By

GANGARAM BISWAKARMA
Registration No. 18710176

UNDER THE GUIDANCE OF

DR. DEBA PRASAD PANDA

DEPARTMENT OF MANAGEMENT SHRI JAGDISH PRASAD JHABARMAL TIBREWALA UNIVERSITY, VIDYANAGARI, JHUNJHUNU, RAJASTHAN 333001 2012

DECLARATION BY THE CANDIDATE

I declare that thesis entitled AN EXPLORATORY STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION OF

PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA is my own work conducted under the supervision of Dr. Deba Prasad Panda, Associated Professor of Commerce at Jawaharlal Nehru College, Pasighat under Rajiv Gandhi University, Itanagar, Arunachal Pradesh. I have put in more than 200 days of attendance with the supervisor at the centre. I further declare that to the best of my knowledge the thesis does not contain any part of any work which has been submitted for award of any degree either in this University or any other university/ deemed university without proper citation.

Signature of Supervisor (with stamp)

Signature of candidate

Signature of the Head/Principal (with stamp)

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CERTIFICATE OF SUPERVISOR

This is to certify that work entitled AN EXPLORATORY STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES IN RURAL AREAS IN INDIA is a piece of research work done by Shri Gangaram Biswakarma, under my supervision for the degree of Doctor of Philosophy in Management of JJT University, Jhunjhunu, Rajasthan, India. That the candidate has put attendance of more than 200 days with me.

To the best of my knowledge and belief the thesis 1. Embodies the work of candidate himself 2. Has duly been completed 3. Fulfills the requirement of ordinance related to Ph.D. degree of the University and 4. Is upto the standard both in respect of content and language for being referred to the examiner.

Signature of the Supervisor (with stamp)

3

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This work is dedicated to my parents: For their inspiration, support, prayers and constant encouragement for accomplishing my academic peak

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ACKNOWLEDGEMENT
This is the part in the Thesis that I am very happy to write without any boundation of pre-requisites, norms etc.. and overall with a very peaceful mind, not just like writing the chapters in this thesis with tense mind. First of all I would like to thank GOD- the almighty for blessing me and gave me the patience, tolerance and courage to complete my final ladder of my PhD studies with this thesis and put me to the 50% part of the people who as per the study of Kurup and Arora, the total number of students who enroll for a PhD only 50% end up completing their thesis. I always believe in dream-a dream you dream alone is on a dream, a dream you dream together is a reality- JOHN LENNON . So, this thesis would never have been completed without the dream of my father, mother, wife, brother and my beloved sister and off-course my in-laws and their moral support altogether. In research study, as we know, choosing a good mentor/guide is the most crucial factor in the successful outcome and timely completion of the thesis, on this front, I made a perfect choice. I would like to express my gratitude to my supervisor Dr. Deba Prasad Panda, Associate Professor, who was always equally passionate and has shown amazing patience and diligence in assisting me to produce this thesis. I would like to sincerely thank my Dad for immense morale support and encouragement throughout my study period not only to complete my PhD but since my first step to the school. Yes DAD, I m proud of being your son. Sincerely thanks from core of my health to my younger brother Pradeep, who went to Qatar to earn for the family as let me continue my PhD study behind. I m proud to get you my brother. My sister Bunu and MUM were always a supportive and encouraging throughout the period of study. At home, finally I would like to express my deep gratitude to my wife Jun. I would never have been able to complete this work without her serenity, her understanding and tolerance, and her sacrifices during the course of study. Thank you Jun, for the countless moments of encouragement and support during my lows in study period and taking care of our little angle ANWESHA in absence of me for almost one and half year since her birth. My Love for Anwesha, as she missed the

needed moments of tender love of a father in her infancy, because I could not be with her side in period of study. I would also like to thank all my in-laws especially father-in-law and elder sister-in-law, who were always in my support throughout the period for my study. I would also like to thank Kartu and his family to support and care for ANWESHA in my absence. This work would not have been possible without the responses I received to both the questionnaire and the interviews. My thanks go to all the respondents who contributed to the research especially those who agreed to be interviewed. I would like to thank Dr. D.D. Agarwal, VC, Dr. Reecha Ranjan Singh & Dr. Manish Sharma, Management Department from JJT University for their help and valuable comments time to time to improve the quality of the thesis. I would also like to thank Lakshminarayan Meena, Narshing Meena, Badri Meena from Jaipur, Sandeep Agarwal from Noida, Rajita Goswami from Itanagar, D.K. Dhir from IISASTR, Delhi, Jacob Mays from SPSSvideotutoral.com, Dr. Ali Nasef from Tripoli University Lybia, Rabiu Ado, Research Scholar from Aberdeen UK, Library Rajiv Gandhi University Itanagar, Library IBS Hyderabad, Library JJT University and all DPMs of Arunachal Pradesh for their support and off course other supporting staffs of JJT University who use to be cordial and always helpful in the event of need during entire period of my stay in the University. Though if I forget to note you down here, do not think that I m not thankful to you, but its just a slip of mind. Thank you, thank you all for your constant support.

Gangaram Biswakarma

LIST OF FIGURES
Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: 1: Total Physicians and nursing workforce in urban and rural areas- a global view 2: Countries with a critical shortage of health service providers (doctors, nurses and mid-wives) 3: Density of health workers. Source: WHO Global Atlas of the Health Workforce 4: Different environments and location of decision-makers associated with attraction and retention in the public sector 5: Map of India 6: Map of Arunachal Pradesh 7: Number of Physicians (doctors), Nurses and Mid-wives in Arunachal Pradesh 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives in Arunachal Pradesh 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh 10: District wise numbers of Physicians (doctors/ medical officers) in Arunachal Pradesh 11: District wise percentage share of Physicians (doctors/ medical officers) in Arunachal Pradesh 12: Graphical mapping of district wise number of Physicians (doctors/ medical officers) in Arunachal Pradesh 13: District wise numbers of nurses in Arunachal Pradesh 14: District wise share of nurses in Arunachal Pradesh 15: Graphical mapping of district wise number of nurses in Arunachal Pradesh 16: District wise numbers of mid-wives in Arunachal Pradesh 17: District wise share of nurses in Arunachal Pradesh 18: Graphical mapping of district wise number of nurses in Arunachal Pradesh 19: Numbers of Physicians, nurses and mid-wives in rural and remote areas in Arunachal Pradesh 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives in rural and remote area of Arunachal Pradesh 21: Percentage Share of Nurses and Mid-wives in rural and remote area in Arunachal Pradesh 22: District wise numbers of Physicians (doctors/ medical officers) in Arunachal Pradesh 23: District wise percentage share of Physicians (doctors/ medical officers) in Arunachal Pradesh 24: Graphical mapping of district wise number of Physicians (doctors/ medical officers) in Arunachal Pradesh 25: District wise numbers of nurses in rural and remote area Arunachal Pradesh 26: District wise share of nurses in rural and remote area Arunachal Pradesh 27: Graphical mapping of district wise number of nurses in rural and
7

22 23 24 40 47 47 60 60 60 63 64 64 66 66 66 68 68 69 69 70 70 72 72 73 74 75 75

Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure: Figure:

28: 29: 30: 31: 32: 33: 34: 35: 36: 37: 38: 39: 40: 41: 42: 43: 44: 45:

remote area in Arunachal Pradesh District wise numbers of mid-wives in rural and remote area in Arunachal Pradesh District wise share of mid-wives in rural and remote area Arunachal Pradesh Graphical mapping of district wise number of mid-wives in rural and remote area in Arunachal Pradesh Urban-rural distribution of Physicians (doctors) in comparison to urban rural population in Arunachal Pradesh Urban-rural distribution of Nurses in comparison to urban rural population in Arunachal Pradesh Urban-rural distribution of Mid-wives in comparison to urban rural population in Arunachal Pradesh District wise urban-rural percentage distribution of Physicians (doctors) in Arunachal Pradesh Graphical mapping of district wise rate of urban concentration of Physicians (doctors) in Arunachal Pradesh District wise urban-rural percentage distribution of nurses in Arunachal Pradesh Graphical mapping of district wise rate of urban concentration of nurses in Arunachal Pradesh District wise urban-rural percentage distribution of mid-wives in Arunachal Pradesh Graphical mapping of district wise rate of urban concentration of mid-wives in Arunachal Pradesh Percentage of migrating intention of the physicians, nurses and mid wives Percentage of migrating intention of the physicians Percentage of migrating intention of the nurses Percentage of migrating intention of the mid-wives Percentage of migrating intention of the contract workforce (Physicians, nurses and mid-wives) Percentage of migrating intention of the Permanent workforce (Physicians, nurses and mid-wives)

77 77 77 78 78 79 80 80 81 81 82 82 154 155 155 155 156 156

LIST OF TABLE:
Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: 15: 16: 17: 18: 19: 20: 21: 22: 23: 24: 25: 26: 27: Global health workforce by density Estimated critical shortage of doctors, nurses and midwives The areas falls under Urban areas in the state for this study Demographic indicators Census 2011 and 2001 of Arunachal Pradesh Urban Rural comparison of demographic indicators of Arunachal Pradesh Demographic characteristics of management representatives respondents Mean age and experience of management representatives respondents Demographic characteristics of employee respondents Mean age and length of service of the respondents Showing health infrastructure growth in rural areas of the states Distribution of Public Health Facilities in Arunachal Pradesh Population covered by the health institutions in Arunachal Pradesh Numbers of Pediatricians, Anesthetist and Gynecologist in Arunachal Pradesh (District Wise) Numbers of Physicians (Medical Officer) in Arunachal Pradesh district wise Ranking of Density of Physicians (doctors) in Arunachal Pradesh (District wise) Numbers of Nurses in Arunachal Pradesh (District Wise) District-wise ranking of density of Nurses in Arunachal Pradesh Numbers of Mid-Wives (ANM) in Arunachal Pradesh (District Wise) District-wise ranking of density of Mid-wives in Arunachal Pradesh District wise number of Physicians (Doctors) in Rural Area in Arunachal Pradesh District wise Doctor-Population ratio in Arunachal Pradesh District wise number of Nurses in Rural Area in Arunachal Pradesh District wise Nurses Population ratio in Rural Area in Arunachal Pradesh District wise number of Mid-wives in Rural Area in Arunachal Pradesh District wise number of Mid-wives-population ratio in Rural Area in Arunachal Pradesh Showing the trend in physicians and nurses in-position in 2005 & 2010 District wise requirement and shortfall of ANMS in Arunachal Pradesh
9

22 23 42 45 46 54 54 55 55 58 58 59 61 62 62 65 65 67 67 71 71 73 74 76 76 83 84

Table : Table : Table : Table : Table : Table :

Table : Table : Table :

Table :

Table : Table : Table :

Table : Table : Table : Table :

Table :

Table : Table : Table : Table :

28: District wise requirement and shortfall of Nurses in Arunachal Pradesh 29: District wise requirement and shortfall of Physicians in Arunachal Pradesh 30: District wise rural and remote area requirement and shortfall of ANMs in Arunachal Pradesh 31: District wise rural and remote area requirement and shortfall of Nurses in Arunachal Pradesh 32: District wise rural and remote area requirement and shortfall of Physicians (doctors) in Arunachal Pradesh 33: Descriptive Statistics of the factors that attracted or placed the Physicians, nurses and mid-wives in the current job in the rural and remote area 34: Percentage selection of factors for attraction or placed by Physicians, nurses and mid-wives 35: Descriptive Statistics of the factors that attracted or placed the Physicians in the current job in the rural and remote area 36: Descriptive Statistics of the factors that attracted or placed the contract Physicians in the current job in the rural and remote area 37: Descriptive Statistics of the factors that attracted or placed the permanent Physicians in the current job in the rural and remote area 38: Percentage selection of factors for Attraction or placed by Physicians 39: Descriptive Statistics of the factors that attracted or placed the nurses in the current job in the rural and remote area 40: Descriptive Statistics of the factors that attracted or placed the permanent nurses in the current job in the rural and remote area 41: Descriptive Statistics of the factors that attracted or placed the contract nurses in the current job in the rural and remote area 42: Percentage selection of factors for Attraction or placed by nurses 43: Descriptive Statistics of the factors that attracted or placed the mid-wives in the current job in the rural and remote area 44: Descriptive Statistics of the factors that attracted or placed the contractual mid-wives in the current job in the rural and remote area 45: Descriptive Statistics of the factors that attracted or placed the permanent mid-wives in the current job in the rural and remote area 46: Percentage selection of factors for Attraction or placed by midwives 47: Relationship between the factor for attraction or placement with the demographic attributes of Physicians 48: Relationship between the factor for attraction or placement with the demographic attributes of nurses 49: Relationship between the factor for attraction or placement
10

85 85 86 87 87 90

91 92 93

94

95 96 97

98 98 99 100

101

102 106 109 113

Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table :

50: 51: 52: 53: 54: 55: 56: 57: 58: 59: 60: 61: 62:

Table : Table : Table :

63: 64: 65:

Table : Table : Table : Table : Table : Table : Table :

66: 67: 68: 69: 70: 71: 72:

with the demographic attributes of mid-wives Descriptive Statistics of the factors that may attract the physicians, nurses and mid-wives in the rural and remote area Percentage of factors that may attract physicians, nurses and mid-wives in rural and remote areas Descriptive Statistics of the factors that may attract the physicians Percentage of factors that may attract physicians in rural and remote areas Descriptive Statistics of the factors that may attracted the nurses Percentage selection of Factor that may attract nurses Descriptive Statistics of the factors that may attracted the Mid wives Percentage of factors that may attract mid-wives in rural and remote areas Analysis of Variance in factor that may attract the physicians, nurses and mid-wives Percentage showing Job Satisfaction of physicians, nurses and mid-wives in rural and remote area setting Descriptive statistics of Job Satisfaction of Physicians, Nurses and Mid-wives Analysis of Variance in Job Satisfaction among the Physicians, nurses and mid-wives Percentage showing Job Satisfaction of contractual and permanent physicians, nurses and mid-wives in rural and remote area setting Descriptive statistic of Job Satisfaction of contract and permanent Physicians, nurses and mid-wives Analysis of Variance (T-Test) of Job Satisfaction among contractual and permanent Physicians, nurses and mid-wives Correlation between Job satisfaction and the demographic attributes of the employees (Physicians, Nurses and Midwives) Descriptive statistic of Job Satisfaction of contract and permanent Physicians. Analysis of Variance (T-Test) of Job Satisfaction among contractual and permanent Physicians. Correlation between Job satisfaction and the demographic attributes of Physicians Descriptive statistic of Job Satisfaction of contract and permanent nurses. Analysis of Variance (T-Test) of Job Satisfaction among contractual and permanent nurses Correlation between Job satisfaction and the demographic attributes of Nurses Descriptive statistic of Job Satisfaction of contract and permanent mid-wives.

115 116 118 119 120 121 123 124 126 129 130 130 130

131 131 132

133 133 134 135 135 136 136

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Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table :

73: Analysis of Variance (T-Test) of Job Satisfaction among contractual and permanent mid-wives 74: Correlation between Job satisfaction and the demographic attributes of mid-wives 75: Descriptive Statistics of Factors contributed for job satisfaction of the physicians, nurses and mid-wives 76: Regression Analysis of factors contributed for job satisfaction of the physicians, nurses and mid-wives. 77: Correlation matrix of overall job Satisfaction with factor of job satisfaction for physicians, nurses and mid-wives 78: Descriptive Statistics on Factors contributed for job satisfaction of the physicians. 79: Regression Analysis of factors contributed for job satisfaction of the physicians. 80: Correlation matrix of Overall job Satisfaction with factor of Job satisfaction of Physicians 81: Descriptive Statistics on Factors contributed for job satisfaction of the Nurses. 82: Regression Analysis of factors contributed for job satisfaction of the nurses. 83: T-test results of factors contributed for job satisfaction of the nurses. 84: Correlation matrix of Overall job Satisfaction with factor of Job satisfaction of Nurses 85: Descriptive Statistics on Factors contributed for job satisfaction of the Mid-wives. 86: Result of Regression Analysis of factors contributed for job satisfaction of the mid-wives. 87: Correlation matrix of overall job Satisfaction with factor of job satisfaction of Mid-wives 88: Descriptive Statistics for factors for job satisfaction of permanent Physicians, nurses and mid-wives 89: Descriptive Statistics for factors for job satisfaction of contracts Physicians, nurses and mid-wives 90: Analysis of variance in factors of Job satisfaction of Contractual and Permanent Physicians, nurses and mid-wives in rural and remote area 91: Percentage showing the intention of migration of the physicians, nurses and mid wives 92: Percentage showing the intention of migration of the contract and permanent workforce (physicians, nurses and mid wives) 93: Descriptive Statistics of contributing factor of likelihood of retention of physicians, nurses and mid-wives 94: Descriptive statistics for contributing factor of likelihood of retention of physicians 95: Descriptive statistics for contributing factor of likelihood of retention of permanent physicians 96: Descriptive statistics for contributing factor of likelihood of
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137 137 139 140 141 142 143 143 144 146 146 147 148 149 149 150 151 152

Table : Table : Table : Table : Table : Table :

154 156 159 161 162 163

Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table :

97: 98: 99: 100: 101: 102: 103: 104: 105: 106: 107: 108: 109: 110: 111: 112: 113: 114: 115:

Table : Table : Table : Table : Table :

116: 117: 118: 119: 120:

retention of contract physicians Descriptive statistics for contributing factor of likelihood of retention of nurses Descriptive statistics contributing factor of likelihood of retention of permanent nurses Descriptive statistics for contributing factor of likelihood of retention of contract nurses Descriptive statistics for contributing factor of likelihood of retention of Mid-wives Descriptive statistics for contributing factor of likelihood of retention of Permanent Mid-wives Descriptive statistics for contributing factor of likelihood of retention of contract Mid-wives Descriptive statistics for contributing push factors for physicians, nurses and mid-wives Descriptive statistics for contributing push factors for physicians Descriptive statistics for contributing push factors for permanent physicians Descriptive statistics for contributing push factors for contract physicians Descriptive statistics for contributing push factors for nurses Descriptive statistics for contributing push factors for regular nurses Descriptive statistics for contributing push factors for contract nurses Descriptive statistics for contributing push factors for midwives Descriptive statistics for contributing push factors for permanent mid-wives Descriptive statistics for contributing push factors for contract mid-wives Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to another rural area Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to rural to urban Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to other employer or outside state Relationship of demographic attributes to intention to migrate in physicians, nurses and mid-wives Relationship of demographic attributes to intention to migrate in physicians Relationship of demographic attributes to intention to migrate in nurses Relationship of demographic attributes to intention to migrate in mid-wives Descriptive statistics of factors that may motivate the physicians, nurses and mid-wives to retain in current job in
13

164 165 166 167 168 169 171 172 173 174 175 176 177 178 179 180 181 183 184

185 185 186 186 188

Table : Table : Table :

121: 122: 123:

Table : Table : Table :

124: 125: 126:

Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table : Table :

127: 128: 129: 130: 131: 132: 133: 134: 135: 136: 137: 138: 139: 140: 141: 142: 143: 144:

rural and remote area Descriptive statistics of factors that may motivate the physicians to retain in current job in rural and remote area Descriptive statistics of factors that may motivate the contract physicians to retain in current job in rural and remote area Descriptive statistics of Factors that may motivate the permanent physicians to retain in current job in rural and remote area Descriptive statistics of factors that may motivate the nurses to retain in current job in rural and remote area Descriptive statistics of factors that may motivate the contract nurses to retain in current job in rural and remote area Descriptive statistics of factors that may motivate the permanent nurses to retain in current job in rural and remote area Descriptive statistics of Factors that may motivate the Midwives to retain in current job in rural and remote area Descriptive statistics of factors that may motivate the contract Mid-wives to retain in current job in rural and remote area Factors that may motivate the permanent Mid-wives to retain in current job in rural and remote area Gist of various training under NRHM for physicians, nurses and mid-wives Achievement cumulative Training for Maternal and Child Health (March 2005-2012) Categorization of rural and remote area for incentive scheme for workforce Information on new Constructions of infrastructure in the state under reform process Information on Upgradations of infrastructure in the state under reform process New Constructions of infrastructure in the state under reform process Identified District Hospitals where New Residential Quarters will be constructed Identified List of facilities (PHCs) that are proposed for new construction of Residential Quarters: Identified CHCs for Construction of Residential Quarters Descriptive Statistics of views on health sector reform process on HR by physicians, nurses and mid-wives Descriptive Statistics of views on health sector reform process on HR by physicians Descriptive Statistics of views on health sector reform process on HR by nurses Descriptive Statistics of views on health sector reform process on HR by Mid-wives Analysis of Variance of views on health sector reform process on HR by physicians, nurses and mid-wives Scale of satisfaction on Policies for planning, placement,
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189 190 192

193 194 195

196 198 199 214 215 216 218 218 218 219 219 219 227 228 229 230 231 236

Table :

145:

Table :

146:

Table : Table : Table : Table : Table :

147: 148: 149: 150: 151:

Table :

152:

Table :

153:

Table :

154:

Table :

155:

Table :

156:

Table :

157:

Table :

158:

Table : Table :

159: 160:

Table :

161:

Table :

162:

transfer and promotion by position of Respondents Descriptive statistics on scale of satisfaction on policies for planning, placement, transfer and promotion by position of respondents Analysis of Variance for scale of satisfaction on policies for placement, transfer and promotion among the physicians, nurses and mid-wives among the group of respondents Scale of satisfaction on Recruitment and selection process and Position of Respondent Descriptive statistics on scale of satisfaction on Recruitment and selection process by position of respondents Analysis of variance for Scale of satisfaction on Recruitment and selection process among the group of respondents Scale of satisfaction on fairness in HR Practice for placement, transfer and promotion and Position of Respondent Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position of respondents Analysis of Variance for the scale of satisfaction on fairness of HR Practice for placement, transfer and promotion among the group of respondents Scale of satisfaction on Magnitude of management favouritism and political interference in transfer and posting among the group of respondents Descriptive statistics on scale of satisfaction on magnitude of management favouritism and political interference in transfer and posting by the position of respondents Analysis of Variance for the scale of satisfaction on Magnitude of management favouritism and political interference in transfer and posting among the group of respondents Scale of satisfaction on response of administration/management on your placement, transfer and promotional grievances Descriptive statistics on scale of satisfaction on response of administration/ management on your placement, transfer and promotional grievances by the position of respondents Analysis of Variance for the scale of satisfaction on Response of administration/management on your placement, transfer and promotional grievances among the group of respondents Scale of satisfaction on Participation and involvement in the decision making of your placement and transfer Descriptive statistics on scale of satisfaction on participation and involvement in the decision making of your placement and transfer by the position of respondents Analysis of variance for the scale of satisfaction on Participation and involvement in the decision making of your placement and transfer among the group of respondents Scale of satisfaction of HR Practice for retentions Financial Interventions
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237

237

241 242 242 243 243

243

244

244

244

245

245

245

246 246

246

247

Table :

Table :

Table : Table :

Table :

Table : Table : Table : Table :

Table :

Table :

163: Descriptive statistics on scale of satisfaction of HR Practice for retentions Financial Interventions by the position of respondents 164: Analysis of variance for the Scale of satisfaction of HR Practice for retentions Financial Interventions among the group of respondents 165: Scale of satisfaction of HR Practice for retentions NonFinancial Interventions 166: Descriptive statistics on scale of satisfaction of HR Practice for retentions Non Financial Interventions by the position of respondents 167: Analysis of variance of Scale of satisfaction of HR Practice for retentions Non Financial Interventions among the workforce among the group of respondents 168: Scale of Satisfaction of Training and Development 169: Descriptive statistics on scale of satisfaction of HR Practice of Training and Development by position of the respondents 170: Analysis of variance of Scale of Satisfaction of Training and Development among the group of respondents 171: Level of satisfaction of employees on HR practice of planning, recruitment and placement in respect of physicians, nurses and mid-wives in rural and remote area in the state 172: Level of satisfaction of Contractual employees on HR practice of planning, recruitment and placement in rural and remote area in the state 173: Level of satisfaction of Permanent employees on HR practice of planning, recruitment and placement in rural and remote area in the state

247

248

248 248

248

250 250 251 251

251

251

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ABBREVIATION

ANM- Auxiliary Nurse-Midwives AYUSH- Ayurvedic, Yoga, Unani, Sidda, and Homeopathic BEmOC- Basic Emergency Obstetrics Care CEO-Chief Executive Officer CHC-Community Health Centre CMOs- Chief Medical Officers DH- District Hospital DMOs- District Medical Officers DNA- Data Not Available EmOC- Emergency Obstetrics Care F-IMNCI- Facility based Integrated Management of Neonatal and Childhood Illness GDP- Gross Domestic Product GH- General Hospital GNM- General Nursing and Midwifery GOAP Government of Arunachal Pradesh GoI- Govt. of India HICs- High-income countries HIV/AIDS- Human immunodeficiency virus infection / Acquired immunodeficiency syndrome HQ- Head Quarter HR- Human Resources HRD-Human Resource Development HRH- Human Resource for Health HRM- Human Resource Management IMNCI- Integrated Management of Neonatal and Childhood Illness IPHS- Indian Public Health Standard IUCD- intrauterine contraceptive device LICs- Low income countries LR- Labour Room LSAS- Life Saving Anesthesia Skills MBBS- Bachelor of Medicine, Bachelor of Surgery MDG- Millennium Development Goals MDGPs- Millennium Development Goals Programmes MiniLap- Mini Laparoscopic MO- Medical Officer MoHFW- Ministry of Health and Family Welfare MTP- Medical Termination of Pregnancy MVA- Manual Vacuum Aspiration NCHRH- National Council for Human Resources in Health NE- North Eastern NHP- National Health Policy NRHM- National Rural Health Mission NSSK- Navjaat Shishu Suraksha Karyakram NSV- No Scalpel Vasectomy PHC-Primary Health Centre PIP- Program Implementation Plan
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PMU- Programme Management Unit RHS- Rural Health Statistics RRWG- Rural and Remote Working Group. RTI/STI Reproductive Tract Infection /Sexually Transmitted Infection SBA- Skill Birth Attendance SC- Sub Centre SN- Staff Nurse SPSS- Statistical package for the social sciences TFR- Total Fertility Rate UFWC- Urban Family Welfare Centre UHC- Urban Health Centre UN United Nation WHO- World Health Organization WHR- World Health Report

