff numbers and mix are as appropriate as possible to these needs,

and whose cost is affordable. However, the study finds that in the reform process in

Arunachal Pradesh, decentralization in many field including HR management issues

have be percolated down up-to the district level and to some extend to the health

institutes, but there is a need of far greater attention to HR skill deficits. The

decentralization has been done in respect of power and resources to the district level

and lower level of health administration for HR administration and management.

Under this decentralised process, the recruitment is done with the District

Recruitment Board, as formed at the district level to perform the functions of

Recruitment and selection. The main human resource management roles at the district

level were to identify staff requirements i.e., Human Resource planning, and their

training needs and to ensure that health facilities had the minimum staffing

requirements. In addition, the powers to recruit, exercise disciplinary control, and to

remove persons from district service were delegated to the District. Pay determination

is heavily centralized at state level and national level, as part of broad based culture as

other public sector. Decentralized the district autonomy is facilitating the local



240

preference and to retain the workforce in the district. However, as mentioned earlier

to manage the decentralized activities there is shortage of HR management personnel

in the district level, which create a challenging environment at this and subsequent

level of administration. As to increase the requirement for administrative and

managerial staff in the system and likely to associated increase requirement for

performance management also.

4.5.2. REFORM INITIATIVES FOR ATTRACTION AND

RETENTION

4.5.2.1. ADOPTION OF SIMPLIFIED WAY OF RECRUITMENT AND

SELECTION PROCESS

The contractual employees are recruited by walk-in-interview process in most

of the districts, which reduces the cost of recruitment process. The process of

selection is based on the performance of the candidate in the walk in interview. All

the vacancies for contractual appointments both new and recurring are immediately

filled up through open advertisement in the local newspapers at the district level in a

decentralised manner. The appointments are made for a period of 1 year on

contractual basis, with the provision for renewal of contract further for another year

on the basis of previous year’s performance. 4.5.2.2. EMPHASIZED ON TRAINING AND DEVELOPMENT

OPPORTUNITIES Training and development is vital for every organization to cope with changes

from time to time and perform well. This helps in honing of skills, developing

versatility and adaptability. In this content Mark Twain’s statement is crucial which

states. “There is nothing that training cannot do. Nothing is above its reach or below

it”(Ramani, 2003). In case of growing and learning organizations the importance of

training is even much more crucial. Andragogy (the science of adult learning)

demands tremendous effort from the trainer what should be more effective and

purposeful (Rao, 2003).

There is tremendous efforts can be seen in the reform process for skill up-

gradation of the training and the physicians, nurses and mid-wives are satisfied with

the process and most of the workforce are attracted and retain themselves due to this

factor in the sector. A major pre-requisite for providing quality health care service is

upgrading the skills and knowledge of all health personnel as well as this is an

integral factor for retaining technical human resource in rural and remote areas. The



241

Government is providing frequent scope for programme based training with time to

time refresher training to all level of functionaries including ANMs, GNMs &

Medical Officers. Huge investments on the employees are done in the form of training

and development opportunities. There are different types of skill up-gradation training

such at Skill Birth Training, Medical Termination of Pregnancy, Life Saving

Anesthesia Training, Emergency Obstetrics Care, Neo-natal care etc. which are

provided to physicians, nurses & midwives in primary and secondary level of health

institutes. There is no discrimination regarding the status of employment for proving

various skill up-gradation training. Availability of in service training opportunities

can be seen as a factor of attraction and retention of the employees in primary and

secondary health institutes in rural and remote areas. They are getting opportunity for

skill acquisition and have the access to all type of training in the department as per

their eligibility and location of the health institutes. They are provided with a wide

variety of training opportunity and provide exposure to different type skill up-

gradation of their related work and techniques. It can also be developmental in a

wider sense of developing both technical and professional skills. The multi-skill

trainings & capacity building of the workforce are emphasized on physicians, nurses

& mid-wives from the rural and remote area. Skill up-gradation is an essential

component of in-service training programmes. The skill up-gradation varies

enormously depending upon the qualifications of the personnel and the institution

where he/she is working. For optimum utilization of human resources, skill and

competence enhancement is of paramount importance. Therefore, with the objective

to maintain the skill and competence level of the employees as well as to improve

upon these skills, different training programmes are designed and undertaken in

Health Sector under NRHM.

Table 130: Gist of various training under NRHM for physicians, nurses andmid-wives

Sl.

No.

Type of Training Category of participants Duration

1 SBA SN/ANM/LHV 3-6 weeks

2 EmOC MOs 16 weeks

3 Life Saving Skills in

Obs. Anesthesia

MOs 18 weeks

4 Blood storage MOs, Lab. Tech. 3 days

5 RTI/STI MO/SN/ANM/LHV 2 days

6 MTP including MVA MOs 15 days7 IMNCI MO/ANM/LHV/AWW etc 8 days



242

8 Immunization Health Workers 2 days

9 MiniLap MOs for CHCs/FRU &DH 12 working days

10 Lap. Sterilization Gynecologist, Surgeon with

OT nurse and Assist.

12 working days

11 IUCD ANM/LHV 5 days

12 NSV MOs 5 days13 Adolescent Health Mos/ANM 5 days

14 PDC CMO/Civil sur./hospital suptd. 10 weeks

15 PMU 5 days

Source : MoHFW, Govt. of India

Under this training and development component for the technical workforce of

physicians, nurses and mid-wives, the achievement from 2005 to 2012 under NRHM

is presented detail in table 131. Training programmes are conducted on specific thrust

areas of maternal health, child health and family planning.

Table 131: Achievement cumulative Training for Maternal and Child Health

(March 2005-2012)

Type of

Training for Maternal and Child Health

Achievement cumulative

till March 2012

LSAS 7EmOC 8BEmOC 12SBA (MO/GNM/ANM) 256

MTP (MO) 124

RTI/STI (MO/GNM/ANM) 258IMNCI (MO) 184IMNCI (SN) 79

IMNCI (ANM) 208F-IMNCI (MO) 69F-IMNCI (SN) 108

NSSK (MO) 203

NSSK (SN) 156 NSSK ANM 16

Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

4.5.2.3. OPPORTUNITY FOR CAREER ADVANCEMENTThe State health department has in place a concrete system for career

progression for permanent physicians, nursing staff where physicians and nurses have

promotional avenues as per seniority and availability of vacancies. The ladder of

career is also not absence in the scenario of contract employment of physicians and

nurses & mid-wives. The State Govt. provides avenue for career advancement for

contractual doctors and nurses by absorbing them into permanent service subject to

availability of vacancies and based on the satisfactory performance and placed at the

rural and remote areas. Thus, contracting jobs for physicians, nurses and Mi-wives



243

may ultimately lead to a permanent offer. A good number of the contract physician

and nurses were offered and regularized from the contract pool to the state govt.

permanent posts.

In Arunachal Pradesh it has compulsory for all the medical graduates to serve

in rural areas for a duration varying from 2 - 3 years and also has made it mandatory

for all the graduates to complete two to three years of rural service for admission to

the PG degree programs. In the state of Arunachal Pradesh Medical Officers on

completion of two years of rural service in permanent capacity are eligible to be

sponsored by the State, which will cover all expenses of their PG training.

4.5.2.4. FINANCIAL AND OTHER INCENTIVE SCHEMESConsolidated pay rates have been revised on the lines of the rates fixed by the

6th Pay Commission so as to attract contractual physicians, nurses and mid-wives to

rural jobs. Salary increments are periodically enhanced subject to availability of fund

in the NRHM budget. It is proposed to enhance the pay by about 5% every year from

2013-14. According to the Arunachal Pradesh State Programme Implementation

Plan, 2011-12 and 12-13, in order to ensure stay of Health workers in difficult rural

and remote areas, the state proposed incentive schemes. Incentive for Difficult Area

(A Category) @Rs 2000 per month to 83 ANM, 41 MO, 2 Specialist, 57 Pharmacist,

1 Radiographer, 24 Lab. Tech, and 115 Staff Nurse. For Most Difficult Area (B

Category) @Rs 4000 per month to 57 ANM, 16 MO, 21 Pharmacist, 4 Lab. Tech,

and 41 Staff Nurse. For Inaccessible Area (C Category) @Rs 6000 per month, 74

ANM, 13 MO, 13 Pharmacist, 5 Lab. Tech, and 26 Staff Nurse are proposed. Among

the inaccessible areas, the state has further identified 11 health facilities as most

difficult to access. Over and above their salary and incentives proposed above, the

health staff will get special package - Medical officer@ Rs 10,000 per month and

Nurses @Rs 5,000/- per month. However, the incentives are yet to be seen

materialized, it may be due to financial constraints in the state.

Table 132: Categorization of rural and remote area for incentive scheme for

workforce

Sl.

No.

Staff

Category

Difficult Area

(A Category)

Most difficult area

(B Category)

Inaccessible area

(C category)

Total

1 Specialist 2 - - 2

2 MO 41 16 13 70

4 Staff Nurse 115 41 26 182

6 ANM 83 57 74 214

Total 323 139 131 593Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh



244

4.5.2.5. AVAILABILITY OF EQUIPMENTS FOR HEALTH WORKFORCE

IN RURAL AND REMOTE AREAS

Availability of essential equipments is an imperative for functionalising a

health centre as per IPHS and attracts and retain health workforce in rural services.

There are several health centres devoid of the essential functional equipments. In

view of this, under reform initiatives fully equip PHC and CHC are ensured through

regular needs assessment. A robust system of indenting and procurement in respect

of medical equipment are in process of development and put in place. Identification

of non repairable / functional equipments is done annually and unserviceable

equipments are condemned and disposed off to scrapes. As far as possible, the state

is looking into awarding of AMC for all categories of equipments and instruments.

(Source: SPIP 2012-13)

4.5.2.6. SUPPORTIVE SUPERVISIONSupervision of supporting nature has been found relatively more effective. It

supportive supervision includes identification of the gap and subsequent immediate

best possible immediate solution on the spot with an objective to strengthening the

capacity of person being supervised on one hand and obtaining the result through

smooth implementation of the programme. The State and District level supervisory

monitoring team are regularly visiting the field up to the community level besides

facility on the way. The periodical meetings of all concern from the field at district

and the State level are also accelerating the pace of both way communications

resulting the minimising of impediments in case there is any.

4.5.2.7. INFRASTRUCTURE DEVELOPMENT INITIATIVES INCLUDING

ACCOMMODATION FACILITIES AT RURAL AND REMOTE AREAS FOR

UNDER REFORM PROCESS

Chronically there is inadequacy of residential quarters for workforce at rural

and remote areas. For ensuring deploying, attraction and retention of physicians,

nurses and especially Mid-wives in rural and remote area, the reform process is

emphasizing to develop the residential facilities all over the state. However within the

limited resources, prioritization is done to provide residential quarters in the health

facilities phase-wise. The identification of the health facilities has been done linking

the HR availabilities and acceptable infrastructure. Table 133 to 138 put more light on

the infrastructure development in the state regarding residential quarters.



245

Table 133: Information on new Constructions of infrastructure in the state under

reform processHealth

Facility

New Construction sanctioned

under NRHM so far in High Focus

Districts

New Construction sanctioned under

NRHM so far in Non High FocusDistricts

Total

2 0 0 7 - 0 8

2 0 0 8 - 0 9

2 0 0 9 - 1 0

2 0 1 0 - 1 1

2 0 1 1 - 1 2

2 0 0 7 - 0 8

2 0 0 8 - 0 9

2 0 0 9 - 1 0

2 0 1 0 - 1 1

2 0 1 1 - 1 2

CHCs 1 1

SCs 6 4 0 4 3 44 21 0 11 12 105

Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 134: Information on Upgradations of infrastructure in the state under

reform processHealthFacility

New Construction sanctioned under NRHM so far in High Focus Districts

New Construction sanctioned under NRHM so far in Non High Focus

Districts

T o t a l

2 0 0 7 - 0 8

2 0 0 8

- 0 9

2 0 0 9 - 1 0

2 0 1 0 - 1 1

2 0 1 1 - 1 2

2 0 0 7 - 0 8

2 0 0 8 - 0 9

2 0 0 9 - 1 0

2 0 1 0 - 1 1

2 0 1 1 - 1 2

DH 2

(Staff Qtr.)

3

C/o. of

tore

ouse)

7

(Staff

Qtrs).

3

(Staff

Qtr.)

14

C/o. of

tore

ouse)

29

CHCs 2

(C/o of

residential

Qtr.)

2

C/o of

esidential

tr.)

10 6

(C/o of

residential

Qtr.)

3(C/o. of

LR)

1

(C/o. of

2

(C/o of

residential

Qtr.)

22

PHCs 2(Upgra

dation)

4(Staff

Qtts.)

1

(Upgradati

on)

2

(Staff Qtr.)

7

(C/o of

residential

Qtr.)

2

(C/o. of

LR)

3

(Provision

of waiting

room &

Furniture)

3

(C/o of

resident

ial Qtr.)

Upgrada

ion)

6

(Staff

Qtr)

3

(Staff

Qtr.)

16

(C/o of

residential

Qtr.)

9

(C/o. of

LR)

17

(Provision

of waiting

room &

Furniture)

11

(C/o of

residential

Qtr.)

89

Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 135: New Constructions of infrastructure in the state under reform process 2012-13

Sl.No Type of Health Institute New ConstructionPh sic al Tar et

1 District Hospital 13 (Qtrs)

2 CHC 4 (Residential Qtr.), 2 LRs,

10 (Residential Qtr.)

3 PHC 28 (Residential Qtr.), 5 LRs

4 SC 34

5 Training Centre 1(On going)Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh



246

Table 136: Identified District Hospitals where New Residential Quarters to be

constructed in 2012-13

District Hospitals Existing Qtrs Nos. of New Residential Qtrs

proposed

Tawang 18 1

Bomdila 24 1Seppa 15 1

Ziro 21 1

Aalo 25 1Daporijo 20 1GH-Pasighat 31 1Yingkiong 18 1Roing 25 1Anini 8 1Tezu 22 1Changlang 22 1

Khonsa 20 1Total 299 13Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 137: Identified List of facilities (PHCs) that are proposed for new

construction of Residential Quarters in 2012-13

District Name of PHCs

West Kameng Thrizino, Sinchung

E/ Kameng Bameng, Bana, Pakke kesang

P/ Pare Jote

L/Subansiri PoruKurung Kumey Sangram, Yangte

West Siang Gensi, Tirbin, Kaying

East Siang Yembung, Namsing, Borguli, Koyu

U/Siang Jeying

LD Valley Anpum

D/Valley Etalin

Lohit New Mohong

Anjaw Wallong

Changlang Khimiyong, Kharsang

Tirap Wakka, Panchou

Upper Subansiri MaroSource: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 138 : Identified CHCs for Construction of Residential Quarters in 2012-13

District Name of CHCs

West Siang Rumgong, Likabali

Tirap Deomali, Longding

Upper Siang Geku

Papumpare Balijan

East Siang Ruksin

East Kameng SeijosaLower Subansiri Yazali



247

Additional 30 nos. of SCs with ANM quarters were constructed from state

govt. financial resources in the year 2010-11.

4.5.3. EXPLORING THE VIEWS ON HEALTH SECTOR REFORM FROM THE PERSPECTIVE OF PHYSICIANS,

NURSES AND MID-WIVESTo explore the views of the physicians, nurses and mid-wives upon the

ongoing reform processes which include the HR activities related to public health

sector. The questionnaire was included with seventeen (17) nos. of preset statements

on a scale of 1 to 5 of degree of agreement [1) Strongly Disagree 2) Disagree 3)

Undecided 4) Agree 5) Strongly agree]. The analysis of the responses has the

following descriptive.

The analysis of the responses, it is revealed that these three categories have

different views on the health sector reform process on Human resource activities.

The analysis of the all responses with the preset variable factors is presented point-

wise below:

1. Statement : The Reform has made the Human Resource Policies clear and

understandable at all level

The first question in this part of questionnaire was to explore that theemployees are clear about the human resource policies of the organization and that is

also it their own context and level. All the employees are quite reserved at this, that

they are clear about the HR policies of the organization, the mean of the response is

only 2.06 in the scale of 5, which is lower and signifies that there is more

disagreement to the statement that reform has succeeded to clear presentation of the

HR policies in the context of the physicians, nurses and mid-wives. The responses

revealed that there is difference between the groups, the values of F(2, 331) = 6.093,

p = .003. The Physicians have the mean of 2.25 for the responses, 2.03 for the nurses

and 1.92 for the mid-wives. It seems the physicians are little understanding, but we

cannot say this group is also in favour that the reform has made the Human Resource

Policies clear and understandable at your level. However, the mean of the responses

are the lowest we cannot say that the reform process has made human resource

policies understandable at all level and contributed to the HR function of the

organisation.



248

2. Statement: Reforms have made the placement, transfer and promotion

transparent, fairer and unbiased

All the employees are quite reserved and disagreed on this statement; the mean

of the responses is only 2.05 in the scale of 5, which is lower at side. The responses

revealed that there is no significant difference between the groups, the values of F(2,

331) = 1.110, p=.331 and the groups thinks in similar way. The physicians have the

mean of 2.12, nurses have 2.04 and the mid-wives only 1.92. The mean scores clearly

indicating in the scale of five, that there is no change in the scenario and still no

existing of transparent, fairer and unbiased placement, transfer and promotion. The

groups have the view that the reform has failed to make placement, transfer and

promotion to transparent, fairer and unbiased.

3. Statement: The reform has made your job description clear

All the employees agreed in some extent of agreement but the agreement is

not so strong on this statement; the mean of the responses is only 3.73 in the scale of

5. The responses revealed that there is statistically significant difference between the

groups, the values of F(2, 331) = 3.450, p= .033 and the groups have difference on

this. The physicians have the mean of 3.83; nurses have 3.79 and the mid-wives only

1.99. The mean scores clearly indicating, that there is differences in agreement on the

statement and the physicians and nurses are likely to agree upon, but no agreement

from the mid-wives.

Thus, it is found that the physicians and nurses are familiar with their job

description clear as they agree upon the statement, but not so strongly. Whereas, the

mid-wives has no agreement on the statement and it seems, may be they are not so

clear about the job description of the mid-wives and has no agreement.

4. Statement: The reform has increased your chances of being promoted

No agreement could be seen in all the employee responses, they are quite

reserved and disagreed on this statement; the mean of the responses is only 2.15 in the

scale of 5, which is lower at side. The responses revealed that there is statistically

significant difference between the groups, the values of F(2, 331) = 5.344, p= .005.

The physicians have the mean of 2.35, nurses have 2.04 and the mid-wives only 2.07.

The mean scores clearly indicating in the scale of five, that the reform process has not

increased the change of their promotion. Thus, it is found that the physicians, nurses

and mid-wives do not think that they are getting promotional chances strongly.



249

5. Statement: The reform has made the Salary structure Competitive for rural

area posting

No agreement could be seen as well for this statement also. No groups agree

upon that the reform process has created the salary structure competitive for the rural

area posting. There is no difference between the groups, the values of F(2, 331) =

1.211, p= .299. The mean of the responses is only 2.85 in the scale of 5, which is

lower at side. The responses revealed that there is statistically no significant

difference between the groups. The physicians have the mean of 2.93, nurses have

2.88 and the mid-wives only 2.76. Thus, it is found that the reform process has failed

to achieve a competitive salary structure for the rural area postings.

6.

Statement: The reform has made regular and adequate financial incentives and allowances for rural area posting

The statement that reform has made available regular and adequate financial

incentives for rural areas physicians, nurses and mid-wives has no agreement between

the group responses. The groups have differences, the values of F(2, 331) = 12.479,

p=.001. The mean of the responses is only 2.21 in the scale of 5, which is lower at

side. The responses revealed that there is statistically significant difference between

the groups. The physicians have the mean of 2.21, nurses have 2.43 and the mid-

wives only 2.11. The group of nurses has little higher mean than that of the two other

groups. Thus, reform has failed to made regular and adequate financial incentives and

allowances for physicians, nurses and mid-wives who are posted in remote and rural

areas.

7. Statement: The reform has increased the activities for your performance

appraisal and positive action them

All the employees are disagreed or undecided on this statement; the mean of

the responses is only 2.29 in the scale of 5. The responses revealed that there is no

significant difference between the groups, the values of F(2, 331) = 1.510, p=.222

and the groups thinks in similar way. The physicians have the mean of 2.37, nurses

have 2.28 and the mid-wives only 2.24. The mean scores clearly indicating in the

scale of five, that there are no increase activities for actual performance appraisals and

positive actions on them.



250

8. Statement: The reform has made an improvement in working condition in your

work place

This statement that reform has made an improvement in working condition at

the respondent’s posted health institutes has agreement in group responses, though themean of the responses is 3.40, quite no so impressive, but we can say that the

statement have a favorable response. The groups have differences, the values of F(2,

331) = 23.958, p=.001. The mean of the responses is 3.40 in the scale of 5. The

responses revealed that there is statistically significant difference between the groups.

The physicians have the mean of 3.53, nurses have 3.69 and the mid-wives only 3.05.

The group of mid-wives has little lower mean than that of the two other groups. Thus,

it seems at the lower level of the health care delivery system where the Mid-wives are

largely posted are deviated of improving the working conditions. However, the other

two groups have also do not have the highest mean, which also revealed that there is

no sufficient improvement of work conditions at their workplace.

9. Statement: The reform has increased the training & skill development opportunity

This statement that reform has increased the training and skill development

opportunities for the respondent’s posted rural health institutes has agreement in

group responses, though the mean of the responses is 3.72, which shows the statement

have a favorable response. The groups have statistically significant differences, the

values of F(2, 331) = 4.958, p=.008. The physicians have the mean of 3.55, nurses

have 3.86 and the mid-wives only 3.78. The group of physicians has little lower mean

than that of the two other groups. Thus, it seems at the physicians do not get more

chance for training and development opportunities in comparison to the nurses and

mid-wives. Thus, it reveals that the reform has failed to address the need of training

and development in equal manner to all the groups of the employees.

10. Statement: The reform has improved the availability of equipment, drugs and

supplies essential to perform your assigned tasks

This statement that reform has improved the availability of equipments, drugs

and essential supplies for performing the assigned tasks for the respondent’s posted

rural health institutes has been agreed in group responses, though the mean of the

responses is 3.35, however, the favor is not so strong. The groups have statistically

significant differences, the values of F(2, 331) = 47.220, p=001. The physicians have

the mean of 3.59, nurses have 3.81 and the mid-wives only 2.76. The group of mid-



251

wives has lowest mean than that of the two other groups. Thus, it seems at the mid-

wives do not get adequate equipments, drugs and essential supplies and the reform has

failed to provide them as well, in comparison to the physicians and nurses. Thus, it

reveals that the reform has failed to address 360 degrees of these needs too.

11. Statement: The reform has improved mix of other cadres in your workplace

This statement that reform has improved the mix of cadres in respondent’s

posted rural health institutes has low agreement, that’s the mean of the responses is

3.28, however, the favor is not so strong. The groups have statistically significant

differences, the values of F(2, 331) = 13.465, p= .001. The physicians have the mean

of 3.39, nurses have 3.58 and the mid-wives only 2.93. The group of mid-wives has

lowest mean than that of the two other groups. Thus, it seems at the mid-wives do notget team-work on with other cadres, while physicians and nurses also revealed that

they are also not so adequately gets improved atmosphere of team. Thus, it reveals

that the reform has failed to address 360 degrees of these needs too.

12. Statement: The reform has made your workload more manageable

There was no agreement revealed from the responses from the groups, the

mean of the responses is 2.25. The groups have statistically significant differences,

the values of F(2, 331) = 4.144, p=017 . The physicians have the mean of 2.39, nurseshave 2.24 and the mid-wives only 2.09. The group of mid-wives has lowest mean than

that of the two other groups. Thus, it seems at the mid-wives are more affected bythe

reform process, but all the groups still have the same situation rather high or low.

They do not agree upon that the reform process has made their work load manageable

but rather they think more unmanageable at their level. The disagreement increases at

the lower level of the groups. Thus, it reveals that the workload are more

unmanageable to all level due to the reform process.

13. Statement: The reform has made improvement in supportive supervision,

management and mentoring form higher authority

This statement that reform has made improvement in supportive supervision,

management and mentoring form higher authority, has an agreement mean of the

responses is 3.65. The groups have statistically significant differences, the values of

F(2, 331) = 3.850, p=.022. The physicians have the mean of 3.50, nurses have 3.68

and the mid-wives only 3.76. Thus, the responses reveals that there is an improvementof supervision and mentoring due to the reform process, and the trend is higher to the



252

lower health institutes because the mean of the mid-wives is higher than that of the

two other higher groups.

While putting light from the management representative interview responses

that the supervision services also suffers from the financial constraints, geographical

constraints and overall suffers from the skill scarcity that is scarcity of supervisors.

The supervision structures starts from very state level to the lowest layer of SCs, the

SCs are supervised by the Medical Officers (Physicians) at PHCs or CHCs and these

PHCs/CHCs by the district level. The matter is more concern upon lot of higher

institutes is without the supervisors and if they are also, they are concern with the

clinical abilities and lacks the managerial skills like supervision and monitoring at

various levels.

14. Statement: The reform has made work independent and more autonomy

When the responses are analyzed the mean comes to 3.06, which revealed that

there is more undecided or neutral about the statement rather agreement or no

agreement. While the responses are analyzed separately according to the different

groups, physicians have Mean of 3.55, which shows an agreement but a weak one.

Other two groups, nurses have 2.49, which reveal that they have disagreement and

mid-wives are undecided on this statement thus making the group in neutral position

with Mean of 3.07. The responses revealed that there is significant difference between

the groups, the values of F(2, 331) = 27.992, p=.001. The mean scores clearly

indicating in the scale of five, that there is more autonomy to physicians rather than

that of nurses and mid-wives in the reform process.

15. Statement: The reform has made improvement in housing and other amenities

at your workplace

When overall responses are analyzed the mean comes to 2.53, which revealed

total disagreement with the statement that reform has shown an improvement in

housing and other amenities at the workplace of the respondents. While the responses

are analyzed separately according to the different groups, physicians have Mean of

3.24, which shows an agreement but a weak one. Other two groups, nurses have 2.13

and 2.20 for mid-wives, which reveal that they have disagreement on this statement

thus making the group significant different, the values of F(2, 331) = 41.599, p=.001.

The mean scores clearly indicating in the scale of five, that there is an improvement in

housing and other amenities at the workplace of the physicians that is at the higher



253

level of health institute rather in the lower health institute where the nurses and mid-

wives are posted.

16. Statement: The reform has made rural health care services an attraction for the

potential physicians, nurses and mid-wives to work in rural and remote area

The response to this statement reveals that none of the respondents think that

the reform process has succeeded or made rural health care services an attraction for

the potential physicians and nurses to work in rural and remote area. When overall

responses are analyzed the mean comes to 2.01, which is the worst side of the

response, which revealed total disagreement with the statement that reform has made

the rural service an attraction for the physicians, nurses and mid-wives. While the

responses are analyzed separately according to the different groups, physicians haveMean of 2.08, nurses have 2.11 and 1.87 for mid-wives, which reveal that they have

disagreement and highly disagreement on this statement thus making the group

significant different, the values of F(2, 331) = 3.171, p=.043. The mean scores clearly

stated that there is no attraction on rural health services for physicians, nurses and

mid-wives and reform process has failed to attend so.

17. Statement: The reform has made overall HR practice effective and conducive in

the organization

Reform process has the HR dimension along with other activities on the

pipeline also. The responses revealed that the reform had failed to attend the

contribution to make the overall HR practice effective and conductive for the

organization and to the physicians, nurses and mid-wives. The Mean is 1.99 for all the

responses, which is strongly disagreement with the statement. While the responses are

analyzed separately according to the different groups, physicians have Mean of 2.21,

nurses have 1.95 and 1.81 for mid-wives, which reveal that they have disagreementand strong disagreement on this statement. The group has significant difference, the

values of F(2, 331) = 10.716, p=.001. The mean scores clearly stating that reform has

less attended overall HR practice effective and conducive in the organization for

physicians, nurses and mid-wives. It also revealed that the reform process failed to

give attention to the HR front rather giving attention to the other components of

reform process in the state.

The table 139 to 143 has the descriptive tables for putting more light on these

issues point-wises.



254

Table 139 : Descriptive Statistics of views on health sector reform process on

HR by physicians, nurses and mid-wives

Sl.

No.Attributes

N MinMax

Mean

Std.

Dev.

Stati

stic

Std.

Error

1 The reform has made the Human ResourcePolicies clear and understandable at your level

334 1 4 2.06 .041 .743

2 The reform has made the placement, transfer and promotion transparent, fairer and unbiased

334 1 4 2.05 .037 .685

3 The reform has made your job description clear 334 2 5 3.73 .042 .772

4 The reform has increased your chances of being

promoted

334 1 4 2.15 .043 .781

5 The reform has made the Salary structure

Competitive for rural area posting

334 1 5 2.85 .046 .834

6 The reform has made regular and adequate

financial incentives and allowances for ruralarea posting

334 1 4 2.21 .034 .617

7 The reform has increased the HR activities for

your performance appraisal

334 1 4 2.29 .034 .613

8 The reform has made an improvement in

working condition in your work place

334 1 5 3.40 .043 .779

9 The reform have increased the training and skill


334 1 5 3.72 .042 .761

10 The reform have improved the availability of equipment, drugs and supplies essential to

perform your assigned tasks

334 1 5 3.35 .053 .968

11 The reform have supported to create andimprovement in good mix of other cadres in

your workplace

334 1 5 3.28 .055 .997

12 The reform has made your workload more

manageable

334 1 5 2.25 .041 .756

13 The reform has made improvement in

supportive supervision, management and

mentoring form higher authority

334 1 5 3.65 .042 .763

14 The reform has made work independent and

more autonomy

334 1 5 3.06 .060 1.10

5

15 The reform has made improvement in housing

and other amenities at your workplace

334 1 5 2.53 .062 1.13

0

16 The reform has made rural health care services

an attraction for the potential physicians and

nurses to work in rural and remote area

334 1 5 2.01 .044 .798

17 The reform has made overall HR practice

effective and conducive in the organization

334 1 5 1.99 .038 .689



255

Table 140: Descriptive Statistics of views on health sector reform process on HR

by physicians

Sl.

No.

N Min ax

Mean

Std.

Dev.

Stati

stic

Std.

