Date Published: January 10, 2019
Publisher: Public Library of Science
Author(s): Sonu Goel, Federica Angeli, Nonita Dhirar, Garima Sangwan, Kanchan Thakur, Dirk Ruwaard, Nicola Lacetera.
The shortage of doctors, especially in rural areas, is a major concern in India, which in turn affects the effective delivery of health care services. To support new policies able to address this issue, a study was conducted to determine the discouraging and encouraging factors affecting medical students’ interests towards working in rural areas.
This cross-sectional, descriptive qualitative study has been conducted in three states of North India. It comprised six focus group discussions, each consisting of 10–20 medical students of six government medical colleges. The verbatim and thematic codes have been transcribed by using a ‘categorical aggregation approach’. The discussions were thematically analyzed.
Ninety medical students participated in the study. The discouraging factors were grouped under two broad themes namely unchallenging professional environment (poor accommodation facilities and lack of necessary infrastructure; lack of drug and equipment supplies; inadequate human resource support; lesser travel and research opportunities) and gap between financial rewards and social disadvantages (lower salary and incentives, social isolation, political interference, lack of security). Similarly, the encouraging factors were congregated under three main themes namely willingness to give back to disadvantaged communities (desire to serve poor, underprivileged and home community), broader clinical exposure (preferential admission in post-graduation after working more than 2–3 years in rural areas) and higher status and respect (achieving higher social status).
This qualitative study highlights key factors affecting medical students’ interest to work in rural areas. A substantial similarity was noted between the factors which emerge from the current study and those documented in other countries. These findings will help policymakers and medical educators to design and implement a comprehensive human resource strategy that shall target specific factors to encourage medical students to choose job positions in rural areas.
There is a shortage of doctors globally, especially in rural and remote areas, which hinders the progress towards improving the health of people in these areas [1–2]. This global challenge has been accorded high priority by the World Health Organization (WHO) . Against the optimal threshold of 4.45 skilled health professionals including one doctor per 1,000 population, the estimated shortage is17.4 million experienced professionals and 2.6 million doctors globally, with the greatest shortage in the high disease burden countries of South East Asia and African regions . There is a need to increase the health workforce for achieving essential health services in both low income and upper-middle-income countries . Current data document that more than44% of WHO member states have fallen short of the WHO standard of one physician per 1,000 populations .
Ninety students participated in the study with males (n = 51, 56.7%) outnumbering females (n = 39, 43.3%). The age range was 20–27 years (mean age 22.4 years, SD 2.03) and all were unmarried. Nearly one-third of the study subjects were from the state of Himachal Pradesh (n = 33; 36.7%), and quite similar numbers belonged to Punjab (n = 30; 33.3%) and Haryana (n = 27; 30%). There were almost equal numbers of final year medical students (n = 46, 51.1%) and interns (n = 44, 48.9%). Around one third (n = 32, 36%) belonged to the rural background while one fifth (n = 15, 20%) underwent premedical studies (i.e., prerequisite educational track during secondary schooling for obtaining admission in medical school) from rural areas. (Table 2)
This is the first qualitative study from the northern part of India, which explored the factors influencing medical students’ interest to work in rural areas. The earlier studies have evaluated isolated governmental effortsto retainhealth workforce in rural areas, such asfinancial incentives, compulsory rural field experience, and preferential admission in post-graduation [10–12].Little research on understanding the perceptions of medical students about the factors that can promote rural practice has been conducted, which could serve as good predictors for their subsequent practice location in rural areas. The themes generated out of the present exploratory qualitative study are in confirmation with the themes emanated from the quantitative development and validation study by Goel et al., hence strengthening the findings . Further, the findings of the present study can be mirrored to the Maslow’s Hierarchy of needs theory for the better understanding of the issue of motivation of medical students towards working in rural areas .
This study throws light upon the significant topic of medical students’ interest to work in rural settings and highlights discouraging and encouraging factors that deter or attract them to work in rural areas. The discouraging factors prevailed over encouraging factors which need to be identified and rectified to attract the medical students to work in rural areas. With the present state of affairs where recruitment and retention of students in rural areas appear to remain a continuous challenge for the governments across the globe, the present study offers important clues to policymakers for designing tailor-made, field-tested and cost-effective measures for attracting and retaining a workforce in rural areas. Countries like India need to provide basic infrastructure of health services in rural areas to attract and retain doctors.