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ABSTRACT
Background: In adopting the Millennium Declaration in the year 2000, the eight Millennium Development Goals (MDGs) have been adopted by the international community. To accomplish the MGDs no. 4, 5 and 6, related to Reduce Child Mortality, Improve Maternal Health and Combat HIV/AIDS, malaria & other diseases respectively, calls the strengthening of health care delivery system and improved health care services. Healthcare is a service sector, depends highly on specially trained professionals, which needs to produced, attract and retain at all level. Health worker shortages are one of the main challenges internationally. The most concerning issues on this is producing, attracting, recruiting, deploying and retaining them in rural and remote areas. This study aimed at understanding the major HR issues in distribution, attraction and retention of Physicians, nurses and mid-wives in Public health care delivery system in rural areas in India with special reference to the state of Arunachal Pradesh. Method: The primary data required for the study was collected with the help of interview schedule, survey questionnaire and observation. The primary data was collected through questionnaire among 334 nos. (113 nos. of physicians, 98 nos. of Nurses and 123 nos. of midwives) of physicians, nurses and mid-wives, to understand their attitude towards working and living in rural areas and accepting the rural posting and insight on the HR issues in the area of study. One management representatives each from the 16 districts and one state level management representatives were picked as a sample of management representatives and conducted the interview. The interview materials were coded and quantitative data was analyzed with SPSS 19. Results, discussion and conclusion: Over the last few decades the establishment of health institutions in rural areas of the state is haphazard and not kept pace with adhering to the norms and keeping view of the consequences of human resource requirement. Consequently, many rural communities/areas are deprived of the primary health care and desperately need the attention. The inequities in the geographic distribution of Physicians, nurses and mid-wives, itself has meant too many rural and remote areas with the shortage of Physicians, nurses and mid-wives. The poor availability of Physicians, nurses and mid-wives co-exists and creating an imbalance and a problem with debilitating health care delivery system in the region along with the absence of adequate training institutes for medical and nursing courses
19

results in low numbers of medics and paramedics produced for the state. Maldistribution, that is the distribution of health workforce is characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from within district perspective also. While 77% of the population lives in rural and remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives are serving in rural and remotes areas of the state. This creates urban and rural imbalance in distribution. The phenomenon of urban skewness and mal-distribution among the districts are there. In this study it is also found that the information on human resource is in-consistence among the state and district level, while it is also found that the inconsistency between the divisions of the health department. While, the major issue on attraction, the study revealed that the workforces who are presently working in the rural and remote areas of the state are altogether in compulsion, either working to finish their minimum rural service tenure or on nontransferable positions or Management and political pressure or demand. It is found that 58% of the workforce is service in rural and remote areas in the compulsion. Moreover, the other HR issues on attraction are the lack of career development opportunity, inactive recruitment strategy, lack of hospital infrastructure and resource availability, poor working condition, lack of other cadres, team work and staff relationship, the reward and recognition for the performance and achievement is not there in the system which could attract the physicians, nurses and mid-wives in the rural area service, poor use of financial means of attraction. The study also reveals a limited scope of attraction due to training and development opportunities and Poor supervision and mentoring is a hindrance for attraction. While the HR issues on retention are in the issue of internal migration to urban areas. The study reveals that only 19% of them want to continue with their present rural posting place. 24% wants to shift to another rural health institute, 51% wants to shift to another urban health institute and 6% wants to shift to another job in some other State/sector in search of an alternative employer. The Factors that contributed for migration of the physicians, nurses and mid-wives as a whole, from the present rural area to other rural area, urban area or to leave the sector have two factors significant that are the Lack of adequate financial incentives / rural

allowances/performance incentives, poor working condition, lack of Career development opportunities and poor salary. The other retention measures of financial and non-financial incentives area absent from the system that could retain the
20

workforce in rural and remote areas. It is also revealed that the factors that may motivate the physicians, nurses and mid-wives to retain themselves in the present rural area have four factors -financial incentives, improved living condition, career development and Good reward and achievement recognition system. It is found in this study that the intention of migration of physicians, nurses and mid-wives from a rural area health institute to another rural health institute is propelled mainly by the factor of team work and interpersonal relationship in the present place of work. This study also revealed that the intention of migration of this workforce is related with the level of job satisfaction of these groups of health workforce and propel them to migrate. So forth, in addition to the other issues and concerns, there is a growing dissatisfaction among the physicians, nurses and mid-wives in presently working in the rural and remote areas. While the reform initiatives in the sector are the emphasizing on contractual employment, emphasizing on development of professional training institutes, initiatives for comprehensive HR policy, decentralisation of HR activities to district level, adoption of simplified way of recruitment and selection, emphasized on training and development, emphasized on career development opportunities, shifting of view towards the financial incentives, emphasizing of availability of essential equipments for functionalising a health centre as per IPHS, development of supportive supervision and emphasizing on infrastructure development initiatives including accommodation facilities. It is also found in respect of HR practice under reform process for distribution, attraction and retention, that in the absence of appropriate and concrete human resources policies on deployment, there is always a hindrance in managing people at work as the entire district agreed to this. Along with, there is a major issue of HR planning, recruitment and selection process, the common minimum tenures are not followed along with the time bound promotions are not practices for several reasons to these categories of staff, there is no use of provision of financial and non-financial incentives for rural and remote area posting and retention, The reward and recognition for the performance and achievement is also not there in the system, and there is no random access of training needs, the planning of training and the execution of the same have a random mismatch in the district and as well as in the state level. Adequate human resources for health (HRH) are a key requirement for reaching health goals, the study found that, the shortages of physicians, nurses and mid-wives
21

are an ongoing problem in the public health sector in Arunachal Pradesh with uneven distribution. There is low job satisfaction in the workforce in the current job at rural and remote areas. It is contributed by many of the factors including financial and nonfinancial benefits. Attraction and retention of physicians, nurses and mid-wives in remote and rural areas are determined by many factors including financial incentive, career development opportunities, recognition etc. But, the factor of compulsion is the main factor of stock in rural and remote areas, and rest of the factors have less contribution, and the financial benefits along with non-financial benefits seems to be migrating factors. The attraction, deployment and retention of physicians, nurses and mid-wives in rural and remote areas are a real challenge and a difficult situation, and affected by several factors ranging from organizational factors to external environmental factors and to personal factors. However, the personal factors have less affect on the situation. The massive poor living conditions in the rural and remotes areas, poor working condition in health institutes, poor career development opportunities with lack of financial benefits are some of the factors that contribute to the reluctances of the physicians, nurses and mid-wives to serve the rural and remote areas in the state. The sector has nothing to offer presently, to attract and retain and to distribute rationally this workforce, which in result deteriorating the situation in the rural and remote areas. Moreover, the reform process is doing less for the HRM perspectives and the HR practices are not effective enough to solve the problems in the state. it is clear that many factors affect the rational distribution, attraction and retention of Physicians, nurses and mid-wives in the rural and remote area ranging from environment issues, organisation issues as well as the personal issues, along with the production issues, the facilities and basic amenities along with financial incentives are determinant of manpower in rural areas of the state. It is also known that to solve these HR issues, no individual interventions are not adequate, it need a pyramid of interventions to ensure the minimization of the issues. Moreover, a blend of initiatives is needed to address the problems of distribution, attraction and retention of manpower in the state, there is a need of continue focus and commitment on the part of government and as well as the political will to solve the problem. In conclusion, efforts to strengthen health sector must address the HR issues and a good Human Resource Management and a far sight in HR requirements are needed.

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LIST OF THE CONTENTS

Title Declaration by the candidate Certificate of supervisor Acknowledgement List of figures List of table Abbreviation Abstract List of Contents CHAPTER -1 1.1. 1.2. 1.2.1. 1.2.2. 1.2.3. 1.3. 1.4. 1.5. CHAPTER -2 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.7.1. 2.7.2. 2.7.3. CHAPTER 3 3.1. 3.1.1. 3.1.2. 3.1.3. Page No. i ii iv-v vi-vii viii-xv xvi-xvii xviii-xxi xxii-xxvi

1-9 INTRODUCTION Introduction to research theme 1 Rationale behind the research 4 Why Physicians, nurses and mid-wives are selected for 5 the study? Why rural and remote areas selected for the study? 6 Why HR Practices (including distribution, attraction and 6 retention) selected for the study? Objective of the study 7 Significance of the study 8 Outline of the thesis 9 10-42 LITERATURE REVIEW Introduction 11 Key HR issues in public health sector- in a global 11 perspective Distributional issues of Health workforce- in global 20 context Attraction and retention of physicians and nurses in 24 rural areas- in a global context Health Sector reform : the international and Indian 33 context Gaps in the literature 34 Conceptual framework for the study 34 HRM in public health sector a conceptual framework 34 Attraction and retention of health workers in rural areas 38 -Conceptual framework Framework of urban area and rural area for this study 41 43-51 RESEARCH METHODOLOGY Research Methodology 44 Research Design 44 Objective of the study 44 The Study area 45
23

3.1.4. 3.1.5. 3.1.6. 3.1.7. 3.2. 3.3. CHAPTER -4 Section-1 4.1.1. 4.1.2. Section 2

Map of the studied area Data Collection methods and instruments Sampling frame Data Analysis Limitation of research Contribution of the research DATA ANALYSIS AND INTERPRETATION Characterstics of respondents Introduction Characterstics of respondents Analysis of dimension of HR issues in Distribution of Physicians, Nurses and Mid-wives in rural and remote areas of the state Introduction Scenario of distribution of Health Institution in Arunachal Pradesh Scenario of distribution of physicians, nurses & midwives in Arunachal Pradesh District-wise Distribution pattern of Physicians (Medical Officers) & Specialists (Paediatrics, Anaesthetics and Gynaecologist): Distributional pattern of Nurses (Staff Nurses & GNM) district-wise Distribution pattern of Mid-wives (ANM) district-wise Scenario of distribution of physicians, nurses & midwives in rural and remote areas in Arunachal Pradesh Distribution pattern of Physicians (Medical Officers) in rural & remote areas (district wise) Distributional pattern of Nurses (Staff Nurses & GNM) in Rural and Remote area in Arunachal Pradesh districtwise Distributional pattern of Mid-wives (ANM) in Rural and Remote area in Arunachal Pradesh district-wise Urban-Rural distribution of physicians, nurses and midwives District wise Urban-Rural distribution of Physicians (doctors) in Arunachal Pradesh District wise Urban-Rural distribution of Nurses in Arunachal Pradesh District wise Urban-Rural distribution of Mid-wives (ANM) in Arunachal Pradesh Numerical inadequacy of physicians, nurses and midwives in Arunachal Pradesh Requirement and shortfall of human resources in SCs, PHCs and CHCs in the state according to IPHS norms.
24

47 48 49 50 50 51 52251 53-55 54 54 56-87

4.2.1. 4.2.2. 4.2.3. 4.2.3.1.

57 57 59 61

4.2.3.2 4.2.3.3. 4.2.4. 4.2.4.1. 4.2.4.2.

64 67 69 70 73

4.2.4.3. 4.2.5. 4.2.5.1. 4.2.5.2. 4.2.5.3. 4.2.6. 4.2.6.1

75 78 79 80 82 83 84

Section 3

4.3.1. 4.3.2.

4.3.2.1. 4.3.2.2. 4.3.2.3. 4.3.3. 4.3.3.1. 4.3.3.2. 4.3.3.3. 4.3.4.

4.3.4.1. 4.3.4.2. 4.3.4.3. 4.3.4.4. Section 4

4.4.1. 4.4.2.

4.4.2.1. 4.4.2.2. 4.4.2.3. 4.4.3. 4.4.3.1.

Analysis of the dimension of HR issues in attraction of Physicians, Nurses and Mid-wives in rural and remote areas of the state Introduction Factors that attracted or placed the physicians, nurses and mid-wives in the current job in the rural and remote area: current determinants of attraction and placements Factors that attracted or placed the physicians in present rural and remote area Factors that attracted or placed the nurses in present rural and remote area Factors that attracted or placed the mid-wives in present rural and remote area Relationship of factors of attraction and demographic characteristics of physicians, nurses and midwives Relationship of factors of attraction and demographic characteristics of physicians Relationship of factors of attraction with the demographic characteristics of nurses Relationship of factors of attraction with the demographic characteristics of mid-wives Factors that may attract physicians, nurses and midwives to rural area- choice of current physicians, nurses and mid-wives Factors that may attract physicians to rural area- Choice of current Physicians Analysis of the factors that may attract nurses to rural and remote area- choice of current nurses Analysis of the factors that may attract mid-wives to rural and remote area- choice of current mid-wives Variance in choice of factor that may attract the physicians, nurses and mid-wives Analysis of the dimension of HR issues in retention of Physicians, nurses and mid-wives in Rural and remote areas of the state Introduction Overall Job satisfaction of Physicians, nurses and midwives in Present rural and remote area and relationship with other demographic attributes Job satisfaction of Physicians in rural and remote area and relationship with other demographic attributes Job satisfaction of Nurses in rural and remote area and relationship with other demographic attributes Job satisfaction of Mid-wives in rural and remote area and relationship with other demographic attributes Factors of job satisfaction of physicians, nurses and mid-wives in rural and remote area Factors of job satisfaction of physicians in rural and
25

88126 89 89

92 95 99 102 103 107 110 114

117 119 122 124 127199 128 129

132 134 136 138 141

4.4.3.2. 4.4.3.3. 4.4.3.4.

4.4.4. 4.4.4.1. 4.4.4.2. 4.4.4.3. 4.4.4.4. 4.4.5.

4.4.5.1. 4.4.5.2. 4.4.5.3. Section 5

4.5.1. 4.5.2. 4.5.3. Section 6

4.6.1. 4.6.2. 4.6.3. 4.6.4. 4.6.5. 4.6.6. CHAPTER- 5 Section 1

remote area Factors of job satisfaction of nurses in rural and remote area Factors of job satisfaction of mid-wives in rural and remote area Factors of job satisfaction of contractual and permanent physicians, nurses and mid-wives in rural and remote area Likelihood of migration of physicians, nurses and midwives- choice to migrate Contributing factor of likelihood of retention of physicians, nurses and mid-wives- Choice to stay Push factors of likelihood of migration of physicians, nurses and mid-wives- Choice to migrate Push factors of likelihood to migrate according to the choice of place Relationship of demographic and satisfaction attributes with the major intention to migrate to urban areas Factors that may motivate the physicians, nurses and mid-wives to retain in current job in rural and remote area- What is their choice? Factors that may motivate the physicians to stay Factors that may motivate the Nurses to stay Factors that may motivate the Mid-wives to stay Analysis of the Reform initiatives for distribution, attraction and retention of physicians, nurses and mid-wives Reform initiatives for recruitment and deployment (Distribution) Reform initiatives for attraction and retention Exploring the views on health sector reform from the perspective of physicians, nurses and mid-wives Analysis of the HR policies and practices on attraction, distribution and retention of physicians, nurses and mid-wives for rural and remote area in the state Introduction Policies for HR Planning, recruitment (attracting), placement, transfer and promotion HR planning, recruitment and selection process HR practice for placement, transfer and promotion HR practice for retention - financial & non-financial interventions HR practice for retention - training and development MAJOR FINDINGS, SUGGESTIONS AND CONCLUSION Major HR issues in distribution of physicians, nurses
26

144 147 150

153 159 170 181 184 187

188 192 196 200232 201 213 220 233251

234 234 237 242 246 249 252 253-

5.1.1. 5.1.2. Section 2 5.2.1. Section 3 5.3.1. Section 4 5.4.1. Section 5

and midwives in rural and remote areas Introduction Major HR issues in distribution of physicians, nurses and midwives Major HR issues in attraction of physicians, nurses and midwives in rural and remote areas Major HR issues in attraction of physicians, nurses and midwives Major HR issues in retention of physicians, nurses and midwives in rural and remote areas Major HR issues in retention of physicians, nurses and midwives Major reform initiatives and issues thereon Major Reform initiatives and issues thereon Major issues in HR practice related to attraction, distribution and retention of physicians, nurses and mid-wives Major issues in HR practice for attraction, distribution and retention of physicians, nurses and mid-wives Suggestion Introduction Broad suggestions Conclusion Conclusion Reference Appendix 1: Manpower Recommended under IPHS Appendix 2: Questionnaire for physicians, nurses and mid-wives Appendix 3: Interview schedule for State and District management representatives Conference attended Paper Published

264 254 254 265277 266 278299 279 300308 301 309314 310 315323 316 318 324326 325 327343 344346 347353 354356 357 358

5.5.1. Section 6 5.6.1. 5.6.2. Section 7 5.7.1.

27

Chapter -1 INTRODUCTION

28

1.1.

INTRODUCTION TO RESEARCH THEME

It is apparent that the human element in an organisation is the most important

element in achieving the organisational goal. Focusing to the management of human affairs within the organizations is the responsibility of human resources management (HRM) in an organisation. Traditionally, management of this system has gained more attention from service organizations than from manufacturing organizations (Radcliffe, 2005). The early decades of the 21st century considered as the era of human resources for health sector. The public health sector is purely a service sector, the human element is a critical element for it success and achievement of organizational goals. In the health sector, a strong human infrastructure is fundamental to closing todays gap between health promise and health reality and anticipating the health challenges of the 21st century (WHO, 2006). The World Health Organization (WHO) estimates the current HRH workforce at 59 million and its global shortage at 4.3 million. Both developed and developing countries are currently of Health worker shortages. Such shortages are symptoms of a poorly managed health workforce and health care system. The causes of the crisis are more complex with insufficient production capacity, and overall with an inability to keep the workers in the places where they are needed. Despite of significant achievements after 64 years (1947-2011) of Independence, public health sector in India is facing a critical challenge on several fronts. While the country has made substantial strides in economic growth, its performance in health has been less impressive. Despite an extensive network of government funded clinics and hospitals providing low cost care, curative health services, the country fails to address public health needs of the people. An important reason for this is the inability of the health system to provide health care for all due to inadequate infrastructure and human resource. Distortions in the area of human resources in health sector are one of the significant issues in Indian public health sector today. The country faces a shortage of qualified health workers with large geographic variations in the health workforce, across states and rural and urban areas. These issues are the important challenges in reforming Indian public health sector. The public sector of the health system has been one of the main targets of the national initiatives of reform for the public administrations, particularly because of the
29

magnitude of their expenses and the number of personnel employed (Roberto & Jose, 2003). Designers and implementers of decentralization and other reform measures have focused much attention on financial and structural reform measures, but ignored their human resource implications. Concern is mounting about the impact that the reallocation of roles and responsibilities has had on the health workforce and its management. (Kolehmainen-Aitken, 2004). While to accomplish the Millennium Development Goals (MDG) which was adopted in the Millennium Declaration in the year 2000, the strengthening of health care delivery system and improved health care services are utmost importance. Healthcare is a service sector, depends highly on specially trained professionals and technical human resources. Both developed and developing countries are currently facing Health worker shortages along with attraction and retention problems. At the same time, India is also struggling to accomplish the development goals along with the rest of the developing world. For this, the human resource are needed to developed and retain at all level. There is a need to respond and address the HR issues and challenges and to mobilize a motivated human resource in particular the technical workforce towards the accomplishment of targets of the organization. In India, health worker shortages are one of the main challenges in achieving population health goals. Adding more on this challenge the geographical distribution of heath workforce is always a matter of concern, featured with urban attraction in the country. More on the issue, the mostly concerned area in health sector are difficulty in producing, recruiting and retaining health workforce in rural and remote areas. Thus, the major challenge in the new millennium is the retention of health workers, not only in poorer countries, but also within any country in remote and rural areas (Bangdiwala et al., 2011). Therefore, this study aimed at understanding the HR issues on distribution, attraction and retention of Physicians and Nurses including the Mid-wives in Public health care delivery system in rural India with special reference to the State of Arunachal Pradesh. This research process not only generated useful contributions to the field of research, but that it also provided time for reflection and learning for other people involved in the process as there is no literature on the topic as on date in Arunachal Pradesh (as far as this researcher has been able to establish).

30

1.2 . RATIONALE BEHIND THE RESEARCH

Geographical mal-distribution of health care providers, especially physicians and nurses including mid-wives, is a ubiquitous problem, affecting many countries and reasons (Pong, 2008). While adopting the Millennium Declaration in the year 2000, the international community pledged to spare no effort to free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty. We are now more than halfway towards the target date 2015 by which the Millennium Development Goals are to be achieved (MDG, Report 2008, UN). The MDGs no. 4, 5 and 6 are related to Reduce Child Mortality, Improve Maternal Health and Combat HIV/AIDS, malaria & other diseases respectively. To accomplish these MGDs, the strengthening of health care delivery system and improved health care services are utmost importance. Whereas, the healthcare is a service sector, depends highly on specially trained professionals and technical human resources. Both developed and developing countries are currently facing Health worker shortages especially physicians and nurses along with their attraction and retention problems. Efforts to overcome physicians and nurses shortage can be divided into two major categories: attraction/recruitment and retention. Whereas the former is an effort to get a doctor to set up practice in a community, the latter is an attempt to keep the doctor there as long as possible (Pong, 2008). The causes of the crisis are complex, with insufficient production capacity, but also with an inability to keep the workers that are being produced in the places where they are mostly needed. The availability of human resource is one of the important components for the efficient functioning of public healthcare delivery system. Increase in health indicators needs increase in the availability of health workers through improved health workforce attraction, distribution and retention. Thus, the causes of the crisis are complex, with insufficient production capacity, inability to keep the health workers that are being produced in the places where they are mostly needed. India is a vast country with a wide network of public health service with diversified challenges in the achieving health goals, including health worker shortages. The National Health Policy of India (2001) acknowledges the acute shortage of healthcare professionals especially in rural areas. Such shortages are the symptoms of a poorly managed health workforce and health care system. Several issues which are foremost important are producing, distributing, attracting and their

31

retention rural and remote areas. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved. (Sundararaman & Gupta, 2011). The widespread poverty, illiteracy, malnutrition, absence of safe drinking water and sanitary living conditions, poor maternal and child health services and ineffective coverage of national health and nutritional services have been traced out in several studies as possible contributing factors to dismal health conditions prevailing among the tribal and rural population in India (Basu, 2000). 1.2.1. WHY PHYSICIANS, NURSES AND MID-WIVES ARE SELECTED FOR THE STUDY? The rationale behind the selection of the physicians and the nurses from the pool of professional workforce in the healthcare sector is due to the nature of these categories of workforce. As, these healthcare categories of professionals require special consideration, particularly to the availability, acquisition, retention, development of their competence and meeting their professional needs and expectations. The main skilled health workers in rural areas work in the public health sector are these two categories of health workforce. Moreover, according to the National Health Policy 2000, India is committed to achieve the reduction in maternal and infant mortality rates set for National Population Policy-2000. The Maternal Mortality in India continues to remain unacceptably high, and there is enough evidence globally to demonstrate that an effective package of obstetric and child health services provided within reach of the communities and families can successfully reduce maternal and childhood mortality. So, to operationalization of all Community Health Centers, Primary Health Centers and Sub Health Centers for providing 24 hours x 7 days obstetric (maternal) and child health services including the management of common obstetric complications, emergency care of sick children and referrals round the clock, all seven days of the week, in the public health setting, the services of Physicians, Nurses and Mid-wives are the critical components besides the infrastructural development at all level. Thus, the rationale behind the selection of the physicians and the nurses from the pool of professional workforce in the healthcare sector is due to the nature of these categories of workforce, as these healthcare categories of professionals require special consideration, particularly to the availability, acquisition, retention, development of their competence and meeting their professional needs and expectations.
32

1.2.2. WHY RURAL AND REMOTE AREAS SELECTED FOR THE STUDY? In recent year, major initiatives have been launched to tackle health and inequalities in access to health. The mal-distribution of personnel has its roots in longstanding global inequalities. It is in this global context of accelerating inequities that health-service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote and rural areas (Lehmann et al, 2008). Recruiting and retaining highly qualified health workers in remotely located areas presents an enormous challenge in both developed and developing countries (Chomitz et al, 1998). In view of these quotes, the remarks are particularly for the rural and remote areas. To talk of Asia as a whole, according to Chen. L., et al. in Joint Learning Initiative (2004) Asia which has about half the world's population, has access to only about thirty percent of the world's health professionals and has confirmed that global inequities in the distribution of health personnel hit those countries hardest which can least afford it. India is predominantly a rural area and the Rural Health Care System forms an integral part of the National Health Care System. Provision of Primary Health Care is the foundation of the rural health care system. For developing vast public health infrastructure and human resources of the country, accelerating the socio-economic development and attaining improved quality of life, the Primary health care is accepted as one of the main instrument of action. The studied area- the state of Arunachal Pradesh is a pre-dominantly a rural and remote area. The rural population constitutes 77.33% whereas; the urban population consists of only 22.67% of the total population of the state (Census 2011). Thus, the importance of rural and remote areas argues for the selection. 1.2.3. WHY HR PRACTICES (INCLUDING DISTRIBUTION, ATTRACTION AND RETENTION) SELECTED FOR THE STUDY? According to Infosys CEO, Narayana Murthy said My employees seek challenging opportunities, respect, dignity and opportunities to learn new things. I keep telling them that my assets are not this building, the business or foreign contacts, My assets all 8,000 of them walk out of the gate every evening and I wait for them to come back to me the next morning This is what has made Infosys one of the best proactive HRD practicing company and also one of the first companies to adopt an employee stock option and create additional wealth for its employees (Ramani, 2003).