Error


113 1 4 2.25 .068 .726


113 1 4 2.12 .059 .629


4 The reform has increased your chances of being promoted

113 1 4 2.35 .086 .914

5 The reform has made the Salary structureCompetitive for rural area posting

113 1 4 2.93 .071 .753


financial incentives and allowances for rural area posting

113 1 4 2.43 .059 .625



113 1 4 2.37 .056 .601



113 1 5 3.53 .070 .745

9 The reform have increased the training and skill


113 1 5 3.55 .096 1.018

10 The reform have improved the availability of

equipment, drugs and supplies essential to


113 1 5 3.59 .081 .862

11 The reform have supported to create and

improvement in good mix of other cadres in your

workplace

113 2 5 3.39 .080 .850


manageable

113 1 5 2.39 .085 .901

13 The reform has made improvement in supportive

supervision, management and mentoring formhigher authority

113 1 5 3.50 .084 .888


more autonomy

113 1 5 3.55 .092 .982

15 The reform has made improvement in housingand other amenities at your workplace

113 1 5 3.24 .119 1.270




113 1 5 2.08 .077 .814

17 The reform has made overall HR practiceeffective and conducive in the organization

113 1 5 2.21 .076 .807



256

Table 141 : Descriptive Statistics of views on health sector reform process on

HR by nurses

Sl.

No. Attributes

N Min Max

Mean

Std.

Dev.

Stati

stic

Std.

Error

1 The reform has made the Human ResourcePolicies clear and understandable at your

level

98 1 4 2.03 .073 .724

2 The reform has made the placement, transfer

and promotion transparent, fairer and

unbiased

98 1 4 2.04 .071 .702

3 The reform has made your job descriptionclear

98 2 5 3.79 .071 .707

4 The reform has increased your chances of

being promoted

98 1 3 2.04 .065 .641



98 1 5 2.88 .092 .911


financial incentives and allowances for rural

area posting

98 1 4 2.11 .063 .624

7 The reform has increased the HR activities

for your performance appraisal

98 1 3 2.28 .059 .588



98 2 5 3.69 .072 .709

9 The reform have increased the training andskill development Opportunities

98 2 5 3.86 .058 .574

10 The reform have improved the availabilityof equipment, drugs and supplies essential to


98 2 5 3.81 .068 .668


your workplace

98 2 5 3.58 .072 .717


manageable

98 1 4 2.24 .058 .645


supportive supervision, management and


98 2 5 3.68 .075 .741

14 The reform has made work independent andmore autonomy

98 1 5 2.49 .103 1.01


housing and other amenities at your

workplace

98 1 4 2.13 .079 .782

16 The reform has made rural health care

services an attraction for the potential

physicians and nurses to work in rural and

remote area

98 1 5 2.11 .093 .918



98 1 4 1.95 .042 .415



257

Table 142: Descriptive Statistics of views on health sector reform process on HR

by Mid-wives

Sl.

No. Attributes

N Min Max

Mean

Std.

Dev.

Stati

stic

Std.

Error


123 1 4 1.92 .067


123 1 4 1.99 .065 .719


4 The reform has increased your chances of

being promoted

123 1 3 2.07 .065 .721



123 1 5 2.76 .076 .840


financial incentives and allowances for ruralarea posting

123 1 3 2.07 .049 .546



123 1 4 2.24 .058 .641



123 2 4 3.05 .066 .734

9 The reform have increased the training and

skill development Opportunities

123 2 5 3.78 .051 .566

10 The reform have improved the availability of

equipment, drugs and supplies essential to


123 1 5 2.76 .088 .976


your workplace

123 1 5 2.93 .108 1.199


manageable

123 1 4 2.09 .068 .675


supportive supervision, management andmentoring form higher authority

123 2 5 3.76 .057 .628


more autonomy

123 1 5 3.07 .096 1.069

15 The reform has made improvement in housing

and other amenities at your workplace

123 1 5 2.20 .082 .905




123 1 4 1.87 .059 .652



123 1 5 1.81 .063 .694



258

Table 143: Analysis of Variance of views on health sector reform process on

HR by physicians, nurses and mid-wives

Sl.

No.Attributes

Sum of

Squares df

Mean

Squar F Sig.

1 The reform has made the Human

Resource Policies clear andunderstandable at your level

Between

Groups

6.523 2 3.261 6.093 .003

Within

Groups

177.157 331 .535

2 The reform has made the

placement, transfer and

promotion transparent, fairer and

unbiased

Between

Groups

1.041 2 .520 1.110 .331

Within

Groups

155.094 331 .469

3 The reform has made your jobdescription clear

BetweenGroups

4.048 2 2.024 3.450 .033

WithinGroups

194.159 331 .587

4 The reform has increased your

chances of being promoted

Between

Groups

6.356 2 3.178 5.344 .005

Within

Groups

196.856 331 .595

5 The reform has made the Salary

structure Competitive for rural

area posting

Between

Groups

1.685 2 .842 1.211 .299

WithinGroups

230.127 331 .695

6 The reform has made regular and

adequate financial incentives and

allowances for rural area posting

Between

Groups

8.887 2 4.443 12.47

9

.001

WithinGroups

117.859 331 .356

7 The reform has increased the HR

activities for your performance

appraisal

Between

Groups

1.132 2 .566 1.510 .222

Within

Groups

124.113 331 .375

8 The reform has made an

improvement in working

condition in your work place

Between

Groups

25.574 2 12.78 23.95

8

.001

Within

Groups

176.665 331 .534

9 The reform have increased the

training and skill developmentOpportunities

Between

Groups

5.603 2 2.802 4.958 .008

Within

Groups

187.055 331 .565

10 The reform have improved the

availablity of equipment, drugs

and supplies essential to performyour assigned tasks

Between

Groups

69.262 2 34.63 47.22

0

.001

Within

Groups

242.753 331 .733

11 The reform have supported to

create and improvement in good

mix of other cadres in your

workplace

Between

Groups

24.911 2 12.45 13.46

5

.001

Within

Groups

306.194 331 .925



259

12 The reform has made your

workload more manageable

Between

Groups

4.651 2 2.325 4.144 .017

Within

Groups

185.724 331 .561

13 The reform has made

improvement in supportivesupervision, management and


Between

Groups

4.411 2 2.205 3.850 .022

Within

Groups

189.604 331 .573

14 The reform has made work

independent and more autonomy

Between

Groups

58.851 2 29.42 27.99

2

.001

Within

Groups

347.952 331 1.051

15 The reform has madeimprovement in housing and

other amenities at your

workplace

BetweenGroups

85.395 2 42.69 41.599

.001

WithinGroups

339.743 331 1.026

16 The reform has made rural health

care services an attraction for the

potential physicians and nurses

to work in rural and remote area

Between

Groups

3.985 2 1.992 3.171 .043

Within

Groups

207.967 331 .628

17 The reform has made overall HR

practice effective and conducive

in the organization

Between

Groups

9.605 2 4.803 10.71

6

.001

WithinGroups

148.347 331 .448



260

SECTION 6ANALYSIS OF THE HR POLICIES

AND PRACTICES ON

ATTRACTION, DISTRIBUTION

AND RETENTION OF


WIVES FOR RURAL AND

REMOTE AREA IN THE STATE



261

4.6.1. INTRODUCTION

As the human resource practices is related to the day-to-day HR activities of

job responsibilities, included administrative duties and recruitment; supervision

(including performance appraisals, conflict resolution, and mentoring); training; staff

deployment (including placement, transfer and benefits functions); and HR planning

and policy (covering policy-making, budgeting, and advising senior management).

HRM practices, which play a central role in the exchange relationships between the

organisation's management and its employees, are connected to every stage of the

employment circle, and through these engagements employees obtain valuable

information about the organisation and the way it is managed. These activities show

employees, in practice, what is valued in general, and how the organisation views

them in particular. When employees deal with customers they bring to the interaction

their perceptions of HRM practices (Ulrich, Halbroock, Meder, Stuchlick & Thorpe

1991).

This section is particularly for exploring and discussion on the HR policies

and practices related to Attraction, distribution and retention. It also presents the

satisfaction level of the physicians, nurses and mid-wives of these practices.

4.6.2. POLICIES FOR HR PLANNING, RECRUITMENT(ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION

Manpower planning or human resource planning is essentially the process of

getting the right number of qualified people into the right job at the right time. It is a

system of matching the supply of people (existing employees and those to be hired or

searched for) with opening the organization expects over a given time frame. (Rao,

2000). Further the efficient utilization of resources, manpower or other does not just

happen. It requires a careful planning. According to Sikula (1976) “maximum

productive use of any organization input can only be attained through the conscious

and prolonged attention to planning details. Hence, raised the need and importance of

Human Resource Planning (HRP).

Every organization has a view of the people it employs. It is fact that no

organization can rise above the calibre of its personnel. It is no accident, therefore,

that the managements’ emphasis must be laid with acquisition of right personnel. But

acquisition of right personnel is not an easy task (Samantray & Pradhan, 1998).The

selection, promotion and placement process includes all those activities related to the

internal movement of people across positions and external hiring into the



262

organisation. The essential process is one of matching available resources to jobs in

the organisation. It entails defining the organisations human needs for particular

positions and assessing the available pool of people to determine the best fit.

(Fombrun, C., et al. (1984).





regular doctors and specialist cadre comes under the purview of service rule of APHS.

The State health department has in place a concrete system for career progression for

physicians, nursing staff where physicians and nurses have promotional avenues as

per seniority and availability of vacancies. The recruitment rules are the specific

instrument of the state govt. for recruitment, classification, method of

recruitment/promotion including constitution of departmental promotion committee,

salary etc. However, there is no specific HR Policy for contractual physicians, nurses

and midwives and other health workers.

The state Govt. is preparing a 5 year strategies and policy document for


and policy reform from restructuring/ rationalization of HR deployment. The vibrant

HR policy includes terms of recruitment / filling up of vacancies, rationalising




Absence of appropriate and concrete human resources policies on deployment,

there is always a hindrance in managing people at work (interviewee from district- 1

to 16). Moreover, the 5 year strategies and policy document for augmentation and

maximization of Human Resources. This includes sustainable HRD and policy reform

from restructuring/ rationalization of HR deployment.



specific health centres without provision of transfer. The contractual position is on

facility based need and recruitment is only for that facility other than district health

society. The appointments are district and facility specific and non transferable as far

as the documents. However, intra district relocation is allowed in certain exceptions



263

on mutual transfer and postings. The state is also contemplating rational transfer of

permanent physicians and nurses & mid-wives on rotation after completion of atleast

3 years in a particular posting place (State interviewee). The measures include

compulsory rural posting for certain period, earmarking certain percentage of

postgraduate seats for doctors who have served in rural areas, and provision of rural

service allowance, etc.

For the regular groups of employees the intra-district transfer and posting are

handled by the District Medical Officer and inter-districts transfer is handled by the

Director of Health Services.

The recruitment and other service conditions for staff in health services of all

the state government are regulated by the respective central or state services

recruitment rules. These rules are elaborate and provide clear cut guidelines for

recruitment, promotions etc.

Effective recruitment, selection practices are cohesively depends on the HR

policies and in the absence of the same, a number of difficulties have been highlighted

in the interview. Thus, in the absence of the human resource policies, personnel

decisions like recruitment, placement, transfer and promotion are the major problems.

The analysis of employee attitude survey revealed that the Level of

satisfaction of these employees for Policies for placement, transfer and promotion is

not very low and above the average of the scale (N=334, mean=3.28) in the scale of 1

to 5.

Table 144: Scale of satisfaction on Policies for planning, placement, transfer

and promotion by position of Respondents

Category Highly

Dissatisfied

Dissatisfied Neither

Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 0 (0%) 6(5.3%) 33(29%) 74(65.1%) 0

Nurses 3(3.06%) 13(13.2%) 29(29.59% 53(54.08%) 0

Mid-wives 4(3.2%) 34(27.64%) 50(40.6%) 35(28.4%) 0

Total 7(2.09%) 53(15.8%) 112(33.5%) 162(48.5%) 0

The separate analysis of the scale of satisfaction of this component by the

group of these employees, the mid-wives have the lowest level of satisfaction that is

mean=2.94, whereas physicians and nurses have mean=3.60 and 3.35 respectively,

and the Contract employee has mean of 3.2 and Permanent Employee has 3.36. The

ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331)= 22.743, p =.001.



264

Table 145: Descriptive statistics on scale of satisfaction on policies for

planning, placement, transfer and promotion by position of respondents

Category N Mean Std. Dev. Std. Error Min Max

Physician 113 3.60 .591 .056 2 4

Nurse 98 3.35 .826 .083 1 4

Mid-Wife 123 2.94 .833 .075 1 4Total 334 3.28 .805 .044 1 4

Table 146: Analysis of Variance for scale of satisfaction on policies for

placement, transfer and promotion among the physicians, nurses and mid-

wives among the group of respondents

Sum of Squares Df Mean Square F Sig.

Between Groups 26.094 2 13.047 22.743 .001


Total 215.979 333

4.6.3. HR PLANNING, RECRUITMENT AND SELECTION

PROCESS

The core HRM practices for fairness in the distribution according to the norms

are based on HR planning, recruitment and selection process in the organisation. HRP

as a process is essentially a careful thought-out strategy with a futuristic lookout of

the kind of human resource requirements of an organization. Planning the health

workforce is not only a technical process, but also a political one, as decisions on the

number, types and distribution of health workers depend on the political choices and

values enshrined in the organization of national health systems (Fulop and Roemer

1987; Dussault et al. 1997). As the question itself is indicating towards the Health

Human Resources Planning that further aimed at having the right number of people

with the right skills in the right place at the right time to provide the right services to

the right people (Birch 2002, adapted from Birch et al, 2007).

Planning is most important in every sectors including health sector especially in

manpower recruitment and placing. It involves comparing estimates of futurerequirements for and supplies of human resources and considering policy options for

addressing any differences between requirements and supplies (Lomas et al. 1985-

adapted from Birch et al, 2007). Research Observation shows that accurate

information systems on staffing trends and conditions are not in place-e.g., there is

more difficulty in part of knowing the sanction post in the district or in the state, also

there is no tradition of research on workforce issues in the state. HR planning under

NRHM division is theoretically based on decentralized system, however, in the

absence of proper information, and trends of staffing makes HR planning more



265

exhaustive and difficult. While, the HR planning in permanent physicians, nurses and

mid-wives are done by the Health Directorate and based on vacancies and annual

operating plans. It is also found that there is lack of extensive co-ordination between

the two divisions for planning.

As manpower planning involves assessment of current and future demand &

supply and analyzing the gap and formulating short and long term strategies for

ensuring availability of sustainable levels of staff. The states do not have a formal

mechanism in place to undertake manpower planning on a continuous basis except the

Annual Action Plans. Planning exercise in the department of health is primarily

focused on creation of new infrastructure/institutions.

The recruitment and selection process of physicians, nurses and mid-wives

after the initiation of Reproductive and Child Health programme in 1997 and

subsequently National Rural Health Mission in 2005 has been concentrated to the

contractual manpower and the process is decentralised to the district level since 2010-

11. The decentralisation of this process is only for the contractual physicians, nurses

and mid-wives. For the recruitment of the permanent employee of this category, the

contractual employees are regularised and continued their services as regular

employees, the process is basically based on the sanctioned post vacancies and

seniority based and the process is undertaken by the Directorate of Health Services

headed by the Director of Health Services.

However, decentralization of recruitment and selection process to the district

included HR planning, recruitment; transfer and maintenance of human resource have

at the district level only for the contractual physicians, nurses and mid-wives. District

authority is now had to play a new role as employers, often without the appropriate

technical abilities to do so. The recruitment process under the decentralised

arrangement in the district is closely linked to the instruction and financial provision

at the state level.

The implementation of the decentralisation policy is only for the contractual

manpower in the district. Whereas, the appointment and deployment of the permanent

physicians, nurses and mid-wives are not comes under the decentralised recruitment

and deployment. So, it does not left any room for majority of the recruitment process

and deployment. Thus, the recruitment under centralisation, whereby the state level

would post permanent physicians, nurses and mid-wives to district may be without

taking into consideration the specific needs of each district. Thus districts requiring



266

more physicians, nurses and mid-wives could not get the required number or the

willed workforce.

Management representatives Interviewees from all the districts have the

common consensus that they do not have the sufficient pool of the candidates and

suffered from the shortage of entry level physicians and nurses (GNM). However, two

of the district (3, 8) faced problems in Mid-wives pool also. Hughes (2002) has

pointed out that when supply is scarce; the development of an effective recruitment

and selection strategy becomes significantly more challenging and imperative.

Interviewees from Districts (3, 6, 8 and 11) put light on recruitment & selection of

less skilled candidates in the light of the scare pool of the candidates. The majority of

the management representatives emphasized that there is a need for a division of

responsibilities between the districts and the state level in matters related to

recruitment and distribution of health workers, to gain a favourable impact on

recruiting and deploying the physicians, nurses and mid-wives in rural and remote

areas.

In order to select the skilled physicians, nurses and mid-wives, various

recruitment sources are utilised by the districts. Advertising in state level newspapers,

local newspapers, office notice board publications and informal way of word of

mouths of present employees (district 1,2, 5, 8, 10, 13, 16) are used as the medium for

recruitment of these category of employees. The recruitment advertisement for the

contractual vacancies is only undertaken for this kind of process in the districts. The

recruitment advertisement for permanent positions is placed in the newspaper and

office board by the Directorate of Health Services. However, the internal source of

recruitment is widely used, whenever a sanctioned regular post is vacant. This process

of recruitment of internal candidates for regular posts supports career development

opportunities for internal contractual employees.

Selection is basically a matching process. How well an employee is matched

to a job affects the amount and quality of a employee’s work. Improper job placement

affects his moral as well. Ultimately, it costs an organization a great deal of money,

time and trouble. Effective human resource management requires constant monitoring

of the ‘fit’ between person and job. (Rao, 2000). As rightly pointed out, “If a

systematic selection procedure (test, patterned interview and so forth) prevented one

or two selection errors a year, it would represent a substantial return on investment”

(Durbin, 1981). Now –a-days some new methods like ‘walk-in-interview’ are



267

becoming so popular that many corporations are adopting it. In this process the venue

is just checked out from the advertisement and if one becomes successful in the

interview, he gets a plum job and pay package within two and half hours. More and

more companies recruiting for entry-level and front-line jobs are opting for the walk-

in method (Beach, 1980).

So forth, the selection processes is based on Walk-in-interview (districts-2, 8,

12, 16), Written-test and panel interview (district-1,3,4,5,6,7,9,10,11,13,14,15) across

districts for these categories of contractual employees. In every district, a standing

recruitment and selection board is in place, which is headed by Deputy Commissioner

of the District and involved in every recruitment and selection process in the

individual districts. The section process is based on merit in written test and technical

and skill knowledge, personality and attitude assessment of the candidates in panel

interview.

For final selection, the selection committee assess the comparative merits of

each candidate in terms of his / her qualifications, experience if any and on the basis

of performance in the selection tests as per criteria laid down and come to a

conclusion as to whether or not the candidate would measure up to the requirements

of the job. However wherever marks are assigned, committee members give marks on

the basis of criteria laid down. Finally, candidates found suitable are empanelled in

order of merit. The panel / merit list so prepared are subject to the approval of the

competent authority and remain valid for a period of six months from the date of such

approval. If required the authority may extend the validity of the panel for a further

period not exceeding six months. Lastly, after the final selection of the candidates,

appointment offers are issued to the required number of candidates from the panel in

order of merit with the approval of the competent authority. All the appointment

offers are centrally issued by the establishment section.

The assessment of the requirement of Physicians, Nurses and Mid-wives

particularly for rural and remote areas is done annually in the form of Health Action

Plan based on the service based facility planning and it is a recurring planning in

nature. But these requirement planning are based for contractual employees. While

assessment of requirement of permanent Physicians, nurses and mid-wives, under

Annual Operating Plan in Directorate of Health Services under Planning and

Development Branch is done. However, the planning is done to create sanction post.



268

Thus, the recruitment and selection process of the employee in the state public

health system is a traditional approach and lack the professional forefront in this

process. The system of recruitment and selection methods may be judged as the

traditional, and the advertisement, walk-in-interview, written-test with panel interview

as the dominant tools in use. However, the system failed to use a good recruitment

and selection techniques or the process for the recruitment of right skill and the right

number of employees in the system. It seems, the transfer of human resources

functions from State level to district level without a comprehensive design and

structure is quite a big challenge for the district administration. To manage the

decentralized activities there is no proper system of professional HR management

personnel in the district level or in the state level, which create a challenging

environment at this and subsequent level of administration.


satisfaction of these employees for Recruitment and selection process is low (N=334,

mean=2.43) in the scale of 1 to 5. It may be there is no concrete HR policy for

recruitment and selection process, and may lead to favouritism, political dictates, and

nepotism in the recruitment and selection process.

Table 147: Scale of satisfaction on Recruitment and selection process and

Position of RespondentCategory Highly

Dissatisfied


Satisfied Nor Dissatisfied

Satisfied Highly

Satisfied

Physicians 3 (2.6%) 66(58.4%) 31(27.4%) 13(11.5%) 0

Nurses 6(6.1%) 61 (62.2%) 28(28.5% 3(3.06%) 0

Mid-wives 15(12.1%) 50(40.6%) 41(33.3%) 17(13.8%) 0

Total 24(7.18%) 177(52.9%) 100(29.9%) 33(9.8%) 0


group of these employees, the nurses have the lowest level of satisfaction that is

mean=2.29, whereas physicians and mid-wives have mean=2.48 and 2.49

respectively, and the Contract employee has mean of 2.51 and Permanent Employee

has 2.35. The ANOVA test shows that there is a no significant difference in the scale

of satisfaction for this theme among the three groups, the values of F(2, 331) = 2.318,

p =0.1.



269

Table 148: Descriptive statistics on scale of satisfaction on Recruitment and

selection process by position of respondents

Table 149: Analysis of variance for Scale of satisfaction on Recruitment

and selection process among the group of respondents

Sum of Squares Df Mean Square F Sig.

Between Groups 2.702 2 1.351 2.318 .100


Total 195.629 333

4.6.4. HR PRACTICE FOR PLACEMENT, TRANSFER AND

PROMOTIONThe deployment of contractual physicians, nurses and mid-wives are done

according to the recruitment done for the particular vacancies for the specific health

institution. However, the deployments are interchange able on mutual consent of the

employees or the management decisions at the district level.

The deployment of the regular cadre employee is done according to the

requirement of the district and the District Medical Officer looks the matter and

depends on the physical infrastructure and basic amenities in the health institution e.g.

accommodation.

The common tenure following transfer posting is of minimum 3 years of

posting in one location, however, which is not followed at the district level or the state

level. The current practices however are non systematic and non transparent in many

district.

Promotion acts as an important motivational factor even when it is not

accompanied by substantial monetary benefits. The contractual groups do not have

any scope of promotion, as they are considered as the temporary employees.

Promotion as an internal source of recruitment is a long established policy in the

department. As per the recruitment rules the states follow the promotional avenues for

their permanent workforce. However, time bound promotions are not practices for

several reasons to these categories of staff. However, seniority-cum-merit promotions

are followed by the state.

N Mean

Std.

Deviation

Std.

Error Min Max

Physician 113 2.48 .733 .069 1 4 Nurse 98 2.29 .626 .063 1 4

Mid-Wife 123 2.49 .881 .079 1 4

Total 334 2.43 .766 .042 1 4



270


satisfaction of these employees for fairness of HR Practice for placement, transfer and

promotion is low (N=334, mean=2.11) in the scale of 1 to 5. The result revealed that

there may exists some extent of favouritism and unfairness in practicing related to the

placement, transfer and promotional avenues to the employees.

Table 150: Scale of satisfaction on fairness in HR Practice for placement,

transfer and promotion and Position of Respondent

Category Highly

Dissatisfied


Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 16 (14%) 77(68%) 14(12.3%) 6(5.3%) 0

Nurses 10(10.2%) 65 (66%) 17(17.3% 6(6.12%) 0

Mid-wives 23(18.6%) 78(63.3%) 14(11.3%) 8(6.5%) 0

Total 49(14.6%) 220(65.8%) 45(13.4%) 20(5.9%) 0



mean=2.06, whereas physicians and nurses have mean=2.01 and 2.19 respectively.

The ANOVA test shows that there is a no significant difference in the scale of

satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p

=.346.

Table 151: Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position of respondents


Physician 113 2.09 .689 .065 1 4

Nurse 98 2.19 .698 .071 1 4

Mid-Wife 123 2.06 .750 .068 1 4

Total 334 2.11 .715 .039 1 4

Table 152 : Analysis of Variance for the scale of satisfaction on fairness of HR

Practice for placement, transfer and promotion among the group of respondent

Sum of Squares Df Mean Square F Sig.Between Groups 1.087 2 .543 1.064 .346


Total 170.120 333


satisfaction of these employees for magnitude of management favouritism and

political interference in transfer and posting is low (N=334, mean=2.36) in the scale

of 1 to 5. The result revealed that, the employees feel that there may existence of

management favouritism and political interference in the transfer and posting of these

groups of employees.



271

Table 153: Scale of satisfaction on Magnitude of management favouritism and

political interference in transfer and posting among the group of respondents

Category Highly

Dissatisfied


Satisfied Nor Dissatisfied

Satisfied Highly

Satisfied

Physicians 10 (8.8%) 64(56.6%) 32(28.3%) 7(6.1%) 0 Nurses 10(10.2%) 43 (43.8%) 36(36.7% 9(9.18%) 0

Mid-wives 12(9.7%) 68(55.2%) 35(28.4%) 8(6.5%) 0

Total 32(9.5%) 175(52.39%) 103(30.8%) 24(7.18%) 0


group of these employees, the physicians and mid-wives have the lowest level of

satisfaction that is mean=2.32, whereas nurses have mean=2.45. And the Contract

employee has mean of 2.41 and Permanent Employee has 2.31. The ANOVA test

shows that there is a no significant difference in the scale of satisfaction for this theme

among the three groups, the values of F(2, 331) = 1.052, p =0.350.

Table 154: Descriptive statistics on scale of satisfaction on magnitude of

management favouritism and political interference in transfer and posting by the

position of respondents

N Mean Std. Deviation Std. Error Min Max

Physician 113 2.32 .723 .068 1 4

Nurse 98 2.45 .801 .081 1 4

Mid-Wife 123 2.32 .739 .067 1 4Total 334 2.36 .753 .041 1 4

Table 155: Analysis of Variance for the scale of satisfaction on Magnitude of

management favouritism and political interference in transfer and posting


Sum of

Squares

Df Mean Square F Sig.

Between Groups 1.192 2 .596 1.052 .350


Total 188.602 333


satisfaction of these employees for magnitude of response of

administration/management on your placement, transfer and promotional grievances

is low (N=334, mean=2.39) in the scale of 1 to 5. The result revealed that, the

employees feel that there exists a delay in response of administration/management on

your placement, transfer and promotional grievances of these groups of employees.



272

Table 156:Scale of satisfaction on response of administration/management on

your placement, transfer and promotional grievances

Category Highly

Dissatisfied


Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 10 (8.8%) 46(40.7%) 40(35.3%) 16(14.1%) 1 (0.8%)

Nurses 10(10.2%) 59 (60.2%) 23(23.4% 6(6.1%) 0

Mid-wives 18(14.6%) 57(46.3%) 38(30.8%) 10(8.1%) 0

Total 38(11.3%) 162(48.5%) 101(30.2 %) 32(9.5%) 1 (0.29%)


group of these employees, the nurses have the lowest level of satisfaction that is


And the Contract employee has mean of 2.36 and Permanent Employee has 2.41. The

ANOVA test shows that there is a significant difference in the scale of satisfaction for

this theme among the three groups, the values of F(2, 331) = 4.663 , p =.01.

Table 157: Descriptive statistics on scale of satisfaction on response of

administration/ management on your placement, transfer and promotional

grievances by the position of respondents

N Mean

Std.

Deviation

Std.

Error Minimum Maximum

Physician 113 2.58 .874 .082 1 5

Nurse 98 2.26 .722 .073 1 4

Mid-Wife 123 2.33 .825 .074 1 4

Total 334 2.39 .823 .045 1 5

Likewise, the analysis of employee attitude survey revealed that the Level of

satisfaction of these employees for participation and involvement in the decision

making of employees placement and transfer is low (N=334, mean=2.32) in the scale

of 1 to 5. The result revealed that, the employees feel non existence of participation

and involvement of employees in placement and transfer decisions.

Table 158: Analysis of Variance for the scale of satisfaction on Response of

administration/management on your placement, transfer and promotional

grievances among the group of respondents

Sum of

Squares Df Mean Square F Sig.

Between Groups 6.176 2 3.088 4.663 .010


Total 225.401 333



273

Table 159: Scale of satisfaction on Participation and involvement in the

decision making of your placement and transfer

Category Highly

Dissatisfied


Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 13 (11.5%) 57(50.4%) 39(34.5%) 4(3.5%) 0

Nurses 4 (4.08%) 51 (52%) 40(40.8% 3(3.06%) 0

Mid-

wives

15(12.1%) 68(55.2%) 35(28.4%) 5(4.06%) 0

Total 32(9.5%) 176(52.6%) 114(34.1%) 12(3.5%) 0




And the Contract employee has mean of 2.36 and Permanent Employee has 2.28. The

ANOVA test shows that there is a no significant difference in the scale of satisfaction

for this theme among the three groups, the values of F(2, 331)=1.991, p=0.138.

Table 160: Descriptive statistics on scale of satisfaction on participation and

involvement in the decision making of your placement and transfer by the

position of respondents

N Mean Std.

Deviation

Std. Error Minimum Maximum

Physician 113 2.30 .718 .068 1 4 Nurse 98 2.43 .626 .063 1 4

Mid-Wife 123 2.24 .717 .065 1 4

Total 334 2.32 .694 .038 1 4

Table 161: Analysis of variance for the scale of satisfaction on Participation

and involvement in the decision making of your placement and transfer


Sum of

Squares Df Mean Square F Sig.

Between Groups 1.906 2 .953 1.991 .138Within Groups 158.453 331 .479

Total 160.359 333

4.6.5. HR PRACTICE FOR RETENTION - FINANCIAL & NON-

FINANCIAL INTERVENTIONSThere is no provision of financial and non-financial incentives for rural and

remote area deployment and retention. In the light of no provision of such incentives

for the physicians, nurses and mid-wives for rural area services and the compensation

package also is same irrespective of the place of posting. Other non financial benefits



274

such quarters with electricity, water facilities etc. are minimum in the system to retain

the workforce in those underserved areas. Moreover, other rewards system linked to

performance is also not the system, may resulted to the low job satisfaction and

motivation of the workforce. The reward and recognition for the performance and

achievement is also there in the system which could boost the satisfaction and

motivation to perform by the workforce. The study findings seem that the workforce

is dissatisfied with these components in the system.


satisfaction of these employees for financial incentives as retention interventions is

low (N=334, mean=2.13) in the scale of 1 to 5. The result revealed that there is no

satisfaction regarding the HR Practice for retention taking financial incentives as an

intervention.

Table 162: Scale of satisfaction of HR Practice for retentions –Financial

Interventions

Category Highly

Dissatisfied


Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 36 (31.9%) 50(44.2%) 15(13.3%) 12(10.6%) 0

Nurses 24 (24.5%) 46 (46.9%) 20(20.4% 8(8.2%) 0

Mid-wives 28 (22.8%) 52(42.3%) 28(22.8%) 15(12.2%) 0

Total 88(26.3%) 148(44.3%) 63(18.9%) 35(10.5%) 0


group of these employees, the physicians have the lowest level of satisfaction that is

mean=2.03, whereas mid-wives and nurses have mean=2.24 and 2.12 respectively.

