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Tuesday, 13 March 2012

Why the doctors don’t go to the villages?

One of the most common complaints against the government doctors is that they don’t want to go to the villages. They are of no use to the poor people with respect to the provision of healthcare services though the cost of making doctors is met from the public exchequer. When they are forced to go (e.g., a few days at the behest of the prime minister), they don’t remain there for long. They try their best, through exercising of their political linkages and monetary power, to issue a transfer order to a nearby town or Dhaka city as early as possible.

The question is: why it is so? When asked about the motivation of becoming a doctor, during student life or after passing, they invariableysay that they want to serve the suffering humanity and want to dedicate their life at the services of their poor country folk. But alas! Nobody keep their promise once they enter into their professional life. They run after earning a fortune within a short span of time, the pervasive disease which is chasing the people of Bangladesh now! All the good intentions, etc. are left behind. Of course, there are exceptions but these are only to prove the norms!

But why this change of heart? I would rather say, why not? Let’s take a closer look at the problem. The root of the problem lies in the process through which medical students are admitted, educated and trained to be a doctor! The current admission process recruits the most meritorious students through a highly competitive, country-wide examination. Then they are educated and trained in a largely urban environment, using a curriculum which deals with diseases mostly prevalent in western countries and with little relevance to the situation obtaining in the rural areas of our country, extending for a long period of time (5+1years or more). This training does not equip the novice doctors to face and tackle real life problems of health and diseases in the countryside. Unfortunately, the role model before them is that of a highly skilled professor who is efficient in the use of sophisticated instruments and techniques, professors who earn a fortune from private practice! Nobody motivates them to serve the rural people with almost bare hands. Rather, there is the motivation for going abroad to earn petro-dollar or build careers. Given this situation, how can we hope that the doctors will go and remain in the villages to serve the poor people?

There are other problems as well e.g., poor infrastructure, equipments and facilities. Then there is the problem of shortage, inappropriate skills mix, and inequitable distribution of health workforce. The doctors may be there, but not the nurse or laboratory technicians or anaesthetists,  etc. without whom doctors cannot work. Beside the problem of security from the political hoodlums, there is lack of education facilities for these children and standard accommodation. There is no career planning for doctors posted in rural areas and no clear transfer policies. All these combine together to de-motivate the doctors to take up rural postings whatever may be the consequences. You may persuade them to go to rural areas by coercion, but you can’t make them reside there for long!

So, what is to be done? We have to start at the very beginning i.e., the admission process of medical students. To make a general practitioner or community/family physician, you don’t need very meritorious students. What is needed is the love to humanity and the country and its people among these young aspirants, mentality of going to and residing in rural areas, and the motivation of serving the disadvantaged community and to be empathic to them. Of those who are admitted through, approximately 1/3rd opt for becoming some kind of specialist and they need to be meritorius. Therefore, the admission process should be designed in such a way so that   both the requirements are fulfilled.

How to do this? What we need is some kind of quota system (though it is very self-destructive while recruiting the public servants) in the admission process. In this revised system, 1/3rd seats will be filled through open competition as currently existing. For the rest, district quota system will be in place for selecting competent candidates from each district (seats allocated proportion to population in districts) according to merit, under the unique exam. While admitting from district quota, attention should be given to allocate seat as near to the home district as possible. This can also be done on Division basis. Whoever is admitted through district quota should give an undertaking to serve his home district/division for a definite period of time after graduating, say at least two years. Only then he can apply for admission into higher education or inter division transfer. This system can be further refined based upon experimentation and experience.

Next, attention should be given to update and revise the current curriculum. The current westernized curriculum needs a thorough overhauling for adapting it to the needs of the people and health system of Bangladesh. Emphasis should be given on the disease burden of the country, how these can be managed in a situation of resource constraints most effectively and efficiently i.e., the basics of health economics. Prevention should get priority over treatment and the students should be adept in understanding and using public health tools of epidemiology and biostatistics. Medical sociology and behavioural science should be included in the curriculum to make doctors humane, and responsive to the woes of the patient, not to treat them as tools of earning money. Emphasis should be given on community medicine, and practicals should be so designed that the students have an idea about the state of affairs in the rural health systems from the very beginning, before they are dumped there after passing. A paradigm shift is needed in the current system of internship---from hospital-based training to community-based training in the upazila health facilities.

Then comes the incentive issue. Incentives for remote posting, an effective system of reward and punishment, a transparent and judicial policy of posting and transfer, etc. would go a long way in motivating doctors to live and serve in the rural areas. Finally, a transparent, equitable and non-partisan career planning is essential for the young doctors, so that they can study and/or serve the country/promoted according to their merit and capability. S/he must not be punished for residing and serving rural areas. For translating these into practice, political commitment and visionary leadership is required, not threat or coercion!

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