33

The increased attention paid to new HRM practices has been particularly prevalent in the fields of strategic management, human resource management, and increasingly, the economics of organization (Laursen & Foss, 2000). There are significant relationship between human resources practice and organisational success. This is well known that human beings are the most important resources of an organisation especially in service sector organisation as they play a crucial role in its growth and development and achievement of goals. In the health sector, along with several HR issues, according to Lehmann et al, 2008, one of the most negative effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in rural and remote areas. Efforts to overcome physician and nurse shortage can be divided into two major categories: recruitment/attraction and retention. Whereas the former is an effort to get a doctor to set up practice in a community, the latter is an attempt to keep the doctor there as long as possible (Pong, 2008). Resulted in, the main challenges as experienced to be the recruitment, distribution and retention of health workers. Thus, keeping the synergies between the research problems, a look on at HR issues regarding distribution, attraction and retention of physicians and nurses in rural and remote areas are considered. The discussion of attraction, distribution/placement and retention factors and strategies falls within the broad scope Human Resource Management (HRM) as a strategic and coherent approach to managing staff (with inclusions from Armstrong, 2007). These areas are equally important with a focus on rural and remote areas and thus the order of discussion does not represent their relative importance.

1.3. OBJECTIVE OF THE STUDY

As the researcher could able to establish, that there is no academic literature available as on date relating to the research topic in the state of Arunachal Pradesh. In view of the above, this research study aims at exploring the issues on the distribution, attraction and retention of Physicians and Nurses in Public health care delivery system in rural area in the state of Arunachal Pradesh. The study is focused on physicians (doctors) and nurses (Staff Nurse/GNM, ANM -the Mid-wives) only. The research question puts for the study are that- What are the major HR issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in

34

Arunachal Pradesh? What are the major reform initiatives under reform process for major issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh? Rationally, the following objectives are place for the study:1. To explore the major HR issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh. 2. To explore the major reform initiatives under reform process for major issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh. 3. To suggest some remedial measures to address the major issues.

1.4. SIGNIFICANCE OF THE STUDY

The early decades of the 21st century considered as the era of human resources for health. This research work has brought out major issues and reform initiatives of distribution, attract and retention of physicians and nurses in Public Health sector of Arunachal Pradesh. Among all factors of production, man is by far the most important. The importance of human factor in any type of co-operative endeavour cannot be overemphasized. It is a matter of common knowledge that every business organization depends for its effective functioning not so much on its material or financial resources as on its pool of able and willing human resources. The human resource becomes even more important in the service industry whose value is delivered through information, personal interaction or group work (Tripathi, 2009). In the health sector, a strong human infrastructure is fundamental to closing todays gap between health promise and health reality and anticipating the health challenges of the 21st century (WHO, 2006). The health care sector is both labour-intensive and labour-reliant, and the delivery of quality health care services is strongly dependent on having enough well-trained health care workers to meet patient needs and expectations. There is a growing awareness that human resource issues need to be prioritized more effectively within reforms in order to secure an adequate health care workforce to deliver services now and in the future (Lethbridge, 2004). Health reforms that aims at increasing efficiency, quality and users' satisfaction need to take into consideration human resource issues, because the health sector is labour intensive and the performance of health systems depends on qualified and motivated workers
35

(Homedes and Ugalde, 2005). Health sector reform often focuses on changes in financing or organisational structure, but neglects a key resource the staff. This may result in inappropriately skilled staff for new tasks, poorly motivated staff, or even serious opposition to the reforms (Martineau & Buchan, 2000). There has been several analysis of the successes and failures of health reforms in general. However, relatively little attention has been paid to the critical part that human resources (HR), which will play in determining the success or failure of health reforms(Martineau & Buchan, 2000). Several studies have pointed out that human resource issues need to be a primary consideration in reform design, suggesting that reforms can only be implemented successfully where there is consensual participation on the part of the workforce (Ssengooba et al, 2007). Therefore, the importance of this research is due to : - FIRSTLY, the urgency behind Health Care Delivery System Reform emphasizes by Government of India, and the human resource is always behind in thinking of Health Sector Reforms. SECONDLY, Human resources management occupies a unique niche in our system of health care and the importance of attraction and retention of physicians and nurses in rural and remote areas in delivering health care services. THIRDLY, the need of motivated and skilled workforce to deliver better and quality primary health care services to the rural mass. The urge about, how this aspect of issues in India, particularly in the state of Arunachal Pradesh are and can be addressed, motivated the researcher to explore the subject.

1.5. OUTLINE OF THE THESIS

The first chapter is on Introductory part includes the objective, rationale and significance of the study. The succeeding chapters are organized as follows: Chapter2 is Literature review which summarizes the previous study and other related themes. Chapter-3 presents the research methodology. Chapter-4 presents the data analysis and interpretation. Chapter-5 summarizes the Major findings on HR Issues on distribution, attraction and retention of the Physicians, Nurses and Mid-wives and it also presents the suggestions and conclusion of the study. Thereafter, followed by the Bibliography and Appendix.

36

Chapter -2 LITERATURE REVIEW

37

2.1. INTRODUCTION
In the field of Human Resource Management, fortunately there is no dearth of literature. Excellent researchers, academicians and practitioners have been devoting considerable thought to the different aspects of HRM. However, comprehensive studies covering HR in Health Sector in India or Arunachal Pradesh is limited. An attempt is made here to explore the literature addressing issues of distribution, attraction and retention of physicians and nurses in a global context, along with the health sector reforms. This chapter discussed the literature available on the study topic. It includes key HR issues in public health sector in global context, gaps in literatures and conceptual framework for the study.

2.2. KEY HR ISSUES IN PUBLIC HEALTH SECTOR- IN A GLOBAL PERSPECTIVE

While examining health care systems in a global context, several issues are highlighted in the literature in context of the general human resources issues. Some of the issues of greatest relevance in the literature are discussed in subsequent section. Here in a nutshell, the literatures emphasize the variation of size, distribution and composition within a county's health care workforce is of great concern. One of the biggest concerns is critical shortages of Human Resource. The importance of health workforce provision has gained significance and is now considered one of the most pressing issues worldwide (Hawthorne and Anderson, 2009). The international shortage of health care professionals exists in different severities and has different root causes, depending on the particular health profession and the country of origin. Health care priorities therefore change between countries: a universal health system would invariably not provide the required health care efficiently to all those who need it (Hawthorne and Anderson, 2009). At the global level, many countries are facing critical HRH challenges including worker shortage, skill-mix imbalance, maldistribution, poor work environment, and weak knowledge base (Chen, 2004; Wyss, 2004). Health professionals are insufficiently committed to the present public health system (Homedes & Ugalde, 2005), and that is of particularly nurses and physicians (El-Jardali et al; 2007) and especially in critical areas like specialist dentists, anaesthetists etc, (Ramadoss, 2007). The World Health Organization (WHO) estimates the current HRH workforce at 59 million and its global shortage at 4.3

38

million (WHO, 2006). According to the WHO, there are currently 57 countries with critical shortages of human resource for health (including India) equivalent to a global deficit of 2.4 million doctors, nurses and midwives. The general HR issues are highlighted below:
1.

Shortage of skilled health workers: The functioning and growth of health

systems depends on the availability of human resources and on the time, effort and skill mix provided by the workforce in the execution of its tasks (Ozcan et al, 1995, Martnez et al, 1998- adapted from Gupta and Dal Poz, 2009). The severe shortage of health workforce globally, especially in developing countries like African countries, Pacific and Asian countries is a critical issue that must be addressed as an integral part of strengthening health systems (Henderson and Tulloch, 2008). Factors that contribute to the shortage of skilled health workers which was highlighted in the studies of Henderson and Tulloch, 2008; Hawthorne and Anderson, 2009; Satpathy & Venkatesh, 2006; Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; El-Jardali et al, 2007; Kabene et al, 2006; Henderson and Tulloch, 2008; Dubois & McKee, 2006; Management Science for Health, 2009; Institute for Public Health, 2007; WHO,

World Health Report, 2006; Bach, 2000; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar, 1999; Dussault and Dubois, 2003; Uneke et al 2008; Liu, et al., 2006; Joaquin, 2009, Mutizwa, 1998, Mathauer and Imhoff, 2006, Brien and Gostin, 2009). The factors includes a lack of effective planning (Henderson and Tulloch, 2008; Martineau & Buchan, 2000; McCaffery, 2006; Mavalankar, 1999; Martnez & Martineau , 1998; Uneke et al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al,

2007), limited health budgets (Henderson and Tulloch, 2008; Ssengooba et al, 2007; Uneke et al 2008), migration of health workers (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Manafa et al, 2009; Martinez & Martineau, 2002;

Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006; Ssengooba et al, 2007), inadequate numbers of students entering and/or completing professional training (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Institute for Public Health, 2007; WHO, World Health Report, 2006; Martnez & Martineau, 2002; Bach, 2000;McCaffery, 2006; Martinez & Martineau, 1997; Dussault and Dubois, 2003; Kushwah, 2000, Brien and Gostin, 2009), limited

employment opportunities (Henderson and Tulloch, 2008), low Salaries (Homedes & Ugalde, 2005; Kabene et al, 2006; Martnez & Martineau ,1998; El-Jardali et al,
39

2007; Henderson and Tulloch, 2008; Institute for Public Health, 2007; WHO, World Health Report, 2006; Martnez & Martineau, 2002; Martineau & Buchan, 2000;

Mavalankar, 1999; Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009), poor working conditions (Homedes & Ugalde, 2005; Chen, 2004 ; Wyss, 2004; Henderson and Tulloch, 2008; Management Science for Health, 2009; El-Jardali et al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar, 1999; Uneke et al 2008; Kolehmainen-Aitken, 2004), weak support and Supervision (Henderson and Tulloch, 2008; Institute for Public Health, 2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008; Dieleman et al, 2009) , and limited opportunities for professional Development (Henderson and Tulloch, 2008; Uneke et al 2008; Kolehmainen-Aitken, 2004; Dieleman et al, 2009). The shortage of workers often results in inappropriate skill mixes in the health sector (Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; Henderson and Tulloch, 2008; Dubois & McKee, 2006; McCaffery, 2006; El-Jardali et al, 2007; Bach, 2000; Martineau & Buchan, 2000; Mavalankar, 1999; Mathauer and Imhoff, 2006), as well as gaps in the distribution of health workers (WHO, 2006; Homedes & Ugalde, 2005; Chen,2004 ; Wyss, 2004; Kabene et al, 2006 ; Martinez & Martineau, 1997; El-Jardali et al, 2007; Henderson and Tulloch, 2008; Martinez & Martineau, 2002; Bach, 2000; McCaffery, 2006; Mavalankar, 1999; Dussault and Dubois, 2003; Martnez & Martineau , 1998; Kolehmainen-Aitken, 2004; Joaquin, 2009). Overall staffing shortages due to the inability to attract and retain sufficient numbers, or due to financial constraints that may be externally imposed e.g. as part of structural adjustment. Yet there may be an over concentration of staff in urban areas at the expense of poorer, more remote, under-served areas where posts are left vacant (Ghana, India, Bangladesh and many poor countries) (Martnez & Martineau, 2002). This is especially so in rural and remote areas where the provision of services is difficult because of limited health budgets and scattered populations living in isolated villages or islands (Henderson and Tulloch, 2008). According to Bach, (2000), shortages of personnel trained in disciplines such as primary health care, health economics, public health, health communication, health education, nutrition, and environmental engineering continue to severely limit the possibilities for improving the quality and efficiency of the health care system, that is we can say deals with number and the composition of health workforce (Kabene et al, 2006). Almost all countries suffer from misdistribution characterized by urban concentration and rural
40

deficits, but these imbalances are perhaps most disturbing from a regional perspective (WHO 2006). There is an over-concentration of qualified health personnel in urban hospitals and urban centers, coupled with shortages in poor neighborhoods and rural areas (Homedes & Ugalde, 2005). At the global level, many countries are facing maldistribution (Chen, 2004; Wyss, 2004; El-Jardali et al, 2007) and human resources units are not adequately staffed (Homedes & Ugalde, 2005), distribution of health care workers (Kabene et al, 2006 ) are not equally distributed, especially to manage change in the health sector. Inequity in rural-urban distribution of human resources for health (HRH) is a worldwide problem (Lexomboon, 2003). So, it may be summaries that the regional differences of workforce is the major public health issues and in the organization and delivery of public health services (Beaglehole and Dal Poz, 2003).
2.

Working conditions: Several researchers highlighted and summed up with

poor working condition for public health workforce in this sector. At the global level, health workforce in the different countries are facing poor work environment which was highlighted in the studies of Homedes & Ugalde, 2005; Chen, 2004 ; Wyss, 2004; Henderson and Tulloch, 2008; Management Science for Health, 2009; ElJardali et al, 2007; McCaffery, 2006; Martinez & Martineau, 1997; Mavalankar, 1999; Uneke et al 2008; Kolehmainen-Aitken, 2004. After understaffing which was the most commonly reported HR challenge; poor working conditions and staff grievances (Management Science for Health, 2009) are the most viewed issues. 3. Compensations issues: The issue of low remuneration or inadequate salary

has attracted many research studies like Homedes & Ugalde, 2005; Kabene et al, 2006; Martnez & Martineau ,1998; El-Jardali et al, 2007; Henderson and Tulloch, 2008; Institute for Public Health, 2007; WHO, World Health Report, 2006; Mavalankar, 1999;

Martnez & Martineau, 2002;

Martineau & Buchan, 2000;

Uneke et al 2008; Kolehmainen-Aitken, 2004; Joaquin, 2009, Mathauer and Imhoff, 2006 and their studies concludes that, health workers in developing countries are underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006). Under production of health workforce, inability to pay higher salaries and benefits, inability to sustain are other some of the issues pertaining to this, which is highlighted by WHO, World Health Report, (2006). 4. Migration of health workforce: Even where there are an appropriate number

and mix of trained health workers, there may not be jobs available for them in their
41

country of origin, despite the population experiencing widespread unmet health needs (Brien and Gostin, 2009). Another issue highlighted in the literatures is the migration of health workforce from own place of origin to other part of the world in search of better avenues. Many researchers have come across this key issue while studying on HR issues. As poor compensation packages may be one of the reasons for the migration of the health workforce. Silently the education opportunities for their (workforce) children (Uneke et al 2008), the migration of workers are also there. In addition to international migration there is also considerable in-country migration between the public and private health sectors, between urban and rural areas and between tertiary and primary health care delivery (Manafa et al, 2009). Many countries lack the human resources needed to deliver essential health interventions and migration of health workers within and across countries (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Manafa et al, 2009; Martnez & Martineau, 2002; Mavalankar, 1999; El-Jardali et al, 2007; Uneke et al 2008; Kabene et al, 2006; Ssengooba et al, 2007) is one of the main concern. 5. Retention and high attrition: Due to poor working conditions, low

compensation package and migration, it is very difficult for retention of these workforce in a developing or an underdeveloped countries and make use of their services in rural areas. Retention and high attrition issues have been highlighted by many research including- Martnez & Martineau, 2002; McCaffery, 2006; Mavalankar, 1999; Institute for Public Health, 2007. 6. Aging workforce: It is yet another issue confronting some of the countries

and these aging workforces cannot be utilized fully for health interventions. This is highlighted in the study of El-Jardali et al; (2007). 7. Professional training and production issues: The issue of inadequate

professional training is in disparity as suggested by several studies. The regulation of training institutions and conditions of practice is weak (Homedes & Ugalde, 2005). Insufficient numbers of people trained in primary health care and public health related fields and the training centers are unable to produce personnel to operate the reformed health system (Henderson and Tulloch, 2008; Dubois & McKee, 2006; Institute for Public Health, 2007; WHO, World Health Report, 2006; Javier Martnez & Tim Martineau, 2002; Bach, 2000; McCaffery, 2006; Martinez & Martineau, 1997;

Dussault and Dubois, 2003; Kushwah, 2000). So, there is a need of educational reform (Chen- 2004; Wyss, 2004; Mavalankar, 1999; El-Jardali et al, 2007).
42

8.

In-service-training

issues:

Besides

insufficient

numbers

of

health

professionals are produced, the in service-training of other health workforce is inadequate. Health workforce education has been a low priority (Brien and Gostin, 2009). The training of health promoters and other auxiliary personnel such as dental assistants, midwives, laboratory technicians, equipment maintenance and repair technicians, and pharmacist is poor or non-existent (Homedes & Ugalde, 2005). At the global level, many countries are facing critical weak knowledge base (Chen, 2004; Wyss,2004). Workforce training is yet another important issue (Homedes & Ugalde, 2005; Kabene et al, 2006; Chen, 2004; Wyss, 2004; Kabene et al, 2006; Mavalankar,1999; Martinez &

Management Science for Health, 2009;

Martineau, 2002;; McCaffery, 2006; Martnez & Martineau , 1998; Kushwah, 2000; Joaquin, 2009). It is essential that human resource personnel consider the composition of the health workforce in terms of both skill categories and training levels. The prevalence of inadequate training at various levels resulted in Limited opportunities for professional development (Henderson and Tulloch, 2008; Uneke et al 2008; Kolehmainen-Aitken, 2004; Dieleman et al, 2009) at the service period, which

adversely affect the professional life of the professional workforce in the health sector. 9. Motivational issues: Health workers especially in underserved areas usually

have motivational problems at work which may be reflected and resulted in a variety of circumstances like poor compensation packages, more opportunities for career and educational advancement and unsatisfactory working conditions as mention above. More to explore on the issue, Rewards are not linked to performance or the incentives (Mavalankar, 1999; Martinez & Martineau, 2002; Martineau & Buchan, 2000,

Ssengooba et al, 2007; Martnez & Martineau , 1998; Dieleman et al, 2009), added to the low morale and motivation of the workforce. Health workers in developing countries are underpaid, poorly motivated and very dissatisfied (Kabene et al, 2006; Management Science for Health, 2009; Martinez & Martineau, 2002; McCaffery, 2006; Uneke et al 2008; Kolehmainen-Aitken, 2004). Lack of satisfaction is the most commonly reported HR challenge, (Management Science for Health, 2009) resulted from poor working conditions, workers health and well-being (Mavalankar, 1999; McCaffery, 2006; El-Jardali et al, 2007) and staff grievances (Management Science for Health, 2009). The motivations of health worker also affected by the Job security (Ssengooba et al, 2007) in a great extend.
43

10.

Human resource policy: The medical profession strongly dominated the

definition of health sector policies and the regulation of the conditions of practice of all health professions (Homedes & Ugalde, 2005). Regional differences in the major public health issues and in the organization and delivery of public health services contribute to the need for public health human resource policy advice to be contextspecific, sustainable and in tune with the available resources. (Beaglehole and Dal Poz, 2003). The formulation of national policies and plans in pursuit of health workforce development objectives requires sound information and evidence. (Dubois & McKee, 2006, adapted from Gupta and Dal Poz, 2006). Absence of appropriate human resources policies (Beaglehole and Dal Poz, 2003; Homedes & Ugalde, 2005 ; Dubois & McKee, 2006; Dussault and Dubois, 2003; Martnez & Martineau , 1998; Kolehmainen-Aitken, 2004), chronic imbalance with multifaceted effects on the health workforce: quantitative mismatch, qualitative disparity, unequal distribution and a lack of coordination between HRM actions and health policy needs are the main issues in HR in health sector. (Dussault and Dubois, 2003). In the absence of the human resource policies, personnel decisions (hiring and promotion) were too often guided by favoritism, political dictates, and nepotism (Homedes & Ugalde, 2005). Recruitment, hiring and retention are the major problems highlighted in many studies such as (Homedes & Ugalde, 2005; Bach, 2000; Martineau & Buchan, 2000; El-

Jardali et al, 2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007; Martnez & Martineau , 1998). 11. Health human resource planning: Planning is most important in every

sectors including health sector especially in manpower recruitment and placing. Health human resource planning (future needs) (Martineau & Buchan, 2000; McCaffery, 2006; Mavalankar, 1999; Martnez & Martineau , 1998; Uneke et

al 2008; Kolehmainen-Aitken, 2004; El-Jardali et al, 2007; Henderson and Tulloch, 2008) and human resource management skills generally do not exist at local, peripheral levels in developing countries ( Kolehmainen-Aitken, 2004). 12. HR information, absence of database: Human resource planning can be

difficult in the absence of database on present human resource in the sector. Moreover, mentioned earlier that, the formulation of national policies and plans in pursuit of health workforce development objectives requires sound information and evidence (Dubois & McKee, 2006). Very limited HR information, absence of database or accurate information on staffing (Dubois & McKee, 2006; Bach, 2000;
44

McCaffery, 2006; Mavalankar, 1999; Martnez & Martineau , 1998; Uneke et al 2008; El-Jardali et al, 2007) is not in the system as suggested by many researchers is affecting human resource management practices, sufficient attention to HR problem of shortage, misdistribution, poor staff utilization, appropriate skills, recruitment, performance management. 13. HRM systems: As a result of this circumstances of no access to tools and

information, Human resources management systems are weak (Homedes & Ugalde, 2005; Kolehmainen-Aitken, 2004; Management Science for Health, 2009; Martnez & Martineau, 2002; Bach, 2000; Martineau & Buchan, 2000; McCaffery, 2006; Dussault and Dubois, 2003; Ssengooba et al, 2007; Martnez & Martineau , 1998; Uneke et al 2008; Joaquin, 2009), largely due to dispersal of accountability

(Homedes & Ugalde, 2005). Lack of management experts, especially experts in insurance systems and contract managers (Homedes & Ugalde, 2005) is highlighted. In most countries, managerial positions were traditionally given to physicians with little or no management training (Homedes & Ugalde, 2005). Human resource management skills generally do not exist at local, peripheral levels in developing countries (Kolehmainen-Aitken, 2004). It comes out in light that, the lack of welltrained human resource managers mirrors the regions shortage of health care professionals in general (Management Science for Health, 2009). Low pay and staff motivation, unequal and inequitable distribution of the health workforce, and poor staff performance and accountability, qualified staff move more freely among countries, and even countries that can train and produce large numbers of health workers are unable to retain them, Failure of existing performance management systems, effective use of incentives in managing performance, weak HR capacity in the health sector (Martnez & Martineau, 2002). Health workers with relatively high professional and material expectations are working in a resource poor environment with little support or supervision (Ferrinho & Lerberghe, 2000). As mentioned above, Lack of management experts (Homedes & Ugalde, 2005), resulted in weak supervision at all levels (Henderson and Tulloch, 2008; Institute for Public Health, 2007; McCaffery, 2006; Mavalankar, 1999; Ssengooba et al, 2007; Uneke et al 2008; Dieleman et al, 2009). Insufficiently/limited resourced and neglected health systems (Henderson and Tulloch, 2008; Ssengooba et al, 2007; Uneke et al 2008), Centralized planning (Mavalankar, 1999) often results in above situation in the health sector as can be figured out of various literature review. Decentralization of HR management
45

systems (Martineau & Buchan, 2000; Martnez & Martineau , 1998; Dieleman et al, 2009) and capacity, staff performance management, designing/ implementing new pay/ career structures, changing skill mix new roles for professions, HR planning in a decentralized system., establishing new employment systems and conditions of service, development of new types of incentives to support new ways of working (Martineau & Buchan, 2000), which is absence in majority of the health sector.

14.

Absenteeism: Absenteeism among health care workers is a obstacle to

successful health service deliverance and is caused by a number of factors. As figured out above paragraphs, there is inadequate training, poor working conditions, low compensation at various levels, so, resulted in lack of availability and accountability of the staff (Homedes & Ugalde, 2005; Mavalankar,1999; Javier Martnez & Tim Martineau, 2002), for example only 52% of the auxilliary nurse-midwives (ANM) and 57% of the medical officers (MO) stay at their place of posting in India (ICMR, 1997). This system of working has not done much to develop a team spirit and remains a very hierarchical and bureaucratic (Mavalankar,1999). 15. Performance of the workforce: Performance of the public health system

depends on multiple factors, among which human resources (HR) are one of the most important components (Djibuti et al; 2008). In Latin America, the need to improve the performance of the workforce had been pointed out in many health sector assessments conducted in the 1970s and 1980s by the United States Agency for International Development (USAID), the World Bank (WB). The training of health personnel is poor or non-existent (Homedes & Ugalde, 2005), thus their performance was poor (Homedes & Ugalde, 2005), with low productivity and efficiency (Homedes & Ugalde, 2005), and resulted in poor utilization of the present workforce (Bach, 2000). 16. Equipment and supplies: Inadequate equipment (Homedes & Ugalde, 2005),

shortages of supplies and drugs (Homedes & Ugalde, 2005), workforce ill-equipped (Institute for Public Health, 2007; Uneke et al 2008) were also highlighted in literatures. 17. Duality of roles: Minimal supervision, high attrition rates of employees, Less-

qualified personnel, very low government salaries (Institute for Public Health, 2007), often resulted in duality of roles, overburden and workload (Management Science for Health, 2009; McCaffery, 2006; Uneke et al 2008, Martinez & Martineau, 2002) to

46

the present health human resources. Thus, there are two reasons for this duality of roles: First, a shortage of staff, especially in rural areas, results in HRM responsibilities being added to already over-burdened health care practitioners (Management Science for Health, 2009). So to sum up, old and new challenges threaten the human resources (HR) responsible for health care planning and delivery in public sector funded national health systems. Among the old challenges, low pay and staff motivation, unequal and inequitable distribution of the health workforce, and poor staff performance and accountability remain key obstacles to health sector development. Among the new challenges, qualified staff move more freely among countries, and even countries that can train and produce large numbers of health workers are unable to retain them (Martnez & Martineau, 2002).