The ANOVA test shows that there is a no significant difference in the scale of

satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p

=0.195.

Table 163: Descriptive statistics on scale of satisfaction of HR Practice for

retentions –Financial Interventions by the position of respondents

Category N Mean Std. Deviation Std. Error Minimum Maximum

Physician 113 2.03 .940 .088 1 4

Nurse 98 2.12 .877 .089 1 4

Mid-Wife 123 2.24 .944 .085 1 4

Total 334 2.13 .925 .051 1 4



275

Table 164: Analysis of variance for the Scale of satisfaction of HR Practice for

retentions –Financial Interventions among the group of respondents

Sum of Squares df

Mean

Square F Sig.

Between Groups 2.803 2 1.402 1.644 .195

Within Groups 282.134 331 .852Total 284.937 333


satisfaction of these employees for non-financial incentives as retention interventions

is low (N=334, mean=2.36) in the scale of 1 to 5. The result revealed that, the

employees feel that there exists management favouritism and political interference in

the transfer and posting of these groups of employees.

Table 165: Scale of satisfaction of HR Practice for retentions –Non- Financial

InterventionsCategory Highly

Dissatisfied


Satisfied Nor

Dissatisfied

Satisfied Highly

Satisfied

Physicians 2 (1.8%) 33(29.2%) 42(37.2%) 36 (31.9%) 0

Nurses 24 (24.5%) 26 (26.5%) 25(25.5%) 23(23.5%) 0

Mid-wives 15 (12.2%) 65(52.8%) 33(26.8%) 10(8.1%) 0

Total 41(12.3%) 124(37.1%) 100(29.9%) 69(20.7%) 0


group of these employees, the nurses and mid-wives have the lowest level of

satisfaction that is mean=2.48 and 2.31, whereas physicians have mean=2.99. The


this theme among the three groups, the values of F(2, 331) = 17.722, p =.001.

Table 166: Descriptive statistics on scale of satisfaction of HR Practice for

retentions – Non Financial Interventions by the position of respondents


Physician 113 2.99 .829 .078 1 4

Nurse 98 2.48 1.105 .112 1 4

Mid-Wife 123 2.31 .791 .071 1 4

Total 334 2.59 .950 .052 1 4

Table 167: Analysis of variance of Scale of satisfaction of HR Practice for

retentions – Non Financial Interventions among the workforce among

the group of respondents

Sum of Squares df

Mean

Square F Sig.

Between Groups 29.095 2 14.547 17.722 .001

Within Groups 271.710 331 .821Total 300.805 333



276

4.6.6. HR PRACTICE FOR RETENTION - TRAINING AND

DEVELOPMENTIn this context Mark Twain’s statement is crucial which states. “There is

nothing that training cannot do. Nothing is above its reach or below it” (Ramani,

2003). Andragogy (the science of adult learning) demands tremendous effort from the

trainer what should be more effective and purposeful (Rao, 2003).

Skill up-gradation and multi skilling practices are much emphasizes in the

sector. Lot of skill up-gradation and multi skilling training are undertaken and the

physicians, nurses and mid-wives are satisfied with the process and most of the

workforce are attracted and retain themselves due to this factor in the sector. A major

pre-requisite for providing quality health care service is upgrading the skills and

knowledge of all health personnel as well as this is an integral factor for retaining

technical human resource in rural and remote areas. The Government is providing

frequent scope for programme based training with time to time refresher training to all

level of functionaries including ANMs, GNMs & Medical Officers. Huge investments

on the employees are done in the form of training and development opportunities.

There are different types of skill up-gradation training such at Skill Birth Training,

Medical Termination of Pregnancy, Life Saving Anesthesia Training, Emergency

Obstetrics Care, Neo-natal care etc. which are provided to physicians, nurses &midwives in primary and secondary level of health institutes. There is no

discrimination regarding the status of employment for proving various skill up-

gradation training. Availability of in service training opportunities can be seen as a

factor of attraction and retention of the employees in primary and secondary health

institutes in rural and remote areas. They are getting opportunity for skill acquisition

and have the access to all type of training in the department as per their eligibility and

location of the health institutes. They are provided with a wide variety of training

opportunity and provide exposure to different type skill up-gradation of their related

work and techniques. It can also be developmental in a wider sense of developing

both technical and professional skills.

The multi-skill trainings & capacity building of the workforce are emphasized

on physicians, nurses & mid-wives from the rural and remote area. Skill up-gradation

is an essential component of in-service training programmes. The skill up-gradation

varies enormously depending upon the qualifications of the personnel and the

institution where he/she is working. For optimum utilization of human resources, skill



277

and competence enhancement is of paramount importance. Therefore, with the

objective to maintain the skill and competence level of the employees as well as to

improve upon these skills, different training programmes are designed and undertaken

in Health Sector.


satisfaction of training and development as retention interventions is low (N=334,

mean=3.22) in the scale of 1 to 5. The result revealed that, the employees are to the

extent satisfied with the training and development practices of the organisation.

Table 168: Scale of Satisfaction of Training and Development

Category Highly

Dissatisfied


Satisfied

Nor Dissatisfied

Satisfied Highly

Satisfied

Physicians 2 (1.8%) 27 (23.9%) 27(28.4%) 48 (42.5%) 9(8%)

Nurses 5 (5.1%) 26 (26.5%) 33(34.7%) 34(34.7%) 0

Mid-wives 6 (4.9%) 17(13.8%) 35(36.8%) 59(48.0%) 6 (4.9%)

Total 13(3.9%) 70 (21%) 95(28.4%) 141(42.2%) 15(4.5%)


group of these employees, the nurses have the lower level of satisfaction that is

mean=2.98, whereas physicians and mid-wives have mean=3.31 and 3.34. The


this theme among the three groups, the values of F(2, 331) = 4.658, p =.010.

Table 169: Descriptive statistics on scale of satisfaction of HR Practice of

Training and Development by position of the respondents

N Mean Std. Deviation Std. Error Min Max

Physician 113 3.31 .983 .092 1 5

Nurse 98 2.98 .908 .092 1 4

Mid-Wife 123 3.34 .948 .085 1 5Total 334 3.22 .959 .052 1 5

Table 170: Analysis of variance of Scale of Satisfaction of Training and

Development among the group of respondents

Sum of Squares df Mean Square F Sig.

Between Groups 8.382 2 4.191 4.658 .010


Total 306.159 333

The overall descriptive table on satisfaction of employees on HR practice of

planning, recruitment and placement in respect of physicians, nurses and mid-wives is presented in table: 171 to 173.



278

Table 171 : Descriptive statistics on level of satisfaction on HR practice of

planning, recruitment & placement in respect of physicians, nurses & mid-wivesSl. No. Dimensions N Scale Mean SD

1 Recruitment and selection process 334

1 to 5

2.43 .766

2 Policies for placement, transfer and promotion 334 3.28 .8053 Fairness of HR Practice for placement, transfer and

promotion

334 2.11 .715

4 Magnitude of management favouritism and politicalinterference in transfer and posting

334 2.36 .753

5 Response of administration/management on your

placement, transfer and promotional grievances

333 2.39 .824

6 Participation and involvement in the decision making

for placement and transfer

334 2.32 .694

7 Practice for retentions –Financial Interventions 334 2.13 .925

8 Practice for retentions – Non Financial Interventions 334 2.59 .950

9 Training and Development Practices 334 3.22 .959

Table 172 : Descriptive statistics on level of satisfaction of Contractual

employees on HR practice of planning, recruitment and placement

Attributes N Mean SD

Recruitment and selection process 154 2.51 .834

Policies for placement, transfer and promotion 154 3.20 .858

Fairness of HR Practice for placement, transfer and promotion 154 2.01 .657

Magnitude of management favouritism and political interference in

transfer and posting

154 2.41 .772

Response of administration/management on your placement, transfer and promotional grievances

154 2.36 .847

Participation and involvement in the decision making for placement

and transfer

154 2.36 .729

Practice for retentions –Financial Interventions 154 2.16 .937

Practice for retentions – Non Financial Interventions 154 2.38 .951

Training and Development Practices 154 3.36 .861

Table 173: Descriptive statistics on level of satisfaction of Permanent employees

on HR practice of planning, recruitment and placement

Attributes N Mean SD

Recruitment and selection process 180 2.35 .697Policies for placement, transfer and promotion 180 3.36 .752

Fairness of HR Practice for placement, transfer and promotion 180 2.19 .753

Magnitude of management favouritism and political interference intransfer and posting

180 2.31 .735

Response of administration/management on your placement, transfer and promotional grievances

180 2.41 .804

Participation and involvement in the decision making for placement

& transfer

180 2.28 .662

Practice for retentions –Financial Interventions 180 2.12 .917

Practice for retentions – Non Financial Interventions 180 2.77 .916

Training and Development Practices 180 3.11 .024



279

CHAPTER- 5

MAJOR FINDINGS,SUGGESTIONS AND

CONCLUSION



280

SECTION 1

MAJOR HR ISSUES IN

DISTRIBUTION OF PHYSICIANS,

NURSES AND MIDWIVES



281

5.1.1. INTRODUCTIONAfter having an analysis and descriptive interpretational previous chapter, this

chapter presents the major findings on distribution, attraction and retention of

physicians, nurses and mid-wives in rural and remote areas. Section 1 highlights the

major findings of HR issues on Distribution, Section 2 highlights major HR issues on

Attraction and Section 3 highlights major HR issues on retention and Section 4

provides a preview of the specific findings on Health Sector Reform initiatives and

Section 5 presents the major issues in HR Practice related to attraction, distribution

and retention of physicians, nurses and mid-wives in rural and remote areas.

Thereafter, Section 6 highlights possible options in form of suggestion on the major

issues and followed by Section 7 the Conclusion of the study.

5.1.2.MAJOR HR ISSUES IN DISTRIBUTION OF PHYSICIANS,

NURSES AND MIDWIVES

5.1.2.1. DISPARITIES IN ESTABLISHMENT OF HEALTH INSTITUTIONS:

ISSUE OF HEALTHCARE DELIVERY SYSTEM WHICH LINK DIRECTLY TO

HR ISSUES.

Over the last few decades the establishment of health institutions in rural areas

of the state are haphazard and not kept pace with adhering to the norms. The state has

created 468 numbers of Sub-centres out of which only 286 no. of SCs are functional

likewise 119 PHCs were established, whereas functional 24x7 PHC is 29, and

functional CHC are 49 numbers, where as functional as FRUs is only one (1).

Moreover, the figures of the health institution at the rural areas are different in the

central database and the state figures.

Health institution Central Figure (RHS, 2010) State Figure

SC 286 468

PHC 97 119

CHC 48 49

However, the government have attempted the disparities and on the verge of

rectification and de-notification of many of the SCs in the rural areas, which were

created randomly.

The average population covered by the health institutions district wise has no

similarities and the nurses were not followed it ranges from 6064 to 781 population

for a Sub-centre in the districts. However, at the state level the figure is 2954 which is

better than that of the norms for a SC. While a PHC covers a population from 22048



282

to 1590 in the district and the state figure is 11619 which is also a better figure at the

state level. Similarly, CHC covered a population from 8822 to 48513 and the state

level figure is 28217 which is also a better figure than that of the norms. This trends

show that the institution were randomly created without thinking the consequences of

human resource requirement and without keeping in mind the Govt. of India norms. It

seems the inter district disparities are there in respect of creation of the health

institution, which in repulsion create the problem of inadequacy of human resource

and inadequacy of importance.

5.1.2.2. THE HUMAN RESOURCE CRISIS IN RURAL AREA: NUMERICAL

INADEQUACY OF PHYSICIANS, NURSES AND MID-WIVES The ramped and unplanned creation of health institution in the state has

created a demand of Physicians, nurses and mid-wives. There is huge gaps of demand

and supply, placement of Physicians, nurses and mid-wives in the region.

Consequently, many rural communities/areas are deprived of the primary health care

and desperately need the attention. However, the population norms of establishment

of the health institutions does not fit in the state like Aruanchal Pradesh, because the

state have lesser population in comparing to the other states in India. The state has the

lowest density of population in the country. However, the norms are norms and

should be followed by the state. Besides, the in-equities in distribution of Physicians,

nurses and mid-wives, there is huge gaps and shortage of these category of health

workforce, to cater the maternal and child health needs as well as primary health care

in the state. This study found that there are geographical imbalances and shortages of

Physicians, nurses and mid-wives. The inequities in the geographic distribution of

Physicians, nurses and mid-wives, itself has meant too many rural and remote areas

with the shortage of Physicians, nurses and mid-wives.

This is a major reason for Arunachal’s weak health sector performance is due

to the crisis in the health workforce. There is a critical shortage of skilled manpower

like doctors, nurses and midwives. There are also shortages of personnel trained in

concerned disciplines like various specialists, we can say this deals with number and

the composition of health workforce, major public health issues. The health systems

of the region were characterized by an insufficient number of medical specialists,

MBBS doctors, and other professionals such as nurses and mid-wives. Other level of

problem is that at many places posts are vacant in wants of appropriate candidate or procedural delays in appointing staff.



283

Shortage of human resources is a major problem facing Arunachal’s Health

sector, where more than 80% of the population lives in rural areas. Most of the

districts have the rural population, maximum of the districts are having urban areas

only in their District HQ and the rest are comprises of rural areas. Every District is

having a district level hospital in its HQ, but these hospitals are also having acute

shortage of manpower especially the graduate doctors, PG doctors and staff nurses.

Whereas, the availability of ANMs in the state is quite good but this category of

workforce is having an artificial crisis. However, under NRHM, doctors, staff nurses

and mid-wives are currently recruited on a contractual basis. Among the newly

recruited doctors, many of them do not join the service and some numbers leave the

job within short span of time.

As per the existing practices, staff nurse are recruited from those having

passed out of nursing college and the nursing schools at the state and off-course from

outside state. Although, the existing pool are not adequate to fill the vacant posts.

Further, new requirements have come up after the launch of central government

flagship programmes. There is demand for additional positions under these

programmes in many of the district out of their sanctioned posts. The vacancy rates

are particularly high for skills that are mostly needed. However, the determination of

sanctioned post and vacancies there on, is also not cleared at the district as well as the

state level. Most health occupations are highly interdependent when carrying out their

tasks. Problems in one professional category may spill over into another. For

example, a shortage of nurses resulting from inadequate planning may have adverse

effects on the work of doctors.

The shortfall of Physicians, nurses and mid-wives are continues to represent

one of the major constraints to the development of health services and access to basic

health care in Arunachal Pradesh.

According to the Indian Public Health Standards, the availability of HR is one

of the vital prerequisites for competency in the rural health care delivery system in the

country. It is also very important where 77% of the population lives in rural and

remote areas and poverty is the dominating factors among the population.

Requirement based on the IPHS norms for Physicians, nurses and mid-wives

for existence health institution are – 570 midwives with current shortage of 51%, 926

Nurses with current shortage of 70% and 510 Physicians with current shortage of



284

53%. The shortage of mid-wives among the districts ranges from 6% to 82%, nurses

from 37% to 92% and 1% to 85% of physicians for all the existing health institution.

Similarly, the requirement for rural and remote area is similarly high. We find

that the requirement of mid-wives is 714 nos. with current shortfall of 65%, nurses is

747 nos. with current shortfall of 78% and physicians are 545 with current shortage of

66%. The situation is critical in respect of the requirement and the shortfall in rural

and remote areas. This is a serious indicator of inadequacy of Physicians, nurses and

mid-wives in rural and remote areas in comparison to the urban areas. The

requirement is more because of the concentration of more Physicians, nurses and mid-

wives in urban areas, which creates inequity in the distribution as well as the shortage

of Physicians, nurses and mid-wives.

Therefore, it is found that there is acute shortage of Physicians, nurses and

mid-wives in the region and especially in rural and remote areas, while the urban

areas have more concentration though there is also have the shortage in some

numbers. While, the disparity of distribution of Physicians, nurses and mid-wives in

rural and urban co-exists and contributing to the shortage and the huge gaps in the

region.

Thus, the poor availability of Physicians, nurses and mid-wives co-exists and

creating an imbalance and a problem with debilitating health care delivery system in

the region. The shortage of these categories of the health workforce is reaching the

crisis proportion and should be the centre of attraction of the government machineries.

5.1.2.3. PRODUCTION ISSUES OF PHYSICIANS, NURSES AND MID-

WIVES

Generation of health workers is another issue in the state. It has not been kept

pace with the need, especially with the physicians (MBBS) and nurses (GNMs).

Absence of adequate training institutes for medical and nursing courses results in low

numbers of medics and paramedics produced for the state. There is no medical college

in public sector or in private sector for Allopathic disciplines besides a Homeopathy

Medical College in private sector. Yearly a fixed numbers of students according to the

Govt. Of India quota seats, are placed in various Medical colleges all over India. 32

seats in First nomination 2010 and 34 seats in first nomination 2011 has been allotted

to the students for the MBBS course in various Medical Colleges in India (DHTE,

2010 & DHTE, 2011). For the training of nursing personnel, the state runs a lone



285

Nursing School for ANMs at General Hospital, Pasighat, East Siang District of

Arunachal Pradesh. The institute runs training programs on midwifery (ANM)

nursing courses. There are no fix numbers of ANM admission seats per year in this

ANM School, in the year 2009-10, the number was 70, a year before in 2008-09, it

was 47. The variation depends on Government of Arunachal Pradesh continuing

changing policy. There exists a chronic and serious shortage of Nureses (GNMs) at

present time, as there is no GNM training school in govt. sector in Arunachal

Pradesh. A few number of GNMs are produced in GNM School at Ramakrishna

Mission Hospital, Itanagar. With this inadequacy in teaching schools, insufficient

numbers of professionally trained personnel to compensate the situation.

5.1.2.4. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVESAMONG THE DISTRICTS: GEOGRAPHIC INEQUITY

Adding to the acute shortage of manpower in the health sector in Arunachal

Pradesh, the issues and options for deploying health workforce is always a big deal of

concern. Mal-distribution, that is the distribution of health workforce is characterized

by urban concentration and rural deficits, but these imbalances are perhaps most

disturbing from a district perspective also. Urban/rural imbalance in the distribution of

health workers is a problem in the past and present also, and it may be worsening

more. There is an over-concentration of qualified health personnel in urban hospitals

and urban centres, coupled with shortages in poor neighbourhood districts and rural

areas that are not equally distributed, especially to manage change in the health sector.

Health workforce especially the nursing staffs, the physicians are concentrated

to the urban hospitals. Doctors and nurses are reluctant to relocate to remote areas and

forest locations that offer poor communications with the rest of the main land and few

amenities for health professionals and their families. Urban areas in the states are

good and convenient to health care professionals for their comparative social, culturaland professional advantages. The Health workforce have been reluctant to work in

rural and remote areas in the state, possibly because of little support at these areas, a

lack of material resources for them, poor working and living conditions, isolation

from professional colleagues and possibly less opportunities for self professionally

developed and Silently the education opportunities for their (workforce) children.

Moreover, there is a poor distribution of doctors as well as an acute shortage of

midwives outside the capital city, particularly in remote areas and sparsely populated

communities.



286

Doctors and nurses are currently recruited on a contractual basis under

NRHM, among the newly recruited doctors and nurses do not join the service if they

are posted in remote and inaccessible areas in the state and some of them leave the job

within short span of time on being regularized or of other reasons. The percentage of

such doctors varies from district to district. Furthermore, there is no financial

incentive for Working in rural, remote and inaccessible areas, that’s why the problem

of geographic mal-distribution of health workers persists.

The majority of skilled health service providers are concentrated in urban

areas and the mal-distribution is concern for artificial crisis of health workforce in the

rural and inaccessible areas in the state.

The accessibility of Physicians, nurses and mid-wives has been threatened

mostly in the rural and remote area of the state. While 77% of the population lives in

rural and remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives

are serving in rural and remotes areas of the state. This creates urban and rural

imbalance in distribution. The phenomenon of urban skewness and mal-distribution

among the districts are there, consequently, many rural and remote areas are in

desperate need of the physicians, nurses and mid-wives. Thus, creating inequities in

the geographical distribution of physicians, nurses and mid-wives have meant a wide

range of rural & remote area are deprived of the primary healthcare at the doorsteps.

In Arunachal Pradesh, the depth of inequities in the distribution of physicians,

nurses and mid-wives in urban and rural area is truly a breathtaking. It is also found

that the distribution of physicians, nurses and mid-wives is skewed among the

districts. It is observed that the physicians, nurses and mid-wives concentrated to the

districts which are with good accessibility and communication. The specialist cadre

essential for the maternal and child health- Paediatrician, Gynaecologist and

Anaesthetist are almost zero in the rural and remote areas and only concentrated to the

urban areas. The 449 nos. of physicians are distributed across the health institutions

having 1:3079 of doctor population ratio, which is poor than that of the norms. The

doctor population ratio among the districts have different and ranges from 1506 to

8972 population per physicians (doctor). It is observed that the concentration of the

physicians to the district is asymmetrical and maximum of them are concentrated to

the three district with good communication and with more urban and semi urban area

and easy rural area accessibility. The distribution of the physicians ranges from 17%



287

to 1% among the districts, which creates a wide gap in the distribution. The remotest

and harder districts have lesser number of physicians.

Similarly, the nurses share the same situation. 390 number of nurses area

distributed across the geographical boundary of the state. It is observed that the

similar situation like the physicians to nurses. The nurse population ratio is 1:3545

for the state and does not fulfil the norms. The nurses are also concentrated to the

same three districts as similar to the physicians. These three districts have good

communication and urban areas. The distribution of nurses among the districts ranges

from 23% to 1% among the districts. This trend resulted in Nurse Population ratio

ranging from 1597 to 9802. It is observed that the nurses are also concentrated to the

easy and good districts, whereas the hard and the remotest districts are deprived of the

adequacy of the nurses in rural area.

There are 542 numbers of Mid-wives and this category of health workers are

to be placed in SCs, which is the lowest and the first contract points to the population.

The mid-wives population ratio is 1:2551 in the state, which is also a worst among the

ratio norms. The density of min-wives among the districts has the inequities ranging

from 1 mid-wife serving 883 to 4722 populations. It is also observed similar to the

other two categories – physicians and nurses, that the distribution is also skewed

among the district. The district with good communication and urban concentration has

the highest mid-wives. The distribution ranges from 12% to 2% of the mid-wives

across the districts. The distribution pattern of the mid-wives in the region shares the

similar situation as the physicians and nurses have and concentrated to the same three

districts.

Thus, we found that there is poor distribution of physicians, nurses and mid-

wives, wherein the ratio and percentage of distribution varies across the districts.

5.1.2.5. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVES

IN RURAL AND REMOTE AREAS AMONG THE DISTRICTS There are 283 numbers of Physicians, 210 numbers of nurses and 390 nos. of

mid-wives distributed across the rural and remote areas of the state. This accounted

for 32% of physicians, 24% of nurses and 44% of mid-wives in this pool. Physicians

outnumbered the nurses, whereas in norms the nurses should outnumber the

physicians. Whereas, the nursing cadre in rural area consists of 35% of nurses and

65% of mid-wives.



288

The total 283 numbers of physicians are distributed among the rural health

institutes across districts. The highest numbers are concentrated to the three districts,

which have easy to access rural areas from the urban areas. The percentage

distribution ranges from 13% to 2%, the deviation exist in the remotest and hardest

districts. While the doctor population ratio in the rural areas is 1:3797, which is 74%

deviation from the norms and wider that the state ratio of 1:3079. The district ratio

ranges from 1:1506 to 1:8972. The better ratio can be observed in the district with

smaller populated district followed by the same three districts which have highest

numbers of Physicians, nurses and mid-wives and have the good communication and

easy access of the rural areas.

Similarly, the distribution of nurses has almost the same picture as of

physicians. The 210 numbers of nurses are distributed asymmetrically among the

districts. The average rural population serve by the nurses is 5117, which is 90%

deviated from the norms. The distribution ranges from 16% to 1% among the districts.

The ratio ranges from 2164 to 15039 among the district. The better ratio among the

districts is of the three districts. Out of these, two districts are of good communication

and easy access of rural areas.

While, it is observed that 390 nos. of mid-wives are distributed

asymmetrically among the districts. The distribution pattern ranges from 9% to 2%

among the districts. The average rural population served by mid-wives is 2755 against

the 2551 of the state, which deviates to 82% of the norms. The mid-wives ratio ranges

from 883 to 6332 among the districts. The lowest population districts are having the

good ratio among the districts and followed by the good accessible districts.

Thus, we find that there is also poor distribution of Physicians, nurses and

mid-wives among the districts in the rural and remote areas.

5.1.2.6. URBAN AND RURAL DISPARITY IN THE DISTRIBUTION OF

PHYSICIANS, NURSES AND MID-WIVES IN WITHIN THE DISTRICTS: ACHRONIC PROBLEM

The inequitable distribution of physicians, nurses and mid-wives found

between districts. Almost all districts display serious disparities between levels of

physicians, nurses and mid-wives between urban and rural areas. Most of the

management representatives have a common consensus that the difficulty in

distribution of the workforce particularly in the district level. The process of the

transfer and posting are a challenging matter in the absence of the residential quarters



289

and basic amenities at the rural and remote areas. They also pointed out that in the

absence of comprehensive HR policy it is very difficult to rationalise the distribution.

Overall, the shortage of the staffs is the main challenges in rational distribution of

staffs in the rural areas. It is a matter of concern that the urban areas are also running

out of the staffs and it is very difficult on their part to get equitable distribution. It is

also pointed out that there are many cases of personal and medical reasons in which

the management representative cannot force the staffs to be in the remote and rural

areas for long durations. It is also sensed from the interview that there is influence of

political pressure for the distributional process. However, it is not outspoken by the

management representatives.

Thus, the urban-rural disparity in distribution is observed within the districts.

The analysis of urban and rural distributional disparity was done in the previous

chapter, where the urban and rural areas were also defined in conceptual framework

section in chapter of literature review, as being based in a hospital in urban areas

especially only the institute in the district headquarter. Urban areas have 37% of

physicians in urban areas and 63% in rural areas. The figures ranges from 14% of

physicians to 57% of physicians concentrated to the urban health institutions within

the districts. The tendency of urban concentration has been observed in the study of

distribution of the physicians, out of 16 districts, 8 districts have more than 40% of

physicians concentrated to the urban health institutions of the districts, wherein only

one health institution is established in almost of the entire districts in the state.

This signals inefficiencies in the distribution of physicians, nurses and mid-

wives. The situation is grimmer in the cases of the nurses. The percentage of urban –

rural distribution is 46% and 54% respectively. It is observed the nurses are more

concentrated to the urban health institutions. The figures of urban concentration

ranges from 79% of nurses to 16% of nurses in the districts. The highest number of

concentration of 79% of nurses is in the capital district of the state. There are more

than 8 districts having more than 40% of nurses concentrated to the urban health

institution within the districts. This creates a huge gap in rural and urban disparities in

the distribution of nurses within the districts.

Moreover, the distribution pattern of mid-wives is 28% in urban and 72% in

rural areas in the state. However, the urban concentration of the mid-wives is

observed within the districts. It ranges from the 59% of urban concentration to 7% of

urban concentration. Basically mid-wives are meant for rural areas and meant for



290

especially the SCs in huge numbers. But huge numbers are concentrated to the urban

health institutions. 8 nos. of the districts have more than 20% of mid-wives

concentrated to urban areas, creating a havoc situation in the rural areas. The most of

the mid-wives are concentrated to the higher health institutions in the urban areas.

Thus, we find a disparity in the distribution of Physicians, nurses and mid-

wives in urban –rural areas within the districts. These trends of Physicians, nurses

and mid-wives to gravitate in urban health institutions where urban areas have

facilities of good communication, accommodation and other basic amenities, this has

create a vacuum in rural area and left the primary health care in the mercy of god and

this in turn compels the rural mass to seek services to the urban tertiary level health

institutes. This situation has also created the patient crowd in the urban level health

institutions.

5.1.2.7. DECENTRALISATION OF DISTRIBUTIONAL FUNCTIONSDecentralisation of HR functions like distribution and deployment of

Physicians, nurses and mid-wives had a twin context, in the sense that the function of

distribution, deployment of contractual manpower is in the hand of district authority,

rather the deployment criteria centralised to state level for regular employees. The

second context was the transformation of roles in the health sector in response to

crisis in local level only. So, matters relating to the deployment and distribution are a

part of district authority as well as the state level authority.

The core HRM practices for the distribution according to the norms are based on

recruitment and selection process in the organisation. The recruitment and selection

process of physicians, nurses and mid-wives after the initiation of Reproductive and

Child Health programme in 1997 and subsequently National Rural Health Mission in

2005 has been concentrated to the contractual manpower and the process is

decentralised to the district level since 2010-11. The decentralisation of this process is

only for the contractual physicians, nurses and mid-wives. For the recruitment of the

permanent employee of this category, the contractual employees are regularised and

continued their services as regular employees, the process is basically based on the

sanctioned post vacancies and seniority based and the process is undertaken by the

Directorate of Health Services headed by the Director of Health Services.

However, decentralization of recruitment and selection process to the district

included HR planning, recruitment; transfer and maintenance of human resource have



291

at the district level only for the contractual physicians, nurses and mid-wives. District

authority is now had to play a new role as employers, often without the appropriate

technical abilities to do so. The recruitment process under the decentralised

arrangement in the district is closely linked to the instruction and financial provision

at the state level.

The implementation of the decentralisation policy is only for the contractual

manpower in the district. But the appointment and deployment of the permanent

physicians, nurses and mid-wives are not comes under the decentralised recruitment

and deployment. So, it does not left any room for majority of the recruitment process

and deployment. Thus, the recruitment under centralisation, whereby the state level

would post permanent physicians, nurses and mid-wives to district may be without

taking into consideration the specific needs of each district. Thus districts requiring

more physicians, nurses and mid-wives could not get the required number or the

willed workforce.

5.1.2.8. OTHER ISSUES

In addition to the above major issues, the other persistent issues remain on

eyes. The issues are of data inconsistency on HR deployment, use of the data for

planning. In this study it is found that the information on human resource is in

consistence among the state and district level, while it is also found that the

inconsistency between the divisions of the health department. The official figures are

very difficult to match on and come to any conclusive and concrete data on the human

resource placement records, especially in the state level. This makes difficulty in

estimating and establishment of facts and plan accordingly. The situation is grimmer

in the state level taking the HR deployment data in the district level. There is absence

of data base related to deployment of physicians, nurses and mid-wives, which could

give the planner help.



