70242



                       SlIpportillg E vidence-based Policies am/lmplemefltatioll

               CHALL ENGES IN RECRUITMENT OF DOCTORS BY GOV ERN MENT'
                                              Shom ikho Raha' , Peter Bcmlan!, Krishna D. Rao"

This /lote describes sO lli e oflhe problems found in recrtliting flew doctors 10 the government health care !>ystem. drawing
 on rite recent experiences illlhree cases: the Ceil/raJ Health Service (CHS). the VilaI' Pradesh (UP) government health
  care .\ystem alld Tamil Nadll governmen t health care !,yslem. In comparing tlte dijJerell1 experiences of recruilmell/ ill
  the l!tree cases, the policy /wle highlights ills/ifIllionai issues alld 'he incenlives built il1tO all employment package as
               imporfalll JorJurther cOllsideration in rhe ailll to scale lip rhe /llImbers ofgaven/men! doctors.

FRAMING THE PROBLEM                                                       governmen t on the numbers who do join. In the CHS, fewer
Insufficient numbers of doctors in government health care                 doctors were selec ted than the exist ing vacancies;
service provision throughout the country, both general                    signi fi cant ly fcwer sti ll joined. For both states, the numbers
medi cal officers and specialists, has bcen a matter of                   of applicants werc vastly more than the vacancies, but fewer
government concern for some lime (7<11 Plan, 1985-89; Bajaj               physicians than the numbers required were selected largely
Report, 1987; NHP 2002; NCM I-I2005). This has come to                    due to the shortage or absence of applicants in certain
the fore as evidenced by significant government efforts to                specializations such as anatomy, community medicinc,
scale-up health care delivery through the National Rural                  obstetrics, gynecology, pathology, physiology and forensic
Health Mission (NRHM). The Government of India has                        medicine. 1 In UP, no data was available on the numbers who
increased its financial allocation to health through NRHM                 joined since the districts had to report whether a doctor has
and set out a new Indian Public Health Standard (I.PI-I S) -              taken up a post. Invariably, di stricts in UP reported
nornlS for health facilities that, to be achieved, will require           vacancies but not accurate data on numbers that joined after
many more doctors to enter public service '.                              receiving initial posting orders. This is an important lacuna
                                                                          to be addressed. On the basis of current anecdotal evidence
Increasing the numbers of physicians in government service
                                                                          from the UP Directorate, numbers joining were generally
and particularly for the staffing of rural and lower level
                                                                          much lower than the vacancies to be filled and therefore
health facilities is a multi-dimensional problcm. One useful
                                                                          simi lar to the CBS experience. Data from a recent
way to look at it is in tcnns of three related processes -
                                                                          recruitment cycle in Tamil Nadu (TN) demonstratc it has
production of physicians, recruitment to government
                                                                          bcttcr performance in the numbers that arc selected and join
service, and retention. in this note, we will focus primarily
                                                                          compared to the CHS.l
on inst itutional factors affecting physician recruitmcnt and
the incentives in the employment package offered to the                   EXPLAINING THE DIFFERENCES IN PHYSICIAN
physician.                                                                RECRUITMENT
EXAMPLES OF RECENT EXPERIENCES IN PHYSICIAN                               The causes of these differences arc complex. While the
RECRUITMENT IN UTTAR PRADESH, TAMIL NADU
                                                                          experience of the CHS, TN and UP cannot be generalized to
                                                                          other states, they highlight important constraints to
AND TO THE CHS
                                                                          successful recruitment. Some of them stem from the
Figures 1-3 show vcry differcnt experiences in the three
                                                                          institutional cOlltext. Others relate to either organizational
cases under study in their ability to successfu lly recruit
                                                                          issues within the health department orto coordination issues
physicians into government service. Variation is also
                                                                          between the hea lth and other government agencies in volved
evidcnt in thc quality of basic infommtion available with
                                                                          in recruitment, such as the Public Service Commission. But