2.3. DISTRIBUTIONAL ISSUES OF HEALTH WORKFORCE- IN GLOBAL CONTEXT

Globally the problem of distribution of health workforce is a matter of concern. The uneven distribution of health workforce is a global phenomenon. World Health Organisation (WHO) estimates show a shortage of about 4 million health workers, and this more than any other single factor may lead to failure of attaining the Millennium Development Goals (MDGs) within the set timelines. It also suggests that in absolute terms, the greatest shortage occurs in South-East Asia, dominated by the needs of Bangladesh, India and Indonesia. The largest relative need exists in Sub Saharan Africa, where an increase of almost 140% is necessary (WHO, 2006). Unbalanced distribution of health personnel between and within countries is a worldwide, longstanding and serious problem. All countries, rich and poor, report a higher proportion of health personnel in urban and wealthier areas. (Dussault & Franceschini, 2006). Shortage and mal-distribution of health workers in rural areas is a concern in all countries. The central health care issue for many communities across the nation is the inadequate supply of health care professionals and limited access of residents to health services (Sultz & Young, 1999; Christianson & Moscovice, 1993). The mal-distribution of health care professionals has left many areas underserved or without health care services, while other areas deal with surpluses of health care specialists and services. (LaSala, 2000). This contributes directly or indirectly to

47

increased inequalities of access to basic health care and therefore health outcomes (Wafula et al, 2011). Health workers are distributed unevenly across the globe (Speybroeck, et al, 2006). Within regions and countries, access to health workers is also unequal. In India current ratios for doctors are 1 per 1507 and 1 per 1205 for nurses, the problem of mal-distribution remains unchanged since independence (Sundararaman & Gupta, 2011). Similar variation prevails globally, Viet Nam averages just over one health service provider per 1000 people, but the range is wide. 37 of Viet Nams 61 provinces fall below this national average, while some province have around four health service providers per 1000 (Prasad, et al, 2006). In Nicaragua, around 50% of the health personnel are concentrated in the capital, Managua, which comprises only one-fifth of the country's population (Nigenda & Machado, 2000). In Mexico, it is estimated that 15% of all physicians are unemployed, underemployed or inactive. Yet despite this apparent surplus, rural posts remain unfilled (WHO, 2000). In Bangladesh the metropolitan areas contain around 15% of the country's population but 35% of doctors and 30% of nurses, in government positions. Since there are virtually no doctors or nurses in the private sector outside the metropolitan areas, the geographical concentration of these providers in the metropolitan areas is even greater (MoHFW, Bangladesh, 1997). In Brazil in 1995, the number of physicians per 1000 population by region varied from 0.52 and 0.66 in the poorer regions of the north and the northeast to 1.75 and 2.05 in the states of So Paulo and Rio de Janeiro, in the richer southeast region. The average for the whole country was 1.19. This gap in favour of richer regions is smaller than it was 25 years earlier, thanks to efforts to expand the coverage of the population by public services. But "the low incomes of the population have discouraged the settlement of doctors" in the poorer regions(Machado, 1997). In Ghana in 1997, 1087 of the 1247 (87.2%) general physicians worked in the urban regions, although 66% of the population lives in the rural areas (WHO, 1997). Health worker density is higher in urban areas globally (WHO, 2006). The distribution of health workers is heavily skewed towards urban areas. The imbalanced distribution of health personnel can contribute to great disparities in health outcomes between the rural and urban population (Dussault & Franceschini, 2006). Approximately one half of the global population lives in rural areas, but these areas are served by only 38% of the total nursing workforce and by less than a quarter of the total physicians workforce (figure : 1). The nurse to population/patient ratio is low compared to other
48

countries. In 2004, the ratio was 1:2250 in India and 1:100-150 in Europe. This ratio in African countries, Sri Lanka and Thailand is 1:1400, 1:1100 and 1:850, respectively. Many States in India face a shortage of nurses and midwives. This shortage is due to variety of reasons including: migration to well developed countries, under production of health workforce, inability to pay higher salaries and benefits, inability to sustain other measures to retain health workers in some countries, illness and death and other factors that are uncontrollable. Estimates by WHO (2006), the critical shortage are in 57 (fifty seven) countries, which includes India.

50% %

50% %

62% %

38% %

24% % 76% %

population.

Figure : 1 : Total Physicians and nursing workforce in urban and rural areas- a global view A clear-cut distinction between public health and clinical services is not entirely realistic or practical (Beaglehole and Dal Poz, 2003). WHO estimates the current full time health workforce to be 59.2 million. Out of this, health service providers constitute about two third, whilst the remaining portion comprises of management and supporting staffs (WHO, 2006). Based on the above estimates by WHO (2006), the critical shortage are in 57 (fifty seven) countries, which includes India. It is estimated that the deficit is 2.4 millions of doctors, nurses and midwives globally. Sub-Saharan Africa region has the highest proportional shortfalls, and by absolute numerical terms it is highest in deficiency in South-East Asian region due to its vast population size. The global profile shows that there are more than 59 million health workers in the world, distributed unequally between and within countries. They are found predominantly in richer areas where health needs are less severe. Their numbers remain woefully insufficient to meet health needs, with the total shortage being in the order of 4.3 million workers (WHO, 2006). Table: 1 and 2 along with figure 2 & 3 presented can highlight more on this situation.
49

Table 1 : Global health workforce by density WHO Region Total Health Worker Health Service Providers Number Density Number Percentage (Per 1,000 of total population) health workforce Africa 1640000 2.3 1360000 83 Eastern 2100000 4.0 1580000 75 Mediterranean South East 7040000 4.3 4730000 67 Asia Western 10070000 5.8 7810000 78 Pacific Europe 16630000 18.9 11540000 69 Americas 21740000 24.8 12460000 57 World 59220000 9.3 39470000 67
Source: WHO, 2006, Pg- 5

Health management and support workers Number Percentage of total health workforce 280000 17 520000 25 2300000 2260000 33 23

5090000 31 9280000 43 19750000 33

Table 2: Estimated critical shortage of doctors, nurses and midwives WHO Region Number of countries In countries with shortages Total With Total Estimated Percentage shortages Stock Shortage increase required Africa 46 36 590198 817992 139 Americas 35 5 93603 37886 40 South East Asia 11 6 2332054 1164001 50 Europe 52 0 NA NA NA Eastern 21 7 312613 306031 98 Mediterranean Western Pacific 27 3 27260 32560 119 World 192 57 3355728 2358470 70 Source: WHO, 2006, Pg- 13

Figure 2: Countries with a critical shortage of health service providers (doctors, nurses and mid-wives) Source : WHO, 2006, Pg-12.
50

Figure 3 : Density of health workers. Source: WHO Global Atlas of the Health Workforce (created on 4 July 2007) (adapted from Henderson & Tulloch, 2008).

2.4. ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES IN RURAL AREAS- IN A GLOBAL CONTEXT
Attraction and Retention of physicians and nurses in rural areas is a challenge globally, mostly related to attraction towards urban area and leaving the rural areas underserved. This section of literature review explores the perspective of attraction and retention of both physicians and nurses including mid-wives in rural areas, as these groups of health workforce are the largest and the important workforce to cater the need of maternal and child health services in the community. Due to the limited documentation on retention in low-income countries (LICs), literature on high-income countries (HICs) has also been included to explore whether lessons could be learnt from experiences in them (Dieleman and Harnmeijer, 2006). The issue of attraction and retention of rural physicians is a long-standing problem globally. The hindrance of the countries in achieving the health objectives and goals are of the reasons that the countrys inadequacy and mal-distribution in health workforce (Snow et al (2011). Difficulty in production, recruitment and retention of health professionals issues for severely weakened and under resourced health sector (Lehmann et al, 2008) is a concern. WHO (2006), also emphasized on the production issue of enough doctors, nurses and other key health workers. But, only increase in production is not enough. Recent attempts at trying to solve the
51

problem of underserviced areas have resulted in much hostility and little achievement (Jason & Alison, 1999). While the rural population has continued to grow, the number of physicians in these areas has steadily declined. Urban areas are more attractive to health care professionals for their comparative social, cultural and professional advantages (Lerberghe, et al, 2002). This problem is not exclusive in underdeveloped or developing counties but it in developed countries also, to name a few are Canada, USA & Australia. According to the study by Jason & Alison (1999) for physicians in Canada, they explore the problem of physician recruitment and retention in rural areas in the three main areas of physician needs professional satisfaction, financial remuneration, and lifestyle. They also emphasized on useful approach in defining the solution is to examine it at all levels of a rural physicians training and career. They concluded that an integrated approach to problem solving requires not only interventions at the high school, university, medical school, and residency levels, but also the active participation and co-operation of the physicians, the communities in which they practice, and the regional and provincial governments. Rural physicians' recruitment and retainment has traditionally been a challenge for hospitals and rural communities (Full, 2001). Several researches have been done regarding the attraction/recruitment and retention of physicians and nurses to stay in rural area service. There are different factors in different country setting that make a physicians and nurses more likely to attract and retain themselves in rural services. This section summarises findings of the literature review on factors impacting on staff attraction and retention, with a focus on remote rural areas (Lehmann, U. et al, 2008). Individual factors may depend on a person's personal characteristics, such as age, gender, marital status, etc. How they impact on an individual's decision-making is often fluid and may change in a person's life and career cycle (Lehmann, U. et al, 2008). Research suggests that the ability to adapt to rural practice and, especially, rural life is the key determinant of retention (LaRavia. D., et al., 2002). Health workers have been reluctant to work in rural and remote areas because of little support or supervision, a lack of material resources for health, poor working and living conditions, and isolation from professional colleagues (Henderson & Tulloch, 2008). Doctors and nurses are reluctant to relocate to remote islands and forest locations that offer poor communications with the rest of the country and few amenities for health
52

professionals and their families (Chomitz, et al., 1998). It has been proposed that the low numbers of physicians in rural area has more to do with retention than with recruitment (Oreilly, 1997). Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas (Lehmann, U. et al, 2008). Preferences of location may also depend on what kind of living conditions health personnel are used to. The correlation between geographical origin of students and their future choice of practice, i.e. whether students from under-served areas will return to under-served areas to practise their profession, is much debated in the literature. (Lehmann, U. et al, 2008). Study of Snow et al (2011), an assessment of rural posting preferences by the senior students of medical was considered. The responses were emphasized in three orders, which are to provide career development incentives, to provide clear terms of appointment with reliable endpoints and salary top-ups. Other responses included were clinical infrastructure, adequate accommodation and provision of schooling of children. Witter et al. (2011) in his study suggested the order of importance of the factors that encourage the doctors to work and stay in rural areas. His order of importance of the factors are : Salary, working condition, training opportunities, Allowances, Career development, Living condition, Supervision and management. According to the study by Lagarde and Blaauw (2009), while they carried out a literature review using discrete choice experiments to investigate the human resources issues related to health workers, both in developed and developing countries. They conclude with the salary variable as an important determinant of job preferences. Beside salaries, the other attributions which were found are workload in case of developed country, location characteristics, housing, and opportunity to benefit for further education and drugs and equipments in the facilities in case of developing countries. In the study of Irene. A. A. (1999), following factors are identified of rural area posting -lack of equipments, non-availability of electricity, safe water, communication system and isolation. She also emphasized on method of selection of community nurses, who often have an urban background and family ties and reluctant to work in rural areas. Advocated on changing the process of selection to enable retain trained nurses in rural areas.
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Kristiansen & Forde (1992), has also suggested proper education facility for workforces children as one of the priority requirements for rural posting of doctors and staffs. He also emphasized on work load and suggested the overtime payments. Navajo Area Indian Health Services (Kim C., 2000) study suggested lack of housing, lack of health care and lack of schools for children are quoted internationally as reasons why staff either do not join or leave health services in remote areas, they were raised in research conducted among health care providers. The importance of general living conditions, including staff accommodation, schools and qualified teachers, good drinking water, electricity, roads and transport, also features very prominently in a study conducted by Mensah, (2002), into factors affecting retention in rural Ghana. (Lehmann, U. et al, 2008). According to the study of Dormael et al, (2008), in which retention was assessed for all 65 trainees between 2003 and 2007. Out of the 65 trained doctors between 2003 and 2007, 55 were still engaged in rural practice end of 2007, suggesting high retention for the Malian context. Participants viewed the training as crucial to face technical and social problems related to rural practice. However, they concluded that retention can however not be attributed solely to the training intervention but first, incentives related to living and working conditions, which influenced rural doctors' attraction, also contribute to retention. Second, other support mechanisms known to foster retention are provided: mentoring, supervision, and access to further rurally relevant continuous training sessions. While complementary bundles of interventions indeed work better than isolated interventions, it is difficult to disentangle their effects. According to the recent study by Murthy et al., (2012) in Indian context, covering a few parts of the country, in which the study examine what doctors expect in order to work in rural areas. Doctors perceived that the current salaries were not sufficient. They expected increase in salaries; some expected double the current salaries or parity with private healthcare sector. Many doctors were demotivated by the lack of infrastructure. Lack of quality education facilities for children in rural areas was a big deterrent. Security, living facilities, connectivity and proximity to family were among the prominent expectations of doctors to work in rural areas. Better management, well-defined and transparent transfer policy and increased leaves were seemed as important incentives by doctors to serve in rural areas.

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In the study of Ebuehi & Campbell, (2010) in Nigeria, major rural motivators included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. Similarly, in a study in Nepal by Nick Simons Institute (2008), the key issues identified as critical to the retention of Nepali MDGPs in rural areas were: Career/promotion prospects, Status/recognition, financial incentives, working conditions, Education for children, Continuing medical education and Political stability and security. Yet another study Shankar (2010), which was done for Nepal and wrote that the recent introduction of mandatory rural service for scholarship students was aimed to reduce the loss of medical graduates to developed nations. High tuition fees in private medical schools and low Government wages prevent recent graduates from taking up rural positions, and those who do face many challenges. In the study of Glasser. M., (2010) in United States, most rural physicians in this study decided to practise in rural areas because of family ties. The major reason for deciding to practise in a rural location was family ties to the community, followed by a loan or scholarship obligation. With respect to attributes positively impacting practice satisfaction in the community, the most frequently mentioned was good partners/call coverage, followed by good revenues/patient volume and

autonomy/freedom in the rural practice setting. Negative attributes of rural professional practice were varied: the top three mentioned were lack of private paying patients; hard work/long hours; and distance from specialists and medical testing. In the study of Awofeso. N., (2010), in Nigeria, highlighted the factors as the Spartan living standards in rural and remote areas (Open defecation, severely limited access to electricity, primitive social amenities, chronic poverty, poor quality educational or communication facilities, fragile health systems and the inadequacy of potable water), Inadequate numbers of trained health staff and limited employment capacity in the public sector, Inadequate remuneration, Sub-optimal mix and distribution of healthcare worker, Burnout of staff (excessive workload, coupled with relatively poor remuneration, inadequate clinical facilities and limited opportunities

55

for professional development, hinder efforts to recruit and retain skilled health staff in rural and remote areas. According to the study by Nestman, N. A., ( 1998), factors of retaining physicians and nurses in rural areas of Canada emphasized on lack of time off and working hours, frustrated with earnings, not valued by regulatory bodies, medical schools, and government, reduced availability of acute care services and specialty services and working conditions. According to Ballance, D. et al., (2009), while nature or rural background is a common factor in many physicians who choose rural practices, nurture or programs that encourage and maintain rural affinity. Effective recruitment efforts that highlight the positive aspects of rural life and address work-life balance are also shown to attract providers and retain them in their rural practices. In a study of doctors and medical students in Vietnam by Vujicic. M., (2010), respondents positively value being located in an urban area, having adequate equipment, higher official income, being offered skills development (short-term training), long-term education (specialist training), and free housing. In a cohort study of 145 doctors responded by Pagaiya. N., etal., (2011) under International Health Policy Program, found in relation of their job preference, 6 attributes found to be statistically significant in the decision to choose a job in a rural area: hospital size, location, salary, overtime work, specialty training opportunities and career promotion. In the study of King. B., (2006) of Health Professions Resource Center, Texas, the reasons given for not wanting to practice in rural areas in Texas had less to do with the amenities or social activities associated with urban areas than with the patient base (large numbers of uninsured or poor people) or the quality of the facilities. They ranked competitive salaries as very important to the retention of providers in rural areas along with facilities in rural areas, long term service to patients, recognition of efforts and updated equipment. In the research paper of McDonald. J., (2002), factors that have been

identified as barriers include: professional isolation and lack of organisational support, inadequate access to hospitals, unreasonable workloads, unsatisfactory levels of procedural work, and the lack of availability of good social and cultural facilities. Factors likely to attract medical graduates to rural areas include: childhood experience of country life, and rural internship.
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A study by Straume & Shaw (2010), the area of study was northern Norway and they explore the issues of Lack of opportunities for professional development to be the most common reason for leaving more common than wage- and workloadrelated factors. On the other hand, the enjoyable aspects of rural living and working conditions were the most important reasons for staying. According to the study of Kornik & Clark, (undated) on retention of doctors in rural areas of South Africa, emphasizes on issues of professional isolation, Poor management at facility and department level, poorly equipped hospitals, erratic salary. The study of LaSala (2000), it is found that both rural and urban settings, nursing administrators perceived salaries, lack of full-time positions for nurses, and a competitive job market as barriers to both recruitment and retention. Rural administrators also reported the local economy and unmet family needs as barriers. The administrators in both areas indicated nurse relationships (with other nurses, administration and physicians) and work related variables (benefits, working conditions, and workload) were viewed as positive incentives for retention. Geographic location, housing, and community amenities were not significant factors in either the rural or urban settings. Hegney, McCarthy, Rogers-Clark and Gorman (2002) conducted a crosssectional survey of 146 registered and enrolled nurses in rural Australia. The survey asked nurses to rank 91 separate items on level of importance in relation to the decision to remain in rural practice. The results suggest job satisfaction and being part of a professional team are the most important predictors of remaining in rural practice (Cited in Manahan, 2008). Bilodeau and Leduc (2003), when discussing factors affecting retention of health personnel in rural and remote areas, define three categories of factors affecting health personnel's motivation to practise in these locations: personal (age, gender, education, etc.), professional (specialization, working hours, incentives, etc.), and contextual/ environmental (community amenities, quality of life, population's educational level, etc). (Chomitz, et al., 1998). Lea & Cruickshank (2007), the factor analyzed were-the ward culture, workload and level of responsibility within rural healthcare facilities were of concern for new graduates and influenced their retention within the rural nursing workforce. While in Mullei et al. (2010), investigated reasons for poor recruitment and retention in rural areas of 345 nursing trainees in Kenya interviewed. The findings
57

were, positive aspects included lower costs of living and more autonomy at work. Negative issues included poor infrastructure, inadequate education facilities and opportunities, higher workloads, and inadequate supplies and supervision. Bushy (2006), suggested to retain a highly skilled rural nursing workforce, continuing education must be accessible to nurses. The major inferences drawn from a study of Klaas (2007) is that nurses are dissatisfied with lack of promotional opportunities, lack of professional support, facing drastic responsibilities but with less income, tremendous workloads, emotional demands and unrealistic salary package. A study by Vujicic M., et al. (2010) of recruitment and retention of nurses and certified midwives in rural areas of Liberia focused the six key job attributes-location, total pay, conditions of equipment, availability of transportation, availability of housing, and workload. RRWG (2004), Identified the following issues or challenges as priorities facing rural nursing in Nova Scotia are Quality of Work Life, Limited Work Opportunities, Continuing Education. In study of Reardon, (2010), significant differences were identified by country. The rank ordered items for nurses from Australia and the United States proved to be different, but emphasized the importance of a positive workplace, good management, job satisfaction, and job security for nurses. Decisions to leave a rural facility included, feeling unvalued, workplace morale/culture, and job satisfaction. The findings indicated non-financial issues rated high as factors nurses considered when leaving rural employment. Incentives had a large impact on the willingness (Chomitz, 1998). Taking into consideration of a study of running financial incentive program in Canada they argued that only financial incentives cannot solve the rural accessibility of health workforce. The programme fails to attend the objective of locating physicians in remote rural areas of Ontario. Anderson & Rosenberg (1990), emphasized on combination of compulsory service and incentive, which is being used by various developed and developing countries. In Blaauw et al., 2010 study findings in Thailand, Kenya and South Africa, suggested that financial incentives are very important in persuading health workers to choose a rural posting, especially in poorer countries, but only if they are fairly large.
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Non-financial strategies are just as important. Improved housing and accelerated promotion were moderately effective, but preferential access to training and career development opportunities were very powerful non-financial strategies. Frehywot et al. (2010), put another dimension of retention of physicians. In their study, they put emphasize on compulsory service programme for physicians in rural areas. They found more than 70 (seventy) countries including India with compulsory service programme as a strategy for physicians in rural areas. However, the study emphasizes on compulsory service in rural but, opinion on that no commitment for service could be seen in this circumstances. According to the study of Matsumoto M, et al., (2010), they write about the bound medical education program followed by obligatory rural service in Japan for retention of the physicians in rural Japan. Free medical education in exchange for obligatory rural service; and close, long-term cooperation of national and local governments, and the medical school over the period from pre entrance selection to completion of the nine-year obligation for each student. Other than those of the factors highlighted, yet another issue is the migration out of the country of the health workforce. While some countries, such as India, Indonesia and the Philippines, have specifically trained health professionals for export to developed countries, the unplanned loss of health workers can be extremely costly due to their lengthy education programs, the high cost of teaching materials and techniques, and the need to hire replacements that may lack appropriate skills, languages or cultural sensitivity (WHO, 2004). Literatures characterized health sector with shortage and poor availability of physicians and nurses in rural areas globally. Health workforce is reluctant to be posted in rural and remote areas. Several factors have been identified from monetary to non-monetary, which affects the willingness or desire of physicians and nurses for rural posting. The studies also suggested and encouraged a wide range of mixed interventions for possibly solve the problem and let physicians and nurses to work for the rural community by their own will or by compulsion. The international

experience shows that alone the monetary incentives could not change the picture and blends of interventions are needed.

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2.5. HEALTH SECTOR REFORM : THE INTERNATIONAL AND INDIAN CONTEXT

Reform means to reorganize, to change the way in which things are being done or to make something better. Reform in the Health Sector means to reorganize the manner in which the system is run so that it can become a more efficient entity. It is with this thought in mind that health policy makers around the world embarked on a mission to find new and improved ways to make the health sector a vibrant and productive organization that will meet the needs of its customers. (Gittens-Gilkes, _). Infante (1999) describes health sector reform as a dynamic process employed by governments and health authorities to improve efficiency and effectiveness in the health sector. The goal is to provide equity in health care, increase productivity and improvement in the general management of health systems. Health sector reform became a worldwide phenomenon in the 1990s (Alwan and Horny, 2002). As Kutzin (1995) pointed out, Health Sector Reform is not a new development. In its broader sense, it has been happening for many years in many countries. However, in its more recent usage, it is associated with a set of fairly focused activities and objectives which are being considered or implemented by countries across the developing world and the political spectrum. These are particularly addressed to financing, resource allocation and management issues, although the precise mix and emphasis of HSR policies varies (Standing, 2000). Health sector reforms have been used as crutches to pretend one is changing the system, but basically staying the course or even regressing (Bjorkman, 2010). So, Health system reforms have been a regular occurrence in countries around the world for several decades (Yepes et al, 2010). Since the late 1980s, many developing countries have initiated efforts to improve their health systems. (Dmytraczenko et al, 2003). Both developed and developing are undertaking health sector reform in their respective countries. Philippines, Thailand, South Korea, Malaysia, Indonesia, India and Pakistan are some of the developing countries and underdeveloped countries like Nepal and Bangladesh in Asia-Pacific are taking initiatives for health sector reform in their respective countries. Although there are many useful ways to categorize reforms, in practice, many health sector reforms cannot be grouped under a single heading because of the complex and inter-related nature of the components of the health system (PAHO, 2003). During the 1990s, the pace of reforms accelerated. In some countries, this
60

occurred in response to internal political changes, but in many others it was caused by external pressures from international organizations. A common thread has been the search for universality and efficiency, with most health reforms of the 1990s being market-oriented. Decentralization has also been a strategy of many reforms, being seen as effective in stimulating service delivery, better allocating resources according to needs, and involving communities in decisions on priorities, so as to reduce inequities. (Yepes et al, 2010). The decade of the 1990s is seen as a marker for the beginning of health sector reform in South Asia. These reforms are premised on four cardinal market principles of Individual, charities and private organizations should be made responsible for health care; Public funding must be restricted to health promotion and prevention of disease; Central governments role should be restricted to policy formulation and technical guidance, with delivery of services left to the private sector and local authorities; Private and non-governmental sector should be supported to become the key providers of health and social services. It is these principles that guided the design of health sector reforms across South Asia (South Asia includes India, Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan) with the active support of multilateral and bilateral agencies. Most of these countries initiated reforms in the 1990s and has been guided by a similar design for these reforms. (Baru, 2010). Many other developing countries in the globe adopted Health Sector Reform like Bolivia, Bamako, China , Chile, Czech Republic, Colombia, Egypt, Ghana, Hungary, Kyrgyzstan Kenya, Poland, Senegal, South Africa, South Africa , Zambia, Zimbabwe and other Central and Eastern European nations. While literatures available on Indian context, though Government initiatives in public health have recorded some noteworthy success over time, the Indian health system is ranked 118 among 191 WHO member countries on overall health performance. Health is a priority goal in its own right, as well as central input into economic development and poverty reduction. India is well placed now to develop a uniquely India set of health sector reforms to enable the health system in meeting the increasing expectation of is users and staff (Ramani et al, 2005). The health sector reforms in India were started way back in 1970s .The Govt. of India identifies the need HSR and stated in the eighth five year plan. The Ninth Five Year Plan (1997-2002) introduce more on health system reforms to enable the population to obtain optimum care at affordable cost, increase the involvement of
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voluntary, private organizations, self-help groups and Panchayati Raj Institutions (PRI) in planning and monitoring of health programmes. The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary and tertiary level. (www.april24.info) According to the study of Agarwal (2006), the importance of working on sector reforms and the important elements of health sector reforms are paramount in Indian context. India is one of the country which are less developed are reforming their health systems in an effort to achieve public health goals more affordably and effectively. In India, the health sector reforms broadly cover the following areas:

Reorganisation and restructuring of existing government health care system Involving Community in health service delivery and provision Health Management Information System Quality of care

2.6. GAPS IN THE LITERATURE

Although the research specific to rural physicians and nursing including midwives is growing, it is still very limited in the side of academic literature. Research specific to rural physicians and nurses including mid-wives-distribution, attraction and retention needs to be replicated and elaborated in terms of remote rural area in context of Indian scenario especially a state which is sharing international boundary and predominately a tribal area in sector reform environment, which is scare at this time of research.

