Shortage and inequalities in the distribution of specialists across community health centres in Uttar Pradesh, 2002–2012

Government health services in rural India are mainly provided through a three-tier hierarchy of publicly funded health facilities, with community health centres (CHCs) – 30-bed, 24 × 7 rural hospitals that serve about 120,000 people – at the top, primary health centres (PHCs) in the middle, and health sub-centres (HSCs) at the bottom [1]. While HSCs and PHCs provide essential healthcare services, the CHC provides specialist services and acts as a referral centre for the PHCs and HSCs in its catchment area. It provides specialist services to deal with surgical, paediatric, obstetric, and gynaecological emergencies through a team of healthcare professionals that includes four specialist doctors (doctors with a postgraduate medical degree in specific areas), namely surgeon, paediatrician, obstetrician, and anaesthetist [2].

Since private health facilities that offer specialists services are mostly found in urban areas, the onus of providing access to specialist services in rural areas primarily lies with CHCs [3]. The shortage and unequal distribution of a specialist workforce at the CHC level can have serious implications not only for maternal and child mortality, but also for the quality of health-service delivery at higher levels, such as in district or regional hospitals [4]. Since the rural poor mostly rely on publicly funded facilities for their healthcare needs, the lack of specialists at the CHCs often forces them to either forgo treatment or avail specialist services from the private sector, which is infamous for its exorbitant fees [5, 6]. The lack of CHC specialists may cause higher disease burden and mortality for the rural population, and it could also trap rural households into a vicious poverty cycle due to the high out-of-pocket expenditures faced when seeking medical care [5].

The lack of specialists in CHCs also forces the rural poor to seek specialist services from higher-level, publicly-funded hospitals (such as district hospitals and medical colleges) or other CHCs in proximity [7]. The influx of those patients who should have been treated at their local CHC, into the higher-level facilities that are meant for complex and serious cases or in other CHCs, often results in overcrowding, long queues, delays in treatment, and untimely deaths [8]. The lack or unequal distribution of the health workforce (for instance, specialists across CHCs) could also lead to the ineffective use of physical infrastructure and equipment, rendering the invested infrastructure and equipment useless [9]. Hence, it is important to ensure that all CHCs are equipped and staffed with a team of four specialists, as recommended by the Indian Public Health Standards (IPHS) of the Government of India.

The state of Uttar Pradesh (UP), home to over 200 million people, is the largest state in India in terms of population size [10]. It is usually ranked lower than the other states in terms of health- and mortality-related indicators, especially in maternal and child mortality. For instance, the current maternal mortality ratio (MMR) (300 maternal deaths per 100,000 births) and infant mortality rate (IMR) (50 deaths per 1000 births) is about same as the MMR and IMR of many underdeveloped and poor African countries [11]. To improve the situation and reduce the level of burden placed on higher-level facilities, the state of UP not only needs a strong pool of doctors, nurses, and midwives for PHCs and HSCs but also requires a strong and effective specialist workforce at the rural CHCs.

Although the state has rapidly expanded its network of rural health facilities in the last decade, and the number of CHCs in the state has more than tripled [12], little is known about the changes that have occurred in the size and distribution of the health workforce at CHC level in UP. The focus of previous studies on the health workforce in India has been primarily on doctors, nurses, and midwives, and specialist doctors have never received due attention [13‐17]. Much of the past literature that measured distributional inequalities and shortages in specialists have emerged from developed countries [18‐20].

The aim of this study, therefore, is to measure the change in the shortage and inequality in the distribution of a specialist workforce across publicly funded rural hospitals in UP, while accounting for the sources of those inequalities during a period of about 10 years (between 2002 and 2004 and 2012–2013), which is when major health system reforms were implemented and the number of CHCs had increased significantly within the state [21]. This paper also aims to identify the factors associated with variation in the availability of specialists across CHCs during the most recent period for which data are available (i.e., 2012–2013).