. Health workers in sufficient numbers. in the right places. and adequately trained, motivated and supported arc the backbone of an
effective, equitable, and efficient health care system. Success in creating and sustaining an effective health workforce in India to achieve
national health goals will require sound policy and creative and committed implcmentation. More and better infomlation on human
resources for health in India is onc clemcnt nceded to achieve this. lllis policy note summarizes recent and ongoing work in support of
India's health work force goals. For the full report. see Raila. S. el al "HRH: A Polilical Eco"omy and IlIslillllio"al A"alysis of IIle I"dia"
COlllexl" HRH Tech"ical Reporl #2 at www.hrhi"dia.org
t The World Bank. New Delhi. India; : The World Bank, Washington DC; " The Public Health Foundation of India, New Delhi
 Figure I : Doctor Recruilmenl in CHS                                                     Due to budgetary reasons, 'vacancies ' declared and
 CMSE Batehes 2004-06 and Specialisls 2005-07                                             advertised arc based on the unfilled numbers of sanctioned
                                                                                          posts, which do not necessarily match population-norm
  ''''''                                                                                  requirements. As per the GO I norms, thc number of doctors
  '''''''
   .00                                                                                    required at PH C and CHC are 83,945 witl] a present
   "'"                                                                                    short fa ll of 61 ,672. With the adoption of lPl-IS norms, the
   "'"                                                                                    extent of the recruitmcnt problem is significant ly more
   "'"
     o                                                                                    acute. N umbers of doctors req uired increase to 183, 153
                 Vacancies               Set"",. d by Gol                 Jo;nl'<i
                                                                                          with an over 60% increase of the current shortfall in doctors
 Source : CCA, Mo HFW
                                                                                          at· these faci lities to 160,880 (Rao·NHSRC, 2008). The
 Figure 2: Doctor Recruitment in Uttar Pradesh
                                                                                          numbers of declared vacancies rema in much fewer.
 Round o f 2005 Requisition
                                                                                          Especially in light ofthe Centra l Government's aim to reach
  ."""                                                                                    IPH S standards, the recruitment chall enge of physicians is
  ""'"
  "''''                                                                                   consequentl y signi fi cantl y under-represcnted in the number
  2~L       •••L~
              Vacanci""           Appl; cants
                                                                           "    I '
                                                                               Jo;ned
                                                                                          of sanctioned posts to fill.
 Source : UP Minis"), of Hcahh. UP Public   Ser.'k~   Commission
                                                                                          In UP such under-representation, in sancriol/ed /lum bers of
                                                                                          doctors the government system requires, can adversely
 Figure 3: Doctor Recruitment in Tamil Nadu
 Round of2oo3 Requ isition                                                                effect recruitment. In this state, reports from the distri cts arc
  .000                                                                                    the basis for ascertaining whethcr a doctor in government
  '''''''                                                                                 servicc is acti ve. Acknowledging reporting defic ienc ies, the
  """
  '''''''
                                                                                          UP Directorate admits many of the 2278 doctors at e nt ry~
                                                                                          leve l may not currently be active in the system. The process
  "'''''
  '''''''                                                                                 for determining a 'vacancy,' when a non -practicing doctor
  '''''''                                                                                 remains on rcgisters is furthermore lengthy since the UP
  ''''''
      o                                                                                   Publi c Servi ces Comm ission needs to confirm that a doctor
                                  Appl; ean1s                                  Joil\Cd
 Source : rn Di,,,,,' ora'c of Public Ilcal1h. TN Public Services Commission
                                                                                          recnlited by the Commiss ion is no longer in active service.
                                                                                          At the institutional level of th e UP Directorate, the resu lting
our case studies al so identi fy causes oflow performance that                            chall enge may be sunmlCd up in the fo llowing way: there
relate to an incentive environment, including the scope and                               exi sts an undi sputabl e need to recnllt more doctors, but
content of the employment package offered to physic ians                                  since the total number of doctors (practicing and non-
under recruitment. The remainder of this note focuses on the                              practi cing) who remained on the rolls exceeded the numbers
institutional and the incenti ve-based causes separately.                                 sanctioned, no recruitment could be possiblc. In contrast , all
A_Institutional issues                                                                    recnlitment of entry-level doctors into govcrnmcnt service
Data from different recruitment rounds for the CHS show                                   in TN has been centralized into a single nodal agency
that significantly large numbers of offers arc cancelled at a                             responsible - the Directorate of Public Health and
late stage in the recruitment process; that is, subsequent to                             Preventi ve Medicinc (DPH). Infornlation on numbers who
offer leiters issued. This would imply that doctors arc keen                              join arc available from the nodal agency that has a tracking
to participate in earl y stages of the recruitment process, but                           system for determining active and non-active doctors. 4
by the time offer letters are received, far fewer remain                                  B. lncentives in the employment package
interested to join. Although there is no single cause that may                            Tamil Nadu , helped therefore by a morc favorable
be attributable for this decline in interest of doctors, the                              institutional context than UP, has also addressed the
length of the recruitment process itse lf is probably a                                   chall enges in recruitment of doctors through adopting
contributing factor. The entirety of the rccruitment process                              schcmes that adopt a multi-pronged approach. These
that engages the health departments and the respective                                    schemes aim to provide an employment package with
Public Service Commi ss ion takcs close to eighteen months                                incentives to attract and reta in the phys ician to govcrnment
in both to recruit physicians to the CHS and in UP. While the                             service.
Un ion Public Service Commission (UPSC) conducts the                                      In cenrive of regularization into Service: Th e mixed record
Combined Medical Services Examination (CMSE) for                                          of contractual hiring of physicians into government service
phys icians applying to join the CHS, th e UP Publi c Services                            in UP and TN make clear why additional incentives matt er.
Comm ission conducts no such entrance exami nation. In                                    To bypass lengthy regular recruitment through the Public
contrast, even though the TN Public Services Commi ss ion                                 Scrviees Co mmi ssion, recruiting physicians on a
conducts se parate en tranc e exa mination for each                                       contractual basis was attempted in UP and suitable
specialization and oral interviews, evidcnce demonstrates                                 eandidatcs instantly recmited in a wa lk·in interview at the
that the entire process is shorter by months than for CHS and                             district. When the scheme in UP initially paid the
UP, taking no more than a year to complete.                                               contractual doctor a third less than regularized doctors but