2.7. CONCEPTURAL FRAMEWORK FOR THE STUDY 2.7.1.HRM IN PUBLIC HEALTH SECTOR A CONCEPTUAL FRAMEWORK
Human Resource Management today is not a conceptual revolution but a revolutionary concept (Sharma, 2000). In general Human Resource Management refers to the management of people within the organization, not to a specific function. This is the management of people in an organization. This includes consideration of the management of people at a strategic level within the organization (Hyde et al, 2006). HRM is the process of acquiring, training, appraising, and compensating employees, and of attending to their labor relations, health and safety, and fairness
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concerns (Dessler, 2008). HRM is a management function that helps manager recruit, select, train and develops members for an organisation (Aswathappa, K., 2008). According to Saiyadain (2009), HRM is a relative recent title for all the aspects of managing people in an organization. It represents a broad based understanding of the problems of people and their management in view of the development of behavioral science knowledge. This is human resource approach; it is concerned with the growth and development of people towards higher levels of competency, creativity, and fulfillment, because people are the central resource in any organisation and any society (Newstrom, 2007). Conceptually, it may be defined as the art of procuring, developing and maintaining competent workforce to achieve the goals of an organisation in an effective and efficient manner. In coming years there will be great demand for highly developed human capital. This will require systematic and substantial investment in the development of employees skills and knowledge. Firms will build portfolio of skills in the employee base (Kodwani, 2003). To develop firms human capital more concerted effort is necessary from every quarter. Further research by Gallup Organisation (Ramani, 2003); reveals that positive employee attitudes are likely to create 50 per cent more customer loyalty to a company and are 44 per cent more likely to result in above average productivity. The study also revealed that positive attitudes have a significant impact on profits and turnover. The above views are self explanatory to the context of need
and importance of HRM.

The people in the health system carry the knowledge and skill that are the important determinants of sustainable health in the society (Lexomboon, 2003). Human resources play a critical role in delivering health services to the population. Health planners and decision makers have to ensure that the right number of people, with the right skills, is at the right place at the right time to deliver health services for the population needs, at an affordable cost (Dreesch et al, 2005). More than any other type of organization, health organizations are highly dependent on their workforce (Dussault and Dubois, 2003). The health sector is a major employer in all countries. The International Labour Organisation reckons that 35 million persons are currently employed in the health sector worldwide (ILO, 1998). Also, HR account for a high proportion of budgets assigned to the health sector (Narine L, 2000).

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The performance of the health sector is the sum of the performance of individual performers and groups of performers in each organization that comprise the sector. Unlike the physical assets of an institution, human capital which is the capability of the workforce and its willingness and commitment to work, is an asset that, with the proper support, can appreciate. Human resources management in the particular area of management in an organization explicitly charged with people needs and the priorities of employees in the organization (Johnson, 2000). Human Resource Management in health sector involves the different functions involving planning, managing and supporting the professional development of the health workforce within a health system (Esmail et al, 2007). Good human resource management (HRM) is essential to retaining staff and maintaining a high overall level of performance within a health organization and within many health care systems worldwide, increased attention is being focused. Human resource management in the health sector has to function with a unique set of circumstances and characteristics. These include: A large and diverse workforce; A workforce comprising separate occupations and professions, some with sector-specific skills and others with more portable ones; Loyalty of those with sectorspecific skills (e.g. doctors and nurses) tends to be first to their profession and patients rather than to their employer.; Access to health professional training and employment is controlled by standards and entry requirements in many countries; The health sector is a major recipient of public expenditure in many countries; Health care delivery is a politicised process; Health is very labour-intensive and the proportion of the total budget spent on staff is much greater than in manufacturing and many service industries. (Buchan 2004). A refocus on human resources management in health care and more research are needed to develop new policies (Kabene et al, 2006). The health sector is considered an atypical customer when it comes to the effective utilization of HRM interventions and the ability to show sector-specific results or outcomes that can be directly attributed to those interventions (Adano, 2006). Further, Human resources management plays a significant role in the distribution of health care workers. With those in more developed countries offering amenities otherwise unavailable, chances are that professionals will be more enticed to relocate, thus increasing shortages in all areas of health care (Kabene et al, 2006). Human resources management also played an important role in investing in employee development. This case makes obvious the
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important roles that human resources management can play in orchestrating organizational change. As discussed above, all health care is ultimately delivered by people, effective human resources management will play a vital role in the success of health sector. And a strong understanding of the human resources management issues is required to ensure the success of any health care program. Here we have found that the relationship between human resources management and health care is extremely complex, particularly when selected literature reviews from a global perspective. 2.7.2. ATTRACTION AND RETENTION OF HEALTH WORKERS IN RURAL AREAS -CONCEPTUAL FRAMEWORK Health systems employ a large and growing number of medical professionals (Fujisawa and Lafortune, 2008). Hence, it is important to attract and retain the health workforce particularly in rural areas for achieving health goals. The extent to which health workers can be attracted to and retained in rural and remote areas depends on two interconnected sides: the factors which contribute to health workers' decisions to accept and the stay in rural and remote areas and the strategies employed by management to respond to such factors (under its control). It is highlighted by the literature review above that the factors globally are mainly higher salaries, better working conditions, better career opportunities or by compulsion. Both push and pull factors impact on the individual who makes a decision about moving to, leaving or staying in rural and remote area in many different ways. Attitudes towards these factors by an individual physicians and nurses will be the result of adequacy of physicians and nurses in rural and remote areas. There are several theories supporting the mobility of workforce. One of them is the Standard location theory has been used to predict and explain choices of practice location by health professionals (Chomitz, et al., 1998). Location theory is concerned with the geographic location of economic activity (Wikipedia.org). Such that, the Neoclassic Wage Theory, suggest that the choice is driven largely by financial motives (Boyle & Halfacree, 1998) and by the probability of finding employment (Todaro, 1976). (Lehmann et al, 2008). Behavioural theories, such as those developed by Maslow and Herzberg, show a more complex decision-making process regarding the movement of labour with a particular emphasis on the importance of job satisfaction (Lehmann et al, 2008).

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Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for turnover in general include dissatisfaction with work. The lower level of job satisfaction, results in more intention to migrate of this workforce. Performance, motivation and job satisfaction are closely related to each other: workforce satisfied with their jobs remains in their posts and performs well (Dieleman and Harnmeijer, 2006). The term, job satisfaction, has been defined by Grieshaber, Parker, and Deering (1995): Job satisfaction has been measured in various ways: in terms of the gratification of needs in the work place, a ratio of perceived inputs and outcomes, as an emotional response, and more generally as an equivalent to job attitudes. According to the Hughes et al., (2002), Job satisfaction is defined as the extent to which a person likes his or her job and is related to a persons attitudes and feelings towards the tasks, salary, working conditions, training and career opportunities, supportive working environment, etc. Various studies have demonstrated that there is a clear link between job satisfaction and staff retention (Dieleman and Harnmeijer, 2006. Therefore, the job satisfaction component is included in the framework. Riegel (2002) argues that turnover is the consequence of a complicated series of dynamics, including job satisfaction, organisational commitment, and intent to leave, that influence employee attitudes and ultimately affect employee behaviour. Turnover models have been extensively studied, and scholars have provided strong support for the proposition that behavioural intentions (intention to leave) are the most immediate determinant of actual behaviour (turnover) (Igharia & Greenhaus, 1992; Lee & Mowday, 1987). Scholars have recommended using intent to leave attitudes rather than actual staying or leaving behavior because it is relatively less expensive to collect data on turnover intentions than actual turnover (Udo etal., 1997). Prior research also has reported a positive relationship between intention to leave and actual turnover (Igharia & Greenhaus, 1992; Udo et al., 1997). (cited in Guchait, 2007). So, the intention of migration is also included in the framework. According to Lehmann et al; 2008, there are different types of environment surrounding the health workforce attraction and retention. The figure 4 is presenting the different environments.

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Figure 4: Different environments & Location of decision-makers associated with attraction and retention in the public sector. (Source: Lehmann et al; 2008) The factors in the international environment are mainly pull factors such as higher salaries, better working conditions and better career opportunities in other countries. The national environment comprises both push and pull factors such as the general political climate, including the degree of political and social stability, war, crime, etc., as well as general labour relations, the situation of the public service, salary levels, career opportunities, etc. The local environment is primarily made up of general living conditions and the social environment. The work environment again encompass push and pull factors, such as local labour relations, management styles, existence or lack of leadership, opportunities for continuing education, availability of infrastructure, equipment and support. Lastly, there are a number of individual factors which may impact on decisions, such as origin, age, gender and marital status. All factors will be discussed in more detail below. (Lehmann et al; 2008). To best suit for this study, analytical framework for exploring the HR Issues will be two sided exploration, one from the side of Management Representative and the other from the side of employee perceptions that is Physicians, Nurses & Midwives with above framework of attraction and retention.

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2.7.3. FRAMEWORK OF URBAN AREA AND RURAL AREA FOR THIS STUDY The identification of rural and urban area of the state for this study is done within the framework of these definitions. Rural settlement : The definition of a rural settlement depends on the country. In some countries, a rural settlement is any settlement in the areas defined as rural by a governmental office, e.g., by the national census bureau. This may include even rural towns. In some others, rural settlements traditionally do not include towns. (Wikipedia) Urban Settlement: For the Census of India 2011, the definition of urban area is as follows (Census, 2011, Data highlights): 1. All places with a municipality, corporation, cantonment board or notified town area committee, etc. 2. All other places which satisfied the following criteria: a. A minimum population of 5,000; b. At least 75 per cent of the male main working population engaged in non-agricultural pursuits; and c. A density of population of at least 400 persons per sq. km. Other criteria: Along with the considerations of above definitions, the inclusion criteria of presence of a District or General Hospital within the health system structure in the state are also looked into. The framework of urban area and rural area for this study: As highlighted by the above definition and other criteria, the following point will be considered for filtering the urban area: 1. Presence of District Hospital/General Hospital in the location of town area will be considered as Urban area 2. Further it will be filtered with population above the minimum criteria of 5000 3. Rest of the towns falls outside the point 1 & 2 will considered as rural town areas 4. Other areas of the above will be inclusively rural area. 5. The areas falls under urban area is tabulated in the table.3

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Table 3: The areas falls under Urban areas in the state for this study
Sl. no. District District HQ/ District Hospital location Tawang Bomdila Seppa Yupia (Rural area)/ Itanagar & Naharlagun Ziro Koloriang Daporijo Along Pasighat Yingkiong Roing Anini Population District Hospital /General Hospital 1 1 1 Consideration as Urban Area for this study Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area

1 2 3 4

Tawang West Kameng East Kameng Papum Pare including Capital Complex Lower Subansiri Kurung Kumey Upper Subansiri West Siang East Siang Upper Siang Lower Dibang Valley Dibang Valley

8376 6693 15002 ---35022 & 27020 12384 4798 15756 17033 21965 5103 10107 4853

1 1 0 1 1 1 1 1 1

5 6 7 8 9 10 11 12

13 14 15 16

Lohit Anjaw Changlang Tirap

Tezu Hawai Changlang Khonsa

15015 3954 6469 9233

1 0 1 1

Qualify as Urban Area Qualify as Urban Area Not Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area Not Qualify as Urban Area Considered as Rural Town Qualify as Urban Area Not Qualify as Urban Area Qualify as Urban Area Qualify as Urban Area

69

Chapter -3 RESEARCH METHODOLOGY

70

3.1. RESEARCH METHODOLOGY

3.1.1. RESEARCH DESIGN Based on the research objectives, the study is analytical, exploratory and descriptive on the major HR issues on distribution, attraction and retention of physicians and nurses in rural areas in India with special reference to the state of Arunachal Pradesh. The study included both quantitative and qualitative data collection and analyses. This research is primarily based on primary data with inclusion of secondary data as well. Interview and questionnaire are the major technique used in this research along with the technique of observation. Data collection instruments like interview schedule and survey questionnaires were developed with the help of wide literature review. The data as collected from the respondents (physicians, nurses and the management representatives was analyzed and present the findings with description on the topics. Subsequently, the interpretations and commentaries were put on the line keeping in the view of sequences of the respective objectives.

3.1.2. OBJECTIVE OF THE STUDY The research question puts for the study are that- What are the major HR issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh? What are the major reform initiatives under reform process for major issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh? Rationally, the following objectives are place for the study:4. To explore the major HR issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh. 5. To explore the major reform initiatives under reform process for major issues on distribution, attraction and retention of physicians and nurses in rural and remote areas in Arunachal Pradesh. 6. To suggest some remedial measures to address the major issues.

71

3.1.3. THE STUDY AREA For this study, the state of Arunachal Pradesh in India was selected. It is situated in north-eastern most part of the country, sharing the international border of 1628 km with Bhutan to the West, China to the North and North-East and Myanmar to the East. The referred state of Arunachal Pradesh is a pre-dominantly a rural and remote area and one of the most splendid and variegated tribal area of the country. As the researcher could able to establish, that there is no academic literature available as on date relating to the research topic in the state of Arunachal Pradesh. This raises the unexplored issues in context of tribal remote and rural areas and even if it is explored, it is not in record in form of any literature. The health system in Arunachal Pradesh is still in a poor state and this is traceable to several factors especially the gross underinfrastructure of the health system and shortage of skilled medical personnel at the primary health care level. Despite the vast improvement in the establishment of primary health infrastructure in the state, several parts of the state continue to suffer from lack of access to primary care services, particularly those in the poorer hilly tribal regions in the absence of physicians and nurses to provide maternal and child health services. Over the last decade, a series of reforms have been undertaken, in the states. The urge about, how this aspect of issues in the state of Arunachal Pradesh are and can be addressed, motivated me to explore the subject in this study area. Demographic and socio economic feature: The state is situated at latitude of 90.360E to 97.30 E and longitude of 26.420N to 29.300N covering a total land area of 83,743 sq. km., the largest amongst NE States in India. It has a total population of 1,382,611 with an average population density per square kilometer of 17 persons. Due to its peculiar topography and difficult terrain, there is widely dispersed settlement pattern of the population that applies to both rural and urban areas. The rural population constitutes 77.33% and the urban only 22.67 %.Sex ratio of the state is 920 females per 1000 males. The total literacy rate of the state is 66.95% with a male literacy rate of 73.69 % and female literacy rate of 59.57 %. (Source: Census 2011). The district wise Population as per census 2011 is presented in table 4. Table 4: Demographic indicators Census 2011 and 2001 of Arunachal Pradesh Indicators 2011 (census) 2001 (census) Population 1,382,611 1,097,968 Male 720,232 579,941 Female 662,379 518,027 Population Growth 25.92% 26.21%
72

Percentage of total Population Sex Ratio Child Sex Ratio Density/km2 Density/mi2 Area km2 Area mi2 Total Child Population (0-6 Age) Male Population (0-6 Age) Female Population (0-6 Age) Literacy Male Literacy Female Literacy Total Literate Male Literate Female Literate

0.11% 920 960 17 43 83,743 32,333 202,759 103,430 99,329 66.95 % 73.69 % 59.57 % 789,943 454,532 335,411

0.11% 901 798 13 34 83,743 32,333 205,871 104,833 101,038 54.34 % 65.43 % 40.23 % 484,785 303,281 181,504

Table 5 : Urban-Rural comparison of demographic indicators of Arunachal Pradesh Rural Urban Indicators Population (%) 77.33 % 22.67 % Total Population 1,069,165 313,446 Male Population 554,304 165,928 Female Population 514,861 147,518 Population Growth 22.88 % 37.55 % Sex Ratio 929 889 Child Sex Ratio (0-6) 964 944 Child Population (0-6) 164,617 38,142 Child Percentage (0-6) 15.40 % 12.17 % Literates 557,105 232,838 Average Literacy 61.59 % 84.57 % Male Literacy 68.79 % 89.45 % Female Literacy 53.78 % 79.04 % The administrative set up of Arunachal Pradesh and its changing district boundaries correspond broadly to natural boundaries of river basin. Even the boundaries of Sub-Divisions, Community Development Blocks and Administrative Circles within the districts have also been directly affected by the terrain features. There are 16 Districts, 37 sub-divisions, 155 circles, 17 towns, 69 blocks and 3862 villages (Source - Census: 2001) constituting an elaborate administrative structure for diffusing developmental activities in the state.

73

3.1.4. MAP OF THE STUDIED AREA

Focused Studied Area

Figure 5: Map of India (Source : www.Stayfinder.com)

Figure 6: Map of Arunachal Pradesh (Source : www.arunachalipr.gov.in)

74

3.1.5. DATA COLLECTION METHODS AND INSTRUMENTS PRIMARY DATA: The primary data required for the study was collected with the help of interview schedule, survey questionnaire and observation. The primary data was collected through questionnaire among sampled physicians, nurses and mid-wives to understand their attitude towards working and living in rural areas and accepting the rural posting and insight on the HR issues in the area of study. A selected key informants from state and district health official in Arunachal Pradesh was interviewed with the help of interview schedule. Further, the data required on distribution pattern was collected with personal visits to department of health and family welfare, Govt. of Arunachal Pradesh. The survey questionnaire for physicians and nurses including mid-wives was developed with literature review and it was done in two stages. Firstly, it was developed and tested in a pilot survey to ensure that the survey instrument is free from all errors and all inclusions. For the purpose a field visit was undertaken. The pilot survey was done in a rural area Primary Health Centre named as Koronu PHC, Iduli PHC and Parbuk CHC in the Lower Dibang Valley district of Arunachal Pradesh on dated 7.9.2010 to 10.9.10, along with 3 nos. of Physicians, 1 no. of Nurse and 3 midwives. Copies of the instrument in English was prepared for each of them and handed to them personally along with the covering letter attached with the instrument. The filled-in questionnaires were returned to the researcher with some suggestions in about 20 minutes of time. The suggestions of the participants were well taken and necessary suggestions were included and reviewed for a final copy of the survey instrument. The finally developed questionnaire is displayed in Appendix. The participants in pilot survey were again included in the fresh survey after necessary corrections of the instrument. The interview schedule is place in Appendix. SECONDARY DATA: A range of research articles, books and official documents available in soft and hard copies were reviewed which were related to distribution, attraction and retention of workforce in public health sector in rural areas in India and specially referring to the study area. The Rural Health Statistics, 2010, published by Ministry of Health and Family Welfare, Govt. of India was used for exploring the issues in distribution of physicians and nurses in rural India and Arunachal Pradesh. For other secondary data, the printed & online policy manuals of government, printed journals, government publications, articles, research thesis

and books was used for collecting relevant secondary information.

75

3.1.6. SAMPLING FRAME Choosing a study sample is an important step in any research study, since it is rarely practical, efficient or ethical to study whole population. In this study, the multistage sampling, convenience sampling and simple random method was used to frame the sample of physicians and nurses in rural areas in the study area. By applying the sampling techniques, the total sixteen (16) districts were divided in four equal zones comprises of four districts in each zone according to their geographical location. Zone 1: (Tawang, West Kameng, East Kameng and Papumpare); Zone 2: (Kurung Kumey, Lower Subansiri, Upper Subansiri and West Siang); Zone-3(Upper Siang, East Siang, Dibang Valley and Lower Dibang Valley); Zone-4: (Lohit, Anjaw, Changlang and Tirap). The simple random sampling was used to pick the sample of physicians and nurses from each of the zone from selected health institutions through convenience sampling. According to the Rural Health Statistics (2010), there are 200 nos. of physicians (doctors) and 688 nos. of nurses and mid-wives (395 nos. of mid-wives and 293 nos. of nurses) in the rural public health system in Arunachal Pradesh. Therefore, the sample size determined were 132 nos. of physicians and 247 nos. of midwives and nurses. The sample was determined with 95% of confidence level, 5% margin of error with a response distribution of 50%. According to the sample size determined, the survey questionnaires were distributed and total of 353 nos. of questionnaires were returned to the researcher out of which 334 nos. (113 nos. of physicians, 98 nos. of Nurses and 123 nos. of midwives) of questionnaires were useable for the study. Henceforth the useable response rate was 88% in total. Whereas the individual response rate for physicians was 85% and mid-wives and nurses was 89%. To get the high response rate the use of reminders (at-least 3 times) and questionnaire survey were used. The distribution of questionnaire and collection of data was done within the period of 7.9.2010 to 25.03.2012. One management representatives each from the 16 districts and one state level management representatives were picked as a sample of management representatives and conducted the interview.

76

3.1.7. DATA ANALYSIS Possessing relevant information generated from the interviews,

questionnaires and observations are categorizes the interviewees point to the key themes, into main themes of issues including the observational themes. It includes analyzing by organizing the text from the individual interview respondent and grouping the relevant issues and eliminating the answers which seemed irrelevant to the topic. Once the data are organized, the next step followed was the description i.e., the researcher described the various pertinent aspects of the study including the setting, the individual being studied, the purpose of any activities examined, the viewpoints of the participants, etc. Only after data have organized and described, the final step of analysis process i.e., interpretation and commentary was done, which involves explaining the findings. Subsequently, the interpretation and commentary was placed according to the research questionnaire and the study objectives. Findings and results is presented in the sequence of the research problems. The information collected from both the primary and secondary sources was classified, tabulated and subjected to analysis. SPSS software was used for data entry, validation, cleaning and analysis. The statistical package for the social sciences (SPSS for windows version 19) and Microsoft Excel 2007 was used to analyse the quantitative data. The summaries of the data were undertaken which includes percentage, mean, standard deviations. The statistical analysis used included reliabilities, correlation, T-Test (one sample & paired), ANOVA, Chisquare test, multiple & logistic regression etc.

3.2. LIMITATION OF RESEARCH

To lineout the limitation of this study, it may not be free from some of the limitations despite of maximum heed. Although the primary data was collected with the assumption that it truly represented the character, and the views expressed by the respondents and the possibility of personal bias of such respondents cannot be ruled out. Further, analysis includes the researchers own views on the HR Issues and HRM Practice in the health sector of Arunachal Pradesh, which may include personal experience and bias. Moreover, to determine the major issues only pertinent to Physicians and nurses from a wide range of technical professional occupations in health sector was considered. Other service occupations in health sectors are not
77

considered here for the study, as it would have invited a huge area of study which is not possible to sum up in the constraints of funding and timing.

3.3. CONTRIBUTION OF THE RESEARCH

It is mentioned in earlier sections that there is limited literature of the topic as on date in Arunachal Pradesh, (so far as this researcher has been able to establish). This research process would not only generate useful contributions to the field of research, but that it would also provide time for reflection and learning for other people involved in this sector. This research work definitely is useful, which has brought out in the light of Human Resource issues and present HR practice in Public Health sector in Arunachal Pradesh. That would I believe generate an atmosphere of enhancing workforce management in the organization creating a WIN-WIN Situation. It also may act as a resource book for future reference to know the HRM in the Public Health Sector in Arunachal Pradesh in health organisation and other study purposes also. In addition, a study such as this one, which focuses on the experiences and views of healthcare workforce, provides useful information to policy-makers and those responsible for the implementation and effectiveness of health sector reform initiative in the state. It also tries to provide ideas for future improvements.

78

Chapter -4 DATA ANALYSIS AND INTERPRETATION

79

SECTION-1 CHARACTERSTICS OF RESPONDENTS

80

4.1.1. INTRODUCTION
This chapter is present, the detail data analysis of the questionnaire survey and the interview followed by interpretation of all findings. The chapter is divided into six sections and consist of : i) Demographic characteristics of respondents, ii) Dimension on Distribution, iii) Dimension on attraction, iv) Dimension on retention, v) Dimension in Reform initiatives and vi) Exploration of HR Practice in Reform Process.

4.1.2. CHARACTERSTICS OF RESPONDENTS

Characteristics- management representatives: Seventeen (17) nos. of management representatives were pooled from District (16 nos.) and State level (1 no.) for the study. 88.2% of the respondents were male and 11.8% were female. The mean age and management experience of the respondents are 44 years and 8 years (approx.) respectively. Table 6 and 7 shows the sample descriptive. Table 6 : Demographic characteristics of management representatives respondents Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)
1 2 3 Position Level Gender Age State Level District Level Male Female 35-40 41-45 46-50 0-5 6-10 11-15 1 16 15 2 2 9 6 3 8 6 5.9 94.1 88.2 11.8 11.8 52.9 35.3 17.6 47.1 35.3

Years of management experience

Table 7 : Mean age and experience of management representatives respondents Sl. No. 1 2 Attributes Age of the respondents Management Experience of the respondents N 17 17 Mean 44.29 7.88 Std. Dev. 2.88 3.47

Characteristics- employees: According to the data of RHS (2010), 200 numbers of physicians (doctors) and 688 nos. of nurses and mid-wives are in the rural and remote areas in the state. Among these physicians, nurses and mid-wives, 132 nos. of physicians and 247 nos. of midwives and nurses were included in the sampling size. Finally, 334 nos. of responses in completed form were selected and included in the data analysis. Out of total 334 nos. of respondents, 113 nos. (33.8%) are Physicians, 98 (29.3%) nurses and 123 nos. (36.8%) of mid-wives. Out of the total respondents, 26.3% of the respondents were male and 73.7% were female. In individual groups of
81

these three employees 87 nos. (77%) were male and 26 nos. (23%) were female in group of the Physicians and only 1 no. of male in group of nurses and mid-wives. 230 nos.(68.9%) of respondents had rural family Background and 104 nos. (31.1%) had urban family background. 215 nos. (64.4%) of the respondents were married and 119 nos. (35.6%) were unmarried. The mean age and length of in-service were 31 years (approx.) and 7 years (approx.) respectively. Out of the total respondents, 154 nos. (46.1%) were contractual employees and 180 nos. (53.9%) were permanent employees. At the time of study, 12 nos. (3.6%), 101 nos. (30.2%), 157 nos. (47.0%) and 64 nos. (19.2%) of respondents were working in District Hospitals, CHCs, PHCs and SCs respectively. Table 8 and 9 shows the employee demographic characteristics in detail. Table 8: Demographic characteristics of employee respondents Sl. No. Attributes Sub Attributes Numbers (N) Percentage (%)
1 Position Physicians Nurses Mid-wives 20-30 years 30-40 years 40-50 years 50-60 years Male Female Rural Urban Married Unmarried 0-5 years 5-10 years 10-15 years 15-20 years 20-25 years DH CHC PHC SC Contract Permanent 113 98 123 178 121 33 2 88 246 230 104 215 119 172 96 43 16 7 12 101 157 64 154 180 33.8 29.3 36.8 53.3 36.2 9.9 0.6 26.3 73.7 68.9 31.1 64.4 35.6 51.5 28.7 12.9 4.8 2.1 3.6 30.2 47.0 19.2 46.1 53.9

Age

3 4 5 6

Sex Family Background Marital Status Length of Service

Presently Working in

Nature of Employment

Table 9: Mean age and length of service of the respondents Sl. No. Attributes N Mean
1 2 Age of the respondents Length of service of the respondents 334 334 31.38 6.78

Std. Dev.
6.270 4.781

82

SECTION 2 ANALYSIS OF DIMENSION OF HR ISSUES IN DISTRIBUTION OF PHYSICIANS, NURSES AND MIDWIVES IN RURAL AND REMOTE AREAS OF THE STATE

83

4.2.1. INTRODUCTION
This section of this chapter describes the dimensions of distributional issues of the Physicians, Nurses and Mid-wives in the study area i.e., the state of Arunachal Pradesh, focusing on the government health system where the problem is most severe. The state public health delivery system is based on the three tiers that are in primary, secondary and tertiary health care system. Public hospitals in Arunachal Pradesh have to behave and function in accordance with the government's administrative and financial laws issued by specific Government of India and Government of Arunachal Pradesh. With the network of the public hospitals in the state, the State government is responsible for managing and delivering health services, including some aspects of prescription care, as well as planning, financing, and evaluating hospital care provision and health care services. The Public Health Services department that is the Department of Health and Family Welfare is headed by Secretary H& FW and Director of Health Services and the directorate has a separate branches headed by a Joint Directors. The planning department undertakes the planning of new institutions which include creation of posts for the new institutions as per the Govt. of India and state govt. norms. The other respective National health programmes are handled by respective programme officers, under the umbrella of National Rural Health Mission Programme which is being headed by the Mission Director-NRHM in Directorate level.

