BackgroundWhile international literature on rural retention is expanding, there is a lack of research on relevant strategies from pluralistic healthcare environments such as India, where alternate medicine is an integral component of primary care. In such contexts, there is a constant tug of war in national policy on “Which health worker is needed in rural areas?” and “Who can, realistically, be got there?” In this article, we try to inform this debate by juxtaposing perspectives of three cadres involved in primary care in India—allopathic, ayurvedic and nursing—on rural service. We also identify key incentives for improved rural retention of these cadres.MethodsWe present qualitative evidence from two states, Uttarakhand and Andhra Pradesh. Eighty-eight in-depth interviews with students and in-service personnel were conducted between January and July 2010. Generic thematic analysis techniques were employed, and the data were organized in a framework that clustered factors linked to rural service as organizational (salary, infrastructure, career) and contextual (housing, children’s development, safety).ResultsSimilar to other studies, we found that both pecuniary and non-pecuniary factors (salary, working conditions, children’s education, living conditions and safety) affect career preferences of health workers. For the allopathic cadre, rural primary care jobs commanded little respect; respondents from this cadre aimed to specialize and preferred private sector jobs. Offering preferential admission to specialist courses in exchange for a rural stint appears to be a powerful incentive for this cadre. In contrast, respondents from the Ayurvedic and nursing cadres favored public sector jobs even if this meant rural postings. For these two cadres, better salary, working and rural living conditions can increase recruitment.ConclusionsRural retention strategies in India have predominantly concentrated on the allopathic cadre. Our study suggests incentivizing rural service for the nursing and Ayurvedic cadres is less challenging in comparison to the allopathic cadre. Hence, there is merit in strengthening rural incentive strategies for these two cadres also. In our study, we have developed a detailed framework of rural retention factors and used this for delineating India-specific recommendations. This framework can be adapted to other similar contexts to facilitate international cross-cadre comparisons.

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.

No abstract

Disease-specific programmes in India are widely regarded as having made a substantial contribution in disease control. They can have both positive and negative effects on health systems. Certain conditions are necessary for them to have a positive influence on health systems—the programme needs to have an explicit policy to strengthen local health systems, and should also be embedded within the health system administration.

IntroductionIn this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of ‘written’ policies in India—to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study.MethodsTo elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra—collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top–down and bottom–up lenses of the policy process.ResultsPrimary health centres were originally envisaged as ‘social models’ of service delivery; front-line institutions that delivered integrated care close to people’s homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors’ disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals.ConclusionsThis paper highlights some contextual complexities of implementing PHC—considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC—but cannot deliver on its ideals.

Under the NGO–government partnership, wasting among children under age 3 decreased by 28% in intervention areas and by only 5% in comparison areas. Success factors included persuading and engaging with communities including delivery of tailored information, close presence and supervision of field staff, and holistic management of other issues beyond acute malnutrition. This intensive approach may be challenging for the government to adapt effectively at large scale.

BackgroundIn India, though breastfeeding is universally practiced, exclusive breastfeeding (EBF) rates in urban informal settlements are low; and health programs face several challenges in promoting EBF. In this study, ensconced in one program area of a non-government organization, we focused on “positive deviant”- mothers who were able to practice EBF for six months and attempted to delineate factors that shaped their EBF practices. Typically, qualitative research from Lower and Middle Income countries on EBF has focused on understanding why women do not practice EBF; the converse perspective taken in this study has been less explored.MethodsWe employed the positive deviance approach which contends that important programmatic learnings can be attained from persons who adopt positive behaviours. We conducted twenty-five diverse, purposively sampled case-studies of “positive deviant” mothers from two urban informal settlements in Mumbai; and analysed these using a framework approach. The results were summarised using a socioecological framework (consisting of individual, interpersonal, organizational and environment levels).ResultsWe found that mothers typically construed EBF as not giving breastmilk substitutes. Giving the infant minor supplements (water, honey) was not considered a violation of the EBF practice. The main themes that emerged as influencers of EBF included: at individual level, perceptions of having adequate milk; at interpersonal level, having role models who practiced EBF and having family support; at organizational level, advice from health workers (which was purported to play a secondary role); and at environmental level, financial constraints that limited access to supplements. One important finding was that women who practiced EBF could not always do it optimally; we encountered several instances of “poor EBF” practices, where mothers had breastfed infants inconsistently, allowing for long gaps between feeds, and had continued EBF even after six months.ConclusionsThere is an urgent need for health programs to clarify the meaning of EBF and counsel against “poor EBF” practices. Messages received by women from immediate family on EBF were powerful and families play an important role in the actualization of optimal EBF practices. Hence, it is imperative to counsel entire families on EBF rather than women alone.

Community interventions for people with physical disabilities and for people with mental illness have evolved following similar trajectories, although at different periods of time. This study develops and tests indicators for successful integration of community-based rehabilitation (CBR)-mental health and development (MHD) services. An in-depth study was conducted of two organizations in Sri Lanka and India that successfully integrated CBR and MHD services as well as two organizations in Nepal and Bangladesh, which were planning integration. Interviews and focus groups were used to gather nonconfidential information. The study suggests many benefits of integration and several indicators of readiness: willingness to work with mentally ill people, a basic understanding of the mental health concept and mental illness problems, a match of context and strategy between current CBR activities and proposed MHD activities, stability of basic resources and infrastructure in the organization. A second set of indicators determined the long-term viability of an integrated CBR-MHD approach: ability to strategize and plan a mental health programme, ability to network with stakeholders effectively, ability to make use of resources efficiently. A major finding of the study was the need for training in the practical aspects of integration of mental health interventions with CBR. Tool sets are available that can be used by donors and by local organizations for assessing needs and readiness as well as developing viable strategies for the integration of community-based mental health interventions into existing CBR work.