[l'\[)[A [II ,\L 111 BI ·\T. \'OIUlllC I • \Jumhcr                 -* ( .\ugUq ~()()l))
allowed privat e practice, few responded since the                 show Ihat even those selected through the zona l process
remuneration was too low. In a modified scheme, the                continued to avoid postings in these zones, by resorting to
contractual doctor was disallowed private practice, but now        various unstaled means despite orders of postings to
paid the same as regularized doctors. The scheme had               deficient areas. This resulted in an anomaly of doctors
largely appealed to doctors already practicing in the same         awaiting postings on one hand and shortage of doctors on
rural area. The possibility of continued private practice in       the other hand. This defeated the main objective of the Zonal
the initial scheme provided the doctor an incentive to build       System.
credibility and a network of patients through the public           Over the la st two years, however, TN recognizes
health centre, without terminating his existing source of          ' experience ' in drawing up the Merit Li st on which entry
income. With private practice disallowed in the modified           into a post-graduate (PG) course of study in Government
scheme, it appealed even less to local practitioners and only      medica l colleges is based. The entrance examination
those who had been idle or with very few patients entered          accounts for 90 marks of the total maximum of 100
into contract. In late 2007, two years after the sc heme was       attainable, with 10 marks excl usive ly reserved for
introduced, only 611 doctors on contract existed while large       ' ex peri ence' in specified nlral or hilly areas. One mark is
vacancies persisted. Moreover, genuinely interested                awarded for each completed year in a defined rural area for
applicants to a career in government service keen to be            both in-service and non-service candidates up to a
regularized for job security and other benefits petitioned the     maximum of ten marks or ten years of such service. For
Hi gh Court to ban the contractual system , which the Court        service in hilly areas, 2 marks are awarded at the completion
upheld.                                                            of each year up to a maximum of5 years ofsueh service. The
Doctors arc hired on temporary basis in TN, unlike in UP,          extent to which such an incent ive works in recmiting
through an Employment Exchange with the understanding              doctors keen on PG education 10 rural or hilly areas remains
(an incentive) that their services sha ll be regularized. To be    to be eva luated.
regularized, they need to appear for a "special qualifying         [/leel/tiveofreservation ofseats for PG: TN was the first of
examination" the Tamil Nadu Public Services Commission             the stales to reserve 50% of scats in each specialist branch of
(TNPSC) conducts. This "special" examination is an                 post-graduate study for in-service candidates, in addition to
incentive si nce thc cand idate on contractual appointment         those in·service candidates se lected in the 'open category' .1
requires only a minimal pass (and not a high grade unlike in       This measure has been implemented as an inducement for
regu lar recmitment) to be se lected . Data shows almost all       Bachelors of Medicine (MBBS) snldents, eager on further
contractual doctors eligible for the "Special Qualifying           education, to join government service. In addition, the
Examination" pass it. In 2005 alone, 1249 physicians were          government pays in-service candidates a regular monthl y
recruited through the Employment Exchange. Pri vate                sti pend during the course of their studi es, which covers
practice alongside government service is legall y permitted        tuition fees. Interested in-service candidates for further
in TN. Consequentl y, recruiting contractual doctors on the        education are comp ul sorily required to execute a bond for a
same pay·scale as regularized doctors has been more                significant sum (current ly 10 lakh mpees for degree
successful in TN than UP, due largely to the additional            courses) as security amount with the undertaking thai they
incentives of possible future regularization into service and      will serve the TN Government till retirement or, in some
retaining a lega l private practice.                               specialist fields, 15 years. Table I shows signifi cant
Lel/glh ofstay ill rural area: Some such incentive schemes         numbers of in-service doctors avai led of reserved PG-seats
can be more successful than others in nominally recruiting         in recent years, but whether thi s scheme directly resulted in
doctors but not sufficient ly attractive for them to take up the   increased recruitment of MBBS-trained doctors into
posting the scheme requ ires. For instance, Tamil Nadu             governmen t service, remains also to be evaluated.
introduced a Zonal System in 1996 to recruit doctors to the
under-served remote areas of the State. While recmitment of        CONCLUSIONS AND POLICY IMPLICATIONS
doctors to entry-leve l specia list positions was retained on a    There is a requirement to secure substantially more doctors
Stale-wide basis, the recruitment of all General Assistant         in the government health system, especially in light of the
Surgeons became 011 a zonal basis with the State divided           aim to reach IPHS norms in all health facilities. The number
into nine ' zones'. Doctors appointed to these entry-level         of sanctioned posts currentl y in the country represents a
positions were to be from the same zone as their hometown,         significant under-provision in relation to this requirement.
but had to serve for a minimum period of 10 years in that          Creating posts may be necessary but it is not sufficient ; nor
zone. The system fai led and recruitment was centralized to        is it the answer to the recmitment cha llenge where the
the DPI-I in 2000, as noted above.                                 apparanls of recmilment may be very faulty. This note
                                                                   described through three select cases that a faulty recnlitment
Due to the rule that a doctor should serve in a particular zone
                                                                   apparatus matters for both regular and contractual staff- i.e.
for minimum of I 0 years, of which 5 in rural service, doctors
                                                                   simply using contractual staff did not always solve the
remained reluctant to work in zones of their hometown not
                                                                   problem (e.g. UP ex perience). Both institutional factors and
of their preferred personal choice. Records from the DPI-I