4.2.2.SCENARIO OF DISTRIBUTION INSTITUTION IN ARUNACHAL PRADESH

OF

HEALTH

A widespread establishment of health institutions in the state was done across the five year plans. According to the RHS, (2010), there is a sharp increase in the health institutions in rural areas of the state. 55 SCs in sixth plan (1981-85) to 286 SCs in eleventh plan (2007-2012), not a single PHCs to 97 PHCs and not a single CHCs to 48 CHCs in the region. There are 2 General Hospitals in the state, one at Pasighat (the district headquarter of East Siang) and other at Naharlagun in the district of PapumPare (the capital district). Presently the state is having 468 nos. of sanctioned SCs, out of which only 286 SCs are functional due to one of other reasons of human resource inadequacy or inadequacy of infrastructure. Above the hierarchy 119 nos. of sanctioned and functional PHCs are functioning out of which 29 nos. of 24x7 PHCs and rest are non 24x7 PHCs. Above that a wide network of sanctioned 49 nos. of CHCs are functional,
84

out of which only 1 no. of CHC is functioning as FRU. There are 2 General Hospitals at Naharlagun and Pasighat, 13 District Hospitals at Tawang, Bomdila, Seppa, Ziro, Daporijo, Along, Yingkiong, Roing, Anini, Tezu, Changlang, Khonsa and Hawai (under-construction). The District/General Hospital covers an average of 98,758 nos. of population. Similarly, Average population for CHC is 28,217 and for PHC is 11,619 and SC is 2,954. Table 11 puts detail lights of the individual districts. Table 10: Showing health infrastructure growth in rural areas of the states
Sub Centres State
Arunachal Pradesh

Primary Health Centres

10 th 379 11 th 286 6 th 0 7
th

Community Health Centres

11 th 97 6 th 0 7 th 6 8 th 9 9 th 20 10 th 31 11 th 48

6 th 55

7 th 155

8 th 223

9 th 273

8 th

9 th 65

10 th 85

24 45

Source : RHS, 2010

Table 11: Distribution of Public Health Facilities in Arunachal Pradesh

Name of the Districts Lower Dibang Valley

Lower Subansiri

Kurung Kumey

Dibang Valley

West Kameng

East Kameng

Upper siang

West Siang

Papumpare

No. of facilities Tawang Total

Upper Subansiri

Changlang

East Siang

Anjaw

Lohit

Total no. of sanctioned sub centres Total no. of functional sub centres Total no. of sanctioned PHCs Total no. of 24x7 PHC Total no. of non 24x7 PHCs Total no. of CHC Total no. of CHC (FRUs) Total no. of CHC which are non-FRUs Total number of District Hospitals/ General Hospital

468 286 119 29 90 49 1

14 27 41 42 25 45 46 44 38 13 13 7 6 1 5 1 0 1 21 10 30 18 13 25 28 38 11 11 4 3 1 4 0 4 9 1 8 2 0 1 8 1 7 4 0 4 7 1 6 2 0 2 10 11 15 15 2 3 7 4 0 4 1 3 4 1 6 1 5 2 0 2

3 24 27 4 20 12 1 8 2 1 1 1 0 7 1 0 3 2 0 0 0 0 3 2

30 36 18 22 8 4 4 4 0 4 7 2 5 3 0 3

10 12 11 1 4 0 4 5 0 5 6 1 5 4 0 4

48

14

1 1 0

85

Tirap

Table 12: Population covered by the health institutions in Arunachal Pradesh

Sl No Name of District Populati on (Census 2011) Num ber of DH/ GH Populat No. Populat ion of Of ion for DH CHC CHC* No. Populat Of ion for PHC PHC No. Popul Of ation HSC for HSC

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Tawang 49,950 West Kameng East Kameng Papum Pare Lower Subansiri Kurung Kumey Upper Subansiri West Siang East Siang Upper Siang L/D/Vall ey Dibang Valley Lohit Anjaw

1 1 87,013 1 78,413 1 1,76,385 1 82,839 0 89,717 1 83,205 1 1,12,272 1 99,019 1 35,289 1 53,986 1 7,948 1 1,45,538

49,950 87,013 78,413

1 24,975 4 21,753 1 39,207

6 8,325 4 21,753 9 8,713 8 44,096 22,048 7 41,420 11,834 10 22,429 8,972 11 20,801 7,564 15 22,454 7,485 15 16,503 6,601 2 8,822 17,645 6 26,993 8,998 1 1,590 8 48,513 18,192 2 10,545 36,988 37,332 10,545 8 18,494 7 16,000 119 11,619

14 3,568 27 3,223 41 1,913 42 4,200 25 3,314 45 1,994 46 1,809 44 2,552 38 2,606 13 2,715 13 4,153 3 2,649 24 6,064 27 781 30 4,932 36 3,111 468 2,954

1,76,385 4 82,839 0 83,205 2 4 4

1,12,272 5 99,019 35,289 53,986 7,948 6 4 2 0

1,45,538 3 0 2

0 21,089 15 Changlang1,47,951 1 16 Total Tirap 1,11,997 1

13,82,611 14

1,47,951 4 1,11,997 3

98,758 49 28,217

* Population covered by a single Health Institution in the districts are actual population covered by the HI and rest are average

4.2.3. SCENARIO OF DISTRIBUTION OF PHYSICIANS, NURSES & MID-WIVES IN ARUNACHAL PRADESH

In Arunachal Pradesh, there is scarce on the data availability on distribution, and trends in human resources in public health care sector has been observed by the researcher. It is also a barrier to the effective human resource planning in the state. According to the primary data collection from the field districts and state officials,
86

there are 449 nos. of physicians/Medical Officers, 390 nos. of nurses and 542 nos. of Mid-wives (ANM) distributed across the health institutions in Arunachal Pradesh. This accounted for 33% of doctors, 28% of nurses and 39% of mid-wives among this pool of human resource. Among the nursing cadre 58% accounted Mid-Wives (ANM) and 42 % accounted for Nurses (GNM/SN). The trend may be seen at figure 7, 8 & 9.

Figure 7: Number of Physicians (doctors), Nurses and Mid-wives in Arunachal Pradesh

Figure 8: Percentage Share of Physicians (doctors), Nurses and Mid-wives in Arunachal Pradesh

Figure 9: Percentage Share of Nurses and Mid-wives in Arunachal Pradesh

87

4.2.3.1. DISTRICT-WISE DISTRIBUTION PATTERN OF PHYSICIANS (MEDICAL OFFICERS) & SPECIALISTS (PAEDIATRICS, ANAESTHETICS AND GYNAECOLOGIST): The Physicians are synonymously called doctors or Medical Officers in the field. The distribution of the physicians is skewed and mal-distributed among the districts. They are more concentrated to the district which is with good access to communication. The Specialist cadres, essential for the maternal and child like Paediatrics, Anaesthetics and Gynaecologist are very scare and concentrated only to the highest possible level of hospitals in urban area in the state. There are overall 11 nos. of Paediatrician, 13 nos. of Anaesthetist and 15 nos. Gynaecologist in the state. Only 6 (37%) out of 16 districts have pediatrician. They are distributed as 3 nos. in Papum Pare district, 2 nos. in Lower Subansiri district, 1 nos. in Upper Subansiri district, 2 nos. in East Siang district, 2 nos. in Upper Siang and 1 no. in Lohit district. Only 5 (31%) out of 16 districts have Anesthetist, 4 nos. in Papum Pare, 1 nos. in Upper Subansiri, 5 nos. in East Siang, 2 nos. in Upper Siang and 1 no. Lohit Districts. Only 8 out of 16 districts have Gynaecologist, 1 no. in West Kameng, 3 nos. in Papum Pare, 2 nos. in L/Subansiri, 1 no. in U/Subansiri, 1 no. in West Siang, 4 nos. in East Siang, 2 nos. in Upper Siang, and 1 no. in Lower Dibang Valley. Table 13: Numbers of Pediatricians, Anesthetist and Gynecologist in Arunachal Pradesh (District Wise) Sl. No. Name of District Paediatrician Anaesthetist Gynaecologist 1 Tawang 0 0 0 2 West Kameng 0 0 1 3 East Kameng 0 0 0 4 Papum Pare 3 4 3 5 L/Subansiri 2 0 2 6 Kurung Kumey 0 0 0 7 U/Subansiri 1 1 1 8 West Siang 0 0 1 9 East Siang 2 5 4 10 Upper Siang 2 2 2 11 L/D/Valley 0 0 1 12 Dibang Valley 0 0 0 13 Lohit 1 1 0 14 Anjaw 0 0 0 15 Changlang 0 0 0 16 Tirap 0 0 0 Total 11 13 15

88

There are 449 nos. of physicians/Medical Officers distributed across the health institutions in Arunachal Pradesh having 1:3079 of doctor-population ratio against a norm of 1:1000 by WHO, which deviates 68% of the norms. Comparing the concentration of physicians across the districts the districts of Papum Pare (75), East Siang (53) and West Siang (40) are three highest districts. These districts are featured by good communication and other basic amenities in urban areas. The Doctorpopulation ratio is good in comparing to other district in Anjaw district (1:1506) to the worst scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in Table: 15. Table 14: Numbers of Physicians (Medical Officer) in Arunachal Pradesh district wise
Sl. No. Name of District No. of MOs

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total

Papum Pare East Siang West Siang Lohit L/Subansiri Changlang West Kameng U/Subansiri East Kameng Upper Siang Tirap L/D/Valley Tawang Anjaw Kurung Kumey Dibang Valley

75 53 40 33 32 29 26 24 23 23 22 21 19 14 10 5 449

Table 15: Ranking of Density of Physicians (doctors) in Arunachal Pradesh (District wise)
District Population No. of (2011 Physicians census) Density of physicians Difference from the norm of WHO &GOI % Difference (norm actual)

Rank 1 Anjaw Upper 2 Siang Dibang 3 Valley 4 East Siang Papum 5 Pare

21,089 35,289 7,948 99,019 1,76,385

14 23

1506 1534 1590

506 534

34% 35% 37% 46% 57%

5 53 75

1868 2352

590 868 1352

89

6 7 8 9 10

11 12 13 14 Tirap 15 Changlang Kurung 16 Kumey Total

L/D/Valley L/Subansiri Tawang West Siang West Kameng East Kameng U/Subansiri Lohit

53,986 82,839 49,950 1,12,272 87,013 78,413 83,205 1,45,538 1,11,997 1,47,951 89,717 13,82,611

21 32 19 40 26 23 24 33 22 29 10 449

2571 2589 2629 2807 3347 3409 3467 4410 5091 5102 8972 3079

1571 1589 1629 1807 2347 2409 2467 3410 4091 4102 7972 2079

61% 61% 62% 64% 70% 71% 71% 77% 80% 80% 89% 68%

The distribution of the physicians in Arunachal Pradesh is concentrated to the districts with good access to communication, semi-urban, rural towns and higher health institutions. The number of physicians of 75 nos. (17%) is in Papum Pare the capital district followed by East Siang 53 nos. (12%), West Siang 40 nos. (9%), Lohit 33 nos. (7%), L/Subansiri 32 nos. (7%), Changlang 29 nos.(6%), West Kameng

26nos.(6%), U/Subansiri 24 nos. (5%), Upper Siang 23 nos. (5%), East, Kameng 23 nos. (5%), Tirap 22 nos. (5%), L/D/Valley 21 nos. (5%), Tawang 19 nos. (4%), Anjaw 14 nos. (3%), Kurung Kumey 10 nos (2%), Dibang Valley 5 nos. (1%). This trend is presented graphically in figures 10, 11 and 12.

Figure 10: District wise numbers of Physicians (doctors/ medical officers) in Arunachal Pradesh

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Figure 11: District wise percentage share of Physicians (doctors/ medical officers) in Arunachal Pradesh

Figure 12: Graphical mapping of district wise number of Physicians (doctors/ medical officers) in Arunachal Pradesh 4.2.3.2 DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES & GNM) DISTRICT-WISE The Nurses are synonymously called Staff Nurses and GNM in Arunachal Pradesh. There are 390 nos. of Nurses across the geographical boundary of the state, covering 3545 average population by a single Nurse against an expected norm of 1:500 by Govt. of India. Comparing the concentration of nurses across the districts the districts of Papum Pare (90), East Siang (62) and West Siang (35) are three highest districts. The density of Nurse-population ratio is good in comparison within the districts in East Siang (1:1597) to the worst scenario in Kurung Kumey district (1:9802). The district wise ratio is placed in table 17.

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Table 16: Numbers of Nurses in Arunachal Pradesh (District Wise) Sl. Name of District No of Sl. Name of District No of No. Nurses No. Nurses 1 Papum Pare 90 9 West Kameng 16 2 East Siang 62 10 Upper Subansiri 14 3 West Siang 35 11 Upper Siang 12 4 Changlang 31 12 Tawang 11 5 Lohit 27 13 Kurung Kumey 11 6 Lower Subansiri 24 14 East Kameng 8 7 L/D/Valley 20 15 Anjaw 8 8 Tirap 19 16 Dibang Valley 2 Total 390 Table 17: District-wise ranking of density of Nurses in Arunachal Pradesh Rank Name of District Population No of Density of (2011 census) Nurses Nurses 1 East Siang 99,019 62 1597 2 Papum Pare 1,76,385 90 1960 3 Anjaw 21,089 8 2636 4 L/D/Valley 53,986 20 2699 5 Upper Siang 35,289 12 2941 6 West Siang 1,12,272 35 3208 7 Lower Subansiri 82,839 24 3452 8 Dibang Valley 7,948 2 3974 9 Tawang 49,950 11 4541 10 Changlang 1,47,951 31 4773 11 Lohit 1,45,538 27 5390 12 West Kameng 87,013 16 5438 13 Tirap 1,11,997 19 5895 14 Upper Subansiri 83,205 14 5943 15 Kurung Kumey 89,717 11 8156 16 East Kameng 78,413 8 9802 3545 Total 13,82,611 390 As per the norms Nurses are placed in higher health institution than SubCentres. The distributional pattern of the nurses in the state is also concentrated to the districts with good access to communication and higher health institutions. The number of nurses is concentrated to the districts are Papum Pare 90 nos. (23%), East Siang 62 nos. (16%),West Siang 35 nos. (9%),Changlang 31 nos.(8%), Lohit 27 nos. (7%), Lower Subansiri 24 nos. (6%), Lower Dibang Valley 20 nos. (5%), Tirap 19 nos. (5%),West Kameng 16 nos. (4%), Upper Subansiri 14 nos. (4%), Upper Siang 12 nos. (3%), Tawang 11nos. (3%), Kurung Kumey 11 nos. (3%), East Kameng 8 nos. (2%), Anjaw 8 nos. (2%), and Dibang Valley 2 nos. (1%). This trend is presented graphically in figure 13, 14 and 15.
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Figure 13: District wise numbers of nurses in Arunachal Pradesh

Figure 14: District wise share of nurses in Arunachal Pradesh

Figure 15: Graphical mapping of district wise number of nurses in Arunachal Pradesh
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4.2.3.3. DISTRIBUTION PATTERN OF MID-WIVES (ANM) DISTRICTWISE The Mid-wives are synonymously called ANM in Arunachal Pradesh. Generally as per norms ANMs are posted in Sub-Centre Level and if adequate are placed in higher institutions as per norms. There are 542 nos. of ANMs are across the geographical boundary of the state, covering 2551 average population by a single Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The density of Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison to other districts to the worst scenario in Kurung Kumey district (1:4722). The district wise ratio is placed in Table: 19. Table 18: Numbers of Mid-Wives (ANM) in Arunachal Pradesh (District Wise) Sl. No. Name of District No of Midwives Sl. no Name of No of District Midwives 65 9 Lower 35 1 Papum Pare Subansiri 2 East Siang 55 10 L/D/Valley 32 3 West Siang 47 11 West Kameng 29 45 12 Kurung 19 4 East Kameng Kumey 5 Changlang 43 13 Tawang 17 6 Upper Subansiri 41 14 Anjaw 16 7 Lohit 38 15 Upper Siang 15 8 Tirap 36 16 Dibang Valley 9 Total 542 Table 19: District-wise ranking of density of Mid-wives in Arunachal Pradesh Rank Name of District Population (2011 No of Density census) Midwives of Nurses 1 Dibang Valley 7,948 9 883 2 Anjaw 21,089 16 1318 3 Lower Dibang Valley 53,986 32 1687 4 East Kameng 78,413 45 1743 5 East Siang 99,019 55 1800 6 Upper Subansiri 83,205 41 2029 7 Upper Siang 35,289 15 2353 8 Lower Subansiri 82,839 35 2367 9 West Siang 1,12,272 47 2389 10 Papum Pare 1,76,385 65 2714 11 Tawang 49,950 17 2938 12 West Kameng 87,013 29 3000 13 Tirap 1,11,997 36 3111 14 Changlang 1,47,951 43 3441 15 Lohit 1,45,538 38 3830 16 Kurung Kumey 89,717 19 4722 2551 Total 13,82,611 542
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The distributional pattern of the ANMs in the state is also concentrated to the districts with good access to communication and higher health institutions. The number of mid-wives is concentrated to the districts as Papum Pare 65 nos. (12%), East Siang 55 nos. (10%), West Siang 47 nos. (9%), East Kameng 45 nos. (8%), Changlang 43 nos.(8%), Upper Subansiri 41 nos. (8%), Lohit 38 nos. (7%),Tirap 36 nos. (7%), Lower Subansiri 35 nos.(6%), Lower Dibang Valley 32 nos. (6%), West Kameng 29 nos. (5%), Kurung Kumey 19 nos. (4%), Tawang 17 nos. (3%), Anjaw 16 nos. (3%), Upper Siang 15 nos. (3%) and Dibang Valley 9 nos.(2%). This trend is presented graphically in figure 16, 17 and 18.

Figure 16: District wise numbers of mid-wives in Arunachal Pradesh

Figure 17: District wise share of nurses in Arunachal Pradesh

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Figure 18: Graphical mapping of district wise number of nurses in Arunachal Pradesh

4.2.4. SCENARIO OF DISTRIBUTION OF PHYSICIANS, NURSES & MID-WIVES IN RURAL AND REMOTE AREAS IN ARUNACHAL PRADESH
According to the primary data collection, there are 283 nos. of physicians/medical officers, 210 nos. of nurses and 390 nos. of Mid-wives (ANM) distributed across the rural and remote health institutions in Arunachal Pradesh. This accounted for 32% of doctors, 24% of nurses and 44% of mid-wives among this pool of human resource. Among the nursing cadre 65% accounted Mid-wives (ANM) and 35% accounted for Nurses (GNM/SN). Figure 19, 20 and 21 represent the situation graphically.

Figure 19: Numbers of Physicians, nurses and mid-wives in rural and remote areas in Arunachal Pradesh
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Figure 20: Percentage Share of Physicians (doctors), Nurses and Mid-wives in rural and remote area of Arunachal Pradesh

Figure 21: Percentage Share of Nurses and Mid-wives in rural and remote area in Arunachal Pradesh 4.2.4.1. DISTRIBUTION PATTERN OF PHYSICIANS (MEDICAL OFFICERS) IN RURAL & REMOTE AREAS (DISTRICT WISE) There are 283 nos. of physicians/Medical Officers distributed across the rural health institutions in Arunachal Pradesh having 1:3797 of doctor-rural population ratio against a norm of 1:1000 by WHO, which deviates 74%. Comparing the concentration of physicians across the districts the districts of Papum Pare (36), East Siang (32) and West Siang (31) are three highest districts. The Doctor-population ratio is good in comparing to other district in Anjaw district (1:1506) to the worst scenario in Kurung Kumey district (1:8972). The district wise ratio is placed in Table: 21.

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Table 20: District wise number of Physicians (Doctors) in Rural Area in Arunachal Pradesh Sl. Name of District Physicians Sl. Name of Physicians NO (Doctors) in NO District (Doctors) in Rural Area Rural Area 1 Papum Pare 36 9 Anjaw 14 2 West Siang 32 10 Tirap 13 3 East Siang 31 11 East Kameng 12 4 Changlang 25 12 L/D/Valley 12 5 Lohit 23 13 Tawang 11 6 Lower Subansiri 18 14 Kurung Kumey 10 7 West kameng 16 15 Upper Siang 10 8 Upper Subansiri 15 16 Dibang Valley 5 283 Total Table 21: District wise Doctor-Population ratio in Arunachal Pradesh Name of Physicians Rural Doctor WHO Difference District (Doctors) Population Populatio norms from the in Rural (Census n ratio norm of Area 2011) WHO &GOI Anjaw 14 21089 1506 1000 506 Dibang 5 7948 1590 1000 590 Valley Papum 36 79500 2208 1000 1208 Pare East Siang 31 71417 2304 1000 1304 West 32 87311 2728 1000 1728 Siang Upper 10 28743 2874 1000 1874 Siang L/D/Valley 12 42601 3550 1000 2550 Lower 18 70029 3891 1000 2891 Subansiri Tawang 11 44323 4029 1000 3029 West 16 68654 4291 1000 3291 Kameng Upper 15 69595 4640 1000 3640 Subansiri Lohit 23 113700 4943 1000 3943 East 12 60156 5013 1000 4013 Kameng Changlang 25 128736 5149 1000 4149 Tirap 13 91113 7009 1000 6009 Kurung 10 89717 8972 1000 7972 Kumey Total 283 1074632 3797 1000 2797

% Difference (norm actual) 34% 37% 55% 57% 63% 65% 72% 74% 75% 77% 78% 80% 80% 81% 86% 89% 74%

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The distributional pattern of the physicians in rural & remote area in Arunachal Pradesh is concentrated to the districts with easy to access of rural from the urban areas. The number of physicians of Papum Pare 36 nos. (13%), West Siang 32 nos. (11%),East Siang 31 nos. (11%), Changlang 25 nos. (9%), Lohit 23 nos. (8%), Lower Subansiri 18 nos. (6%), West Kameng 16 nos. (6%), Upper Subansiri 15 nos. (5%), Anjaw 14 nos. (5%), Tirap 13 nos. (5%), L/D/Valley 12 nos. (4%), East Kameng 12 nos. (4%), Tawang 11 nos. (4%), Upper Siang 10 nos. (4%), Kurung Kumey 10 nos. (4%) and Dibang Valley 5 nos. (2%). This trend is presented graphically in figure 22, 23 and 24.

Figure 22: District wise numbers of Physicians (doctors/ medical officers) in Arunachal Pradesh

Figure 23: District wise percentage share of Physicians (doctors/ medical officers) in Arunachal Pradesh

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Figure 24 : Graphical mapping of district wise number of Physicians (doctors/ medical officers) in Arunachal Pradesh 4.2.4.2. DISTRIBUTIONAL PATTERN OF NURSES (STAFF NURSES & GNM) IN RURAL AND REMOTE AREA IN ARUNACHAL PRADESH DISTRICT-WISE There are 210 nos. of Nurses across the geographical boundary of the state, covering 5117 average population by a single Nurse against an expected norm of 1:500 by Govt. of India. Comparing the concentration of nurses across the districts, East Siang (33), Changlang (26) and West Siang (24) are three highest districts. The density of Nurse-population ratio is good in comparison within the districts in East Siang (1: 2164) to the worst scenario in East Kameng district (1: 15039). The district wise ratio is placed in Table: 23. Table 22: District wise number of Nurses Sl. Name of District Nurses in NO Rural Area 1 East Siang 33 2 Changlang 26 3 West Siang 24 4 Papum Pare 19 5 Lohit 19 6 Lower Subansiri 16 7 Kurung Kumey 11 8 Tirap 11 Total in Rural Area in Arunachal Pradesh Sl. Name of District Nurses in NO Rural Area 9 Upper Subansiri 10 10 West Kameng 8 11 L/D/Valley 8 12 Anjaw 8 13 Upper Siang 6 14 Tawang 5 15 East Kameng 4 16 Dibang Valley 2 210

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Table 23: District wise Nurses Population ratio in Rural Area in Arunachal Pradesh Rural Nurse Name of Nurses WHO Difference % District in Population Population norms from the Difference Rural (Census ratio norm of (norm Area 2011) WHO actual) &GOI East Siang 33 71417 2164 500 1664 77% Anjaw 8 21089 2636 500 2136 81% West Siang 24 87311 3638 500 3138 86% Dibang Valley 2 7948 3974 500 3474 87% Papum Pare 19 79500 4184 500 3684 88% Lower Subansiri 16 70029 4377 500 3877 89% Upper Siang 6 28743 4791 500 4291 90% Changlang 26 128736 4951 500 4451 90% L/D/Valley 8 42601 5325 500 4825 91% Lohit 19 113700 5984 500 5484 92% Upper Subansiri 10 69595 6960 500 6460 93% Kurung Kumey 11 89717 8156 500 7656 94% Tirap 11 91113 8283 500 7783 94% West Kameng 8 68654 8582 500 8082 94% Tawang 5 44323 8865 500 8365 94% East Kameng 4 60156 15039 500 14539 97% Total 210 1074632 5117 500 4617 90% The number of nurses as concentrated to the districts in ranking are East Siang
33 nos. (16%), Changlang 26 nos. (12%), West Siang 24 nos. (11%), Lohit 19 nos. (9%), Papum Pare 19 nos. (9%), Lower Subansiri 16 nos. (8%), Tirap 11 nos. (5%), Kurung Kumey 11 nos. (5%), Upper Subansiri 10 nos. (5%), Anjaw 8 nos. (4%), Lower Dibang Valley 8 nos. (4%) , West Kameng 8 nos. (4%), Upper Siang 6 nos. (3%), Tawang 5 nos. (2%), East Kameng 4 nos. (2%), Dibang Valley 2 nos. (1%). This trend is presented

graphically in figure 25, 26 and 27.