292

SECTION 2

MAJOR HR ISSUES IN

ATTRACTION OF PHYSICIANS,

NURSES AND MIDWIVES



293

5.2.1. MAJOR HR ISSUES IN ATTRACTION OF PHYSICIANS,

NURSES AND MIDWIVES

5.2.1.1. COMPULSION OF STAY IN THE RURAL AND REMOTE

LOCATION

The study revealed that the workforces who are presently working in the rural

and remote areas of the state are either working to finish their minimum rural service

tenure for PG courses especially the physicians, or on non-transferable positions like

contractual employees or either they in transferred from other urban or rural areas by

the Management and political pressure or demand. The cases are different but

altogether they are staying at compulsion. It is found that 58% of the workforce is

service in rural and remote areas in the compulsion, either they are in hurry to

complete minimum rural service tenure or the nature of the position is non-transferable or Management relocations or in political pressure.

When the groups of physicians, nurses and mid-wives are compared

separately, 66% out of total physicians, 74% out of contract physicians and 63% out

of permanent physicians agreed that they are in compulsion posting. Whereas, the

group of nurses have, 49% out of total nurses, 71% out of contract nurses and 30%

out of permanent nurses are agreed on the compulsion posting. While, the group of

mid-wives have 58% out of total mid-wives, 77% out of contract mid-wives and 27%

out of permanent mid-wives have agreed the compulsion.

It is found that the situation is worst in the case of Physicians as more of them

are in compulsion. When it is compared of permanent and contract workforce, the

situation is worst on the part of the contractual. Secondly, the situation of the mid-

wives is also a matter of concern; this group have more percentages of compulsion

posting.

The situation of compulsion posting among the workforce is a matter of

concern and contributes to a high challenge for attraction and retention in the rural

and remote areas. In addition, attracting physicians to rural areas has been a

longstanding challenge (Rao, et al, 2009). In this study also we found that the

situation is more alarming of the Physicians. Evidence on compulsory service from the previous studies seems to be

unfavourable to the organisation. It seems to be less motivation and less commitment

of these workforces and it may result in weak health indicators and low quality in the

services. There are unanimous agreements in several studies that the compulsory



294

positing does attract doctors, nurses and mid-wives to rural areas but there is no

guarantee of commitment and improved service in the rural areas. International

evidence on compulsory rural service has not been very favourable. Thus, such

compulsion was not well received and has not really succeeded in solving the long

term problem.

At best, it is seen to address health worker mal-distribution in the short term,

but tends to alienate people from the medical profession itself (WHO 2009). A recent

review of compulsory education schemes recorded that such schemes rarely got

support from health professionals, and health workers rarely continued on the same

job after the compulsory stint was over affecting continuity of care (Seble F et al

2010). Many international studies point out that compulsory rural service programmes

should be accompanied by support and incentives given to the health personnel (Liaw,

et al 2005, Omole, et al 2005). Whereas, in India, compulsory rural service is not

well-received by medical students. The level of opposition to this compulsion

suggests that implementation is a huge challenge especially with the currently weak

governance structures. Further, there exists little evidence of the effectiveness of

compulsory rural service initiatives. (Rao & Ramani, 2011). Compulsory rural

service schemes (with no incentive attached) may not be the best way to face doctors

in rural areas- such schemes have little appeal among doctors and adherence to such

schemes has been found to be lacking. The effectiveness of compulsory placement

has been assessed by descriptive surveys with inconclusive results (it addresses the

short-term mal-distribution, but is criticized for alienating people from the profession,

and for the difficulties in administration and enforcement) (Dolea 2009). In the Indian

context, linking Post Graduate (PG) programmes to rural service appears to be a

particularly influential incentive for attracting doctors to rural posts. There is a strong

desire for specialization among doctors after their first degree (MBBS). (Rao, et al

2011).

So, the main element in the attraction of the physicians, nurses and mid-wives

in the rural and remote area of Arunachal Pradesh here is compulsion rural postings,

and other factors contributes less among these groups of employees. Since, more of

them are in compulsion, that may lack in commitment towards work, team working,

absenteeism, lack of motivation and so on and so forth, which will create a non

performing environment within the system and resulted in to low indicator of health

services.



295

5.2.1.2. LACK OF CAREER DEVELOPMENT OPPORTUNITYLack of career development opportunities seems to be one of the issues in the

attraction of these workforces. With the option of career development opportunity

only 23% of physicians, 21% of nurses and 29% mid-wives are attracted to the rural

area services in the state. The figures are alarming and it tells us that there is limited

scope of career development in the rural service in public health sector. The lack of

this component in the public health services in the rural and remote areas keeps the

physicians, nurses and mid-wives from the rural areas than that of the urban areas in

the state. The missing component of career development along with the promotion

opportunities in the rural health service seems to push away the physician, nurses and

mid-wives from the rural areas to urban which gives that a potentiality for personal

growth in profession, career development and they can be in job hunting if they are in

the urban areas in comparing to the rural areas. Career progression and development

is always an important point while dealing with the new and young physicians, nurses

and mid-wives. Thus, it seems from the selection of the respondents that there is no

enough scope of career progression that has attracted them to rural area and for new

entrants and it is also revealed that the nurses, mid-wives and especially physicians

are reluctant to work in rural areas as opportunities for career development were

typically less than in urban areas. So, the study found that the physicians, nurses and

mid-wives are at the present posting place at rural and remote areas not for that they

have the opportunity to progress.

5.2.1.3. INACTIVE RECRUITMENT STRATEGY

Recruitment strategy for the physicians, nurses and mid-wives for rural and

remote areas are not attractive and lack strategic recruitment and selection process. It

is found that the organisation is not utilizing other means of recruitment advertisement

other than that of newspaper advertisement. It seems that the strategy is only to lurethe local candidates for the services in the rural areas, whereas to attract it is necessary

for a wider circulation of the recruitment notices for a greater pool of potential

candidates who are interested for the rural areas services for either reason. The

organisation is not utilising the other strategy of recruitments and only relies on days

old form of recruitment and selection tactics. There is little information for HR policy

for the state or for the district. Absence of appropriate human resources policies, there

is always a hindrance in managing people at work. Effective recruitment, selection

practices are cohesively depends on the HR policies and in the absence of the same, a



296

number of difficulties have been highlighted in the interview. The recruitment and

selection process in the sector is characterised as traditional way of approach, only

newspaper medium is used, no practical test, no scientific selection techniques used

and overall there is no written policies that the contractual positions will be

regularised if there is any relevant vacancies. The policy of the recruitment approach

focused on the same geographic areas where staffs were needed, in the expectation

that people would be less likely to want to transfer if they worked close to home. But,

unfortunately this not in reality, the findings revealed that the factor for attraction in

this study for preference for rural areas home town that is the current health facility is

closer to town or Closer to family and friends does have only minimum selection as

one of the factor of attraction are 16% for mid-wives, 20% for Physicians and 26% for

nurses. Moreover, in the absence of HR Policy in the sector is great hurdle on

recruitment and selections procedures. As many research studies concludes that in the

absence of the comprehensive state HR Policies the personnel decisions are too often

guided by favouritism, political dictates, and nepotism. As it is also seems that

recruitment of right people through scientific recruitment and selection process is a

significant aspect of HRM. The experience of the yesteryears in this sector in the

above context is traumatic. As the "new" employment structure requires new/or

modified HRM system to deal with the new organizational types and structure but the

researcher could establish the traditional way of acquiring and managing employees

are stand till date, there is still existence concept of personnel management rather

through the new concept of Human resource management and Human Capital

management. The study has revealed that recruitment of physicians, nurses and mid-

wives under a decentralised arrangement has only been characterised by complex

bureaucratic procedures and political influences and adversely affect the attraction of

this workforce of the government service in the rural areas.

5.2.1.4. LACK OF HOSPITAL INFRASTRUCTURE & RESOURCE

AVAILABILITY IN RURAL AREA AND POOR WORKING CONDITIONS

The study found that, the attraction factor of availability of equipment, drugs

and supplies for the smooth duty discharge of physicians, nurses and mid-wives is

very low. It comes to 8% of physicians, 4% of nurses and 3% of mid-wives that are

attracted to the rural and remote health care service in the state. It reveals that the

hospital infrastructure and resource availability is scares at the rural and remote areas.



297

While looking at the data of the state public health sector, it is very depressing

and from no angle it seems the rural health service an attraction to this workforce.

Out of 486 SCs only 286 SCs are functional all together deviated from one or other

requirements. Taking 486 SCs at stock, 114 SCs are only with staff quarter, 212 SCs

are without proper water supply, 263 SCs does not have electricity. Out of 119 PHCs,

only 97 are functional (as per RHS, 2010) in which taking all 119 PHCs in stock, 52

nos. are without Labour room, 108 nos. are without minor operation theatre, 59 nos.

have indoor facilities and 53 nos. of PHCs are without electricity. Whereas in the 49

CHCs, 3 nos. does not have labour room, 12 nos. does not have OT rooms, 11 nos.

not having laboratories, X-ray machines in only 13 CHCs, only 3 of the CHCs have

quarter facilities for specialist for the CHC and none of the CHCs have atleast 30

beds. Overall none of the health facilities are functioning as per IPHS.

The situation of the poor health infrastructure and resource availability in the

rural areas is a matter of concern and which is an issues on attraction of physicians,

nurses and mid-wives. In the event of lack of equipments, drugs and supplies, it is

very hard for a physician, nurse or a mid-wife to discharge their duty adequately, it is

just like a soldier without arms in a battlefield. So, this is a very discouraging event

for the physicians, nurses and mid-wives to attract towards the rural area services.

However, this factor of attraction is not the only which can attract the physicians,

nurses and mid-wives by its alone.

While, the above points do have an impact on the working condition by which

the attraction of the physicians, nurses and mid-wives could have attraction. The

attraction from the improve working condition in the system in rural areas have

attracted only 10% mid-wives, 8% nurse and 10% physicians. In the absence of

hospital infrastructure and resource availability, it is obvious that the working

condition will be poor in nature and have an adverse effect on the attraction of the

physicians, nurses and mid-wives. Here in the system in rural areas, the working

condition is characterised by poor working conditions and lack of corresponding

inputs, which also contribute to the disillusionment of the health workforce.

Workforce in the different districts and health institutes in Arunachal Pradesh are

facing poor work environment and security at the workplace. Work conditions are

characterised by absence of proper facilities at the health centre, ill-equipments,

inadequate drugs and supplies, unusual working hours and excess work load,

inaccessibility of accommodation, water and electricity etc.



298

5.2.1.5. LACK OF OTHER CADRES, TEAMWORK AND INTERPERSONAL

STAFFS RELATIONSHIP

Teamwork and interpersonal relationship is always a contributing factor for

attraction or leaving the job for any jobs positions. It is revealed that 2% of Mid-

wives, 3% of Nurses and 4% of Physicians have selected as one of the factor that

attracted to the rural and remote areas service. So, the organisation climate internally

is no conducive for the employees. In the absence of adequate cadres in the fields are

one of the non-attracting factors in the sector. It is also found in this study that the

lack of others cadres, teamwork and interpersonal relationship with Mean of 1.65 has

the highest mean among the factors for migration in rural to rural health institutes.

Good mixer of cadres is absent in many of the health institutes, as compared to

requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM atSCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs

without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses

in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without

doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians &

Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know

from the interview of the management representative that many of the health posts in

the rural area are manned by the less skilled workers like nursing assistant and other

semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and

mid-wives or rather they are staying at urban areas. The impact of this mal-

distribution on health care delivery in rural areas is profound, at times resulting in

primary health care facilities being staffed mostly by other staffs. As per primary data

available for this study, there are total no. of sanctioned sub centres are 468, out of

which only 301 have existing infrastructure, 222 No. of SCs having only one ANM

each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical

Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3

ANMs, none of the CHCs except are having full complement of specialists i.e.

Gynaecologist, Anaesthetist and Paediatrician.

And it is also revealed in this study that there is no good interpersonal

relationship between the permanent employees and the contractual. The contractual

are always look down and lack recognition.

So, the lack of good mixer of cadres, team work and interpersonal seems to be

an issue and concern in the rural and remote areas.



299

5.2.1.6. POOR REWARDING, RECOGNIZING AND APPRECIATION OF

ACHIEVEMENT IN THE SYSTEM

The reward and recognition for the performance and achievement is not there

in the system which could attract the physicians, nurses and mid-wives in the rural

area service. The study findings revealed that none of the respondents have attracted

to the rural and remote areas due to this reason. There is no distinction of the

performer and non-performer and it is known by everybody in the system and outside

system in the public health sector in the state. The analysed results indicated that the

lowest mean factors with the lowest score. That means the absence of reward and

recognition for performance is one of the major issues for attraction of physicians,

nurses and mid-wives. It is well know factor in several studies that only the financial

incentives could not attract the health workers to the rural and remote areas. Almostall (90%) of studies discussed the importance of financial incentives on health worker

motivation. However, it was noted that financial incentives should be integrated with

other incentives, particularly with regard to migration where it was concluded that

financial incentives alone would not keep health workers from migrating (Shattuck, et

al., 2008). The reward and recognition and appreciation of service is a important

component of attraction in the rural area service, which is absent in the system in the

state.

5.2.1.7. POOR USE OF FINANCIAL (IN TERMS OF SALARY OR

INCENTIVES) MEANS OF ATTRACTIONFor the attraction of the physicians, nurses and mid-wives for the rural and

remote areas services the state does not have any concrete policies and

implementation. There are no financial rural incentives for the physicians, nurses and

mid-wives, however, there is a provision of hard area allowances under state govt.

norms for only for the harder areas but the allowances are so little that it is negligible.

The study revealed that none of the respondent has selected this option as one of the

reason behind the attraction. It is found that the factors that may motivate the

workforce to stay back commonly seem are financial incentives/ rural

allowances/performance incentives along with other factors. So forth, the same

situational factors may attract the physicians, nurses and mid-wives.

Nevertheless, low salaries were found to be particularly de-motivating as

health workers felt that their skills were not valued. Furthermore, they became

overworked when taking a second job to supplement their income (Shattuck, et al.,



300

2008). Likewise the salary is also not competitive; there is no gaps or no difference

in the urban posting or rural posting and even more no difference in the salary of

performer or non performer.

It is found in this study that the contractual appointments are done majorly to

man the rural posts and the salary for the contractual are not competitive in compare

to the permanent workforce and associated with a low and stagnant salaries

especially for the contractual workforce.

Further, the lack of a linkage between the skills and experience of staff to their

remuneration package is absence the system. While, the compensation level of the

workforce place in the rural and remote area and the urban areas are paid the same

remuneration. The study found no difference in the pay range in the same category of

the health workforce, whether being posted in remote rural area or the urban areas of

the state. As here one can interpret that the remuneration and financial incentives for

rural and remote areas are not competitive than of the urban areas, resulted in non

attraction of the rural area services.

Thus, the issue of low remuneration or salary and non existence of the

financial incentives, which could in either, attract the physicians, nurses and mid-

wives in rural areas.

5.2.1.8. TRAINING AND SKILL DEVELOPMENT ISSUESThe study revealed that only 19% of the respondents have training and skill

development opportunities in their list of attraction. While, the data revealed that only

16% of Physicians, 26% of nurses and 17% of Mid-wives have selected the factors as

one of the factors of attraction for rural and remote areas. This seems that this factor

has a limited scope of attraction especially to Physicians and the Mid-wives than that

of the Nurses, however, the gaps are not wide and can be generalised that the factor

have no much contribution for the attraction of this workforce. This creates a vacuum

in the efforts of the health sector reform to greatly emphasize in the skill up-gradation

and multi-skilling training practices. The non-attraction by this factor could be that

the trainings are not given in regular intervals, with right access of the needs of the

employees etc. The main issues found in the study is there is no random access of

training needs, the planning of training and the execution of the same have a random

mismatch in the district and as well as in the state level. The training needs are

basically planned according to the services to be provided or it is in the health



301

institutes, it’s no way access the personal training needs of these workforces that

could also enhance their skills in personal fronts and interest. Overall, it is also found

that the post evaluation of the training is not done and not in the process and not in

implementation at the ground level.

5.2.1.9. LACK OF SUPERVISION IN CERTAIN AREAS

Poor supervision and mentoring is always associated to the public sector. The

same situation can be seen in the public health sector in the state. It is found that none

of the respondents have attracted due to this factor. That means the factor have no

contribution to the attraction of this workforce. It is also highlighted by the

management representatives that in the absence of adequate workforce with trained in

the matter at the higher level of health institution also contributed to this issue and it is

a concern for the management. In reform initiatives the structural changes had taken

place but the situation of the supervision could not be changed or improved. While

putting light from the management representative interview responses that the

supervision services also suffers from the financial constraints, geographical

constraints and overall suffers from the skill scarcity that is scarcity of supervisors.

The supervision is lack in the upper health institutes than that of SCs, however, whole

of the workforce are not getting comprehensive supervision and mentoring.

Thus, this component does not have the weightage in the sector that could

attract physicians, nurses and mid-wives at the present scenario.

5.2.1.10. OTHER FINDINGS

5.2.1.10.1. FACTORS THAT ATTRACTED: CURRENT DETERMINANTS OF ATTRACTION AND PLACEMENTS

It is found that the compulsion posting is the major determinant of physicians,

nurses and mid-wives in rural and remote areas in the state. The other few factors are

career opportunity, health facility is closer to town or family and training and skilldevelopment. However, the majority influential factor is Compulsion and it is

statistically significant at mean test of 1.5. The study also revealed that the factor that

attracted physicians is basically on Compulsion. Beside this factor, other few factors

are -Continuing education/higher education Opportunities, Career development

opportunity. In the case of nurses also compulsion is the factor, by which they are at

the rural and remote areas. Beside the compulsion other few factors are- Current

health facility is closer to town or closer to family and friends, Training and skill

development Opportunities. In the case of Mid-wives also the have the same factor,



302

the compulsion. Beside the compulsion, Career development opportunity, Training

and skill development Opportunities etc. Compulsion is only the factor which is

statistically significant at Mean Test Value=1.5 for all of the three groups.

5.2.1.10.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THEDEMOGRAPHIC CHARACTERISTICS

The study revealed the relationship of factors of Attraction and the

demographic characteristics of physicians. It is found that there is a relationship

between age group of the physicians and attraction factors like availability of

equipment, drugs and supplies ,; Authority, independency and autonomy, Amenities

like housing & conveyance provided, Safety at workplace and Current health facility

is closer to town or closer to family and friends. Similarly, Family background of the

physicians has the relationship to availability of good schools for children nearby

town. It is also found that the Marital Status of the physicians has relationship with

amenities like housing & conveyance provided; safety at workplace and availability

of good schools for children nearby town. Relationship also found of Length of

service and availability of equipment, drugs and supplies, Authority, independency

and autonomy, Compulsion, Amenities like housing & conveyance provided,

Teamwork and Interpersonal staffs relationship, Availability of good schools for

children nearby town and Current health facility is closer to town or closer to familyand friends. Similarly, it is found that there is a relationship between Nature of

Employment of physicians and attraction factors like Availability of equipment,

drugs and supplies, Authority, independency and autonomy, Career development

opportunity, Amenities like housing, conveyance provided. Wherein, we did not

found any relationship between the factors and sex of the physicians.


characteristics of Nurses, it is found that there is a relationship between age group of

the nurses and Career development opportunity, Training and skill development

Opportunities and Compulsion. No association has been found of marital status and

other attraction factors. Similarly, the length of services (group) has the relationship

to Career development opportunity, Compulsion, Amenities like housing &

conveyance provided and Current health facility is closer to town or closer to family

and friends. It is also found that the nature of employment has relationship with

Career development opportunity, Compulsion, Flexible working hour with minimal



303

workload, Amenities like housing & conveyance provided and Current health facility

is closer to town or closer to family and friends.


characteristics of Mid-wives, it is found that there is a relationship between age group

of the nurses and improved working condition, Availability of equipment, drugs and

supplies, Training and skill development Opportunities, Compulsion, Flexible

working hour with minimal workload, Amenities like housing & conveyance

provided and Teamwork and Interpersonal staffs relationship. Similarly, we found

relationship between Marital status of Mid-wives and Amenities like housing &

conveyance provided, Availability of good schools for children nearby town, Current

health facility is closer to town or closer to family and friends, besides the

Compulsion. The length of service has a relationship with the factor of attraction like

-Availability of equipment, drugs and supplies, Continuing education/higher

education Opportunities, Training and skill development Opportunities, Flexible

working hour with minimal workload, Amenities like housing, conveyance provided,

Availability of good schools for children nearby town, Current health facility is

closer to town or Closer to family and friends, besides the Compulsion. Meanwhile, it

is also found that the nature of employment also have relationship with the factors of

attraction like Authority, independency and autonomy, Career development

opportunity, Continuing education/higher education Opportunities, Flexible working

hour with minimal workload, Amenities like housing, conveyance provided,

Teamwork and Interpersonal staffs relationship, Current health facility is closer to

town or Closer to family and friends, besides the above factor Compulsion also

contribute to factor relationship. However, we found no association between Family

Background and other attraction factors.

5.2.1.10.3. FACTORS THAT MAY ATTRACT - CHOICE OF CURRENT


The few highest percentage selection of the factors are Higher Salary package

in compare to urban posting, Conducive working condition, Training and skill

development Opportunities, Access to amenities like housing & conveyance,

Financial incentives / Rural allowances/ Performance incentives, Safety at workplace,

Rotational Posting after completing minimum rural service tenure and Career

development opportunities. These factors are statistically significant at Mean TestValue (1.5). While the Mean Test value revealed the following factors significant



304

factors for Physicians- Training and skill development Opportunities, Access to

amenities like housing & conveyance, Career development opportunities, Financial

incentives / Rural allowances/ Performance incentives, Rotational Posting after

completing minimum rural service tenure, Conducive working condition, Good

reward and recognition system, Higher Salary package in compare to urban posting

and Continuing education/higher education Opportunities.

While the combination of seven factors are having statistically significant for

Nurses: Higher Salary package in compare to urban posting, Conducive working

condition Access to amenities like housing & conveyance, Training and skill

development Opportunities, Financial incentives / rural allowances/ Performance

incentives, Good reward and recognition system and Safety at workplace.

While the combination of ten factors are having statistically significant being

found for Mid-wives: Higher Salary package in compare to urban posting, Access to

amenities like housing & conveyance, Conducive working condition, Training and

skill development Opportunities, Good reward and recognition system, Rotational

Posting after completing minimum rural service tenure, Financial incentives / Rural

allowances/ Performance incentives, Continuing education/higher education

Opportunities, Career development opportunities and Safety at workplace.

While analysing the variance in the choice of the factors that may attract the

physicians, nurses and mid-wives, it is found that there is difference in the groups in

the view of factors that may attract to the rural and rural areas services. It is found that

the physicians may be attracted to the rural and remote area service when they see

there is scope of training and skill development, a good working environment,

accommodation facilities, incentives and recognition system with a competitive salary

that is more than that of urban areas. That meant that the physicians first look at self

development by training and development, living condition and to the monetary

factors. While, the nurses and mid-wives have attraction of higher salary first, good

work environment, accommodation training and development, recognition and Safety

at workplace. That meant that the group of nurses and mi-wives are more attracted to

financial benefits and then they look after the work and living condition and off-

course to the Safety at workplace. Thus, it meant that the preferences are not in the

same order and the factor cannot be generalised for all the three groups.



305

SECTION 3

MAJOR HR ISSUES IN

RETENTION OF PHYSICIANS,

NURSES AND MIDWIVES



306

5.3.1. MAJOR HR ISSUES IN RETENTION OF PHYSICIANS,

NURSES AND MIDWIVES

5.3.1.1. ISSUES OF INTENTION OF INTERNAL MIGRATION AND

RETENTION

The study revealed that the factors that hindering the state’s effort to retain

physicians, nurses and mid-wives in rural and remote areas are the migration of these

health workforces within the state, very negligible amongst them are intent to search

for an alternative employer. The major problem within the board is the problem of

rural-urban migrations than that of rural to rural migration or outside migration. The

study reveals that only 19% of them want to continue with their present rural posting

place. 24% wants to shift to another rural health institute, 51% wants to shift to

another urban health institute and 6% wants to shift to another job in some other

State/sector in search of an alternative employer. This shows that the physicians,

nurses and mid-wives are eager to shift their current locations. It was also revealed in

the attraction findings that more than half of the workforce that is 58.1% of these

groups is located in the present rural and remote locations in compulsions and it is

obvious that these groups are very eagerly intended to shift their locations.

This is an issue for the group of the physicians that 41.6 % of them intend to

migrate to urban area, 24.8% physicians willing to migrate to other rural area and

7.1% Physicians willing to search for an alternative employer. Wherein, 50% of

nurses are willing to migrate to urban area, 19.4% nurses willing to migrate to other

rural area and only 25.5% wants to retain in the present health institution in rural area

and 5.1% nurses intend to search for an alternative employer. Similarly, 59.3% of

mid-wives intend to migrate to urban area, 27.6% mid-wives willing to migrate to

other rural area and 6.5% nurses intend to migrate in search of new employer.

Similarly, at the other side of the coin which is also an important angle toaccess the issue of migration that is the nature of the employment of these groups. The

finding are 51.3% of contract physicians, nurses and mid-wives are intend to migrate

to urban area, whereas, 50% of the permanent physicians, nurses and mid-wives have

that intention. So, more of the contractual are intended to migrate.

This study also revealed that the intention of migration of this workforce is

related with the level of job satisfaction of these groups of health workforce and

propel them to migrate. The variable job satisfaction is significant at p<.001, has an

impact on the decision of employees to stay at the present rural place of posting.



307

While, the study revealed that there is no significant relationship of job satisfaction

and parallel migration from one rural area to another rural area. It is also explore that

there is a strong relationship of the job satisfaction and urban migration. The variable

job satisfaction significant at p<.001, has an impact and predictive power for the

decision of employees to urban migration. Job satisfaction also has significant

relationship and predictive for migrating in search of an alternative employers.

This intention of migration of physicians, nurses and mid-wives is attributed

by several factors within the health system and it’s co-exist external environment. The

Factors that contributed for migration of the physicians, nurses and mid-wives as a

whole, from the present rural area to other rural area, urban area or to leave the sector

have two factors significant that are the Lack of adequate financial incentives / rural

allowances/performance incentives and poor working condition.

The Factors contributed for intention of migration of the permanent physicians

have the Lack of adequate financial incentives. While, contract physicians have three

factors significant that are the Poor salaries, lack of adequate financial incentives and

lack of Career development opportunities. For intention of migration of the nurses

have two factors, the Lack of adequate financial incentives and Poor working

condition. In which, permanent nurses have the Lack of adequate financial incentives

/ rural allowances/performance incentives. While, contract nurses have two factor that

is the Poor salary and Lack of adequate financial incentives.

The Factors contributed for intention of migration of the mid-wives have two

factors, the Poor salaries and Poor working condition. In which, permanent mid-wives

have two factors that is the Lack of adequate financial incentives and Poor working

condition. While, contract mid-wives have two factors that is poor salaries and Poor

working condition.

The issue of intention to migrate according to the place of choice is that the

highest number of 51% of them is intended to migrate to urban areas. The factors that

contribute highest to migration of this workforce to urban areas have two factors, the

Poor working condition and Lack of adequate financial incentives. While, factors that

contributed to the intention of migration to another rural health institute had the lack

of others cadres, teamwork and interpersonal relationship and lack of Autonomy.

Similarly, five factors found for migrating outside the state, the Lack of Career

development opportunities, Poor salaries, Lack of Job security, Lack of adequate

financial incentives and Lack of scope for continuing education/higher education.



308

The need is to understand the various factors which motivate physicians,

nurses and mid-wives to retain themselves in the present rural posting for taking

decisions into consideration for planning the financial as well as non-financial

incentives, thus, the factors that may motivate the physicians, nurses and mid-wives to

retain themselves in the present rural area have the four factors -financial incentives,

improved living condition, career development and Good reward and achievement

recognition system. For the physicians are financial incentives for rural postings,

Improve living conditions, Career development opportunities, improved working

condition and Good reward and achievement recognition system. While, contract

physicians have six factors, Career development opportunities, Opportunities of

continuing education/higher education, financial incentives for rural posting, Improve

living conditions, Increase salary by half & Job Security. Similarly, the permanent

physicians have five factors, financial incentives for rural posting, Improve living

conditions, improved working condition, Career development opportunities and Good

reward and achievement recognition system.

The motivational factors that may motivate the nurses have three factors,

Financial incentives for rural posting, Improve living conditions and Career

development opportunities. While, the contract nurses have five factors, financial

incentives for rural posting, improve living conditions, Career development

opportunities, Increase salary by half and Job Security are statistically significant.

Similarly, the permanent nurses have three factors, financial incentives for rural

posting, improve living conditions, Good reward and achievement recognition system.

The factors that may motivate the mid-wives have three factors, financial

incentives for rural posting, improve living conditions and Good reward and

achievement recognition system. While, the contract mid-wives have six factors,

financial incentives for rural posting, improve living conditions, Increase salary by

half, Job Security, Good reward and achievement recognition system and Career

development opportunities are statistically significant. Similarly, the permanent mid-

wives have three factors, financial incentives for rural posting, Improve living


communication) and Good reward and achievement recognition system are

statistically significant.



309

Thus, the issue of migration is a major issue in the sector, more of the

workforce wanted to migrate to urban area. So, the major problem within the board is

the problem of rural-urban migrations than that of rural to rural migration or outside

migration and Job satisfaction as a decision maker theme.

5.3.1.2. ISSUES OF DECLINE AND VARIANCE IN JOB SATISFACTIONIn this study finding, in addition to the other issues and concerns, there is a

growing dissatisfaction among the physicians, nurses and mid-wives in presently

working in the rural and remote areas. The mean of overall scale of job satisfaction of

these entire workforce is 2.26 (N=334) in a scale of 1-5, which shows an average low

scale of satisfaction. In the group comparison, the Physicians (2.53, N=113), Nurses

(2.32, N=98) and Mid-wives (1.98, N=123) means respectively. This shows a lower

job satisfaction in the groups this workforce. Low job satisfaction and motivation can

lead to non-adherence to guidelines, dangerous practices, or negative attitudes

towards patients (Rowe et al, 2005 as cited in Logie et al, 2008). The analysis also

shows that the groups of Mid-wives have the lowest scale of job satisfaction, followed

by the group of nurses and the physicians. The satisfaction of Physicians are little

higher than that of the other two groups and the trend of declining job satisfaction is

seen according to the category of employment as the lower groups is having declining

job satisfaction. This may be that the lower group are being posted at the lower health

institute and they represent a more remote and rural location. The Medical professions

like doctor and nurses has been long among the most attractive and satisfied

profession in the society, but when it is analysed in the context of rural and remote

area services, the results suggests that these group of employees are increasingly

dissatisfied with their jobs in rural and remote areas.