                                                                      ['D[ \ [[I \L [[ [ B[ \ [   \·O[lllllc'   1•   'JllIllOc'1   -t   (\llt!ll,l   .:!OOl))
Table I: Candidates utilizing the     PG~ l ncenti ve   in              recmitment so that the time required for a recmitment cycle
Tamil Nadu (recent years)                                               is reduced; publicly available, well maintained infornlation
                                                                        on numbers who join posts after a recruitment cycle exist;
                                                                        the level of attrition after joining is recorded; and the exact
                                                                        location of current vacancies is availab le.
                                                                        Review of recruitment targets with reference to realistic
                                                                        estimates of capacity and yield. In this regard , the current
                                                                        IP]-(S~ s ugge s ted numbers are an ambitious increasc over the
                                                                        current workforce strength and officially sanctioned
                                                                        numbers. Official data reported for the states of Gujarat,
                                                                        Rajasthan , West Bengal and Uttarakhand (as examples)
Source: DME, Tamil Nadu Government                                      suggest that reaching the I.PHS targets require that the
"the package" (incentives) matter. 6 Both may require a                 current workforce of medical officers increase 3.4, 3.5, 7.3
multi~pronged approach to the recruitment challenge, as                 and 3.8times, respectively. Forspccialist doctors, it needs to
seen in the several measures (s uccessful and not) that have            increase 28.5, 5.1 , 6.3 and 5.3 times, respectively (based on
been attempted by government in TN over the years. Above                calculation from thc Ma rch 2007 RJ-IS Bulletin and the
all, evidence from this note suggests solving recmitment                IPHS nornlS for a Primary Health Centre and a Community
issues requires more robust state~speeific analyses, policies           Health Centre. Gi vcn past experience, these targets may
and action strateg ies. Focusing on increasing financing to             require reconsideration forthe immediate future.
expand and fill posts in the current state contexts is unlikely         Incentive packages offered in states such as TN (that include
to bring in the numbers of physicians the health system                 50% reservation for PG studies; possibility of regularization
reqmres.                                                                for contractual doctors ; additional marks in PG entrance for
NEXT STEPS/ RECOMMENDATIONS FOR ACTION                                  mraVhilly postings) need to be urgently eva luated and, if
Reform the in stitutional apparatus around doctor                       proven successful, replicated in other states.