Figure 25: District wise numbers of nurses in rural and remote area Arunachal Pradesh
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Figure 26: District wise share of nurses in rural and remote area Arunachal Pradesh

Figure 27: Graphical mapping of district wise number of nurses in rural and remote area in Arunachal Pradesh 4.2.4.3. DISTRIBUTIONAL PATTERN OF MID-WIVES (ANM) IN RURAL AND REMOTE AREA IN ARUNACHAL PRADESH DISTRICT-WISE Generally as per norms ANMs are posted in Sub-Centre Level. There are 390 nos. of ANMs in rural and remote area of the state, covering 2755 average population by a single Mid-wife/ANM against an expected norm of 1:500 by Govt. of India. The density of Mid-wife-population ratio of Dibang Valley (1:883) is good in comparison to other districts to the worst scenario in Tawang district (1: 6332). The district wise ratio is placed in table 25.

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Table 24: District wise number of Mid-wives in Rural Area in Arunachal Pradesh Sl. Name of District Mid-wives Sl. Name of Mid-wives No. in rural and No. District in rural and remote area remote area 1 Tawang 7 9 L/D/Valley 26 2 Dibang Valley 9 10 Tirap 29 3 Upper Siang 14 11 East Kameng 30 4 Anjaw 16 12 Papum Pare 30 5 Kurung Kumey 19 13 Lohit 30 6 Lower Subansiri 23 14 West Siang 35 7 West Kameng 25 15 East Siang 35 8 Upper Subansiri 25 16 Changlang 37 Total 390 Table 25: District wise number of Mid-wives-population ratio in Rural Area in Arunachal Pradesh Name of District MidRural Mid-wives WHO Difference % wives Population Population norms from the Difference (Census ratio norm of (norm in 2011) WHO Rural actual) &GOI Area Dibang Valley 9 7948 883 500 383 43% Anjaw 16 21089 1318 500 818 62% L/D/Valley 26 42601 1639 500 1139 69% East Kameng 30 60156 2005 500 1505 75% East Siang 35 71417 2040 500 1540 75% Upper Siang 14 28743 2053 500 1553 76% West Siang 35 87311 2495 500 1995 80% Papum Pare 30 79500 2650 500 2150 81% West Kameng 25 68654 2746 500 2246 82% Upper Subansiri 25 69595 2784 500 2284 82% Lower Subansiri 23 70029 3045 500 2545 84% Tirap 29 91113 3142 500 2642 84% Changlang 37 128736 3479 500 2979 86% Lohit 30 113700 3790 500 3290 87% Kurung Kumey 19 89717 4722 500 4222 89% Tawang 7 44323 6332 500 5832 92% Total 390 1074632 2755 500 2255 82% The distributional pattern of the ANMs in rural & remote areas in the state is also concentrated to the districts with good access to communication. The number of nurses is concentrated to the districts are as Tawang 7nos. (2%), Dibang Valley 9 nos. (2%), Upper Siang 14 nos. (4%), Anjaw 16 nos. (4%), Kurung Kumey 19 nos. (5%), Lower Subansiri 23 nos. (6%),West Kameng 25 nos. (6%), Upper Subansiri 25 nos. (6%), L/D/Valley 26 nos. (7%),Tirap 29 nos. (7%), East Kameng 30 nos. (8%), Papum Pare 30nos. (8%), Lohit 30 nos. (8%), West Siang 35nos. (9%), East Siang 35
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nos. (9%) and Changlang 37 nos. (9%). This trend is presented graphically in Figure 28, 29 and 30.

Figure 28: District wise numbers of mid-wives in rural and remote area Arunachal Pradesh

Figure 29: District wise share of mid-wives in rural and remote area Arunachal Pradesh

Figure 30: Graphical mapping of district wise number of mid-wives in rural and remote area in Arunachal Pradesh
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DISTRIBUTION 4.2.5.URBAN-RURAL NURSES AND MID-WIVES

OF

PHYSICIANS,

The global problem of the unequal distribution of the health workforce between urban and rural is also found in Arunachal Pradesh. The phenomenon of workforce mal-distribution can be seen on the data analysed. The percentage share of Physicians (Doctors) in urban and rural area is 37% and 63% respectively, share of Nurses in urban and rural area is 46% and 54% respectively, share of Mid-wives in urban and rural area is 28% and 72% respectively. In comparison to 23% of the population is urban and 77% population is rural in the state. Figure 31, 32 and 33 presents the situation graphically.

Figure 31: Urban-rural distribution of Physicians (doctors) in comparison to urban rural population in Arunachal Pradesh

Figure 32: Urban-rural distribution of Nurses in comparison to urban rural population in Arunachal Pradesh

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Figure 33: Urban-rural distribution of Mid-wives in comparison to urban rural population in Arunachal Pradesh

4.2.5.1. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF PHYSICIANS (DOCTORS) IN ARUNACHAL PRADESH The percentage share of Physicians (Doctors) in urban and rural area is 37% and 63% respectively in the state. When it is analysed district wise, the figures are asymmetrical, Kurung Kumey, Dibang Valley and Anjaw Districts are predominantly a rural area, the rest are having few numbers of health institute in urban area basically the district hospital and general hospitals are in urban area. The figures range from 14% of urban concentration in Changlang district to 52% in Papumpare & 57% in Upper Subansiri districts of physicians concentrated to the urban areas. However, as it is mentioned only one institute per district are in urban areas, so in comparison it has higher concentrations. The figures graphically of the entire district are presented in figures 34 and 35.

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Figure 34: District wise urban-rural percentage distribution of Physicians (doctors) in Arunachal Pradesh

Figure 35: Graphical mapping of district wise rate of urban concentration of Physicians (doctors) in Arunachal Pradesh 4.2.5.2. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF NURSES IN ARUNACHAL PRADESH The percentage share of Nurses in urban and rural area is 46% and 54% respectively. When it is analysed district wise, the figures are asymmetrical throughout the district and maximum of the nurses area concentrated to the urban areas. It is already mentioned in earlier paragraphs that Kurung Kumey, Dibang Valley and Anjaw Districts are predominantly a rural area, the rest are having few numbers of health institute in urban area basically the district hospital and general
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hospitals are in urban area. The figures range from the highest concentration of 79% of Nurses in Urban area of Papum Pare District which is the capital complex of the State, 60% of urban concentration in Lower Dibang Valley district to 55% in Tawang districts. The lowest concentration of urban nurses is of 16% in Changlang district besides the Kurung Kumey, Dibang Valley and Anjaw Districts. The figures of the entire districts are presented in figures 36 and 37.

Figure 36: District wise urban-rural percentage distribution of nurses in Arunachal Pradesh

Figure 37: Graphical mapping of district wise rate of urban concentration of nurses in Arunachal Pradesh

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4.2.5.3. DISTRICT WISE URBAN-RURAL DISTRIBUTION OF MID-WIVES (ANM) IN ARUNACHAL PRADESH The percentage share of Mid-wives in urban and rural area is 28% and 72%, which seems to be a good figure, however, Mid-wives are basically the category of health workforce those are meant for Sub-centres and then to PHCs and CHCs. 54% of ANM are concentrated in the capital complex urban area health institute in Papumpare District. 59% in Tawang and the least in Upper Siang district (7%), besides the predominate rural areas districts of Kurung Kumey, Dibang Valley and Anjaw Districts. The figures of the entire district are presented in figures 38 and 39.

Figure 38: District wise urban-rural percentage distribution of mid-wives in Arunachal Pradesh

Figure 39: Graphical mapping of district wise rate of urban concentration of midwives in Arunachal Pradesh

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4.2.6. NUMERICAL INADEQUACY OF PHYSICIANS, NURSES AND MID-WIVES IN ARUNACHAL PRADESH

According to RHS, 2010, the number of ANMs at Sub Centres and PHCs has decreased from 454 in 2005 to 392 in 2010. The numbers of Nurses at PHCs and CHCs has increased from 105 in 2005 to 293 in 2010. The Doctors at PHCs have increased from 78 in 2005 to 92 in 2010. The number of Specialist doctors at CHCs has increased from 0 in 2005 to 1 only in 2010, along with 108 General Duty Medical Officers (GDMOs) is also available at CHCs. However, as compared to requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM at SCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians & Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. As per primary data available for this study, there are total no. of sanctioned sub centres are 468, out of which only 301 have existing infrastructure, 222 No. of SCs having only one ANM each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3 ANMs, none of the CHCs except are having full complement of specialists i.e. Gynaecologist, Anaesthetist and Paediatrician. It is also came to know from the interview of the management representative that many of the health posts in the rural area are manned by the less skilled workers like nursing assistant and other semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and mid-wives or rather they are staying at urban areas. The impact of this mal-distribution on health care delivery in rural areas is profound, at times resulting in primary health care facilities being staffed mostly by other staffs. Table 26: Showing the trend in physicians and nurses in-position in 2005 & 2010 Physician Physicians SCS/PHC CHCs/PH s (MO) in (MO) Specialists s ANM Cs nurses PHCs in CHCs in CHCs State 2005 2010 2005 2010 2005 2010 2005 2010 2005 2010 Arunachal Pradesh 454 395 105 293 78 92 1 NA 108 0 Source : RHS, 2010

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4.2.6.1 REQUIREMENT AND SHORTFALL OF HUMAN RESOURCES IN SCS, PHCS AND CHCS IN THE STATE ACCORDING TO IPHS NORMS. The availability of human resource is one of the vital prerequisite for the competency in Rural Healthcare Delivery System in the state, where 77% population (2011 census) lives in rural and remote areas. The Government of India has developed the Indian Public Health Standards (IPHS) and indicated the human resources requirements for SHC, PHC, CHC as well as various Hospitals with bed strengths ranging from 31 to 500 beds. The estimation is based on the HR data of the available health facilities as primarily collected by the researcher, the requirement and shortfall of Physicians, nurses and mid-wives is estimated on the basis of Indian Public Health Standards. For the estimation requirement of physicians, nurse and mid-wives, the norms of IPHS for SHC, PHC, CHC , Hospital norms of 31-50 beds for District hospitals and Hospital norms for 101-200 beds for General Hospital has been adapted. The 31-50 beds norm for District Hospital has been considered as most of the district hospitals in the state are yet to attain the full requirement of First Referral Unit norms and lack one of other infrastructural requirement of 51-100 beds. The detail norms of IPHS are presented in Appendix. There is an acute shortage of ANMs, Nurses and Physicians for the existing health facilities (SHCs, PHCs, CHCs and District hospitals). There is a requirement of 570 more nos. of ANM and percentage of current shortfall is 51%. The requirement of Nurses is 926 more nos. of nurses and percentage of current shortfall is 70%. The requirement of Physicians (doctors) is 510 more nos. of nurses and percentage of current shortfall is 53%. The critical human resources required for the entire health institutes district wise in the state are as detailed below in table 27, 28 and 29. Table: 27: District wise requirement and shortfall of ANM in Arunachal Pradesh ANMs Sl. Shortfall % of No Districts Requirement Available (IPHS) Shortfall 1 Tawang 35 17 18 51% 2 West kameng 62 29 33 53% 3 East Kameng 93 45 48 52% 4 Papum Pare 100 65 35 35% 5 Lower Subansiri 59 35 24 41% 6 Kurung Kumey 104 19 85 82% 7 Upper Subansiri 107 41 66 62% 8 West Siang 108 47 61 56%
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9 10 11 12 13 14 15 16

East Siang Upper Siang L/D/Valley Dibang Valley Lohit Anjaw Changlang Tirap Total

100 32 34 7 59 58 72 82 1112

55 15 32 9 38 16 43 36 542

45 17 2 -2 21 42 29 46 570

45% 53% 6% -29% 36% 72% 40% 56% 51%

Table 28: District wise requirement and shortfall of Nurses in Arunachal Pradesh Nurses Sl. Shortfall % of No Districts Requirement Available (IPHS) Shortfall 1 Tawang 56 11 45 80% 2 West Kameng 67 16 51 76% 3 East Kameng 78 8 70 90% 4 Papum Pare 143 90 53 37% 5 Lower Subansiri 68 24 44 65% 6 Kurung Kumey 78 11 67 86% 7 Upper Subansiri 102 14 88 86% 8 West Siang 129 35 94 73% 9 East Siang 185 62 123 66% 10 Upper Siang 57 12 45 79% 11 L/D/Valley 63 20 43 68% 12 Dibang Valley 24 2 22 92% 13 Lohit 80 27 53 66% 14 Anjaw 24 8 16 67% 15 Changlang 87 31 56 64% 16 Tirap 75 19 56 75% 926 70% Total 1316 390 Table 29: District wise requirement and shortfall of Physicians in Arunachal Pradesh Physicians (Doctors) Sl. Shortfall % of Requirement Available (IPHS) No Districts Shortfall 1 Tawang 40 19 21 53% 2 West kameng 53 26 27 51% 3 East Kameng 59 23 36 61% 4 Papum Pare 76 75 1 1% 5 Lower Subansiri 51 32 19 37% 6 Kurung Kumey 68 10 58 85% 7 Upper Subansiri 81 24 57 70% 8 West Siang 104 40 64 62% 9 East Siang 111 53 58 52% 10 Upper Siang 45 23 22 49%
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11 12 13 14 15 16

Lower Dibang Valley Dibang Valley Lohit Anjaw Changlang Tirap Total

47 13 62 22 69 58 959

21 5 33 14 29 22 449

26 8 29 8 40 36 510

55% 62% 47% 36% 58% 62% 53%

There is an acute shortage of ANMs, Nurses and Physicians for the existing health facilities in rural areas (SHCs, PHCs, CHCs and District hospitals). There is a requirement of 714 more nos. of ANM and percentage of current shortfall is 65%. The requirement of Nurses is 747 more nos. of nurses and percentage of current shortfall is 78%. The requirement of Physicians (doctors) is 545 more nos. of nurses and percentage of current shortfall is 66%. The critical human resources required for the entire health institutes in rural and remote area of district wise in the state are as detailed below in table 30, 31 and 32. Table 30: District wise rural and remote area requirement and shortfall of ANMs in Arunachal Pradesh ANMs Sl. Shortfall % of Requirement Available (IPHS) No Districts Shortfall 1 Tawang 35 7 28 80% 2 West Kameng 62 25 37 60% 3 East Kameng 93 30 63 68% 4 Papum Pare 96 30 66 69% 5 Lower Subansiri 59 23 36 61% 6 Kurung Kumey 104 19 85 82% 7 Upper Subansiri 107 25 82 77% 8 West Siang 108 35 73 68% 9 East Siang 96 35 61 64% 10 Upper Siang 32 14 18 56% 11 L/D/Valley 34 26 8 24% 12 Dibang Valley 7 9 -2 -29% 13 Lohit 59 30 29 49% 14 Anjaw 58 16 42 72% 15 Changlang 72 37 35 49% 16 Tirap 82 29 53 65% Total 1104 390 714 65%

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Table 31: District wise rural and remote area requirement and shortfall of Nurses in Arunachal Pradesh Nurses Sl. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Districts Tawang West Kameng East Kameng Papum Pare Lower Subansiri Kurung Kumey Upper Subansiri West Siang East Siang Upper Siang L/D/Valley Dibang Valley Lohit Anjaw Changlang Tirap Total Requirement Available 37 5 48 8 59 4 68 19 49 16 78 11 83 10 110 24 110 33 38 6 44 8 24 2 61 19 24 8 68 26 56 11 957 210 Shortfall % of (IPHS) Shortfall 32 86% 40 83% 55 93% 49 72% 33 67% 67 86% 73 88% 86 78% 77 70% 32 84% 36 82% 22 92% 42 69% 16 67% 42 62% 45 80% 747 78%

Table 32: District wise rural and remote area requirement and shortfall of Physicians (doctors) in Arunachal Pradesh Physicians (Doctors) Sl. Shortfall % of No Districts Requirement Available (IPHS) Shortfall 1 Tawang 31 11 20 65% 2 West kameng 44 16 28 64% 3 East Kameng 50 12 38 76% 4 Papum Pare 60 36 24 40% 5 Lower Subansiri 42 18 24 57% 6 Kurung Kumey 68 10 58 85% 7 Upper Subansiri 72 15 57 79% 8 West Siang 95 32 63 66% 9 East Siang 95 31 64 67% 10 Upper Siang 36 10 26 72% 11 L/D/Valley 38 12 26 68% 12 Dibang Valley 13 5 8 62% 13 Lohit 53 23 30 57% 14 Anjaw 22 14 8 36% 15 Changlang 60 25 35 58% 16 Tirap 49 13 36 73% Total 828 283 545 66%

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SECTION 3 ANALYSIS OF THE DIMENSION OF HR ISSUES IN ATTRACTION OF PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND REMOTE AREAS OF THE STATE

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4.3.1. INTRODUCTION
This section of this chapter describes the dimensions of attraction of the Physicians, nurses and mid-wives to the rural area services. An employee attitude survey measured the employee attitudes towards the rural and remote area services covering the factors that attracted them to the rural services. It is also attempted to explore the factors that may attract them more to work in the rural and remote area. Side by side this section of the chapter also presents where deem fit the management perspective on the issue as well. The determination of the factor that majorly

attracted and may attract the physicians, nurses and mid-wives has considered on the Mean factor which would be statistically significant at Mean Test value of (1.5), that means the selection was done by the majority (more than half) of the respondents and have an greater impact at large workforce. This helps in ascertain the most affected factors for the current attraction and the factor that may attract the workforce.

4.3.2. FACTORS THAT ATTRACTED OR PLACED THE PHYSICIANS, NURSES AND MID-WIVES IN THE CURRENT JOB IN THE RURAL AND REMOTE AREA: CURRENT DETERMINANTS OF ATTRACTION AND PLACEMENTS
Several previous studies have an outlook that the doctors and nurses are reluctant to relocate to rural and remote areas. These workforces who are presently in rural and remote areas are only due to compulsion or with their any other attraction factors contribute to their location. So, in this section it is attempted to explore the factors contributed regarding physicians, nurses and mid-wives for selection of their current employment in the rural and remote area. Is the compulsion is only factor which contributed to their attraction of rural area services, or the other factors do contribute to it. The exploration is based on the sixteen (16) preset factors which were included for the same. The determination of the factor that majorly attracted the physicians, nurses and mid-wives has considered on the Mean factor which would be statistically significant at Mean value of (1.5), that means the selection was done by the majority (more than half) of the respondents and have an greater impact at large workforce. This helps in ascertain the most affected factors presently. The Reliability analysis was done for the present attraction factors consistency of responses to items. The Cronbach alpha coefficient indicates the consistency of responses to items in a measure (Foxcroft & Roodt, 2002). The Cronbachs alpha coefficient for the factor items is =(-0.038) on item 16 and N=334, which is a
116

negative alpha and when the factor no 8: Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) has been dropped and the Cronbachs alpha coefficient comes to =(0.534) on item 15 and N=334, which is higher than 0.5. As it can be derived from Table 33, the results indicated the factors of attraction of the physicians, nurses and mid-wives as : Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) (1.58), Career opportunity (1.25), Current health facility is closer to town or Closer to family and friends (1.20), Continuing education/higher education Opportunities (1.20), Training and skill development Opportunities (1.19), Flexible working hour with minimal workload (1.13), Authority, independency and autonomy (1.09), Improved working condition (1.09), Amenities like housing, conveyance provided (1.07), Availability of equipment, drugs and supplies (1.05), Availability of good schools for children nearby town (1.05), Safety at workplace (1.04), Teamwork and Interpersonal staffs relationship (1.03), Reward and recognition system (1.00), Supportive supervision and mentoring (1.00) and Financial incentives / Rural allowances/ Performance

incentives (1.00). Whereas the Compulsion (minimum rural service tenure or nontransferable or Management or political pressure) having mean of 1.58 has the highest mean and the factor item contributed the employee to be in rural and remote area but it may resulted in non-commitment towards the service. Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)= 2.990, p= .003. The Percentage selection of Factor for Attraction or placed is presented in detail in table 34. Table 33: Descriptive Statistics of the factors that attracted or placed the Physicians, nurses and mid-wives in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. (2Mean t df tailed) Diff. N Mean Dev. Compulsion 334 1.58 .494 2.990 333 .003 .081 Career development opportunity 334 1.25 .433 -10.620 333 .001 -.251 Current health facility is closer 334 1.20 .403 -13.433 333 .001 -.296 to town or Closer to family and friends Continuing education/higher 334 1.20 .401 -13.644 333 .001 -.299 education Opportunities
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Training and skill development Opportunities Flexible working hour with minimal workload Improved working condition Authority, independency and autonomy Amenities like housing, conveyance provided Availability of equipment, drugs and supplies Availability of good schools for children nearby town Safety at workplace Teamwork and Interpersonal staffs relationship Financial incentives / Rural allowances/ Performance incentives Supportive supervision and mentoring Reward and recognition system

334 1.19 334 1.13 334 1.09 334 1.09 334 1.07 334 1.05 334 1.05 334 1.04 334 1.03 334 1.00

.394 .332 .291 .291 .254 .226 .214 .194 .171 .000

-14.298 333 -20.598 333 -25.607 333 -25.607 333 -31.070 333 -36.052 333 -38.630 333 -43.503 333 -50.333 333

.001 .001 .001 .001 .001 .001 .001 .001 .001

-.308 -.374 -.407 -.407 -.431 -.446 -.452 -.461 -.470

334 1.00 334 1.00 .000 .000 -

Table 34: Percentage selection of factors for attraction by Physicians, nurses and mid-wives Factors n n% Compulsion 194 58% Career development opportunity 83 25% Current health facility is closer to town or Closer to family and friends 68 20% Continuing education/higher education Opportunities 67 20% Training and skill development Opportunities 64 19% Flexible working hour with minimal workload 42 13% Improved working condition 31 9% Authority, independency and autonomy 31 9% Amenities like housing, conveyance provided 23 7% Availability of equipment, drugs and supplies 18 5% Availability of good schools for children nearby town 16 5% Safety at workplace 13 4% Teamwork and Interpersonal staffs relationship 10 3% Financial incentives / Rural allowances/ Performance incentives 0 0% Supportive supervision and mentoring 0 0% Reward and recognition system 0 0%

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4.3.2.1. FACTORS THAT ATTRACTED OR PLACED THE PHYSICIANS IN PRESENT RURAL AND REMOTE AREA As it can be derived from table 35, the factors of attraction of the physicians in rural and remote area service are basically is Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) (1.66), beside the factor of compulsion, the other attraction top five factors are-Continuing education/higher education Opportunities (1.46), Career development opportunity (1.23), Current health facility is closer to town or Closer to family and friends (1.20), Authority, independency and autonomy (1.19) and Training and skill development Opportunities (1.16). Only one factor that is the Compulsion is statistically significant at Mean Test Value=1.5, 95%C.I, it is significant at t(113)=3.667, p= .001. The Percentage selection of Factor for Attraction or placed is presented in table 38. Table 35: Descriptive Statistics of the factors that attracted or placed the Physicians in the current job in the rural and remote area Test Value = 1.5 Sig. Factors (2Std. taile N Mean Dev. t df d) Compulsion 113 1.66 .475 3.667 112 .001 Continuing /higher education 113 1.46 .501 -.846 112 .400 Opportunity Career development opportunity 113 1.23 .423 -6.787 112 .001 Current health facility is closer to 113 1.20 .404 -7.792 112 .001 town or Closer to family &friends Authority,independency&autonomy 113 1.19 .398 -8.160 112 .001 Training and skill development 113 1.16 .368 -9.853 112 .001 Opportunities Improved working condition 113 1.10 .298 -14.376 112 .001 Availability of equipment, drugs 113 1.08 .272 -16.431 112 .001 and supplies Flexible working hour with 113 1.08 .272 -16.431 112 .001 minimal workload Safety at workplace 113 1.08 .272 -16.431 112 .001 Amenities like housing, 113 1.07 .258 -17.710 112 .001 conveyance provided Availability of good schools for 113 1.06 .242 -19.231 112 .001 children nearby town Teamwork and Interpersonal staffs 113 1.04 .186 -26.609 112 .001 relationship Financial / Rural allowances/ 113 1.00 .000 Performance incentives Supportive supervision & mentoring 113 1.00 .000 Reward and recognition system 113 1.00 .000 119

Mean Diff. .164 -.040 -.270 -.296 -.305 -.341 -.403 -.420 -.420 -.420 -.429 -.438 -.465 -