It is already explained at the above point of migration and the intention of

migration of this workforce is also related with the level of job satisfaction of these

groups of health workforce and propels them to migrate. It is one of the determinants

of the retention and migration of the physicians, nurses and mid-wives. It is well

known that the job satisfaction is effected by the demographic attributes of the

employees. It is found statistically significant that there is a positive relationship of

job satisfaction with the age, length of service, place of posting and nature of

employment. It is found that as higher age employee has higher job satisfaction,

higher length of service has higher job satisfaction, employee posted at the higher

level of health institute has higher job satisfaction and permanent employees have the



310

higher job satisfaction than the contractual employees. It is also found the correlation

between the marital status and job satisfaction. However, it is found that there is no

relationship between family background and job satisfaction of employees in rural

setting. Thus, statistically it seems that age, length of service, place of posting and

nature of employment has the positive impact on job satisfaction in the rural setting.

While in the group of Physicians, it is found that there is a positive

relationship of job satisfaction of physicians with the age, length of service, and

nature of employment. No relationship found between family background and job

satisfaction of employees in rural setting. While in the group of nurses, it is found

that there is a positive relationship of job satisfaction with the age, length of service

and nature of employment. While in the group of mid-wives, it is statistically

significant that there is a positive relationship of job satisfaction with the age and

nature of employment and the correlation between the lengths of service. No

significance found in marital status and family background with job satisfaction.

However, in entire group of the workforce the common demographic in context of

the nature of employment has a relationship with the job satisfaction or dis-

satisfaction in rural setting. It is found that Salary and Training & Skill development

opportunities are the main contributors to the Job satisfaction in current time of

physicians, nurses and mid-wives altogether in rural and remote area setting.

Thus, there is a growing dissatisfaction among the physicians, nurses and mid-

wives in presently working in the rural and remote areas, more on there is an issue of

job satisfaction differentiation between the groups of physicians, nurses and mid-

wives and the job satisfaction if diminishes according the lower category and it also

revealed that there is a gap of job satisfaction between the contract workforce and

permanent workforce at large. Only the components like Salary and Training & skill

development opportunities found to be the main predictors of job satisfaction and no

other factors found to significantly contributing to the job satisfaction in these

categories of health workforce at the present time in the rural setting.

5.3.1.3. LACK OF ADEQUATE FINANCIAL, RURAL ALLOWANCES AND

PERFORMANCE INCENTIVES

As it is mentioned in earlier sections that the Health workforce are reluctant to

work in rural and remote areas in the state, possibly because of little support in these

areas, a lack of material resources for them, poor working and living conditions,

isolation from professional colleagues and possibly less opportunities for self



311

professionally development. To fuel on this the study found that there is no financial

rural incentives for the physicians, nurses and mid-wives, however, there is a

provision of hard area allowances under state govt. norms for only for the harder areas

but the allowances are so little that it is negligible. Whereas, such allowances for the

contractual health workforce are not recorded in this study. The questionnaire survey

with the options has not selected by any of the respondents that has contributed their

attraction factors or retention factors. It is found that the factors that many motivate

the workforce to stay back commonly seem are financial incentives/ rural

allowances/performance incentives along with other factors.

In the light of no provision of such incentives for the physicians, nurses and

mid-wives for rural area services and the compensation package also is same

irrespective of the place of posting. Other non financial incentives such quarters with

electricity, water facilities etc. are also not in the system to retain the workforce in

those underserved areas.

Moreover, other rewards system linked to performance is also not the system,

resulted to the low morale and motivation of the workforce. The below statement was

found in the documents of the state govt. but till now there is no sign of such

incentives in the field.

“To motivate the manpower located at remote and hard areas will be

given incentives. The incentives will be conditional on regular staying and performance based. The incentives will be given through respective RKS at

facility level. Detail incentive policies are addressed under NRHM Additionalities”-(Govt. of Arunachal Pradesh, 2009, SPIP 2010-11)

Staff job satisfaction has been affected through rapid change, and the

perception of health workers that their compensation levels and working conditions

have been negatively obviously affected the motivational level of physicians, nurses

and mid-wives.Thus, it is one of the major issues; a mixer of interventions both financial and

non-financial is not in place for retention of human resource. Though, the health need

related issues are looked into by the individual states and Govt. of India supports

financially. All the states prepare annual plans to include this intervention in human

resource issues, but still there are no accounts for these incentives in the field.

Few statements on incentives by the respondents are:

“Furthermore, there is no provision of extra incentives till date for us living

in rural area and even did n’t heard about this in my 3-4 years of rural posting ". –A Physician.



312

“ Financial incentives only will not be adequate for us, what do here in rural and remote area….. if we cannot make use of that money in a productive and

entertaining way…, no basic amenities like good housing, regular water and

electricity supply, good road connectivity is not there”. –A Physician.

According to the State Programme Implementation Plan, 2011-12 of all thestates, in order to ensure stay of Health workers in difficult rural and remote areas, the

states proposed incentive schemes. However, the incentives are yet to be seen

materialized, it may be due to financial constraints in the state.

5.3.1.4. ISSUE OF EQUITY IN COMPENSATION:

It is found in this study the public health service is associated with a low and

stagnant salaries especially for the contractual workforce. The issue of low

remuneration or salary is consistent for the health workforce especially for thecontractual employees, the recent pay enhancement corresponding to the Pay

Commission recommendation in the state has been only implemented to the regular

staffs and it has also created a wide gap in the pay parity of contractual staffs and the

regular staffs, but the compensation level was enhanced little to this groups in the year

2011-12, but no how it reaches the level of the regular workforce in the same working

conditions and the nature of job.

As here one can interpret that the contractual health workforce in Arunachal

Pradesh are underpaid, poorly motivated and very dissatisfied and may have an

adverse impact on the health delivery system. Further, the lack of a linkage between

the skills and experience of staff to their remuneration package is absence the system.

While, the compensation level of the workforce place in the rural and remote area and

the urban areas are paid the same remuneration. The study found no difference in the

pay range in the same category of the health workforce, whether being posted in

remote rural area or the urban areas of the state. Moreover, the workforces that are

posted in the urban areas have other options for earning if they will to do so. There are

greater opportunities in urban areas for additional incomes to supplement the ever

increasing inflation that that of rural and remote areas. This creates a burn out in the

rural and remote area physicians, nurses and mid-wives and adversely affects their

retention intention. Moreover, as a result of poor compensation, the available

workforce such as physicians, specialist, nurses and mid-wives do not want to join the

duty and serve in rural areas for longer duration. There is no clear cut policy

implementation regarding duration of service in rural areas by these categories of



313

workforce. Over all it is also mentioned in the earlier point that there is no financial

incentive for working in rural, remote areas. Low pay ranges is also a major reason

for the sector to face difficulty in attracting and retaining staff along with there are no

differences in the compensation packages for serving in urban, rural, inaccessible

areas. Thus, the state is failed to use the Salary component as means of retention of

physicians, nurses and mid-wives in rural and remote areas. The government has

failed to raise the real value of compensation differentiation on the basis place of

posting to be using it as a retention strategy.

Here, it is also understandable on the part of the government to unable to raise

the salaries but the govt. is no doubt capable of being develop a policy implication on

different pay structures for the urban and rural with remote areas for retention of the

physicians, nurses and mid-wives.

5.3.1.5. DISPARITY IN REGULAR AND CONTRACT WORKFORCE,

AFFECTING ADVERSELY IN JOB SATISFACTION AND RETENTION:

We found that contract workforce is more dissatisfied from the job than the

permanent workforce. In the group comparison as per the Nature of Employment, the

means of contractual employees (1.99, N=154) and permanent (2.50, N=180)

respectively. This interprets as the contractual employees have low job satisfaction in

comparison to the permanent employees. There is a difference in the job satisfaction

between the groups. The mean difference is -.513 between the contractual and

permanent employees.

If we analysed the situation in categorizing the workforce in nature of

employment, we found that contract workforce are more dissatisfied than the

permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2%

are satisfied in the group of the contracts. While, the permanent employees have 9.6%

are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only 0.6% arehighly satisfied. Thus, permanent employees have the higher job satisfaction than the

contractual employees.

The job characteristics of contractual employment are very much responsible

for motivating factors to the contractual employee, the factors such as job security,

low pay, no benefits and other factors are fuelling the low satisfaction and low

motivation in the employees. Contract employees are less satisfied with certain

aspects of their jobs, than permanent employees. Contract people are also in job stress

from workload and lack of opportunity for career advancement. Contractual



314

employees receive fewer fringe benefits, have no promotional opportunities, and

receive little or no long training opportunities. Therefore, a job with fewer of these

characteristics would reduce the person's job satisfaction.

While exploring to the variance of factors of job satisfaction in between the

contractual and permanent physicians, nurses and mid-wives, it is observed the

components like salary, job security, career development opportunities, opportunities

of continuing education/higher education, Teamwork and Interpersonal staffs

relationship and Access to free accommodation (Housing) have the differentiation.

While talk about there is differentiation in the compensation package another issue of

job security is one of the most significant issues in contractual employments, which

may create a greater sense of insecurity in short-term and long-term. Moreover, the

work life balance is tough in the context of this contract workforce, who gets only few

days of causal leave with no other kinds of paid leave as compare to the permanent

employees, the contract employees face the difficulties to maintain the family and

work life balance. There is no flexibility for contract employees for leaves to dispose

of their family duties. “Juggling between family and contractual is very difficult”-

one of contractual employee said while informally discussing the topic.

Financially the compensation is less, when they compared their incomes to

those of permanent employees. Contract employee is not eligible for benefits, other

employment benefits, pension plans, medical and dental benefits, life insurance,

educational reimbursement and training etc. “Even the bank is not providing loan to

me as I am a contractual employee” – one of contractual employee said while

discussing the topic. Human resource policies define how an employee is treated in

the workplace, which is absence in the reform process in the sector. There is an

inequity in perception in respect of contractual employees in respect of opportunity

within the organisation, with fuelling of no definite path of career advancement and

most of them are of younger generation and concern about their career advancement

as well. There also an existing of a cold ill treatment of contractual employees by the

fellow permanent employees at the work place. This makes contractual employee

stress, and affects the working ability of the employee. The more stress comes when

under to meet the demands of contract employment. All contract employees (who

were informally interviewed including ) admitted suffering stress connected to contract

employment. “I felt discriminated when I sat with other permanent employees of the



315

department and when they talk about enhanced pay package and accumulated arrears

being paid to them”- one of contractual mid-wife said while discussing the topic.

So, these staff motivation has been affected through rapid change, and the

perception of health workers that their compensation levels and working conditions

have been negatively affected the satisfaction level converted to low motivational

level.

5.3.1.6. POOR WORKING CONDITION:

It has long been known that employees behaviour and attitudes are affected by

the nature of the work they do and the environment they do it in. Much

experimentation and research have taken place in attempts to discover optimal designs

of work and workplaces for maximizing results in organizational improvement and

quality of working life. The studies of Kagi (1985) and Surti (1986), confirms the

desire of workers for better working conditions. Working conditions in the absence of

necessities for human resource in health sector in Arunachal is yet another major issue

in this confront. The working condition is characterised by poor working conditions

and lack of corresponding inputs, which also contribute to the disillusionment of the

health workforce. Workforce in the different districts and health institutes in

Arunachal Pradesh are facing poor work environment and security at the workplace.

Work conditions are characterised by absence of proper facilities at the health

centre, ill-equipments, inadequate drugs and supplies, unusual working hours and

excess work load, inaccessibility of accommodation, water and electricity etc. Work

required certain supplies and logistics which are currently inadequate. These supplies

and logistics should be made available adequately thus ensuring steady and better

service delivery. Added to the ill health infrastructure, absence of proper equipments

and proper office infrastructure, there is no proper toilet facilities in maximum of the

health facilities especially for the woman workforce, which may adversely affect.

Often poor working condition resulted in frustration, low motivation less

effectiveness, and sustainability among the workforce especially in woman

workforce. Thus, poor working conditions and lack of corresponding inputs also

contribute to the disillusionment of the health workforce.

According to Rural Health Statistics (2010), in the state out of 286 SCs only

114 (39.9%) are with quarter facilities, 12 (4.2%) are without regular water supply, 63

(22%) without electricity and out of 97 functioning PHCs, 31 (32%) is without



316

electricity, 29 (29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are

having residential facility for specialist physicians.

Few statements by the respondents on work condition are:

“We are overburden, not with our clinical practice…….there are hardly

5-10 patients in this place daily, which is not a matter of concern for us. But what I am writing about is the managerial and programme management

works entrusted upon us. We are technical and clinical persons, but various

health programs including the health institutions management are to be look

after by us alone with little support of staffs for these works.”-Physician.

“My requirements for works are clinical equipments, adequate medicines

and finance. My requirement was of Rs. 4 lakhs but they provided me as little

as 50,000/- to 80,000/-. So, how can I work in this situation.”-Physicians. “We are teaches for patients care- putting IV fluids, injections,

medicines, bed and ward management…. But here I have to work for all these including maintaining huge registers daily, preparing reports in many

numbers for all health programmes and also management of this healthinstitution.”-Nurse.

"We are performing without adequate supplies and equipments, working

condition should be crucial at the work place."-A Physician respondent.

We can interpret the above statements by the respondents that they are very

much involved and concerned about their working environment. They are entangled

between the clinical and programme management work at present environment. They

also emphasized for adequate supplies, equipments and adequate funding for

discharging their duties of rural health care services.

"Urban areas in counterpart are rich living standards and better income

opportunities. I can even practice privately after my duty hours, where I can

earn a little to support my financial earnings. Overall I am fade up of the less

patient load, sometimes it comes to nil. I can’t keep pace with my clinical side…

I m forgetting all my learning of practice here… now I am becoming a dak (official letter) runner or above that I am becoming a good clerk. This is the

situation where I am becoming isolated from my profession.”

With the above comment of the respondent, it is known that not only the work

environment characterized with over burden, which makes an effect on the interest of

the respondent. But as a professional they are worried about the patient load in their

health institutes in rural area. They can’t keep pace with their clinical side practice in

some of the rural areas. So, overburden as well as under-work makes an effect on the

situational preference of rural services.

Many medical, technical, and managerial positions in health programs and

facilities are needed in a health sector reform environment, and scarce medical

personnel are misused for management tasks at various levels. The supply of professional staff is now severely constrained at the leadership and managerial levels.



317

Shortage of human resource for health with ill-equipped, both technical and

managerial workforce at various levels often resulted in duality of roles, overburden

and workload to the existing health workforce. Staff shortages have increased the

workloads and stress levels, further de-motivating the physicians, nurses and mid-

wives. The formal as well as informal discussion with the staffs for this study shows

that the staffs are frustrated for the duality or roles, over burden with the works and

the workload, with additional with lack of equipment to discharge their duties.

As many of the technical/ clinical health workforce have to do the managerial,

health data information works and other financial management works for which they

not appointed. In this situation they have to often discharge a duality of role in the

existing system and they have to divide themselves for clinical works and other

managerial works, which often have an adverse impact on the discharge to their own

duty of primary health care for the mass. Health workers described their workload as

being relatively to the data and financial related work and often lead them to work

stress. It is the result of new structures, practices, and technologies are imposing a

heavy strain on an already weak human resource base in the health sector.

While with the quantitative data findings revealed the factors that may attract

physicians, nurses and mid-wives for rural and remote services has the working

condition component and followed the percentage of selection of 74%. It is analysed

and found that the factors that contributed for intention of migration of the physicians,

nurses and mid-wives- from the present rural area to other rural area, urban area or to

leave the sector have the factor of Poor working condition after Lack of adequate

financial incentives/ rural allowances/performance incentive. The factor of poor

working condition and inadequate equipments, drugs and supplies have accounted as

top factors for intention of migration among the physicians, nurses and mid-wives.

While the impact of health sector reform on work condition is a matter of

concern. They do not agree upon that the reform process has made their work load

manageable but rather they think more unmanageable at their level. Thus, it reveals

that the workload is more unmanageable to all level due to the reform process. The

statement that reform has improved the availability of equipments, drugs and essential

supplies for performing the assigned tasks for the respondent’s posted rural health

institutes has been agreed in group responses. The group of mid-wives has lowest

mean than that of the two other groups. Thus, it seems at the mid-wives do not get

adequate equipments, drugs and essential supplies and the reform has failed to



318

provide them as well, in comparison to the physicians and nurses. Thus, it reveals that

the reform has failed to address 360 degrees of these needs too.

5.3.1.7. POOR LIVING CONDITIONS

Poor living condition is directly not comes under an HR issues but it affects

the availability of workforce in the rural and remote areas of the state which have lack

of road network, hilly terrains, lack of communication, transport, other

communication facilities and lack of accommodation facilities, lack of television and

radio services and other recreation facilities, lack of effective communication systems

like telephones and mobile service at the place of posting resulted in lack of proper

living environment. The physicians, nurses and mid-wives have disinclined to rural

services, primarily due to absence of accessibility of communication and basicamenities in rural and remote areas. Some of the places are only reachable on foot and

more of the rural and remote areas living standards are characterized by poor basic

facilities and amenities, for which reluctances in workforce can be seen. RHS, 2010,

in the state, out of functional 286 SCs, 95 (33.2%) is without all-weather motor able

approach road. Out of 97 functional PHCs, 11 (11.3%) without all-weather motor able

approach road, 13 PHCs (13.4%) only with telephone facilities and none of the PHCs

having computer access facilities. While, out of 286 SCs only 114 (39.9%) are with

quarter facilities, 12 (4.2%) are without regular water supply, 63 (22%) without

electricity and out of 97 functioning PHCs, 31 (32%) is without electricity, 29

(29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are having residential

facility for specialist physicians.

Absence of accessibility and basic amenities in rural areas is more emphasized

by the respondents in this study. Few statements by the respondents on the

accessibility and amenities are:

"Urban areas are good and convenient because they provide us with basic

facilities and amenities which are needed for a human being in today’s world. But

here posted in rural and inaccessible area, where we are disconnected to outer

world due to the natural and topographic reason. This deprived me of basic

facilities like good accommodation quarter, electricity, and over all connectivity

like regular mobile and internet facilities. This is also having an adverse effect on

my preparation of entrance for PG, I do not have internet access which is a basic

need for an academics preparing for entrance.”-A Physicians.

“I m an ANM (mid-wife) at Sub centre, but I m attached to a PHC and

working for the PHC and visits once a week to the SC area. This is only because

of, there is no provision of residential quarter in that health facility and overall

being a lady there is always a safety and security issue, so why do I prefer the

rural posting….” - Nurse.



319

“Even if we appoint the physicians for rural areas especially specialist cadre,

they are more reluctant to join the area, they did not even join the place. This may

be because of the reason that the places are deprived of the material resources,

poor living standards in the village/rural level and possibly less opportunities for

their practice and educational opportunities for their children.". “They are shows

reluctance to work in rural and remote areas in the state (Arunachal Pradesh),often they come to state headquarters for seeking transfer and posting to capital

and district headquarters areas….some presents their health issues, family

problems and other genuine reasons for to be shifted to the urban areas.-Key

Informant Official.

"We have no quarters for accommodation, good school for our children, so

we are staying in a rent house in nearby urban area and daily I have to cover total

40 KMs in Bus to attend my duty, which cost me physically and financially".- A

Nurse respondent.

"I always will look for basic facilities and amenities like housing, water

supply, electricity and communication facilities at my preferred work place. These

also will include a good school for my child."-A Physician respondent.

“I am frustrated only because I was not posted to my home village, which is

in the same district, I could have been stayed at my own home and attends the

duty.”-A Physician.

We can interpret the above statements by the respondents that the doctors and

nurse including the mid-wives disinclined to rural services in the state, primarily due

to absence of accessibility of communication and basic amenities in rural and remote

areas. Thus, living standards are characterized by poor basic facilities and amenities in

the area where the health institutes are situated, for which reluctances in workforce

can be seen. Moreover, many of the staff prefer to and are allowed to stay in a nearby

town from where they commute to their place of work; it is obviously in the absence

of basic amenities in the posting place. This means that the health services are not

available 24 hours at the health centers as planned. At lower levels health institute,

there is no one to provide care at the time of need after duty hours, or when staff is on

leave. To add to this, many workers do not go to their place of work regularly. There

are also many other interruptions in the regular work such as review meetings, various

camps, and trainings. However, the staffs that stay at their place of posting and

provide 24 hour service get the same salary as staff that are absent or are available for

only three to four hours a day. Other unavoidable situation of staff absenteeism are

due to illness of themselves or their family members, some are due to chasing their

salaries, allowances, and other bureaucratic tasks at the HQ, etc.

5.3.1.8. LACK OF GOOD MIXER OF CADRES, TEAM WORK AND

INTERPERSONAL RELATIONSHIP

Teamwork in health care occurred throughout the 20th century and, morerecently, effective inter-professional teamwork has been identified as an appropriate



320

response to the complex issues in many health care settings. Effective teamwork has

been identified as enhancing staff motivation (Wood et al. 1994), including increased

job satisfaction and improved mental health (Borrill et al. 2000; Peiro et al. 1992),

and improving retention and reducing turnover (Borrill et al. 2001). It is found in this

study that the intention of migration of physicians, nurses and mid-wives from a rural

area health institute to another rural health institute is propelled mainly by the factor

of team work and interpersonal relationship in the present place of work. So, the rural

to rural migration is mainly due to the factor of absence of teamwork and

interpersonal relationship in the workplace.

Good mixer of cadres is absent in many of the health institutes, as compared to

requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM at

SCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs

without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses

in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without

doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians &

Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know

from the interview of the management representative that many of the health posts in

the rural area are manned by the less skilled workers like nursing assistant and other

semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and

mid-wives or rather they are staying at urban areas. The impact of this mal-

distribution on health care delivery in rural areas is profound, at times resulting in

primary health care facilities being staffed mostly by other staffs. As per primary data

available for this study, there are total no. of sanctioned sub centres are 468, out of

which only 301 have existing infrastructure, 222 No. of SCs having only one ANM

each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical

Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3

ANMs, none of the CHCs except are having full complement of specialists i.e.

Gynaecologist, Anaesthetist and Paediatrician.

Most of the management representatives have a common consensus that the

difficulty in distribution of the workforce particularly in the district level. The process

of the transfer and posting are a challenging matter in the absence of the residential

quarters and basic amenities at the rural and remote areas. They also pointed out that

in the absence of comprehensive HR policy it is very difficult to rationalise the

distribution. Overall, the shortage of the staffs is the main challenges in rational



321

distribution of staffs in the rural areas. It is a matter of concern that the urban areas are

also running out of the staffs and it is very difficult on their part to get equitable

distribution. It is also pointed out that there are many cases of personal and medical

reasons in which the management representative cannot force the staffs to be in the

remote and rural areas for long durations. It is also sensed from the interview that

there is influence of political pressure for the distributional process. However, it is not

outspoken by the management representatives.

So, the lack of good mixer of cadres, team work and interpersonal seems to be

a issue and concern in the rural and remote areas.

5.3.1.9. LACK OF JOB SECURITY AND CAREER DEVELOPMENT FOR

CONTRACTUAL PHYSICIANS, NURSES AND MID-WIVES

Lack of job Security in the health sector for contractual physicians, nurses and

mid-wives have adverse effect on the job satisfaction and thereon the motivation to

stay and work in rural and remote areas in the state. There is no provision of job

security for this group of workforce in the sector. The whole workforce under NRHM

is contractual and liable to terminate at any time without assigning any reason with

one month prior notice or in lieu one month salary. This is also a factor for low job

satisfaction and motivations of contractual health workforce. The service of the

employees is renewal every one year on performance based. However, the

performance appraisal process is also not effective due to various reasons. Moreover,

there is no career path or career development for these employees for which the

motivational factor could be high. The study explores the intention of migration of

physicians, nurses and mid-wives from the present rural health institute to any other

sector or other employer. The exploration of the preset factors from the responses job

security option and indicate that this is one of the major issues which propelling the

workforce for quite from the state health sector services in rural areas. The viewsabove of the workforce are quite claimed to be of concern in the part of management

who expresses fear about the issue. To talk about the issue of intention to migrate in

search of other sector and other employer in the same sector, we found five factors

significant that are the Lack of Career development opportunities, Poor salaries, Lack

of Job security, Lack of adequate financial incentives and Lack of scope for

continuing education/higher education. However, in order to give a boost to

contractual employment, the state govt. started pulling senior contract physicians,



322

nurses and mid-wives for permanent vacant posts, but in reality the incumbents have

to act upon on.

While, exploring the motivational factors that may motivate the physicians,

nurses and mid-wives to retain themselves in the present rural area health institution,

the responses of these employees revealed that Career development opportunities and

Job Security as one of the factor for retention. While, exploring the motivational

factors that may motivate the contract physicians to retain, the responses of these

employees revealed factors which include-Career development opportunities and Job

Security. In the group of the contract nurses also includes Job Security as one of the

motivating factor. In the group of contract mid-wives have also Job Security as one of

the motivating factor.

Therefore, the issue of job security and career development is an alarming and

major issue in the retention of the contractual physician, nurses and mid-wives in the

rural and remote areas in the state.

5.3.1.10. WEAK AND IN-EFFECTIVE PERFORMANCE APPRAISAL

SYSTEMS

There are not concrete and effective performance appraisal systems on board.

Historically, the permanent physicians, nurses and mid-wives have service book and

annual confidential report on the performance conduct of the permanent workforce.

However, the system is not effective and does not do anything with the performance

in the field and does not have any link with the rewards or incentives upon them.

Neither there is any mechanism which can monitor the daily activities undertaken by

each workforce, only some clinical services provided are monitored under monthly

reports, which is not at all have any connection with rectification of the performance

or anything to reward or incentives. While, the contractual part of the workforce are

altogether face annual performance appraisal, that is only for the further extension of the contract, which in no way is used effectively for review of the contract. This

performance systems on the board is seems only to be the formalities in the nuisance

public health environment. However, the performance appraisal of permanent

physicians, nurses and mid-wives are used in the service book for pay roll increments,

transfers, and other additional determinants in the service life of the incumbents.

Discussions with the management representatives expressed doubts about

performance appraisal systems and the reports by the concern supervisors that they

give the right feedbacks, which could be used for real performance appraisal for any



323

rewards or any rectification. Moreover, the performance benchmarks were not put in

place at the time of initiating the contracts or start of services in the rural areas.

Thus, although the performance appraisal system is placed in the sector but the

system is almost defunct and to be very weak. Little evidence exists on their effective

use at hospital, district and health facility levels in the state.

5.3.1.11. TOTAL ABSENCE REWARDING AND RECOGNIZING

ACHIEVEMENT SYSTEM:

The use of financial incentives as important motivators has been over

emphasised in the recent past. However, research in human relations and behaviour

sciences has shown that “where as money incentive had not proved effective,

psychic rewards worked” (Gellerman, 1963). Later research by Herzberg (1968) &

Lawler (1971) confirmed the fact that pay has very little to do with motivation.

However, several research studies in India have indicated the positive relationships

between pay and employee performance (Dwivedi, 1980). The reward and

recognition for the performance and achievement is not there in the system which

could boost the satisfaction and motivation to performance in the workforce. The

study findings seem that the workforce is dissatisfied with this component in the

system. There is no distinction of under performer or good performer in the system.

The variable Reward system and recognition have constants or have missing

correlations in the responses of the respondents. The analysed results indicated that

the lowest mean factors of job satisfaction and retention have one of the factors that

are Reward system and recognition system (1.00) which is the lowest scores. That

means the absence of reward and recognition for performance is one of the major

contributors to the dissatisfaction and migration of the physicians, nurses and mid-

wives. Out of the top 8 factors found that contributed to the intention of the

migration to outside the sector, the factor of Achievement not recognized or rewarded with Mean 1.38 can be seen. That means the factor is not in selection for

the internal migrations because the respondents know that there is no such provision

now and they doubt it could be in future in the system. That’s why who are intended

to go out of the system are only selecting this factor as a factor of migration.

Therefore, the need is to understand the various factors which motivate physicians,

nurses and mid-wives to retain themselves in the present rural posting. Taking all

these factors into consideration, financial as well as non-financial incentives can be planned.



324

5.3.1.12. LACK OF SUPERVISION IN CERTAIN AREAS While the analysis of the factors that contributed to stay at the place of posting

for more 3-5 years for both contract and permanent physicians, nurses and mid-wives

for rural and remote services was done it is found that the selection of improved

support, supervision and mentoring with a Mean of 1.17 is only there, which is a

lower mean of contribution. That means the factor failed to contribute to the factor of

stay back in rural and remote place. It shows that there is a system of poor supervision

and support. It is also highlighted by the management representatives that in the

absence of adequate workforce with trained in the matter at the higher level of health

institution also contributed to this issue and it is a concern for the management. In

reform initiatives the structural changes had taken place but the situation of the

supervision could not be changed or improved.

However, the statement that reform has made improvement in supportive

supervision, management and mentoring form higher authority, has an agreement

from the respondents. The physicians have the mean of 3.50, nurses have 3.68 and the

mid-wives only 3.76. Thus, the responses revealed that there is an improvement of

supervision and mentoring due to the reform process, and the trend is higher to the

lower health institutes because the mean of the mid-wives is higher than that of the

two other higher groups. While putting light from the management representative

interview responses that the supervision services also suffers from the financial

constraints, geographical constraints and overall suffers from the skill scarcity that is

scarcity of supervisors. The supervision structures starts from very state level to the

lowest layer of SCs, the SCs are supervised by the Medical Officers (Physicians) at

PHCs or CHCs and these PHCs/CHCs by the district level. The matter is more

concern upon lot of higher institutes is without the supervisors and if they are also,

they are concern with the clinical abilities and lacks the managerial skills likesupervision and monitoring at various levels. The supervision is lack in the upper

health institutes than that of SCs, however, whole of the workforce are not getting

comprehensive supervision and mentoring. Many staff, particularly those working in

the upper health institution in periphery according to the above analysis of Mean

factors of all the health groups revealed are deprived of the supervision and mentoring

activities. For this reason it can be resulted in lower job satisfaction and retention in

rural and remote areas. Ideally, supervision is a formalized HRM instrument to correct

shortcomings and to support good practice, on the basis of which recommendations



325

are provided to help improve individual and facility performance. The weak

supervision at all levels may result in lack of availability and accountability of the

staff at the working place. The supervision system is placed in the system but it is

weak as the supervisors only monitor the work of their subordinates through the

reports they submit of the numerical achievements of targets at the end of the month.

Moreover, it is also mentioned performance appraisal is also very weak. Appraisal

systems in use are basically and practically tend to be based on an assessment of

personal characteristics rather than on achievements against agreed-upon work

objectives or targets.

5.3.1.13. OTHER MINOR FINDINGS RELATED TO DEMOGRAPHIC

ATTRIBUTES

The Medical professions like doctor and nurses has been long among the most

attractive and satisfied profession in the society, but when it is analysed in the context

of rural and remote area services, the results suggests that these group of employees

are increasingly getting dissatisfied with their jobs in rural and remote areas. The

analysis shows that the groups of Mid-wives have the lowest scale of job satisfaction,

followed by the group of nurses and the physicians, similarly contractual employees

have low job satisfaction in comparison to the permanent employees.