 I Achieving IPHS nonns would also require increases in other types of health workers, which is discussed in Note NO.5 of this volume.


' For detailed data, see Raha, S. et al" HRH : A Political Economy and Institutional Analysis of the Indian Context" HRH Technical Report
#2 at www.hrhindia.org
, An imponant incentive the states offer over the CHS to physicians is a posting in likely their 'home statc'. On the other hand , the CHS
provides opportunities of postings that arc mostly not rural.
' Here, 'active' doctors refer to those on the rolls and have reponed to duty and 'absenteeism' is checked by the DPH through occasional
visits but cannot be ruled out.
' Here 'open category' refers to the remaining 50% of scats to which all mcdical students from the state may apply, including the 15%
open to candidates nationwide through examinat ion.
· See Note No.6 of this volume on career preferences ofmcdical students.
REFERENCES
GO I. 1989. Nalional El/ucation Policy in Health Sciences (DraJi): COlISultatil'e Group Rq)ort submitted by Prof. J .S. Bajaj.
GOI. 2006. Retell/ion ofHealth Mallpower in GOl'el'lllllelll Sector (CHS): Repon of the Expert Committee.
IPHS, GO[. 2007. lndiml Public Health Standards(fo rdilTerent facilities). MinistryofHealth & Family Welfare, New Delhi.
NCMH, GO I. 2005. Report Ofthe Natiollal Commission on the Macroeconomics ofHealth. New Delhi: Govemment oflndia.
NHP. 2002. Notiollal Health Policy. Ministry of Health & Family Welfare, New Delhi.
Rao, T. (N HSRC). 2008. HR Challenges. Presentation at Workshop on HRH and Management of Health Systems, Puducherry, 16 October.
Robens, M., Hsiao, W., Bemlan, P. and Reich, M. 2004. Getting Health Reform Right: A Guide to Improving PellaI'll/once and Equity,
Oxford, U.K.

Editors: Gerard La Forgia, Lead Specialist, HNP Unit, The World Bank, New Delhi; and Krishn a D. Rao, Public Hea lth Foundation
of India, New Delhi.
India Health Beal is produced by the Public Health Foundation of India and the World Bank's Health, Nutrition and Population unit
located in Delhi. The Notes arc a vehicle for disseminating policy~rclevant research, case studies and experiences peninent to the Ind ian
health system. We welcome submissions from Indian researchers and the donor community. Enquirics should be made to Nira Singh
(nsingh2@worldbank.org).
Disclaimer: The views, findings. interpretations and conclusions expressed in this policy note arc entirely of the authors and should not
be attributed in any manner to the World Bank, its affiliated organizations, members of its Board of Executive Directors, the countries
they represent or to the Public Health Foundation of India and its Board of Directors .