The results indicate that the absolute number of specialists at CHCs in UP has increased from 2002 to 2013; however, the shortage of specialists in relation to the requirement (as based on the number of CHCs) has grown as well. This is due to the fact that the increase in the number of newly established CHCs has been far greater than the increase in the number of specialists recruited during the study period. The current shortage of specialists is about 80% of the total requirement (based on the current number of CHCs in the state). The overall shortage becomes significantly more acute if the population-based IPHS norms are applied to the current situation. The overall scenario indicates that the efforts being made to fill vacant positions for specialists at CHCs in the state are grossly insufficient.

There could be several reasons why the state government has not been able to increase the number of specialists in the system. First, there are simply not enough specialists graduating every year to fill the gap. For instance, the medical colleges in the state (including private ones) have only 93 and 74 postgraduate seats in total in obstetrics/gynaecology and paediatrics courses, respectively [42]. Even if one assumes that all obstetricians will join CHCs upon completion of their courses which, given the current policies, is obviously not going happen, it would still take six to 7 years to fill all vacant positions for obstetricians at the CHCs in UP. The same holds true for other categories of specialists as well.

One study found that the state has been ‘lethargic’ as far as recruitment of health workers is concerned [43]. It also argues that one of the reasons why the state is not able to recruit enough people could be the lack of candidates applying for the Provincial Medical Services, the method through which specialists in the state are recruited for their service in public health facilities [44]. It has been noted that a lot of those who do apply and get selected for these positions do not show up for the interview due to the lengthy recruitment process, leaving many posts vacant [45]. Since the state does not have a provision of waiting lists for regular appointments, there is no way to fill the posts left vacant by those who prefer not to join the services [43]. Many previous studies have found that specialist doctors are also recruited against the post of ‘medical officer’. Such policy loopholes further aggravate the problem of specialist shortages in the system [44].

In the past, the state has tried to fill specialists positions through short-term contractual appointments, but this has been done with limited success [45]; in fact, only a few seats have been filled in the last 10 years [46]. A recent study has noted that district authorities who were in charge of implementing this measure were not very keen to take up such measures [4]. Although the state government has invited retired specialists to re-join the system this year to provide their services, the specialists’ deployment is limited only to District Hospitals [47]; CHCs do not seem to be the priority at the moment.

Previous studies in other Indian states have found that most specialists, after they finish their studies, prefer private practice rather than joining public health system; this is done primarily for economic reasons [48]. Currently, the state of UP does not have strong financial and non-financial incentives for working in rural areas. Even those that do exist are too weak to offset the opportunity costs of working in the private sector [48‐50]. Another obstacle associated with recruiting specialists is that the policy allows only those doctors who are registered in UP to join the system. Thus, specialists registered in other states cannot become a part of the state’s public health system [4, 43]. In addition, the huge shortage of a specialist workforce in the state is also the result of a lack of vision for the health workforce in rural public health facilities. It is surprising that the state still does not have a framework for medium- or long-term human resource for health (HRH) planning for its rural health system [51]. Moreover, the state also lacks a central HRH database that could help policymakers to keep an eye on HRH dynamics in the public health system [52].

Similar to previous small-scale studies, this study also found that a huge number of CHCs do not have the correct combination of specialists to provide emergency obstetric care or to conduct surgical interventions, such as caesarean section [51]. While some CHCs have a gynaecologist, but not an anaesthetist, there are other CHCs where the latter is posted without any surgeon. Also, there are many CHCs where an anaesthetist is posted alone without any paediatrician surgeon or obstetrician [4]. Such misallocation of the specialist workforce across CHCs can cause gross underutilization of the skills of specialist doctors, while also constituting a waste of financial resources [53]. Therefore, the government of UP should focus not only recruiting more specialists, but also on redistributing the existing specialist workforce in correct combinations to fully utilise their services.