We found that there is a positive relationship of job satisfaction with the age,

length of service, place of posting and nature of employment. It is significantly found

in the study that the higher age of these groups of workforce has higher job

satisfaction, higher length of service has higher job satisfaction, and employee posted

at the higher level of health institute has higher job satisfaction in rural setting. It is

also found about negative relationship between the marital status and job satisfaction.

Wherein, it signifies that the more married employees the less satisfaction level in

rural setting. And there is no relationship between family background and jobsatisfaction of employees in rural setting. Thus, there is no effect of family

background on job satisfaction of the employees. Only the Salary and Training &

Skill development opportunities are the main contributors to the prediction of Job

satisfaction in current time of physicians, nurses and mid-wives altogether in rural and

remote area setting which is a matter of concern.

It is known from the study that the intention to migrate is having relationship

with job satisfaction. Here it is explore the effect of the demographic attributes of the

employees on intention to migrate to urban areas. From the study, it is found that



326

there is no relationship exists between the demographic attributes of age, family

background, marital status, nature of employment, and place of posting. Only the

length of service is significant and reveals the relationship with the migration to

urban areas. And job satisfaction has been statistically significance relationship with

the intention of migration to urban area. While analysing separating the positions of

the workforce as Physicians, it is found that there is no relationship exists between

the demographic attributes of age, Sex, family background, marital status, nature of

employment and place of posting and length of service with the intention of

migration to urban area. As in the case of Nurses, it is found that there is no

relationship exists between the demographic attributes of age, family background,

marital status, nature of employment, place of posting and length of service with the

intention of migration to urban area. While in Mid-wives, it is found that there is no

relationship exists between the demographic attributes of family background, marital

status, nature of employment and place of posting with urban migration but found a

significant relationship with age and length of service.

Thus, it is found that the demographic factors do contribute to job satisfaction

and intention to migrate.



327

SECTION 4

MAJOR REFORM INITIATIVES

AND ISSUES THEREON



328

5.4.1. MAJOR REFORM INITIATIVES AND ISSUES THEREON

5.4.1.2. THE RISE OF CONTRACTUAL EMPLOYMENT: ESTABLISHED

NEW EMPLOYMENT SYSTEMS AND CONDITIONS OF SERVICE WHICH

LINK DIRECTLY TO HR ISSUES.

The vital ingredient in human resource management in health system consists

of workforce management, skill mix, workforce performance capacity building and

the numerical adequacy. To address the issue of numerical adequacy with cost

effectiveness is contracting the human resource. In Arunachal Pradesh along with the

country, increasing the number of health worker is a major challenge in improving the

health system. The past one decade has seen a growing tendency of contractual

employment in the public health sector in the state, toward a fundamental

restructuring for addressing the inadequacy issue under reform process. A significant

change in placement of human resource has been seen since 2005 in the state.

The task of ensuring the availability of physicians, specialists and nurses to

human resource pool by contracting of them is only short-term solution for the

inadequacy. One of the greatest drawbacks is possibility of attrition, non-commitment

of the employee in compulsion of performance which is very real risk in long run for

both employer and employer in the public health sector. In this way, contracting is no

better than engaging permanent employee in the sector in long run. The healthservices are a continuous need of the community and can only be delivered with the

adequacy in numbers of the health care provider and supports competitive strategies

in long run. Contracting is more likely to be successful only when there is a

competitive strategy in long run to convert the contract employment into permanent in

a stipulated time period because healthcare sector is highly dependency on key

professionals like physicians, nurses and mid-wives. It should also be supported by

appropriate policies and guidelines regarding this for the attraction and retention of

the healthcare providers. Contract employment is offered for performance under

pressure to an employee, which may adversely affect both the employee and

employer. It also leads to perceptions of inequity among the co-workers. They also

faced a certain degree of uncertainty and change, regardless of their choice. Thus, the

permanent employment status should be supported by administrative systems and

processes that enable the relationship to operate smoothly in long run. While, the

nature of the contract is also not cleared and the basic framework of expectations and

obligations are also is not cleared in the system.



329

Health professional’s choice regarding contract employment, in this study,

was conditioned by job security and compensation at par with the permanent

employee in the sector. The contract employees were placed in a position of having

insecurity and short-terms and conditions of employment of one year. They were

forced to choose the contracting job as there is no other options remains within the

state. Contract employees are treated differently in the workplace than permanent

employees. They faced a certain degree of uncertainty and change, regardless of their

choice of being permanent employee. Contract employees have a different attitude to

the workplace and their position. Bringing the management perspective contract

employees are off-course manageable and cost less to the department but it does not

seems long run sustainability and free from HR issues arising out of it.

5.4.1.3. EMERGING ISSUES OF PROFESSIONAL MEDICAL EDUCATION

IN ARUNACHAL PRADESH IN REFORM PROCESSThere is existing issues of access, growth and expansion within the agenda of

health sector reform in Arunachal Pradesh, which could to some extend helpful in

solving the problem of inadequacy of physicians, nurses and mid-wives in the state in

long run. Arunachal Pradesh is lagging behind in the field of medical education in

comparison to other states of the country. Production of the graduate doctors, nurses

and mid-wives in comparison to expanding health infrastructure is becoming a matter

of concern and a challenge for the public health sector in the state and its inclusion

under agenda of health sector reform is most an issue and a challenge. There is no

medical college in govt. sector or private sector for Allopathic disciplines, and it is not

adequately addressed by the reform process. It is observed that the aggregate number

of seats for medical and para-medical education for the state is not inadequate

comparing to the requirement of physicians, nurses and mid-wives especially in the

rural and remote areas of the state.

State Public Funding for Medical Colleges, Nursing schools is a matter of

concern and it is not widely addressed in the reform process. In the light of resource

constraints of the state government, state funding for establishment of Medical

Institutes is a matter of concern and challenge. The growth and expansion is only

possible with the interventions of central govt. public funding or attracting private

funds. The government, which is the major funder of medical education institutes for

the state has failed to develop training institutes for medical, nursing, and related

professions in the state. This may be subjected to lack of funds. The growth of



330

potential teaching hospitals for establishment of new medical schools and nursing

school in itself is a challenging issue in the reform process. Wherein, in the entire

state only two hospitals namely State Hospital, Naharlagun with bed strength of 148

nos. and General Hospital, Pasighat with bed strength of 150 are nearly in shape that

can be upgraded to Medical Colleges but proper initiation under the reform process

has not been taken up.

5.4.1.4. ISSUES REGARDING DEVELOPMENT OF COMPREHENSIVE HR

POLICY IN THE HEALTH SECTOR OF ARUNACHAL PRADESH UNDER

REFORM PROCESS




government is regulated by the APHS (Arunachal Pradesh Health Service) rules and

central recruitment rules are followed. However, there is no specific HR Policy for

recruitment, deployment, retention of the physicians, nurses and mid-wives and other

health workers especially for remote and rural areas. This issue is not adequately

addressed in reform process, the state govt. is preparing a 5 year strategies and policy

document for augmentation and maximization of Human Resources as per the

management representative, but it is no way would be soon available and its

sustainability, as it is well known in the public sector all comes late. And it is also

found that the policies regarding recruitment, deployment and retention is much more

emphasized on contractual employees only leaving a loose tight on permanent

employees.

5.4.1.5. ISSUE OF HR FUNCTIONS DECENTRALIZATION UNDER

REFORM PROCESS: CHALLENGES FOR LOCAL CAPACITY

The process of decentralization in the reform process has its own issue.

Decentralization of authority, responsibility, and resources for personnel functions is

delegated in a decentralized way in reform process to the district level. It is important

to achieve effective human resource management and to improve staff performance.

However, decentralization itself entails large-scale development of capacity at the

local level for health planning, financing, allocation and accounting for resources, and

HR management functions including staff recruitment, payroll and allowance

documentation, and maintenance of personnel records. The Human Resource



331

Management functions including recruitment and deployment are decentralized to the

districts level.

Though decentralization is used as an ornamental word into the reform

process, the actual implementation in the view of low capacity at the lower level is a

concern. The new decentralized organizational structures mean that the role of district

authority as employer is transferred from state level, but to configure the new

structure of decentralized environment there is no provision reform process for HRM

system and HRM personnel in the organisation at state or the district level, that to

strategically support the initiation. The transfer of human resources functions from

State level to district level without a comprehensive design and structure is quite a big

challenge for the district administration. Over all in the absence of an appropriate HR

policy at state and district level on human resource, is still provide a big deal of

challenge for the district authority. The study finds that in the reform process in

Arunachal Pradesh, decentralization in many field including HR management issues

have been percolated down up-to the district level and to some extend to the health

institutes, but there is a need of far greater attention to HR skill deficits. The

decentralization has been done in respect of power and resources to the district level

and lower level of health administration for HR administration and management.

Under this decentralised process, the recruitment is done at the district level, Human

Resource planning, and their training needs and to ensure that health facilities had the

minimum staffing requirements. In addition, the powers to recruit, exercise

disciplinary control, and to remove persons from district service were delegated to the

District. Pay determination is heavily centralized at state level and national level, as

part of broad based culture as other public sector. Decentralized the local autonomy is

facilitating the local preference and to retain the workforce in the district. However, as

mentioned earlier to manage the decentralized activities there is shortage of HR

management personnel in the district level, which create a challenging environment at

this and subsequent level of administration. As to increase the requirement for

administrative and managerial staff in the system and likely to associated increase

requirement for performance management also.

5.4.1.6. ISSUES OF RECRUITMENT AND SELECTION PROCESSThe reform process more emphasized on the contractual employees and the

policies are developed only for the same. The recruitment process adapted in the



332

reform process is inadequate and lack professionalism. Only newspaper

advertisement, walk-in-interviews are utilized and no other options are ever tried to

explore to include for better recruitment and selection process in the system of reform.

The recruitment and selection processes are often guided by the personal bias and

favouritism in the system. After that the appointments are made and no proper

performance appraisals are done and many of the physicians, nurses and mid-wives

get regularisation. It is also found that the performance appraisal in the system of

reform process is not effective and comprehensive.

Most of the management representatives have pointed out for the difficulty in

getting physicians, Nurses for the health posts. The management representatives

pointed out the crisis is more for the GNMs and then the physicians for rural and

remote areas. It is may be due to lower graduates of medicines and nursing

candidates. They also revealed that they have many post lying vacant in search of the

GNMs (Nurses) and some of them are even personally arranging these cadres for the

rural health services. It is also pointed out by the management representatives that in

the light of very limited candidates for the posts they have to compromise on the

technical expertise and experience of the candidates and have to appoint them for the

rural and remote areas which obviously affect the quality of the services in the rural

and remote areas.

5.4.1.7. ISSUES IN TRAINING AND DEVELOPMENT SYSTEM UNDER

REFORM PROCESSSkill up-gradation and multi skilling practices are much emphasizes in the


physicians, nurses and mid-wives, but the main issues is there is no random access of

training needs, the planning of training and the execution of the same have a random

mismatch in the district and as well as in the state level. The training needs are basically planned according to the services to be provided or it is in the health

institutes, it’s no way access the personal training needs of these workforces that

could also enhance their skills in personal fronts and interest. Overall, it is also found

that the post evaluation of the training is not done and not in the process and not in

implementation at the ground. The reform process has failed to addressed the access

of training needs and post evaluation of the training in the field and in personal front

of the employees.



333

5.4.1.8. ISSUES IN FINANCIAL AND NON-FINANCIAL INTERVENTIONSThe reform process has tried to address the issue of financial and non financial

incentive for the rural and remote areas physicians, nurses and mid-wives. But the

process had failed to comprehensively plan and execute the same. No adequate

emphasized on making use of provision of financial and non-financial incentives for

rural and remote area posting and retention is there. Over all the reform process has

failed to give emphasizing the compensation equity in the workforce and their

differentiation according to the urban and rural posting. Moreover, other rewards

system linked to performance is also not the system, resulted to the low morale and


achievement is also not there in the system.

5.4.1.9. ISSUES IN INFRASTRUCTURE DEVELOPMENT INITIATIVES

INCLUDING ACCOMMODATION FACILITIES AT RURAL AND REMOTE

AREAS FOR UNDER REFORM PROCESS

However, the infrastructure development is directly a HR activity, but is no

doubt it contribute to HR practice in the organisation, particularly in health sector.

Chronically there is inadequacy of residential quarters for workforce at rural and

remote areas. For ensuring deploying, attraction and retention of physicians, nurses

and especially Mid-wives in rural and remote area, the reform process is emphasizing

to develop the residential facilities all over the state, but it has failed to do it with

proper planning and wide coverage. However within the limited resources,

prioritization is done to provide at-least residential quarters in the health facilities

phase-wise. The identification of the health facilities has been done linking the HR

availabilities and acceptable infrastructure.

5.4.1.10. THE VIEW OF WORKFORCE ON HEALTH SECTOR REFORM IN

ARUNACHAL PRADESHThe exploration of health sector reform process on physicians, nurses and mid-

wives has pointed out some of the issues in understanding of health sector reform

process and the employees. It is revealed that these three categories have different

views on the health sector reform process on Human resource activities. All the

employees are quite reserved at human resource policies of the organization, that they

are clear about the HR policies of the organization, the mean of the response is only

2.06 in the scale of 5, which can be interpreted that reform has not succeeded to clear

presentation of the HR policies (whatever is there exists at present ) in the context of



334

the Physicians, nurses and mid-wives. It seems the physicians are having little

understanding of this, but we cannot say all other groups are equally aware of this

component. However, the mean of the responses are the lowest we cannot say that the

reform process has made human resource policies understandable at all level and

contributed to the HR function of the organisation.

All the employees emphasized on that there is no change in the scenario of

transparency, fairness and unbiased placement, transfer and promotion. The groups

have the view that the reform has failed to make placement, transfer and promotion to

transparent, fairer and unbiased.

However, it is found that the physicians and nurses are familiar with their job

description clear they agree upon the statement, but not so strongly. Whereas, the

mid-wives has no agreement on the statement and may be they are not so clear about

the job description of the mid-wives. It is also found that the physicians, nurses and

mid-wives do not think that they are getting promotional chances are strong in the

light of reform process.

According, the responses of the respondents, the reform process has also failed

to make the compensation a competitive one for rural and remote area posting, as the

salary structure have no differentiation for urban or rural areas. No groups have

agreed upon that the reform process has created the salary structure competitive for

the rural area posting. Moreover, the physicians, nurses and mid-wives have the views

that the reform has failed to made regular and adequate financial incentives and

allowances for physicians, nurses and mid-wives who are posted in remote and rural

areas. They also agreed on that there are no increase activities for actual performance

appraisals and positive actions on them.

On the front of improvement in working condition at the respondent’s posted

health institutes has agreement in group responses, though the mean of the responses

is 3.40, quite no so impressive. However, more on the issue, we can say that the lower

levels of the health care delivery system where the Mid-wives are largely posted are

deviated of improving the working conditions.

The workforce has agreed that reform has increased the training and skill

development opportunities for the respondent’s posted rural health institutes, but the

group of physicians has little lower mean than that of the two other groups. Thus, it

seems at the physicians do not get more chance for training and development

opportunities in comparison to the nurses and mid-wives. Thus, it reveals that the



335

reform has failed to address the need of training and development in equal manner to

all the groups of the employees.

While on the front that reform has improved the availability of equipments,

drugs and essential supplies for performing the assigned tasks for the respondent’s

posted rural health institutes has been agreed in group responses, though the mean of

the responses is 3.35.The group of mid-wives has lowest mean than that of the two

other groups. Thus, it seems at the mid-wives do not get adequate equipments, drugs

and essential supplies and the reform has failed to provide them as well, in

comparison to the physicians and nurses. Thus, it reveals that the reform has failed to

address of these needs too. Reform has also failed to improved the mix of cadres in

respondent’s posted rural health institutes and has made the work load un-

manageable. The disagreement increases at the lower level of the groups. Thus, it

reveals that the workloads are more unmanageable to all level due to the reform

process.

Reform has made improvement in supportive supervision, management and

mentoring form higher authority. It is also found that, there is an improvement in

housing and other amenities at the workplace of the physicians that is at the higher

level of health institute rather in the lower health institute where the nurses and mid-

wives are posted.

In overall, the physicians, nurses and mid-wives, concludes that the reform

process has failed or has not succeeded for making rural health care services an

attraction for the potential physicians and nurses to work in rural and remote area.

And it is also revealed in overall that the reform process failed to give attention to the

HR front rather giving attention to the other components of reform process in the

state.



336

SECTION 5

MAJOR ISSUES IN HR PRACTICE

RELATED TO ATTRACTION,

DISTRIBUTION AND RETENTION

OF PHYSICIANS, NURSES ANDMID-WIVES



337

5.5.1. MAJOR ISSUES IN HR PRACTICE FOR ATTRACTION,

DISTRIBUTION AND RETENTION OF PHYSICIANS, NURSES

AND MID-WIVES

5.5.1.1. INTRODUCTIONIn addressing the three dimensions of HR Practice for Attraction, distribution

(deployment) and retention of physicians, nurses and mid-wives, the researcher could

establish that the HRM system and practice in the organisation is mere personnel

management functions rather a strategic human resource management approach in a

reform environment. In this study researcher could established that the HR practices

for attraction, distribution and retention are to an extent not utilized optimally to

improve organizational performance and to retain the physicians, nurses and mid-

wives. The study found that the HRM practice for Attraction, distribution

(deployment) and retention of physicians, nurse and midwives in rural and remote

areas is not a comprehensive one and its design, the platform is weak. It is found that

from the policies to implementation, there is no concrete and strategic management is

followed.

The major findings may be outlined as - There is inadequate Human resource

capacity as there is no dedicated HRM staffs, department and the staffs handling the

HR activities are having limited experience in the organisation; Annual HR plans

exists but it is an exhaustive process in the organisation, but it is not further evaluated

for effectiveness; Comprehensive HRD policy in Arunachal Pradesh is very weak;

Employee data such as number of staff, location, skill, education, gender, age, year of

hire, and the salary level are maintained manually and partially at the district level;

performance appraisal system is in place, it is done periodically at the interval of one

year, but it does not include the work plans of individual employees and performance

objectives jointly developed with the staff, it is rather a traditional singular downwardappraisal; skill up-gradation training is an integral part of the programme, however,

there is little space for induction trainings and further training and development of

employee is a concern with follow up of training. Further, Key ways to motivate

employees are also inadequate in the system. Nor was there recognition of the

importance of employee empowerment as a powerful mean of developing a service-

oriented culture.



338

5.5.1.2. ISSUES IN POLICIES FOR HR PLANNING, RECRUITMENT

(ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION





regular doctors and specialist cadre comes under the purview of service rule of APHS.

However, there is no specific HR Policy for contractual physicians, nurses and

midwives and other health workers.

Absence of appropriate and concrete human resources policies on deployment,

there is always a hindrance in managing people at work as the entire district agreed to

this. However, the state Govt. is preparing a 5 year strategies and policy documentfor augmentation and maximization of Human Resources. This includes sustainable

HRD and policy reform from restructuring/ rationalization of HR deployment. The

vibrant HR policy includes terms of recruitment / filling up of vacancies, rationalising






specific health centres without provision of transfer. For the regular groups of

employees the intra-district transfer and posting are handled by the District Medical

Officer and inter-districts transfer is handled by the Director of Health Services.

However, the system is not so transparent and lack in proper implementation. Most of

the management representatives have a common consensus that the difficulty in

distribution of the workforce particularly in the district level. The process of the

transfer and posting are a challenging matter in the absence of the residential quarters

and basic amenities at the rural and remote areas. They also pointed out that in the

absence of comprehensive HR policy it is very difficult to rationalise the distribution.

Overall, the shortage of the staffs is the main challenges in rational distribution of

staffs in the rural areas. It is a matter of concern that the urban areas are also running

out of the staffs and it is very difficult on their part to get equitable distribution. It is

also pointed out that there are many cases of personal and medical reasons in which

the management representative cannot force the staffs to be in the remote and rural



339

areas for long durations. It is also sensed from the interview that there is influence of

political pressure for the distributional process. However, it is not outspoken by the

management representatives.

5.5.1.3. ISSUES IN HR PLANNING, RECRUITMENT AND SELECTION

PROCESSResearch Observation shows that accurate information systems on staffing

trends and conditions are not in place. There is no tradition of research on workforce

issues in the state. HR planning for contractual employees is theoretically based on

decentralized system, however, in the absence of proper information, and trends of

staffing makes HR planning more exhaustive and difficult. While, the HR planning in

permanent physicians, nurses and mid-wives are done by the Health Directorate and

based on vacancies and annual operating plans. It is also found lack of extensive

coordination among the two divisions regarding HR planning. The sector does not

have a formal mechanism in place to undertake manpower planning on a continuous

basis except the Annual Action Plans. Planning exercise in the department of health is

primarily focused on creation of new infrastructure/institutions.

Decentralization of recruitment and selection process to the district is often

undertaken without the appropriate technical abilities to do so. There are no staffs

specifically to develop and implement HRM system in the organisation. District and

state level offices do not have staff adequately trained in personnel administration, nor

do they have simple or robust systems for managing personnel affairs. HR

management structures and systems at the district level are weak; District offices are

inadequately staffed and are poorly resourced. There are staffs generally meant for

other services are engaged to look after the HRM activities in the organisation at state

and district level. But these sections of staffs are having limited experience related to

this field such as personnel recruitment, management or have other functions in the

organisation as well as HRM functions. Over all they are at the level of only to

maintain basic procedures and record keeping functions, which cannot be comparable

to the full functions of HRM system in the organisation. The recruitment process

under the decentralised arrangement in the district is closely linked to the instruction

and financial provision at the state level. The implementation of the decentralisation

policy is only for the contractual manpower in the district. Whereas, the appointment

and deployment of the permanent physicians, nurses and mid-wives are not comes



340

under the decentralised recruitment and deployment. So, it does not left any room for

majority of the recruitment process and deployment.

Utilization of various recruitment sources is under-utilised only newspaper

advertising is the source. The recruitment advertisement for the contractual vacancies

is only undertaken for this kind of process in the districts. The recruitment

advertisement for permanent positions is placed in the newspaper and office board by

the Directorate of Health Services. However, the internal source of recruitment is

widely used, whenever a sanctioned regular post is vacant. This process of

recruitment of internal candidates for regular posts supports career development

opportunities for internal contractual employees.

The selection processes is based on Walk-in-interview across the districts for

contractual employees and for permanent employees it is found the contractual

physicians, nurses and mid-wives are taken up to fill the vacancies.

Thus, the recruitment and selection process of the employee in the state public

health system is a traditional approach and lack the professional forefront in this

process, and the newspaper advertisement, walk-in-interview, written-test with panel

interview as the dominant tools in use.

5.5.1.4. ISSUES IN HR PRACTICE FOR PLACEMENT, TRANSFER ANDPROMOTION

The deployment of contractual physicians, nurses and mid-wives are done

according to the recruitments are done for the particular vacancies for the specific

health institution. However, the deployments are interchange able on mutual consent

of the employees or the management decisions at the district level. The deployment of

the regular cadre employee is done according to the requirement of the district and the

district medical officer looks the matter and depends on the physical infrastructure

and basic amenities in the health institution. The common minimum tenures are not

followed along with the time bound promotions are not practices for several reasons

to these categories of staff.

5.5.1.5. ISSUES IN HR PRACTICE FOR RETENTION - FINANCIAL NON-

FINANCIAL INTERVENTIONSThere is no use of provision of financial and non-financial incentives for rural

and remote area posting and retention. In the light of no provision of such incentives

for the physicians, nurses and mid-wives for rural area services and the compensation

package also is same irrespective of the place of posting. Other non financial



341

incentives such quarters with electricity, water facilities etc. are also not in the system

to retain the workforce in those underserved areas. Moreover, other rewards system

linked to performance is also not the system, resulted to the low morale and


achievement is also not there in the system.

5.5.1.6. ISSUES IN HR PRACTICE FOR RETENTION - TRAINING AND

DEVELOPMENT

Skill up-gradation and multi skilling practices are much emphasizes in the


physicians, nurses and mid-wives are satisfied with the process and most of the

workforce are attracted and retain themselves due to this factor in the sector. But the

issues is there is no random access of training needs, the planning of training and the

execution of the same have a random mismatch in the district and as well as in the

state level. The training needs are basically planned according to the services in the

health institutes and likely to starting of the services, it’s no way access the personal

training needs of these workforces that could also enhance their skills in personal

fronts and interest. Overall, it is also found that the post evaluation of the training is

not done and not in the process and not in implementation at the ground. The trainings

are undertaken only the sake of performance in the training activities, but the real

evaluation of the trainings is not done. The trainings are once done, the achievement

of the training achieved and no further plans for evaluation. Expensive and important

skill-up-gradation trainings are given to these groups especially to the physicians, but

the matching of posting place and their performance after the training is not accessed.

This creates a gap in the training skilled acquired and utilisation for the benefit of the

organisation, society and self development of these workforces.

The multi-skill trainings & capacity building of the workforce are emphasized

on physicians, nurses & mid-wives from the rural and remote area. Multi-skilling

training is randomly given to a concentrated workforce and makes them jack of all

trade, master of nothing. There are many cases the research could establish that a

single physician is trained in many skills which makes him confused and specialized

in nothing and it does not helped in their self development.



342

SECTION 6

SUGGESTION



343

5.6.1. INTRODUCTIONThis section of the chapter puts lights on the broad suggestions on the issue of

distribution, attraction and retention of Physicians, nurses and mid-wives. It is found

in the study that most of the workforce is on compulsion to stay at the rural and

remote areas and these workforces have low level of satisfaction and resulted in low

commitment and motivation towards the service. The contributions of other factors

for attraction are very less and seems that the sector has not given due importance and

tried to improve the other bricks of the wall. Most of the workforce is intended to

migrate to urban or to other sector, it is more of the environmental issues and

organisational issues more than that of the personal issues at the current time. The

factors that can attract and motivate them to stay at the rural and remote areas have

been found in this study. The factors like salary in comparison to the urban areas,

conducive working condition, training and development opportunities,

accommodation, financial incentives/rural allowances, rotational postings, safety at

the workplace and career development opportunity. While, the following factors have

been found for the retention of theses workforces: financial incentives, improved

living condition, career development, good reward and recognition system. These

factors for attraction and retention seem to be a blend of financial & non-financial

benefits. The distributional issues have an impact on the shortage of staffs in rural and

remote areas with mal-distribution. The HR practices having many loop holes and the

reform process have failed grossly to take the train on the track smoothly. The

situation of the Rural Public Health Sector in Arunachal Pradesh is “Like riding a

tiger, not knowing how to get off without being eaten”-(Cappelli, et al, 2011). While

the suggestion should be “50 miles to a gallon” (Cappelli, et al, 2011).

Based on the research findings, retention strategies need to include creating a

more positive work environment for rural availability of physicians, nurses and mid-wives. To fill the gap of mal-distribution, recruitment and retention in rural

community in the state is dependent on the perception of the workforce's non-

monetary and monetary needs. A blend of interventions into professional fulfilment,

financial remuneration and lifestyle needs are to be taken into consideration while

making policies or plans. There should be a strategic planning to address the three

fulfilments of manpower. Recruiting and selecting the right people with making

conducive working environment will help greatly with retention in rural areas.



344

Professional fulfilments include the need of adequate supplies, equipments and

fund. Conducive working condition at the work place with a good mixture of other

cadres at the posting place is the some requirements. Due to highly regulated

environment in which health sector operates, professional training needs, career

development and opportunity for continuous education of the workforce must be kept

into account for attraction and retention of the workforce and their interest on the job

and the organisation. Training and multi-skilling will also facilitate the production

issues and professional needs, advancement of the workforce and willingness to

continue their works in the rural sector. The respondents put light on the workload

also; the workload is unlikely due to other management works of a health institution,

which can be minimized by posting of clerical or managerial cadres in health

institutes. Rotational posting of the physicians and nurses are to be taken into

consideration, to increase exposure to rural conditions and overstaying of one staff in

rural areas. One of the factors that we saw in this study is compensation, benefits and

incentives needs, which will enhance attraction and retention of workforce in rural

areas. Likewise, the planners must now recognize the importance of non-monetary

incentives and recognition, special award; career path of the workforce along with the

incentives for rural posting. This study suggests giving importance to the lifestyle

needs of the workforce in today's time for retention. The development of rural

infrastructure of basic facilities and amenities is great need of the time. For example

housing, water supply, electricity and third party's work for development of

communication and other facilities in rural areas should be given emphasize on long

run. Policies and retention strategies needs to consider rural manpower family lives.

Retention strategies should also include recreation and education opportunities for

workforce's children.

Factors affecting rural recruitment and retention are complex and inter-linked;

hence a package of interventions is likely to work better than any incentive in

isolation. So keeping the points above, the following broad suggestion is presented for

this study.



345

5.6.2. BROAD SUGGESTION

5.6.2.1. EMPHASIZE ON RURAL HEALTH INSTITUTE AND PRODUCTION

ISSUE

Building strong institutions for education is essential to secure the numbers

and qualities of health workers required by the health system (WHO, 2006). Creation

of medical and nursing schools for enhanced seats for medical and nursing studies

should be ensured. It should be emphasized that the establishment of the institution in

rural areas, so to create a pool of workforce for rural areas. The options for task-

shifting can also be put into the system. The MBBS physicians can be replaced by a

Registered Medical Practitioner (which is adopted by the State of Assam and other

state in India), State can undertake experimentation in medical education by

introducing 3 ½ year course of Bachelor of Rural Medicine and Surgery to fill the

deficiency of physicians in villages. However, one arguments can be that, 3 ½ course

would produce poor quality doctors. Other in favor argument would be full duration

of MBBS course is not necessary for educating the public about health, hygiene and

treating preliminary ailments in village level. Likewise the inadequacy of nurses can

be filled up by the Mid-wives after getting adequate Nurse training and the vacant

post of Mid-wives can be filled up after the training of the eligible Village Health

worker with education and experience. This will ensure the creation of rural health

workers pool to minimize the gap in the inadequacy.

5.6.2.2. ENHANCING CAPACITY OF MEDICAL EDUCATION THROUGH

PUBLIC-PRIVATE PARTNERSHIP

Access of Medical Education by prospective students within the state is a great

challenge at this time. There is a need of widening of access of medical education

within the state. The state is on the process to setup one Medical college with

upgrading one of its hospitals in recent time. It is important here to consider that, in a

study by Hall (Hall, 1998) shows that a 10% rise in the number of students registering

with medical schools will produce only a 2% increase in the supply of doctors after 10

years. So, the requirement of aspirations and capacities of the increased number of

potential students and to meet up the requirement of physicians seems difficult with

establishing only one Medical College in the state. A healthy Public/Private

partnership can do much in this regard. The state should explore the PPP models to

establishment of more Medical colleges in the state. However, it should be based on



346

accountability and evidence based regulations by both the medical council and the

state. The issue of fees and seats should be monitored by the government. Moreover,

the areas which are not capable of attracting private funds should be supported

sufficiently well from public funds.

5.6.2.3. STRENGTHENING HRM POLICYMAKING, PLANNING AND

SYSTEMS – THE REFORM PRIORITES SHOULD BE!Getting HR policy ‘right’ in order to create a well motivated, appropriately

skilled and deployed workforce needs to be at the core of any sustainable solution to

health system performance (Dussault & Diallo et al. 2003). The HR policy should be

comprehensive and should be completed at the earliest to guide the whole process of

HR system in the sector. The policy should include all the component of the HR

system in an organization so that it will guide the system to implement in all level,

particularly in a decentralized environment. Better distribution of personnel by

categories and places is still a challenge for the health sector in Arunachal Pradesh;

maximum number of health workforce is concentrated to urban and easily accessible

areas counterpart to the rural and remote areas. Interpreting this issue, suggestion

could be to formulate a human resource policy to the deployment and incentives for

attracting the human resource in the needy and remote places.

5.6.2.4. ROBUST RECRUITMENT, SELECTION AND DEPLOYMENT

PROCESSInvestment in employee begins with recruiting process and selection process

should be revived and extensive use of different sources of recruitment should be

used. Recruitment and selection processes should be based on an objective system to

eliminate bias and discrimination. The use of newspaper advertisement should be

continued along with the use of other medium like internet, advertisement in regional

papers or on national papers etc. to search a wide range of pool for the vacant posts.

The selection process should not be bracketed to walk-in-interview only, it should

comprises of written test, interviews and professional practical test along with a

understanding of the candidate’s will to work in rural and remote areas. Side to it the

decentralization of the recruitment should be strengthen in terms of ability to do so.

The new recruiters or the existing physicians, nurses and mid-wives should be

properly deployed based on the needs of each part of the state and the district and job

descriptions. New graduates from training institutions should be promptly absorbed to



347

avoid frustration and consequent brain drain, but the eligibility and recruitment norms

should be followed.

5.6.2.5. FINANCIAL INCENTIVES INCLUDING THE SALARY

COMPONENT Direct financial incentives to practice in rural areas may encourage rural

practice, especially in developed countries, but reports from developing countries are

not positive (Smith, 2010). In the study it is found that the workforce are more trends

to financial incentives and salary differentiation than that of urban areas and salary

hikes in the context of the contractual, while talking about the attraction and retention

of the workforce. There is a need of development and implementation of financial

incentives for rural and remote area posting, it should be plan and adequate budget

provision should be there. Side by side, it is high time to make a differentiation in the

salary structure of the urban posting and rural posting, featured by higher in rural and

lower in urban areas. Along with these interventions, there is a need of enhancing the

salary of contractual physicians, nurses and mid-wives, so that their salary could

match the permanent workforce salary structure. The incentive system should be

competitive that could be accepted by the Physicians, nurses and mid-wives. The

incentive should be placed according to the category of the post and categorization of

place of posting.

5.6.2.6. REWARD AND RECOGNITION PROGRAMS

Irene (1997), advises not to force and manipulate staff to accept rural posting

after their will. Financial incentives are generally ineffective when used alone (Smith,

2010). Many international studies point out that compulsory rural service programmes

should be accompanied by support and incentives given to the health personnel (Liaw

ST et al 2005, Omole O et al 2005). It is well known compulsion alone cannot work

and a mechanism of differential rewards, appreciation and recognition programme

should be developed within the system. It is also suggested to differentiate the

performers and non-performers, which is a missing component presently in the

system. This will motivate the performers to perform more and the non-performer will

kick start.



348

5.6.2.7. FOCUS ON CAREER DEVELOPMENT OPPORTUNITIES AND JOB

SECURITY

Equitable distribution of health professionals and their retention is in turn

related to the prospects of career progression and the incentive packages associated

with the posts (Martinez & Martineau, 2002). Every individual whether working at

the lower level or higher level needs growth in professional life. Thus, the career

development opportunities can attract and retain workforce in job. In this study also it

is found that the respondents are looking for the career develop path while attracting

and retention is concern in rural and remote area. Therefore, the career path should be

pre-defined and strict to rules and regulation, and the implementation should be fair

and un-biased and strictly be based on merit and then seniority based. The policies on

career development should be revived and make strong career path which can attract physicians, nurses and mid-wives in rural and remote areas. The career path

especially of contractual are to be given emphasized at present along with the job

security issue of the contractual. There should be clear written policies for providing

permanent positions to the contractual. It is also suggested that the minimum period of

contractual service should be 3-5 years not 1 year of at present. It will improve the

sustainability of contract positions.

5.6.2.8. IMPROVING LIVING CONDITION

It is found in this study that the living conditions are likely to be important in

determining health workers’ decisions to move to and remain in underserved areas.

The importance of living condition is seems to be higher in ensuring the physicians,

nurses and mid-wives in the rural and remote areas. The living condition including the

housing, electricity, water supply and transport & communication does not directly

relate to the HR activities. Though, the issues have a greater impact on HR attraction,

deploying and retaining in the rural and remote areas. Most of the respondents

emphasized on improve living condition for attracting and retention factors. Thus, the

doable point is infrastructure development for proper accommodation facilities,

provision of electricity (where electricity is not possible Solar could be the option)

and provision of water supply should be ensured. However, the other components are

not directly in the hand of the sector but it can be solved with the convergence with

the other departments and local governance, thus improving the living conditions.



349

5.6.2.9. IMPROVE WORKING CONDITIONS

To attract and retain the workforce is rural areas, it is necessary to improve the

working conditions in the health institutions. It start with it can be done with the

provision of equipments, drugs and supplies and other working conditions like other

basic amenities in the work place and overall the safety of the workforce should be

the priority. The function of the health facilities should be improved by adequate

provision of work related items.

5.6.2.10. INTENSIVE TRAINING AND SKILL DEVELOPMENT WITH POST

EVALUATIONTraining should be designed to help employees not only their positions but is

should be altogether have a benefit to the professional traits also that means they

should take personal benefits also from the training. The training and skill

development should include inductions and refreshing training as well. The post

evaluation of training at the field level should be started and support the workplace to

increase their performance.

5.6.2.11. EMPHASIZE ON SUPERVISION AND MENTORING

‘We believe a great supervisor is actually an excellent coach, not just a boss –

Dr. Reddy’s Lab. (Chapelli,2011). It is suggested that to strengthen up the supervision

and mentoring activities of the Physicians, Nurses and Mid-wives, especially the new

comers. The mentoring and supervision should not be just fault taking out of their

works but to mentor and guide them. This will create conducive environment between

the employees and management and it will give a boost in the job satisfaction of the

workforce and will contribute to motivation to continue in the rural and remote area

service.

5.6.2.12. REGULATING WORKLOAD AND INCENTIVES

Minimizing the workload in a flick is not possible in the inadequacy of

workforce. However, it is suggested that the duty hours should be fixed for every

groups and individual in a manner that it do not adversely affect the mental stability

of an already frustrated groups of employees. The overtime facilities should be

provisioned to boost their morale. The technical workforce should not be waste for

management and clerical works. The posting of clerical and managerial cadres should

be ensured.



350

5.6.2.13. ROTATIONAL POSTING

The option for rotational posting and follow up of minimum rural area posting

may be ensured. The minimum tenure of the posting should be ensuring with the

fairness and without any bias. The transfer and posting should not be influenced by

the favoritism and political influences. The minimum tenure of 3 years for rural

service may be extended to 5 years, but it should be strictly followed by rotational

posting to urban areas.

5.6.2.14. STRENGTHEN PERFORMANCE APPRAISAL

The system of performance appraisal should be further strengthen and make it

meaningful. No performance appraisal should be done in merely to complete the

formalities; rather it should be based on the reality and actual facts. It should be used

regularly to enhance the performances of the workforce. The performance appraisal

should be used for the reward and recognition program and the incentive programs.

Much of the challenge in health reform involves shifting incentives to improve

productivity, quality, and performance (Forgia,2005).Good performance should be

linked to incentives and the system should be based on objective criteria to avoid

favouritism.

5.6.2.15. CONSISTENCY OF DATA ON WORKFORCE

To ensure that the right health worker is in the right place with the right skills,

managers need accurate HRH data for HR planning from beginning to work together

to develop a HRIS that tracks health professionals from training until they leave the

workforce. HRH planning in the absence of reliable data is not optimally possible,

therefore, there is a need of reliable database i.e., more comprehensive data on other

categories of health workers, which is absence in the current position. The HR data

should be maintain properly with the detail of the workforce and their service tenure

in a place. It should be computerized and the consistency of data for every sections of

the department should use the same HR data to plan and execute. By this the proper

distribution of the physicians, nurses and mid-wives can be possible and the minimum

tenures can be managed.



351

SECTION 7

CONCLUSION



352

5.7.1. CONCLUSION

This study has attempted to document the gravity and complexity of the HR

issues in Public Health Sector in ensuring attraction, deployment and retention of the

Physicians, Nurses and Mid-wives along with the contribution of Health Sector Reform in this HR issues along with HR Practice in Reform Process in the health

sector in Arunachal Pradesh.

Adequate human resources for health (HRH) are a key requirement for

reaching health goals, the study found that, the shortages of physicians, nurses and

mid-wives are an ongoing problem in the public health sector in Arunachal Pradesh.

One of the most enduring characteristics of the rural health landscape is the uneven

distribution and relative shortage of health care professionals (Hart, 2002). To fuel on

this part the urban-rural disparities in distribution of this workforce is there, with an

intention of migrating is more and the trend is to migrate to urban areas. There is low

job satisfaction in the workforce in the current job at rural and remote areas. It is

contributed by many of the factors including financial and non-financial benefits.

Attraction and retention of physicians, nurses and mid-wives in remote and rural areas

are determined by many factors including financial incentive, career development

opportunities, recognition etc. But, the factor of compulsion is the main factor of

stock in rural and remote areas, and rest of the factors have less contribution, and the

financial benefits along with non-financial benefits seems to be migrating factors. The

attraction, deployment and retention of physicians, nurses and mid-wives in rural and

remote areas are a real challenge and a difficult situation, and affected by several

factors ranging from organisational factors to external environmental factors and to

personal factors. However, the personal factors have less affect on the situation. The

massive poor living conditions in the rural and remotes areas, poor working condition

in health institutes, poor career development opportunities with lack of financial

benefits are some of the factors that contribute to the reluctances of the physicians,

nurses and mid-wives to serve the rural and remote areas in the state. The sector has

nothing to offer presently, to attract and retain and to distribute rationally this

workforce, which in result deteriorating the situation in the rural and remote areas.

Moreover, the reform process is doing less for the HRM perspectives and the HR

practices are not effective enough to solve the problems in the state.



353

This study shows that a blend of interventions is needed to improvised the

situation. Nevertheless, the implementation of financial as well as non-financial

interventions are to be ensured for improving the situation of Physicians, nurses and

mid-wives in rural and remote areas.

Thus, it is clear that many factors affect the rational distribution, attraction and

retention of Physicians, nurses and mid-wives in the rural and remote area ranging

from environment issues, organisation issues as well as the personal issues, along with

the production issues, the facilities and basic amenities along with financial incentives

are determinant of manpower in rural areas of the state. It is also known that to solve

these HR issues, no individual interventions are not adequate, it need a pyramid of

interventions to ensure the minimization of the issues.

Moreover, a blend of initiatives is needed to address the problems of distribution,

attraction and retention of manpower in the state, there is a need of continue focus and

commitment on the part of government and as well as the political will to solve the

problem. In conclusion, efforts to strengthen health sector must address the HR issues

and a good Human Resource Management and a far sight in HR requirements are

needed.

==============



354

REFERENCES

1. Adano, U. (2006). Human Resources Management (HRM) in the Health Sector ,

Management Sciences for Health.

2. Agarwal, D., (2006). Health Sector Reforms: Relevance in India, Indian Journalof Community Medicine, Volume: 31, Issue: 4, Pp. 220-222.

3. Alwan, A., and Hornby, P. (2002). The implications of health sector reform for

human resources development . Bulletin of the World Health Organization,

Volume: 80, Issue:1, pp. 56-60.

4. Anderson, M., and Rosenberg, M.W. (1990). Ontario's underserviced area

program revisited: An indirect analysis. Social Science & Medicine, Elsevier,

Volume: 30, Issue:1, pp. 35-44.

5. Armstrong, M. (2006). A handbook on Human Resource Management Practice,

10th Edition, Kogan Page Limited.

6. Armstrong, M. (2007). A handbook on human resource management practice,

10th edition, Kogan Page, London.

7. Arunachal Times. (2011). Centre, Arunachal and HSCC inks MoU for up-

gradation of Arunachal State Hospital , Arunachal Times, 23rd

September 2011

edition, p.1

8. Aswathappa, K. (2008). Human Resource Management (5th ed.). Tata McGraw

Hill, New Delhi.

9. Awofeso, N. (2010). Improving health workforce recruitment and retention in

rural and remote regions of Nigeria. Rural and Remote Health , 10: 1319.

10. Bach, S. (2000). HR and new approaches to public sector management:

improving HRM capacity -In Workshop on Global Health Workforce Strategy

Annecy, France. World Health Organization.

11. Ballance, D., etal. (2009). Factors That Influence Physicians to Practice in Rural

Locations: A Review and Commentary. The Journal of Rural Health , Volume: 25,

Issue:3, pp 276-81

12. Bangdiwala. S.I., et al. (2011). Workforce Resources for Health in Developing

Countries, Public Health Reviews , Vol. 32, No 1, pp.296-318

13. Baru, R. V. (2010), Health sector reform in South Asia: a comparative analysis,

Centre of Social Medicine and Community Health, Jawaharlal Nehru University,

New Delhi.



355

14. Basu, S. (2000). Dimensions of tribal health in India. Health and Population-

Perspectives and Issues, Volume: 23(2), pp. 61-70.

15. Beach, A.J. (1980). Personnel : The Management of People at Work , Mac Millan

Pub. Co, New York, p.228

16. Beaglehole, R., and Dal Poz, M.R. (2003). Public health workforce: challenges

and policy issues. Human Resources for Health, 1:4.

17. Bilodeau, H., and Leduc, N. (2003). Recension des principaux facteurs

d'attraction, d'installation et de maintien des medecins en regions eloignees.

Cahiers de Sociologie et de Demographie Medicales, Volume:43, Issue:3, pp.485-

504.

18. Birch, S. (2002). Health human resource planning for the new millennium: Inputs

in the production of health, illness and recovery in populations. Canadian Journal

of Nursing Research, Volume:33, pp.109-114.

19. Birch, S., et al. (2007). Health human resources planning and the production of

health: Development of an extended analytical framework for need based, health

human resources planning, SEDAP Research Paper No. 168.

20. Bjorkman, J.W. (2010). Health sector reform –measures, muddles, and mires.

United Nations Public Administration Network

21. Blaauw, D., et al., (2010), Policy interventions that attract nurses to rural

areas:a multicountry discrete choice experiment , Bull World Health Organ,

Volume: 88, pp. 350–356

22. Borrill, C., et al. (2000). Team working and effectiveness in health care. British

Journal of Health Care Management. Volume: 6, Issue:8, pp. 364-371.

23. Borrill, C., et al. (2001). The Effectiveness of Health Care Teams in the National

Health Service. Aston University, University of Glasgow, University of Leeds, UK.

24. Boxall, P., and Purcell, J. (2003). Strategy and Human Resource Management .

Houndmills, Palgrave/Macmillan.

25. Boyle, P.J., and Halfacree, K. (1998). Exploring contemporary migration.

Longman, Harlow.

26. Brien, P.O. and Gostin, L.O. (2009). Health Worker Shortages and Inequalities:

The Reform of United States Policy. Global Health Governance, Volume: II, Issue:

2.

27. Buchan, J. (2004). What difference does ("good") HRM make? Human

Resources for Health, 2:6



356

28. Bushy, A., (2006). Nursing in Rural and Frontier Areas: Issues, Challenges and

Opportunities. Harvard Health Policy Review. Volume: 7, Issue:1, pp.17-27.

29. Cappelli, P., et al. (2011). The Indian Way, How India’s Top Business Leaders

are revolutionizing management. Harvard Business Review Press, Boston.

30. Census of India. (2001). Census 2001, Arunachal Pradesh. Directorate of Census

Operation, Arunachal Pradesh.

31. Census of India. (2011). Provisional Population Totals, Arunachal Pradesh.

Directorate of Census Operation, Arunachal Pradesh.

32. Chen, L., et al. (2004). Human resources for health: overcoming the crisis.

Lancet, 364:1984 90.

33. Chomitz, K., et al. (1998). What Do Doctors Want? In Developing Strategies for

Doctors to Serve in Indonesia's Rural and Remote Areas. World Bank,

Washington, Policy Research Working Paper no. 1888.

34. Christianson, J., & Moscovice, I. (1993). Health care reform: Issues for rural

areas. Rural Health Care Research Center, Institute for Health Services Research:

School of Public Health, University of Minnesota.

35. Dessler, G. (2008). Human Resource Management, 11th ed . PHI Learning, New

Delhi.

36. Diallo, K., et al. (2003). Monitoring and evaluation of human resources for

health: an international perspective. Human Resources for Health, 1:3.

37. Dieleman, M., and Harnmeijer, J.W. (2006). Improving health worker

performance: in search of promising practices, Evidence and Information for

Policy. Department of Human Resources for Health, WHO, Geneva.

38. Dieleman, M., et al. (2009). Human resource management interventions to

improve health workers' performance in low and middle income countries: a

realist review. Health Research Policy and Systems. 7:7.

39. Directorate of Higher & Technical Education (DHTE). (2010), Allotment of

PCB group seats as per minutes of the meeting held on 09/07/2010, DHTE,

Itanagar.

40. Directorate of Higher & Technical Education (DHTE). (2011), Allotment of

PCB group seats as per minutes of the meeting held on 11/07/2011, DHTE,

Itanagar.

41. Djibuti, M., et al., (2008). Human resources for health challenges of public

health system reform in Georgia, Human Resources for Health, 6:8.



357

42. Dmytraczenko, T., et al. (2003), Health Sector Reform: how it affects

reproductive health, Population Reference Bureau, USA.

43. Dolea, C. (2009). Increasing Access to Health Workers in Remote and Rural

Areas through Improved Retention. WHO, Geneva.

44. Dormael, V., et al. (2008). Appropriate training and retention of community

doctors in rural areas: a case study from Mali. Human Resources for Health,

6:25.

45. Dreesch, N., et al. (2005). An approach to estimating human resource

requirements to achieve the Millennium Development Goals. Journal of Health

Policy and Planning. Oxford University Press.

46. Dubois, C.A., & McKee, M., (2006). Cross-national comparisons of human

resources for health – what can we learn? Health Economics, Policy and Law,

1:59-78

47. Durbin, A.J. (1981). Personnel and Human Resource Management . Strand Co.

New York, p. 82

48. Dussault, G., & Franceschini, M.C. (2006). Not enough there, too many here:

understanding geographical imbalances in the distribution of the health workforce.

Human Resources for Health, 4: 12.

49. Dussault, G., and Dubois, C.A. (2003). Human resources for health policies: a

critical component in health policies. Human Resources for Health, 1:1:1.

50. Dussault, G., et al. (1997). Human resources planning in health and population

services. Instituto de Medicina Social, Universitade do estado de Rio de Janeiro,

Serie ‘Estudos em Saude Colectiva’ 158.

51. Dwivedi, R.S. (1980). Some correlated of Employee Performance. Indian Journal

of Industrial Relations, Volume:15, Issue:4, pp. 563-575.

52. Ebuehi, O.M. and Campbell, P.C. (2010). Attraction and retention of qualified

health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State,

Nigeria. Rural and Remote Health, 11: 1515

53. El-Jardali, Fadi., et al. (2007). Human resources for health planning and

management in the Eastern Mediterranean region: facts, gaps and forward

thinking for research and policy. Human Resource Health, 5: 9.

54. Esmail, L.C., et al. (2007). Human resource management in the Georgian

National Immunization Program: a baseline assessment, Human Resources for

Health 2007, 5:20.



358

55. Fallon Jr., L. F., and McConnell, C. R. (2007). Human Resource Management

in Health care: principles and practice, Jones and Bartlett Publishers, Inc.

Massachusetts.

56. Ferrinho, P., & Lerberghe, V. (2000), Studies providing health care under

adverse conditions: Health personnel performance & individual coping strategies,

Studies in Health Services Organisation & Policy. ITG Press, Belgium.

57. Fombrun, C., et al. (1984). Strategic Human Resource Management , John Wiley

& Sons, USA.

58. Forgia , G.M. L. (2005). Health System Innovations in Central America, Lessons

and Impact of New Approaches. World Bank working paper 57.

59. Foxcroft, C., and Roodt, G. (2002). An introduction to psychological assessment

in the South African context. Oxford University Press, Inc, Cape Town.

60. Franco, L.M., et al., (2002). Health-sector reform and public-sector health

worker motivation: a conceptual framework. Social Science and Medicine,

Volume : 54, pp. 1255–1266.

61. Frehywot, S., et al., (2010). Compulsory service programmes for recruiting

health workers in remote and rural areas: do they work ? Bull World Health

Organ. Volume:88, pp. 364–370.

62. Fujisawa, R. & Lafortune, G. (2008). The remuneration of general practitioners

and specialists in 14 OECD countries: what are the factors influencing variations

across countries? OECD.

63. Full, J.M. (2001). Physician recruitment strategies for a rural hospital . Journal of

Healthcare Management, Volume : 46, Issue: 4, pp. 277-282.

64. Fulop, T., and Roemer, M.I. (1987). Reviewing health manpower development,

A method of improving national health systems. Public Health Papers no. 83.

World Health Organization.

65. Gellerman, S. W. (1963). Motivation and Productivity, American Management

Association, New York, 1963.

66. Gittens-Gilkes, A. (undated). The concept of productivity in health sector reform.

67. Glasser, M. (2010). Factors and outcomes in primary care physician retention in

rural areas, SA Fam Pract, Volume:52, Issue: 4, pp. 336-40.

68. Govt. of Arunachal Pradesh. (2009), National Rural Health Mission, State

Programme Implementation 2010-11, NRHM Division, Govt. of Arunachal

Pradesh



359



Pradesh



Pradesh

71. Govt. of India. (2000). National Health Policy, 2000 & 2001, Ministry of Health

and Family Welfare Govt. of India.

72. Grieshaber, L.D., Parker, P., and Deering, J. (1995). “Job Satisfaction of

Nursing Assistants in Long-Term Care.” Health Care Supervisor, Volume:13,

pp.18-28.

73. Guchait, P. (2007). Human resource management practices and organizational

commitment and intention to leave: the mediating role of perceived organizational

support and psychological contracts. University of Missouri-Columbia.

74. Gupta, N., and Dal Poz, M. R. (2009). Assessment of human resources for health

using cross-national comparison of facility surveys in six countries. Human

Resources for Health, 7:22.

75. Hall, T. (1998). Why plan human resources for health? Human Resource

Development Journal, Volume:2, Issue:2, pp. 77-86.

76. Hart, G., et al. (2002). Rural Health Care Providers in the United States. Journal

of Rural Health, Supplement, Volume:18, Issue:S, pp.211-231

77. Hawthorne, N. & Anderson, C. (2009). The global pharmacy workforce: a

systematic review of the literature. Human Resources for Health 2009, 7:48.

78. Henderson, L.N., & Tulloch, J. (2008). Incentives for retaining and motivating

health workers in Pacific and Asian countries. Human Resources for Health, 6:18

79. Herzberg, F. (1968). One more time : How do you motivate your Employees.

Havard Business Review. pp. 259-262.

80. Homedes, N. and Ugalde, A. (2005). Human resources: the Cinderella of health

sector reform in Latin America. Human Resources for Health, 3:1.

81. Hongoro, C., and McPake, B. (2004). How to bridge the gap in human resources

for health. Lancet, 364:1451-1456.

82. Hoppock, R. (1935). Job Satisfaction, Harper, New York.

83. Hughes, R.L., et al., (2002). Leadership, enhancing the lessons of experience.

New York, McGraw-Hill/Irwin.



360

84. Hyde, P., et al. (2006). Improving Health through Human Resource Management,

Mapping the Territory. Chartered Institute of Personnel and Development and the

Department of Health, Quarry Hill, Leeds, LS2 7UE.

85. Igharia, M., and Greenhaus, J. H. (1992). Determinants of MIS employees’

turnover intentions: A structural equation model. Association for Computing

Machinery. Communications of the ACM, Volume: 35, Issue:2, pp. 34-49.

86. Infante, A. (1999). Monitoring the Sectoral Reform Process in Latin America and

the Caribbean. Americas Health Sector Reform Org.

87. Institute for Public Health. (2007). Health Care Financing Reform: Proposed

Goals Report of the Human Resources Management Study Group. University of

New Mexico.

88. International Labour Organisation. (1998). Terms of employment and working

conditions in health sector reforms. Report for discussion at the Joint meeting on

terms of employment and working conditions in health sector reforms.

International Labour Organisation, Geneva.

89. Irene, A. A. (1999). Reforming Health Service Delivery at District Level in

Ghana-The Perspective of a District Medical Officer. Health Policy and Planning,

Volume:14, Issue (1), pp. 59-69.

90. Jason, A.S., and Alison, D.B. (1999). Keeping Doctors North: Recruiting and

Retaining Physicians in Underserviced Areas. University of Toronto Medical

Journal, Volume:76, Issue:3, pp. 174-78

91. Joaquin, M.E.T. (2009). Human resource challenges in a decentralizing state:

some notes.

92. Johnson, S. (2000). Building capacity in human resources management for health

Sector reform and the organizations and institutions comprising the sector ,

Management Sciences for Health (MSH), Boston Massachusetts,

93. Kabene. S.M., et al, (2006). The importance of human resources management in

health care: a global context . Human Resources for Health, 4:20.

94. Kagi, K. (1985). Improving Working Conditions in Small Enterprises in

Developing Asia, ILO, Geneva, 1985.

95. Kim, C. (2000). Recruitment and retention in the Navajo Area Indian Health

Service. Western Journal of Medicine, Volume: 173, Issue: 4, pp. 240-243.



361

96. King, B. (2006). Recruitment and Retention of Health Care Providers in

Underserved Communities in Texas, Health Professions Resource Center, Center

For Health Statistics Texas Department of State Health Services.

97. Klaas, N.P., (2007). Factors influencing the retention of nurses in the rural health

facilities of the eastern cape province. University of South Africa.

98. Kodwani, A. (2003). Management 2010. HRM Review, ICFAI Press, Dec.2003,

p.46

99. Kolehmainen-Aitken, R.L. (1998). Decentralization and human resources:

Implication and impact. Human Resources for health development journal, 2(1):

pp.1-17.

100. Kolehmainen-Aitken, R.L. (2004). Decentralization's impact on the health

workforce: perspectives of managers, workers and national leaders. Human

Resources for Health, 2(5).

101. Kornik, S., and Clark C. (undated). Retaining doctors in deep rural areas in

South Africa through “marriage counsellors” who work to negotiate the

relationships between management and doctors. Africa Health Placements

102. Kristiansen, I.S. and Forde, O.H. (1992). Medical specialists' choice of

location: The role of geographical attachment in Norway. Social Science &

Medicine, Elsevier, Volume: 34, Issues: 1, pp.57-62.

103. Kushwah, S.S. (2000). Continuing Education in Health Care Sector - The

Issues and Options. Indian Journal of Community Medicine, Volume: 25, Issue:1.

104. Lagarde, M. and Blaauw, D. (2009). A review of the application and

contribution of discrete choice experiments to inform human resources policy

interventions. Human Resources for Health, 7:62.

105. LaRavia. D., et al. (2002). Keeping Physicians in Rural Practice. American

Academy of Family Physicians, Rural Recruitment and Retention Position Paper.

106. LaSala. K. B. (2000). Nursing workforce issues in rural and urban settings:

looking at the difference in recruitment, retention and distribution. Online Journal

of Rural Nursing and Health Care, Volume:1, Issue:1.

107. Laursen, K., & Foss, N.J. (2000). New HRM Practices, Complementarities,

and the Impact on Innovation Performance. Department of Industrial Economics

and Strategy, Copenhagen Business School, Denmark.

108. Lawler, E. E. (1971). Pay and Organisational Effectiveness, Mc Graw Hill,

New York.



362

109. Lea, J., and Cruickshank, M.T. (2007). The experience of new graduate

nurses in rural practice in New South Wales. The International Electronic Journal

of Rural and Remote Health Research, Education Practice and Policy, Rural and

Remote Health, 7: 814.

110. Lee, T.W. & Mowday, R.T. (1987). Voluntarily leaving an organization: An

empirical investigation of Steers and Mowday’s model of turnover. Academy of

Management Journal, Volume:30, pp.721-743.

111. Lehmann, U. et al,. (2008) Staffing remote rural areas in middle- and low-

income countries: a literature review of attraction and retention. BMC Health

Services, 8:19.

112. Lerberghe, V.W., et al. (2002). When staff is underpaid: dealing with the

individual coping strategies of health personnel. Bulletin of the World Health

Organization, Volume 80, pp. 7581-584.

113. Lethbridge, J. (2004). Public sector reform and demand for human resources

for health (HRH), Human Resources for Health, 2:15.

114. Lexomboon, D. (2003). Recruitment and Retention of Human Resources for

Health in Rural Areas: A Case Study of Dentists in Thailand, Liverpool School of

Tropical Medicine, UK.

115. Liaw, S.T., et al. (2005). A compulsory experiential and inter-professional

rural health subject for undergraduate students. Rural Remote Health, 5:460.

116. Liu, X., et al. (2006). Does decentralisation improve human resource

management in the health sector? A case study from China. Social Science &

Medicine, Volume : 63, Issue:7, pp.1836-1845.

117. Lomas, J., et al. (1985). Supply projections as planning: A critical review of

forecasting net physician requirements in Canada. Social Science and Medicine,

Volume:20, pp.411-424.

118. Machado, M. (1997). Os Médicos no Brasil: um Retrato da Realidade, Rio

de Janeiro: Editora Fiocruz.

119. Manafa, O. et al. (2009). Retention of health workers in Malawi: perspectives

of health workers and district management. Human Resources for Health, 7:65.

120. Management Science for Health. (2009). Competency Gaps in Human

Resource Management in the Health Sector, An exploratory study of Ethiopia,

Kenya, Tanzania, and Uganda. MSH.



363

121. Manahan, C., (2008). Who stays in rural practice?: an international review

of the literature on factors influencing rural nurse retention. Journal of Rural

Nursing and Health Care. Volume:8, Issue:2.

122. Martineau, T. & Buchan, J. (2000). Human Resources and the Success of

Health Sector Reform. Human Resources for Health Development Journal,

Volume:4, Issue: 3.