The inequality analysis revealed that while the inequalities for doctors and nurses have decreased, the inequality in the distribution of specialists has increased during the study period (i.e., 2002–2013). The decomposition analysis indicated that the share of within-district inequality has always been higher than between-district inequality. It is interesting to note that the share of within-district inequality has risen steadily over the period. The current share of within-district inequality in terms of total inequality is about 85%; therefore, the strategies to reduce inter-CHC inequality in the distribution of specialists should focus on those districts that contribute the most to overall within-district inequality. Several districts in the Poorvanchal (eastern UP) and Avadh (central UP) regions contribute heavily to the overall within-district inequalities. Most of these districts are characterised by low maternal and child healthcare utilisation when compared to the rest of the districts in the state [54]. They also lag behind in terms of socio-economic development [55]. Thus, the situation of these districts echoes what is known as Hart’s ‘law of inverse care’, which states that the availability of good medical care tends to vary inversely with the need for it in the population served [56]. Therefore, the need of the hour is to update recruitment and deployment policies, so that they not only focus on improving the overall availability of specialists through increased recruitment activities in these districts, but also on equitable deployment of specialists within these districts.

The current distribution of specialists across CHCs could be the result of a number of factors ranging from recruitment and deployment policies of the state, to the personal choices made by doctors who, themselves, are affected by several factors such as working environment, amenities, availability of a residence, and travel times, and so on [57, 58]. A recently conducted study revealed that most postings for doctors in the state are highly politicized and it is not unusual for doctors or health workers to use their political influence to cherry-pick their desired facility. The unavailability of doctors in many facilities across the state makes it even easier for them to get transferred to a place of their choice [44]. As a result, the facilities with the greatest need – largely those that are in far-off and poorly connected rural areas – are often neglected.

Utilizing the variables available in the latest dataset, this study also examined whether these variables are associated with specialist availability at the CHCs in the state. The results of the analysis revealed that the CHCs with a low number of health workers (fewer than 10) are expected to have a low number of specialists. It is possible that those CHCs with a low number of health workers face a higher burden of work that forces specialists to move out to health facilities staffed with higher numbers of health workers, thus experiencing relatively lower burden [59, 60]. The results of the regression analysis also revealed that those CHCs that had residences available for specialists are expected to have a higher number of specialists than those CHCs that do not have residences for specialists. These results are in line with those of several previous studies conducted in developing countries [48, 61, 62]. For instance, several respondents from a study conducted in Malawi reported that poor housing conditions at the hospital served a factor that lead to demotivation; as such, these specialists left their jobs [63]. The same was found to be true for doctors from Ghana, who reported that they were willing to take rural posts, but the lack of work-based accommodations and delayed renovations forced them to give up a prospective rural post, and so they settled in a city instead [36]. It should be noted that over half of the CHCs in the state do not have residences for specialists.

Many previous studies showed how the availability of basic amenities, such as water and electricity, are regarded as necessary by health workers; similarly, the results of this study also showed that the lack of electricity connection is associated with a decrease in specialist availability. The supply of electricity in the state is highly regular and the rural areas receive electricity for only 6 h a day, on average [64]. The urban life (electrical appliances are an integral part of daily life in urban areas) which specialist doctors are accustomed of and wish to lead, is nearly impossible in such rural settings. Given that a considerable number of CHCs, especially the recently commissioned ones, in the state are often located in the outskirts of the main settlement, not having a regular supply of electricity poses a serious security threat, as a lack of lighting, especially during the night, makes them vulnerable to violence, theft, and burglary [50].

In this study, the location of a CHC has been found to be a significant predictor of the number of specialists available at a CHC. It turns out that the CHCs located in rural areas of the state are likely to have fewer specialists than their urban counterparts, regardless of their FRU status. This finding is in tune with those of many previous studies, which have found that rural and remote health facilities are often poorly equipped and inadequately supplied with drugs [65], their physical working conditions are severe [49], the career growth opportunities are fewer [50], and staff are poorly supported or supervised and often feel isolated and neglected [66].

The unavailability of specialists in rural areas could be attributed to a number of push factors such as poor road connectivity, an unreliable public transport system, a lack of quality schooling for children, and so forth, that repel health workers from rural and remote areas [41, 57‐59, 67, 68]. Most rural areas in the state have poor road connectivity and public transport is almost non-existent [69]. In such situations, the use of private vehicles becomes necessary. Since the state government does not provide any transportation or rural allowance [70] to travel to those CHCs located in rural and far-off areas, it is not difficult to understand why rural CHCs have fewer specialists when compared to their urban counterparts, which are well connected to district headquarters or major cities through major district roads and state highways. The unavailability of quality schooling for children in rural areas is another issue that is often quoted as a reason for not joining/leaving rural health services [67, 71]. The desire for specialist doctors to live with their families has also been noted as a reason for the lack of specialists in the rural public health system. In this regard, a recent study conducted in four North Indian states has found that a considerable proportion of specialists are willing to leave rural CHCs to live with their families in towns, cities, or district headquarters [4].

The study has several strengths. First, it contributes to the scant literature available on the issue of HRH shortage and the inequalities in the publicly funded health system in rural India. It is probably the first study to delve into the issues associated with specialist distribution in the public health system of UP. Unlike previous studies that featured small sample sizes, the present study included all rural hospitals of the state in question. Therefore, the reliability of the results is not an issue, and the findings can be used to inform policy development. Furthermore, the decomposable inequality measure applied in this study is a widely used and tested method in the field of HRH inequalities. The limitations of this study must be noted as well. First, given the cross-sectional nature of the dataset, casualty cannot be inferred. The relationship in the regression analysis may suffer from reverse casualty. It is possible that those CHCs where specialists are posted receive more resources and better facilities, or vice versa. Second, several factors such as personal preferences, working conditions and organizational environment, incentives, career growth opportunities, etc. that may affect the distribution of specialists across CHCs were not included in the analysis given the lack of such variables in the dataset. Third, the analysis does not address the situation after 2013. This is because the unit-level data on specialists for 2013 onwards is not available.

The present study has highlighted some critical issues related to the shortages and distributional inequalities of the specialist workforce in the Indian state of UP. Future research could undertake similar analysis for other Indian states; they can also analyse whether areas with higher numbers of specialists in the public health system are more likely to have better maternal and child health outcomes. Such an analysis could help policymakers decide upon the future roadmap to achieve maternal- and child-health-related sustainable development goals [26, 72].

The CHCs in the state are not only suffering from a huge shortage of specialists, but also from deep distributional inequalities in the existing workforce. The situation has become progressively worse over the study period. The shortage of specialists has shot up from 80 to 85% of the total requirement, and the inequality in their distribution has grown considerably as well. Decomposition analysis revealed that a large part of the overall inequality in the distribution of specialist doctors stems from within-district inequality. Moreover, the contribution of within-district inequality to overall inequality has steadily grown over time. The HRH policies in the state should thus focus not only on recruiting more specialists, but also on finding innovative strategies – such as rotation postings or higher monetary incentives for difficult and far-off areas – to influence the within-district distribution of specialists to make it more equitable. The focus should be on those districts from eastern UP where resources are highly concentrated in only a few CHCs. It has also been noted that rural CHCs, on average, have fewer specialists when compared to their urban counterparts. Therefore, targeted attempts should be made to deploy and retain a specialist workforce in rural CHCs. Apart from recruiting and deploying more specialists, the government should ensure the availability of basic facilities such as water, electricity, and quality accommodations for doctors at the CHCs, especially for those CHCs that are in interior locations and where commuting to the city is not possible. Future health workforce policies and interventions in the state should thus focus on increasing specialist availability in rural CHCs. From the discussion, it is clear that the state lacks strong monetary and non-monetary incentives/rewards for rural service that could stave off the negative effects of the rural location of the CHCs. This is a policy gap that the state government needs to consider immediately.