123. Martineau, T., & Buchan, J. (2000). Human Resources and the Success of

Health Sector Reform. Human Resources for Health Development Journal, Vol. 4,

No. 3.

124. Martinez, J., & Martineau, T. (1997). Human resources in healthcare

reform: a review of current issues. Health Policy and Planning 13:345-58.

125. Martinez, J., & Martineau, T. (1998). Rethinking human resources: an

agenda for the millennium. Health Policy and Planning, Volume:13, Issue: 4, pp.

345-358.

126. Martinez, J., & Martineau, T. (2002). Human resources in the health sector:

an international perspective. DFID Health Systems Resource Centre.

127. Martinez, J., and Liz Collini, L. (1999). A Review of Human Resource

Issues in the Health Sector, DFID HSRC, London.

128. Martinez, J., and Martineau, T . (1996). Ghana: HRD policy reform issues.

In Workshop on human resources and health sector reforms, Liverpool School of

Tropical Medicine.

129. Mathauer, I., and Imhoff, I. (2006). Health worker motivation in Africa: the

role of non-financial incentives and human resource management tools. Human

Resources for Health, 4:24.

130. Matsumoto, M., et al., (2010). Retention of physicians in rural Japan:

concerted efforts of the government, prefectures, municipalities and medical

schools. Rural and Remote Health , 10: 1432

131. Mavalankar, D. V. (1999). Human Resource Management, issues and

challenges.

132. McCaffery, J. (2006). Addressing the Crisis in Human Resources for Health.

Global Health Technical Briefs.

133. McDonald, J. (2002). Recruiting and Retaining General Practitioners in

Rural Areas: Improving Outcomes through Evidence-Based Research and



364

Community Capacity-Building. Centre for Health Research and Practice,

University of Ballarat, Australia.

134. Mensah, K. (2002). Attracting and retaining health staff: a critical analysis of

the factors influencing the retention of health workers in deprived/hardship areas.

Accra: Yak-Aky Services

135. Ministry of Health & Family Welfare, GOAP. (2007a). Indian Public

Health Standards (IPHS) for Arunachal Pradesh, Community Health Centres.

Ministry of Health & Family Welfare, Government of Arunachal Pradesh.

136. Ministry of Health & Family Welfare, GOAP. (2007b). Indian Public

Health Standards (IPHS) for Arunachal Pradesh, Primary Health Centres.

Ministry of Health & Family Welfare, Government of Arunachal Pradesh.

137. Ministry of Health & Family Welfare, GOAP. (2007c). Indian Public

Health Standards (IPHS) for Arunachal Pradesh, Sub-Centres. Ministry of Health

& Family Welfare, Government of Arunachal Pradesh.

138. Ministry of Health & Family Welfare. (2007). Indian Public Health

Standards (IPHS) for 31 to 50 bedded Sub-District /Sub-Divisional Hospitals.

MoHFW, New Delhi.

139. Ministry of Health and Family Welfare. (2001). National Health Policy-

2001, MoHFW, Govt. of India.

140. Ministry of Health and Family Welfare. (2010). Meetings people’s health

needs in partnership with states. The journey so far 2005-10. MoHFW, New

Delhi.

141. Mobley, W.H. (1982). Employee turnover: causes, consequences, and

control, Addison-wesley, London.

142. MoHFW, Bangladesh. (1997). Human Resources Development in Health and

Family Planning in Bangladesh: A Strategy for Change. Human Resources

Development Unit, Dhaka.

143. MoHFW, Govt. of India. (2010). Rural Health Statistics in India 2010.

Ministry of Health and Family Welfare, Govt. of India.

144. Mullei, K., et al. (2010). Attracting and retaining health workers in rural

areas: investigating nurses’ views on rural posts and policy interventions. BMC

Health Services Research, Volume: 10, Issue: 1.

145. Murthy et al. (2012). What do doctors want? Incentives to increase rural

recruitment and retention in India. BMC Proceedings, Volume: 6, Issue:1, p5.



365

146. Mutizwa-Mangiza, D. (1998). The Impact of Health Sector Reform on Public

Sector Health Worker Motivation In Zimbabwe. Major Applied Research 5,

Working Paper 4, Abt Associates Inc.

147. Narine, L. (2000). Impact of health system factors on changes in human

resource and expenditures levels in OECD countries. Journal of Health Human

Service Adm. Volume: 22, Issue:3, pp:292-307.

148. Nestman, N. A. ( 1998). Retention of Physicians in Rural Areas: The Case of

Nova Scotia, IRC Press Industrial Relations Centre, Queen’s University.

149. Newstrom, J. W. (2007). Organisational Behaviour, Human Behaviour at

Work (12 Ed.), Tata McGraw Hill Companies, New Delhi.

150. Nick Simons Institute. (2008). Retention of General Practitioners in rural

Nepal – a qualitative study. Australian Journal of Rural Health. Volume:16, pp.

201-206)

151. Nigenda, G., and Machado, H. (2000). From state to market: the

Nicaraguan labour market for health personnel . Health Policy and Planning,

Volume:15, Issue:3, pp.312-318.

152. Oreilly, M. (1997). Take some action, take some risk . Canadian Medical

Association Journal, Volume: 157, pp. 936-937.

153. Ozcan, S., Taranto, Y., and Hornby, P. (1995). Shaping the health future in

Turkey: a new role for human resource planning . International Journal of Health

Planning and Management, Volume:10, Issue:4, pp. 305-319.

154. Pagaiya, N., et al. (2011). Health workers’ preferences and policy

interventions to improve retention in rural areas in Thailand. International Health

Policy Program Ministry of Public Health, Thailand.

155. PAHO (Pan American Health Organization). (2003). Maximizing Quality

of Care through Health Sector Reform: The Role of Quality Assurance Strategies.

PAHO.

156. Peiro, J.M., et al. (1992). The influence of work team climate on role stress,

tension, satisfaction and leadership perceptions. European Review of Applied

Psychology, Volume: 42, Issue:1, pp. 49-46.

157. Pong, W. R. (2008). Strategies to overcome physician shortages on northern

Ontario: A study of policy implementation over 35 years. Human Resource for

Health, 6(24).



366

158. Prasad, A., et al. (2006). Measuring the efficiency of human resources for

health in attaining health outcomes across provinces in Viet Nam. World Health

Organization, Geneva.

159. Radcliffe, D. (2005). Critique of Human Resources Theory. Otago

Management Graduate Review, Volume 3, pp:51-67.

160. Raju, P.V.L. (2003). Sustaining Employee Morale During Layoffs. HRM

Review, ICFAI Press, Apr. 2003, p. 23.

161. Ramadoss, Ambumani. (2007). National Workshop on Human Resources for

Health Options and Challenges , 5-6th April 2007, IHC, New Delhi , A Report.

162. Ramani, K.V., et al, (2005). Health system in India, opportunities and

challenge for improvements, Research and publications, IIM, Ahmedabad.

163. Ramani, V.V. (2003). A Holistic Approach to Training and Development ,

HRM Review, ICFAI Press, p.46.

164. Rao, D. T. (2010). Human Resources for Health-A presentation. National

Health Systems Resources Centre, New Delhi, 2010.

165. Rao, K., et al. (2009). India’s health workforce: size, composition and

distribution. World Bank, New Delhi and Public Health Foundation of India, New

Delhi.

166. Rao, K., et al. (2011). Health Worker Attitudes Toward Rural Service in

India: Results from Qualitative Research. HNP Discussion Paper Series. World

Bank, Washington, DC.

167. Rao, K.D. and Ramani, S. (2011). What works, where and how well?

Lessons from a comparative assessment of current rural retention strategies for

doctors in India. Public Health Foundation of India Human Resources

Background Paper 2, 2011.

168. Rao, R. K. (2003). Training – the Learning perspective. HRM Review, ICFAI

Press, Aprl. 2003, p.51

169. Rao, V.S.P. (2000). HRM Test and Cases, Excel Books, New Delhi, pp. 116-

120

170. Reardon, T.F., (2010). Nursing recruitment and retention issues: Similarities

and differences rural United States and Australia. Dissertation, Michigan

University Mount Pleasant, Michigan



367

171. Riegel, C.D. (2002). The causes and consequences of turnover in the

hospitality Industry in Rutherford . D G (ed) Hotel management and operations,

John Wiley & Sons, New York, pp. 469-476.

172. Roberto, P.N. & Jose, P.S. (2003). Human Resource Management and Public

Sector Reforms: Trends and Origins of a New Approach, Studies in HSO&P,

p.21.

173. RRWG. (2004). Rural and remote nursing recruitment and retention in Nova

Scotia. Report of the Rural and Remote Working Group.

174. Saiyadain, M.S., (2009). Human Resource Management (4th

Ed.), Tata

McGraw Hill Companies, New Delhi.

175. Samantaray, B.K. (1997). HRM in Public Sector – A Case Study.

Unpublished Ph.D. thesis, Utkal University, Orissa, 1997.

176. Samantray, B. K., and Pradhan, P. K. (1998). Human Resource Planning in

Rourkela Steel Plant. The Orissa Journal of Commerce, Volume:22, Issue:1, p. 30

177. Sharma, A.M. (2000). Personnel and Human Resource Management ,

Himalaya Pub.House, Mumbai.

178. Satpathy, S.K. & Venkatesh, S. (2006). Human Resources for Health in

India’s National Rural Health Mission: Dimension and Challenges. Regional

Health Forum, Volume 10, Number 1, p.29.

179. Sayadain, M. S. (1998). Human Resource Management , Tata Mc Graw Hill

Pub. Com. Ltd., New Delhi. Pp. 28-29.

180. Seble Frehywot et al. (2010). Compulsory service programmes for recruiting

health workers in remote and rural areas: do they work? Bull World Health Organ,

Volume:88, pp.364–370.

181. Shankar, P.R. (2010). Attracting and retaining doctors in rural Nepal,

Attracting and retaining doctors in rural Nepal . Rural and Remote Health, 10:

1420.

182. Sharma, A.M., (2000). Personnel and HRM , Himalaya Publishing House,

2000, p. 185.

183. Shattuck, et al. (2008). Motivation and retention of health workers in

developing countries: a systematic review. BMC Health Serv Res. Volume:8, p.

247.

184. Sikula, A. F. (1976). Personnel Administration and Human Resources

Management , John wiley and Sons Inc, Santa Barbara, p. 147



368

185. Smith, T. (2010). Recruitment/Retention to Improve Rural Service, Desk

Review. Arlington, USAID, AIDSTAR-One Project.

186. Snow, R.C., et al. (2011). Key factors leading to reduced recruitment and

retention of health professionals in remote areas of Ghana: a qualitative study

and proposed policy solutions. Human Resources for Health, 9:13.

187. Speybroeck, N., et al. (2006). Inequality in access to human resources for

health: measurement issues. World Health Organization, Geneva.

188. Ssengooba, F. (2005). Human resources for health in decentralized Uganda:

developments and implications for health systems research. Institute of Public

Health, Makerere University, Uganda.

189. Ssengooba, F., et al. (2007). Health sector reforms and human resources for

health in Uganda and Bangladesh: mechanisms of effect . Human Resources for

Health, 5:3.

190. Standing, H. (2000). Gender - a Missing Dimension in Human Resource

Policy and Planning for Health Reforms. Human Resources for Health

Development Journal, Volume:4, Issue:1.

191. Straume, K., & Shaw, D. (2010). Effective physician retention strategies in

Norway’s northernmost county. Bulletin of the World Health Organization.

Volume: 88, pp. 390-394.

192. Sultz, H.A., & Young, K.M. (1999). Health care USA; Understanding its

organization and delivery (2nd edition.). Gaithersburg, MD: Aspen.

193. Sundararamana, T & Gupta, G. (2011). Indian approaches to retaining

skilled health workers in rural areas. Bull World Health Organ, Volume: 89, pp.

73–77.

194. Surti, K. (1986). Labourers Perception about their Work Environment – A

Study of Workers in Engineering Industry, Gandhi Labour Institute, Ahmedabad.

195. Todaro, M. (1976). Internal migration in developing countries. Geneva,

International Labour Office; 1976.

196. Tripathi, P.C. (2009). Human Resource Development (5th

ed.). Sultan Chand

& Sons, New Delhi.

197. Udo, G.J., et al. (1997). An investigation of the antecedents of turnover

intention for manufacturing plant managers. International Journal of Operations

& Production Management, Volume:17, Issue:9, p.912.



369

198. Uneke, C., et. al. (2008). The Nigeria health sector and human resource

challenge. The Internet Journal of Health. Volume: 8, Issue:1.

199. Vujicic, M. (2010). Attracting doctors and medical students to rural Vietnam:

Insights from a Discrete Choice Experiment. HNP Disscussion Paper .

200. Wafula, J., et al. (2011). Attracting and retaining health workers in rural

areas: investigating nurses views, career choices and potential policy

interventions. KEMRI Wellcome Trust Programme, Kenya.

201. Wheeler, K. (2003). What would the ‘perfect’ Recruiting Function Look Like.

HRM Review, ICFAI Press, Dec. 2003, p.37

202. Witter, S., et al. (2011). Understanding the ‘four directions of travel’:

qualitative research into the factors affecting recruitment and retention of doctors

in rural Vietnam. Human Resources for Health, 9:20.

203. Wood, N. (1994). A review of primary health care organisation. Journal of

Clinical Nursing. Volume:3, Issue:4, pp. 243-250.

204. World Health Organisation. (2001). Development and strengthening of

human resource management in the health sector, provional agenda item 4.5, 53rd

session of the regional committee, WHO, p. 5

205. World Health Organization, (1990). Coordinated health and human

resources development, WHO Technical Report Series 801. Geneva.

206. World Health Organization. (1997). Inter -country Consultation on

Development of Human resources in Health in the African Region. Brazzaville:

WHO Regional Office for Africa.

207. World Health Organization. (2000). Relationship between health system

inputs, budget elements and expenditure categories. World Health Report, WHO.

208. World Health Organization. (2000). World Health Report. WHO, Geneva.

209. World Health Organization. (2004). The Migration of Skilled Health

Personnel in the Pacific Region. WHO Western Pacific Region.

210. World Health Organization. (2006). Working Together for Health: The

World Health Report . WHO, Geneva, Switzerland.

211. World Health Organization. (2007). World Health Organization (2007),

Country Office for India, Not Enough Here ….Too. WHO, p. 43.

212. Wyss, K. (2004). An approach to classifying human resources constraints to

attaining health-related Millennium Development Goals. Human Resource Health

2004, 2:11.



370

213. Yang, Hui-O. (2007). Human Resource Management in the hotel industry in

Taiwan. Swinburne University of Technology, Melbourne, Australia.

214. Yepes, F. J., et al. (2010), Aiming for Equity in Colombia’s Health System

Reform: Achievements and Continuing Challenges, IDRC, Canada

215. Zurn, P., et al., (2005). Nurse retention and recruitment: developing a

motivated workforce. World Health Organization, Geneva.

-----------------------------------



371

Appendix

Appendix – 1: Manpower Recommended under IPHS



372



373



374

QUESTIONNAIRE FOR PHYSICIANS NURSES AND MID-WIVES

A. DEMOGRAPHIC INFORMATION

1. Respondent ID :

2. Position:

a) Physician (Medical Officer)

b) Nurse (GNM/Staff Nurse)

c) Mid-wife (ANM)

3. Age:

4. Sex:

a) Male

b) Female

5. Family Background:

a) Rural

b) Urban

6. Marital Status:

a) Married

b) Unmarried

7. Length of Service in rural area:

8. Working in:

a) SC

b) PHC

c) CHC

d) DH

9. Nature of Employment:

a) Permanent

b) Contract

Appendix: 2



375

B. EXPLORING THE DIMENSIONS IN ATTRACTION ISSUES FOR RURAL AND

REMOTE AREAS SERVICES

i) Please select the factors that attracted or placed you to current job in the rural

and remote area?Sl.

No.

Attributes Select

(Tick)

1 Financial incentives / Rural allowances/ Performance incentives

2 Improved working condition

3 Availability of equipment, drugs and supplies

4 Authority, independency and autonomy

5 Career development opportunity

6 Continuing education/higher education Opportunities

7 Training and skill development Opportunities

8 Compulsion (minimum rural service tenure or non-transferable or

Management or political pressure)9 Flexible working hour with minimal workload

10 Supportive supervision and mentoring

11 Amenities like housing, conveyance provided

12 Reward and recognition system

13 Teamwork and Interpersonal staffs relationship

14 Safety at workplace

15 Availability of good schools for children nearby town

16 Current health facility is closer to hometown or Closer to family and friends

ii) Please select the factors that may attract you and new physicians, nurses and

midwives towards rural and remote area?

Sl.

No.

Attributes Select

(Tick)

1 Higher Salary package in compare to urban posting

2 Financial incentives / Rural allowances/ Performance incentives

3 Conducive working condition

4 Availability of equipment, drugs and supplies

5 Opportunity for authority, independency and autonomy

6 Career development opportunities

7 Continuing education/higher education Opportunities


9 Rotational Posting after completing minimum rural service tenure

10 Job security

11 Flexible working hours with minimal workload

12 Supportive supervision and mentoring

13 Access to amenities like housing & conveyance

14 Better teamwork and good interpersonal staffs relationship

15 Safety at workplace

16 Good reward and recognition system

17 Availability of good schools for children

18 Current health facility is closer to home-town or Closer to family andfriends



376

C. EXPLORING THE DIMENSIONS IN RETENTION ISSUES FOR RURAL AND

REMOTE AREAS SERVICES

i) On a scale of 1 to 5, Please rate how satisfied are you with your present job in rural

area?

[ 1) Highly Dissatisfied 2)Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) Highly Satisfied ]

Attributes 1 2 3 4 5

Overall Job satisfaction

ii) Please select the factors that contributed to your satisfaction level of your current job

in rural and remote area service?

Sl.No.

Attributes Pleasetick

1 Salary

2 Better Job Prospects in future

3 Job security


5 Opportunities of continuing education/higher education


7 Work environment

8 Adequacy of equipment, drugs and supplies

9 Financial incentives linked to rural posting

10 Non-financial benefits/allowances linked to rural posting

11 Appropriate Work load

12 Matching of skills and tasks

13 Support, supervision, management and mentoring

14 Reward system and recognition

15 Social recognition and opportunities of public services/ care to patients

16 Teamwork and Interpersonal staffs relationship

17 Safety at the workplace from external environment

18 Access to free accommodation (Housing)with basic amenities

iii) Please share your intention to migrate keeping the salary constant, what will be your

choice to migrate?

Sl. No Attributes Tick one

1 To continue in your present rural area posting (if yes pl. go to no. iv)

2 To shift to another rural health institute (if yes pl. go to no. v)

3 To shift to another urban health institute (if yes pl. go to no. v)

4 To shift to another job in some other State/sector (if yes pl. go to no. v)



377

iv) Please select the factors that motivate you to continue in the current job for at least

3-5 years or more in rural and remote areas

Serial

no.

Attributes Select

(Tick)

1 Satisfied with salary

2 Getting adequate financial incentives/ Rural allowances/performanceincentives


4 Adequate drugs/equipment at the rural health centre


6 Scope for continuing education/higher education

7 Scope for training and skill development

8 Job Security

9 Flexible working hours with minimal workload

10 Improved support, supervision and mentoring

11 Strong Teamwork and interpersonal relationship

12 Anticipation of obtaining a regular position after contractual position

13 Adequate living conditions (access to amenities like housing, water,electricity, conveyance and communication)

14 Achievement is recognized and rewarded

15 Geographical affinities(Hometown near)and familial associations

16 Good schools for children/ education prospects of children

17 Opportunity for both spouses to work and live in the same location

18 More Autonomy in current place of posting

v) Please select the push factors for your intentions of leaving or seeking transfer from

the current job in rural and remote areas for urban areas.

Sl.

no.

Attributes Select

(Tick)

1 Poor salaries

2 Lack of adequate financial incentives/ Rural allowances/performance

incentives

3 Poor working condition

4 Inadequate drugs/equipment

5 Lack of Career development opportunities

6 Lack of scope for continuing education/higher education

7 Limited opportunity of training and skill development

8 Lack of Job security

9 Unusual working hours and excess work load

10 Poor support, supervision and mentoring

11 Lack of others cadres, teamwork and interpersonal relationship

12 Inadequate living conditions (access to amenities like housing, water,electricity, conveyance and communication)

13 Achievement not recognized

14 Lack of safety at workplace

15 Limited or no good schools for children/ education prospects of children

16 Lack of Autonomy



378

vi) Please select the factors that may motivate you to retain the current job in rural and

remote area other than that of factors that what you are satisfied with current time.

Sl.no.

Attributes Select

(Tick)

1 Increase salary by half

2 Increase salary by double3 Financial incentives for rural posting/ Rural allowances/performance

incentives


5 Job Security

6 Adequacy of equipment, drugs and supplies at Health centre


8 Opportunities of continuing education/higher education (support for further education)


10 Rotational posting

11 Opportunity of autonomy12 Flexible working hours with minimal work load

13 Adequate patients/clients at current facility

14 Supportive supervision, management and mentoring

15 Good reward and achievement recognition system

16 Good teamwork and good interpersonal staffs relationship

17 Security & Safety at workplace

18 Availability of good schools for children

19 Improve living conditions (Access to amenities like housing, water,electricity, conveyance and communication)

vii) Please Share any other point related regards your current job in rural area in the

context of HRM.

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

viii) Please share your perspective on contractual employment (only for contractual)

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................



379

D. EXPLORING THE VIEWS IN HEALTH SECTOR REFORM

i) On a scale of 1 to 5 please rate the following statement regarding ongoing health

sector reform process in your organisation?

[ 1) Strongly Disagree 2) Disagree 3) Undecided 4) Agree 5) Strongly agree ]

Serial

No.


1 The Reform has made the Human Resource Policies clear andunderstandable at your level

2 The reform has made the placement, transfer and promotion

transparent, fairer and unbiased

3 The reform has made your job description clear

4 The reform has increased your chances of being promoted

5 The reform has made the Salary structure Competitive for ruralarea posting

6 The reform has made regular and adequate financial incentives andallowances for rural area posting

7 The reform has increased the activities for your performanceappraisal and positive action on them

8 The reform has made an improvement in working condition in

your work place

9 The reform have increased the training and skill developmentOpportunities

10 The reform have improved the availability of equipment, drugs

and supplies essential to perform your assigned tasks

11 The reform have improved mix of other cadres in your workplace

12 The reform has made your workload more manageable

13 The reform has made improvement in supportive supervision,management and mentoring form higher authority

14 The reform has made work independent and more autonomy

15 The reform has made improvement in housing and other amenitiesat your workplace

16 The reform has made rural health care services an attraction for the potential physicians, nurses and mid-wives to work in rural and

remote area

17 The reform has made overall HR practice effective and conducivein the organization



380

E. EXPLORING THE DIMENSIONS IN HR POLICIES AND PRACTICE IN

ACQUIRING (ATTRACTION), DISTRIBUTION AND RETENTION IN RURAL

AND REMOTE AREAS

i) On a scale of 1 to 5 how do you feel about the following practices in yourorganisation regarding rural and remote area services?

[ 1) Highly Dissatisfied 2) Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) HighlySatisfied ]

Serial

No.


1 Recruitment and selection process

2 Policies for placement, transfer and promotion

3 Fairness of HR Practice for placement, transfer and promotion

4 Magnitude of management favoritism and politicalinterference in transfer and posting

5 Response of administration/management on your placement,transfer and promotional grievances

6 Participation and involvement in the decision making of your placement and transfer

7 HR Practice for retentions –Financial Interventions

8 HR Practice for retentions – Non Financial Interventions

9 Training and Development

:::::::::Thank You:::::::::



381

INTERVIEW SCHEDULE FOR STATE AND DISTRICT MANAGEMENT

REPRESENTATIVES

Part –I

DEMOGRAPHIC INFORMATION

1. Your current post/position? ………………………………………………….

2. Gender? Male Female

3. Age? ………………………..

7. Years of management experience? …………………………….

1. EXPLORING DIMENSION OF HR ISSUES IN DISTRIBUTION,

ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES FOR

RURAL AND REMOTE AREAS

1. In your opinion, what are the key human resource issues on distribution of

physicians and nurses in rural and remote areas in your state/district?

2. In your opinion, what are the key human resource issues on attraction and

retention of physicians and nurses in rural and remote areas in your state/district?

3. What you think could be the main reasons for physicians and nurses turnover from the rural and remote areas of area of operation?

4. Could you please summaries the main HR issues and challenges regarding

physicians and nurses that you are facing in order to implement Health Sector

Reform effectively?

5. Do you have any further plans as reform initiatives for addressing the above

mentioned issues regarding distribution, attraction and retention of physicians

and nurses in rural and remote areas of your area? If yes what are they, would

you like to share?

6. Are there any comments you would like to provide regarding the subjects not

covered in this interview regarding HR issues of Physicians and nurses?

2. EXPLORING DIMENSION OF HRM PRACTICE IN REFORM PROCESS

IN DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS

AND NURSES FOR RURAL AND REMOTE AREAS

1. What is the name of the Department/Section which looks after Human ResourceManagement function in the organization at your level?

2. What is the staffing pattern of this section?

3. What HR functions are performed by the Department?

4. How do you assess the requirement of Physicians and nurses for the organization,

particularly for rural and remote areas?

Appendix :3



382

5. What are the HR practices used for attraction of physicians and nurses in ruralareas?

6. What are the sources are utilized for the recruitment for recruiting physicians and

nurses?

7. Did you find any problem in filling up vacancies of physicians and nurses for rural

and remote areas? If yes. Please share the issue and the problems?8. What are the criteria for placing and transfer physicians and nurses in rural and

remote areas at your level?

9. What are the HR practices and core HR area used for retention of physicians and

nurses in rural areas?

10. Does the organization have any financial incentives for rural and remote areas

placement of physicians and nurses for attracting and retaining them in rural area

services? If yes, would you like to share what are the types of incentives aregiven?

11. Does the organization have any non- financial incentives for rural and remoteareas placement of physicians and nurses for attracting and retaining them in rural

area services? If yes, would you like to share what are the types of incentives aregiven?

12. Does the training and promotional system have linked as a kind of incentives for

rural area placement?

13. If Yes, How do you select these employees for training?

14. What are the initiatives at your level to maintain the minimum posting tenure in

rural areas of physicians and nurses?

15. Are there any comments you would like to provide regarding the subjects not

covered in this interview regarding HR practice regarding Physicians and nurses?

16. Would you like to through a light on the following issues under reform initiativesin the state? (TO BE ASKED ONLY FOR STATE LEVEL MANAGEMENT

REPRESENTATIVE)a. Development of HRM & HRD policy especially related to contractual

physicians and nurses under NRHM b. Availability of essential equipments, drugs and supplies for functionalizing a

health centers in rural areas

c. Capacity building

d. Supervision of supporting nature

e. Nursing and Paramedical education and Schools

f. Medical Education and Colleges

g. Accommodation facilities (New Residential Qtrs) in the rural areas health

institutions

3. INFORMATION ON HUMAN RESOURCE IN THE DISTRICTS

1. Would you like to share the details on Health Institution in the district/state?

a. Number of Total Health institutes in the District/State

Sl.No. No of Health institutes in the District Numbers

1 District hospitals/ General Hospitals

2 CHCs

3 PHCs

4 SCs



383

b. Number of Health institutes in Rural and remote areas in the District/State

Sl.No. No. of Health facilities Total

1 Total no. of sanctioned sub centres

2 Total no. of functional sub centres3 Total no. of sanctioned PHCs

4 Total no. of functional PHCs

5 Total no. of 24x7 PHC

6 Total no. of non 24x7 PHCs

7 Total no. of CHC

8 Total no. of CHC (FRUs)

9 Total no. of CHC which are non-FRUs

2. Would you like to share the details on the numbers of physicians, nurses and mid-

wives in the district/state?

c. Numbers of MO, GNM & ANM according to the Health institutions in the District

Sl. No.Health institute in the

District

Total Number of

P h y s i c i a n s

( M e d i c a l

O f f i c e r s )

( i n n o s . )

N u r s e s

S t a f f

n u r s e / G N M

i n n o s .

M i d - w i v e s

A N M

( i n n o s . )

P a e d i a t r i c i a n s

A n a e s t h e t i c s

G y n a e c o l o g i s t

1 District Hospital

2 CHCs

3 PHCs

4 SCs

Total

d. Numbers of MO, GNM & ANM according to the Rural and remote areas Health

institutions in the District/state

Sl. No. No. of facilities Total

1 Total no. of SCs existing / having infrastructure

2 No. of SCs having one ANM

3 Total no. of SCs having two ANMs

4 No. of PHCs not having any MO (MBBS)

5 Total no. of PHCs not having 3 staff nurses/ 3 ANMs

6 No. of CHCs not having full complement of specialists

i.e. Gynaecologist, Anaesthetist, Paediatrician

:::::::::Thank You:::::::::



CONFERENCE ATTENDED

1. NATIONAL CONFERENCE ON INFORMATION AND KNOWLEDGE

MANGEMENT, 12TH

MARCH 2011

AT FAKIR MOHAN UNIVERSITY, VYASA VIHAR, BALASORE,

ORISSA

(Presented a paper entitled: Knowledge management improve

effectiveness in Human Resource Management)

2. INTERNATIONAL SEMINAR ON RESOURCE, TRIBES AND STATE,

13TH

TO 15TH

FEBRUARY 2012

AT RAJIV GANDHI UNIVERSITY, RONO HILLS, DOIMUKH,

ITANAGAR, ARUNACHAL PRADESH

(Presented a paper entitled: A study on distribution, attraction and

retention of physicians and nurses to combat maternal and child

mortality in four predominately tribal state of North-Eastern India)3. INTERNATIONAL 5

THDOCTORAL THESES CONFERENCE, 2

NDTO

3RD

APRIL 2012

AT IBS, ICFAI FOUNDATION FOR HIGHER EDUCATION,

HYDERABAD, ANDHRA PRADESH

(Presented a paper entitled: An exploratory study on distribution,

attraction and retention of physicians and nurses in rural areas in

Arunachal Pradesh)

4. NATIONAL CONFERENCE ON HUMAN RESOURCE

MANAGEMENT (2ND

), 8TH

APRIL 2012

AT MANAGEMENT DEVELOPMENT RESEARCH FOUNDATION,

NEW DELHI

(Presented a paper entitled: Human Resource for Health in rural

communities-A Study on distribution, attraction and retention in Indian

public health system with special reference to Arunachal Pradesh)

5. INTERNATIONAL CONFERENCE ON CONTEMPORARY

INNOVATIVE PRACTICES IN MANAGEMENT, 13TH

TO 14TH

APRIL

2012

AT PACIFIC UNIVERSITY, UDAIPUR, RAJASTHAN

(Presented a paper entitled: The 21st century employment contract for

solving numerical inadequacy of health workforce in Indian rural public

health system – 2005-12)

attraction and retention of physicians and nurses in rural areas in india

Documents