When the group of physicians is further divided to contractual physicians, two factors are significant and the factors are the Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) and Continuing education/higher education is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(34)= 3.064, p= .004 and t(34)= 1.339, p= .037. The Percentage selection of Factor for Attraction or placed is presented in table 38. Table 36: Descriptive Statistics of the factors that attracted or placed the contract Physicians in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. Mean (2N Mean Dev. t df tailed) Diff. Compulsion 34 1.74 .448 3.064 33 .004 .235 Continuing education/higher 34 1.58 .500 1.339 33 .037 .029 education Opportunities Career development opportunity Training and skill development Opportunities Current health facility is closer to town or Closer to family and friends Improved working condition Flexible working hour with minimal workload Financial incentives / Rural allowances/ Performance incentives Availability of equipment, drugs and supplies Authority, independency and autonomy Supportive supervision and mentoring Amenities like housing, conveyance provided Reward and recognition system Teamwork and Interpersonal staffs relationship Safety at workplace Availability of good schools for children nearby town 34 34 34 1.38 1.21 1.12 .493 .410 .327 -1.391 -4.179 -6.817 33 33 33 .174 .001 .001 -.118 -.294 -.382

34 34 34

1.06 1.06 1.00

.239 .239 .000

-10.771 -10.771

33 33

.001 .001

-.441 -.441

34 34 34 34 34 34 1.00 1.00 1.00 1.00 1.00 1.00 .000 .000 .000 .000 .000 .000 34 34 1.00 1.00 .000 .000 -

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When the group of permanent physicians is analysed separately, the same factor, that is the Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(79)= 2.435, p=.017. The Percentage selection of Factor for Attraction or placed is presented in table 38. Table 37: Descriptive Statistics of the factors that attracted or placed the permanent Physicians in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. Mean (2t df tailed) Diff. N Mean Dev. Compulsion 79 1.63 .485 2.435 78 .017 .133 Continuing -1.242 78 .218 -.070 79 1.43 .498 education/higher education Opportunities Authority, independency 79 1.28 .451 -4.365 78 .001 -.222 and autonomy Current health facility is 79 1.24 .430 -5.362 78 .001 -.259 closer to town or Closer to family and friends Career development 79 1.16 .373 -7.990 78 .001 -.335 opportunity Training and skill -9.203 78 .001 -.361 79 1.14 .348 development Opportunities Improved working 79 1.11 .320 -10.732 78 .001 -.386 condition Availability of equipment, 79 1.11 .320 -10.732 78 .001 -.386 drugs and supplies Safety at workplace 79 1.11 .320 -10.732 78 .001 -.386 Amenities like housing, 79 1.10 .304 -11.673 78 .001 -.399 conveyance provided Flexible working hour with 79 1.09 .286 -12.785 78 .001 -.411 minimal workload Availability of good schools 79 1.09 .286 -12.785 78 .001 -.411 for children nearby town Teamwork and 79 1.05 .221 -18.102 78 .001 -.449 Interpersonal staffs relationship Financial incentives / Rural 79 1.00 .000 allowances/ Performance incentives Supportive supervision and 79 1.00 .000 mentoring Reward and recognition 79 1.00 .000 system

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Table 38: Percentage selection of factors for Attraction by Physicians Physicians n n% Compulsion 75 66% Continuing /higher education Opportunities 52 46% Career development opportunity 26 23% Current health facility is closer to town or 23 20% Closer to family and friends Authority, independency and autonomy 22 19% Training and skill development 18 16% Opportunities Improved working condition 11 10% Availability of equipment, drugs and 9 8% supplies Flexible working hour with minimal 9 8% workload Safety at workplace 9 8% Amenities like housing, conveyance 7% 8 provided Availability of good schools for children 7 6% nearby town Teamwork and Interpersonal staffs 4 4% relationship Financial incentives / Rural allowances/ 0% 0 Performance incentives Supportive supervision and mentoring 0 0% Reward and recognition system 0 0% Factors Contract Physicians n n% 25 74% 18 53% 13 38% 4 12% 0 7 2 0 2 0 0 0 0 0 0 0 0% 21% 6% 0% 6% 0% 0% 0% 0% 0% 0% 0% Permanent Physicians n n% 50 63% 34 43% 13 16% 19 24% 22 28% 11 14% 9 11% 9 11% 7 9%

9 11% 8 10% 7 4 0 0 0 9% 5% 0% 0% 0%

4.3.2.2. FACTORS THAT ATTRACTED OR PLACED THE NURSES IN PRESENT RURAL AND REMOTE AREA The factors that attracted or placed the nurses can be derived from table 39. The results indicated the factors of Compulsion (minimum rural service tenure or nontransferable or Management or political pressure) (1.59) have the highest Mean. Beside the compulsion for the choice of the rural posting, the other top five factors of attraction for the nurses are- Current health facility is closer to town or Closer to family and friends (1.26), Training and skill development Opportunities (1.26), Career development opportunity (1.21), Flexible working hour with minimal workload (1.14) and Improved working condition (1.08). Thus, only one factor, that is the Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(97)=1.201, p=.041. The

Percentage selection of Factor for Attraction or presented is place in table 42.

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Table 39: Descriptive Statistics of the factors that attracted or placed the nurses in the current job in the rural and remote area Test Value = 1.5 Factors Compulsion Training and skill development Opportunities Current health facility is closer to town or Closer to family & friends Career development opportunity Flexible working hour with minimal workload Improved working condition Amenities like housing, conveyance provided Availability of equipment, drugs and supplies Availability of good schools for children nearby town Teamwork and Interpersonal staffs relationship Safety at workplace Financial incentives / Rural allowances/ Performance incentives Authority, independency and autonomy Continuing education/higher education Opportunities Supportive supervision and mentoring Reward and recognition system Std. N Mean Dev. 98 1.59 .402 98 1.26 .438 98 1.26 .438 Sig. t 1.201 -5.533 -5.533 df 97 97 97
(2tailed)

.041 .001 .001

Mea n Diff. .09 -.245 -.245

98 98 98 98 98 98 98 98 98

1.21 1.14 1.08 1.07 1.05 1.04 1.03 1.01 1.00

.412 .352 .275 .259 .221 .199 .173 .101 .000

-6.858 -10.052 -15.049 -16.389 -20.096 -22.856 -26.836 -48.000 -

97 97 97 97 97 97 97 97 -

.001 .001 .001 .001 .001 .001 .001 .001 -

-.286 -.357 -.418 -.429 -.449 -.459 -.469 -.490 -

98 98 98 98

1.00 1.00 1.00 1.00

.000 .000 .000 .000

When the data is analysed separately in the case of permanent nurses, it is found that there is the combination of two factors of Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) and current health facility is closer to town or to family are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(52)=2.442, p=.018 and t(52)=3.112,

p=.003. The Percentage selection of Factor for Attraction or placed is presented in table 42.

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Table 40: Descriptive Statistics of the factors that attracted or placed the permanent nurses in the current job in the rural and remote area Test Value = 1.5 Sig. Factor Std. (2N Mean Dev. t df tailed) Compulsion 53 1.64 .578 2.442 52 .018 Current health facility is closer 3.112 52 .003 53 1.60 .563 to town or Closer to family and friends Training and skill development 53 1.21 .409 -5.200 52 .001 Opportunities Flexible working hour with 53 1.21 .409 -5.200 52 .001 minimal workload Amenities like housing, 53 1.13 .342 -7.836 52 .001 conveyance provided Career development opportunity 53 1.09 .295 -10.008 52 .001 Improved working condition 53 1.08 .267 -11.589 52 .001 Availability of equipment, drugs .001 53 1.06 .233 -13.836 52 and supplies Teamwork and Interpersonal 53 1.06 .233 -13.836 52 .001 staffs relationship Availability of good schools for 53 1.06 .233 -13.836 52 .001 children nearby town Safety at workplace 53 1.02 .137 -25.500 52 .001 Financial incentives / Rural 53 1.00 .000 allowances/ Performance incentives Authority, independency and 53 1.00 .000 autonomy Continuing education/higher 53 1.00 .000 education Opportunities Supportive supervision and 53 1.00 .000 mentoring Reward and recognition system 53 1.00 .000 -

Mean Diff. .160 .198

-.292 -.292 -.368 -.406 -.425 -.443 -.443 -.443 -.481 -

While in the case of contract nurses, only one factors of Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(44)=3.090, p=.003. The Percentage selection of Factor for Attraction or

presented is place in table 42.

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Table 41 : Descriptive Statistics of the factors that attracted or placed the contract nurses in the current job in the rural and remote area Test Value = 1.5 Factor Compulsion Career development opportunity Training and skill development Opportunities Current health facility is closer to town or Closer to family and friends Improved working condition Flexible working hour with minimal workload Availability of equipment, drugs and supplies Availability of good schools for children nearby town Financial incentives / Rural allowances/ Performance incentives Authority, independency and autonomy Continuing education/higher education Opportunities Supportive supervision and mentoring Amenities like housing, conveyance provided Reward and recognition system Teamwork and Interpersonal staffs relationship Safety at workplace Std. N Mean Dev. 45 1.71 .458 45 1.36 .484 45 45 1.31 1.16 .468 .367 t 3.090 -2.002 -2.706 -6.304 df 44 44 44 44 Sig. (2Mean tailed) Diff. .003 .211 .052 -.144 .010 .001 -.189 -.344

45 45 45 45 45

1.09 1.07 1.04 1.02 1.00

.288 .252 .208 .149 .000

-9.582 -11.523 -14.663 -21.500

44 44 44 44

.001 .001 .001 .001

-.411 -.433 -.456 -.478

45 45 45 45 45 45 45 1.00 1.00 1.00 1.00 1.00 1.00 1.00 .000 .000 .000 .000 .000 .000 .000 -

Table 42: Percentage selection of factors for Attraction by nurses Nurses n n% 0 0% Contract Permanent Nurses Nurses n n% n n% 0 0% 0 0% 9% 4% 0% 36% 4 3 0 5 8% 6% 0% 9%

Factors Financial incentives / Rural allowances/ Performance incentives Improved working condition Availability of equipment, drugs and supplies Authority, independency and autonomy Career development opportunity
125

8 8% 4 5 5% 2 0 0% 0 21 21% 16

Continuing education/higher education 0 0% 0 Opportunities Training and skill development Opportunities 25 26% 14 Compulsion 48 49% 32 Flexible working hour with minimal workload 14 14% 3 Supportive supervision and mentoring 0 0% 0 Amenities like housing, conveyance provided 7 7% 0 Reward and recognition system 0 0% 0 Teamwork and Interpersonal staffs relationship 3 3% 0 Safety at workplace 1 1% 0 Availability of good schools for children 4 4% 1 nearby town Current health facility is closer to town or 25 26% 7 Closer to family and friends

0% 31% 71% 7% 0% 0% 0% 0% 0% 2% 16%

0 11 16 11 0 7 0 3 1 3

0% 21% 30% 21% 0% 13% 0% 6% 2% 6%

18 34%

4.3.2.3. FACTORS THAT ATTRACTED OR PLACED THE MID-WIVES IN PRESENT RURAL AND REMOTE AREA The factors that attract or placed the mid-wives towards rural and remote area has also the factor of Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) (1.58), which have the highest mean, detail can be derived from the table 43. Beside the compulsion, the other top five factors of attraction for the nurses are- Career development opportunity (1.29), Training and skill development Opportunities (1.17), Current health facility is closer to town or Closer to family and friends (1.16), Flexible working hour with minimal workload (1.15) and Continuing education/higher education Opportunities (1.12). However, only one factor that is the Compulsion (minimum rural service tenure or nontransferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(122)=1.727, p=.047. The Percentage selection of Factor for Attraction or placed is presented in table 46. Table 43: Descriptive Statistics of the factors that attracted or placed the mid-wives in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. Mean (2N Mean Dev. t df tailed) Diff. Compulsion 123 1.58 .496 1.727 122 .047 .077 Career development 123 1.29 .457 -5.033 122 .001 -.207 opportunity Training and skill 123 1.17 .378 -9.666 122 .001 -.329 development Opportunities Current health facility is 123 1.16 .371 -10.099 122 .001 -.337 closer to town or Closer to family and friends
126

Flexible working hour with 123 1.15 .363 -10.560 122 .001 -.346 minimal workload Continuing 123 1.12 .329 -12.761 122 .001 -.378 education/higher education Opportunities Improved working condition 123 1.10 .298 -14.981 122 .001 -.402 Authority, independency 123 1.07 .261 -18.104 122 .001 -.427 and autonomy Amenities like housing, 123 1.07 .248 -19.482 122 .001 -.435 conveyance provided Availability of good 123 1.04 .198 -25.692 122 .001 -.459 schools for children nearby town Availability of equipment, .001 -.467 123 1.03 .178 -29.110 122 drugs and supplies Teamwork and .001 -.476 123 1.02 .155 -34.055 122 Interpersonal staffs relationship Safety at workplace 123 1.02 .155 -34.055 122 .001 -.476 Financial incentives / Rural 123 1.00 .000 allowances/ Performance incentives Supportive supervision and 123 1.00 .000 mentoring Reward and recognition 123 1.00 .000 system When the data for the group of contractual mid-wives are separately analysed, the same factor of Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(74)=5.616, p=.001. The Percentage selection of Factor for Attraction or placed is presented in table 46. Table 44: Descriptive Statistics of the factors that attracted or placed the contractual mid-wives in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. Mean (2N Mean Dev. t df tailed) Diff. Compulsion 75 1.77 .421 5.616 74 .001 .273 Career development 75 1.39 .490 -2.002 74 .049 -.113 opportunity Training and skill 75 1.15 .356 -8.592 74 .001 -.353 development Opportunities Current health facility is 75 1.09 .293 -12.026 74 .001 -.407 closer to town or Closer to family and friends Improved working condition 75 1.08 .273 -13.318 74 .001 -.420
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Continuing education/higher education Opportunities Flexible working hour with minimal workload Availability of equipment, drugs and supplies Authority, independency and autonomy Availability of good schools for children nearby town Financial incentives / Rural allowances/ Performance incentives Supportive supervision and mentoring Amenities like housing, conveyance provided Reward and recognition system Teamwork and Interpersonal staffs relationship Safety at workplace

75 75 75 75 75 75

1.05 1.04 1.01 1.01 1.01 1.00

.226 .197 .115 .115 .115 .000

-17.100 74 -20.193 74 -36.500 74 -36.500 74 -36.500 74

.001 .001 .001 .001 .001

-.447 -.460 -.487 -.487 -.487

75 75 75 75 1.00 1.00 1.00 1.00 .000 .000 .000 .000 75 1.00 .000 -

While in the case of permanent mid-wives, it is also found that the same factor of Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(47)=2.424, p=.019. The Percentage selection of Factor for Attraction or placed is presented in table 46. Table 45: Descriptive Statistics of the factors that attracted or placed the permanent mid-wives in the current job in the rural and remote area Test Value = 1.5 Sig. Factors Std. (2N Mean Dev. t df tailed) Compulsion 48 1.63 .576 2.424 47 .019 Flexible working hour with 48 1.27 .449 -3.535 47 .001 minimal workload Current health facility is closer -3.535 47 .001 48 1.27 .449 to town or Closer to family and friends Continuing education/higher 48 1.23 .425 -4.418 47 .001 education Opportunities Training & skill development 48 1.21 .410 -4.924 47 .001 Opportunities Authority, independency & 48 1.17 .377 -6.132 47 .001 autonomy
128

Mean Diff. .167 -.229 -.229

-.271 -.292 -.333

Amenities like housing, 48 conveyance provided Career development opportunity 48 Improved working condition 48 Availability of good schools 48 for children nearby town Availability of equipment, 48 drugs and supplies Teamwork and Interpersonal 48 staffs relationship Safety at workplace 48 Financial incentives/Rural 48 allowances/Performance incentives Supportive supervision&mentoring 48 Reward and recognition system 48

1.17 1.15 1.13 1.08 1.06 1.06 1.06 1.00

.377 .357 .334 .279 .245 .245 .245 .000

-6.132 -6.880 -7.774 -10.335 -12.391 -12.391 -12.391 -

47 47 47 47 47 47 47 -

.001 .001 .001 .001 .001 .001 .001 -

-.333 -.354 -.375 -.417 -.438 -.438 -.438 -

1.00 1.00

.000 .000

Table 46: Percentage selection of factors for Attraction by mid-wives Contract Midmid- Permanent wives wives Mid-wives Factors n n% n n% n n% Compulsion 71 58% 58 77% 13 27% Career development opportunity 36 29% 29 39% 7 15% Training and skill development Opportunities 21 17% 11 15% 10 21% Current health facility is closer to town or Closer to 20 16% 7 9% 13 27% family and friends Flexible working hour with minimal workload 19 15% 3 4% 16 33% Continuing education/higher education Opportunities 15 12% 4 5% 11 23% Improved working condition 12 10% 6 8% 6 13% Authority, independency and autonomy 9 7% 1 1% 8 17% Amenities like housing, conveyance provided 8 7% 0 0% 8 17% Availability of good schools for children nearby town 5 4% 1 1% 4 8% Availability of equipment, drugs and supplies 4 3% 1 1% 3 6% Teamwork and Interpersonal staffs relationship 3 2% 0 0% 3 6% Safety at workplace 3 2% 0 0% 3 6% Financial incentives / Rural allowances/ Performance 0 0% 0 0% 0 0% incentives Supportive supervision and mentoring 0 0% 0 0% 0 0% Reward and recognition system 0 0% 0 0% 0 0%

4.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION AND DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS, NURSES AND MIDWIVES
The analysing of the relationship of factors of Attraction and the demographic characteristics of physicians such as age, sex, family background, marital status,
129

length of service, place of work and nature of employment is presented in this section. The three factors of attraction viz., Financial incentives / Rural allowances/ Performance incentives, Supportive supervision & mentoring and Reward and recognition system, have at least one of the variables has zero variance and there is only one variable in the analysis chi-square could not be computed for all pairs of variables, henceforth it has been dropped from the analysis. 4.3.3.1. RELATIONSHIP OF FACTORS OF ATTRACTION AND DEMOGRAPHIC CHARACTERISTICS OF PHYSICIANS From the analysis of primary data at table 47, it is found that there is a relationship between age group of the physicians and attraction factors like availability of equipment, drugs and supplies {2(3, N = 113) = 13.9, p = 0.003, Cramers V=0.408} the higher age group (more than 30 years) of the physicians has the tendency to attract by this factor; Authority, independency and autonomy {2(3, N = 113) = 34.43, p = 0.001, Cramers V=0.545} the higher age group (more than 30 years) of the physicians has the tendency to attract by this factor; Amenities like housing & conveyance provided {2(3, N = 113) = 8.79, p = 0.03, Cramers V=0.267} the higher age group (more than 30-50 years) of the physicians has the tendency to attract by this factor; Safety at workplace {2(3, N = 113) = 13.9, p = 0.003, Cramers V=0.408} the higher age group (more than 30-50 years) of the physicians has the tendency to attract by this factor; and Current health facility is closer to town or closer to family and friends {2(3, N = 113) = 9.746, p = 0.021, Cramers V=0.268} the higher age group (more than 30-50 years) of the physicians has the tendency to attract by this factor. It is also found that the Marital Status of the physicians has relationship with Authority independency and autonomy {2(1, N = 113) = 16.16, p = 0.001, Cramers V=0.378, 31% of married physicians against non of the unmarried physicians are attracted by this reason; amenities like housing & conveyance provided {2(1, N = 113) = 5.093, p = 0.024, Cramers V=0.212}, this factor has contributed as a factor to 11.3% of married physicians against none of the unmarried; safety at workplace {2(1, N = 113) = 5.785, p = 0.016, Cramers V=0.226}, 12% of the married physicians were attracted as one of the factor for attraction against none of the unmarried physicians has attract due to this factor; and availability of good schools for children nearby town {2(1, N = 113) = 4.414, p = 0.036, Cramers V=0.198}, it

130

is obvious that the married physicians were attracted of this reason, only 9.9% of married physicians were attracted of this reason. While, there is a relationship between Length of service of the physicians and attraction from the availability of equipment, drugs and supplies {2(4, N = 113) = 13.937, p = 0.007, Cramers V=0.351} the higher service length physicians 52% of more than 10-20 years of service length of the physicians has shown the tendency to attract by this factor; Authority, independency and autonomy {2(4, N = 113) = 26.762, p = 0.001, Cramers V=0.487} the higher age group (more than 10-25 years19% of 5-10 years, 43% of 10-15 years, 66% of 15-20 years and 100% of 20-25 years) of the physicians has shown the tendency to attract by this factor; Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) {2(4, N = 113) = 10.251, p = 0.036, Cramers V=0.301}, the physicians with lower service length are serving in the rural area, 52% out of the service length of 0-5 years and 33% out of the service length of 5-10 years are serving in compulsion; Amenities like housing & conveyance provided{2(4, N = 113) = 16.454, p = 0.002, Cramers V=0.382} the physicians with medium and higher service length are attracted by this factor, 6.3% out of the service length of 5-10 years, 24% out of the service length of 10-15 years and 33% of 15-20 years services length are attracted of this; Teamwork and Interpersonal staffs relationship{2(4, N = 113) = 18.167, p = 0.001, Cramers V=0.401} only the 19% of physicians who have 10-15 years service length have considered this factor; Availability of good schools for children nearby town {2(4, N = 113) = 10.489, p = 0.033, Cramers V=0.305}, only 28% physicians with service length of 5-15 years has considered that this factor has contributed to the attraction to rural areas, and Current health facility is closer to town or closer to family and friends {2(4, N = 113) = 14.217, p = 0.007, Cramers V=0.355}, this factor has attracted almost all the physicians from 12% to 50% of individual service length group, it is observed the attraction tendency is increasing as the length of the services increases. Similarly, it is found that there is a relationship between Nature of Employment of physicians and attraction factors like Availability of equipment, drugs and supplies {2(3, N = 113) = 4.209, p = 0.04, Cramers V=0.193}, 12% of the permanent physicians are more attracted of this factor than that of the contract physicians but more of the both category were not agreed to this factor; Authority, independency and autonomy {2(3, N = 113) = 11.757, p = 0.001, Cramers
131

V=0.323} have 28% of the permanent physicians agreed that they were attracted but more of the both category has not agreed to it; Career development opportunity {2(3, N = 113) = 6.365, p = 0.012, Cramers V=0.237}-39% of contract and 16% of permanent physicians are attracted of this factor; and Amenities like housing, conveyance provided{2(3, N = 113) = 3.705, p = 0.05, Cramers V=0.181} have more of the permanent physicians in comparison to contract employees attracted of this factor. Similarly, it is found that there is a significant relationship between the choice of Place of work (rural health institution) by the physicians and Authority, independency and autonomy at the place of posting {2(3, N = 113) = 7.61, p = 0.05, Cramers V=0.245} have physicians have more tendency to choice PHCs and CHCs of this factor. Wherein, we did not found any relationship between the factors and sex of the physicians and family background of the physicians has no relationship with any other factors of attraction.

132

Table 47: Relationship between the factor for attraction or placement with the demographic attributes of Physicians
With Age group Factor of Attraction or placement
Improved working condition Availability of equipment, drugs and supplies Authority, independency and autonomy Career development opportunity Continuing education/higher education Opportunities Training and skill development Opportunities Compulsion Flexible working hour with minimal workload Amenities like housing, conveyance provided Teamwork and Interpersonal staffs relationship Safety at workplace Availability of good schools for children nearby town Current health facility is closer to town or Closer to family and friends

With Sex
CV ( 2) p
0.6 89 0.0 87 0.5 49 0.6 02 0.1 73 0.038 0.161

With Family Background

( 2)
0.61 7 1.25 3 0.87 1 5.29 2 0.09 2

With Marital Status

( 2)
0.51 1 2.84 3 16.1 6 2.38 1 0.01 6

With Length of service (group)

CV ( 2) p
0.9 0.007 0.09 7 0.35 1 0.48 7 0.20 2 0.22 4

With Place of work

( 2)
6.86 6 2.98 9 7.61

With nature of Employment

CV ( 2) p
0.365 0.04 0.085 0.193

CV ( 2)
1.84 6 13.9

CV p
0.43 2 0.26 3 0.35 1 0.22 1 0.76 1 0.074 0.105

CV p
0.47 5 0.09 2 0.00 1 0.12 3 0.89 8 0.06 7 0.15 9 0.37 8 0.14 5 0.01 2

CV p
0.07 6 0.39 3 0.05 0.274 0.166

p
0.60 5 0.00 3 0.00 1 0.35 3 0.57 7 0.121 0.408

0.61 2.922

1.065 13.937

0.821 4.209

34.4 3 3.26 4 1.97 6

0.545

0.359

0.056

0.088

26.762

0.001

0.245

11.75 7 6.365 0.938

0.001

0.323

0.166 0.119

0.272 1.853

0.049 0.128

0.216 0.029

4.603 5.653

0.331 0.227

4.77 8 1.16 1

0.18 9 0.76 2

0.204 0.101

0.012 0.333

0.237 0.091

3.44 3 3.17 1 3.91 4 8.79

0.32 8 0.42 4 0.27 1 0.03

0.178

0.275

0.6

0.049

4.95 8 0.3 0.12 1 0.35 8 0.96

0.42 6 0.58 4 0.72 8 0.55

0.209

0.02 7 0.13 0.22 2 5.09 3 2.45 3 5.78 5 4.41 4 0.56 1

0.86 9 0.71 8 0.63 8 0.02 4 0.11 7 0.01 6 0.03 6 0.45 4

0.01 5 0.03 4 0.04 4 0.21 2 0.14 7 0.22 6 0.19 8 0.07

2.535

0.638

0.15

0.48 4 1.16 5 1.13

0.92 2 0.83 6 0.77

0.054

0.788

0.375

0.084

0.157 0.21

0.353 0.588

0.5 52 0.4 43 0.4 64 0.2 66 0.4 43 0.1 35 0.6 94

0.056 0.072

0.052 0.033

10.251 5.01

0.036 0.286

0.30 1 0.21 1 0.38 2 0.40 1 0.29 9 0.30 5 0.35 5

0.087 0.076

1.116 0.288

0.291 0.592

0.099 0.05

0.267

0.537

0.069

0.056

16.454

0.002

2.16

0.54

0.147

3.705

0.05

0.181

5.75 2 13.9 9 6.02 3 9.74 6

0.12 4 0.00 3 0.11 1 0.02 1

0.244

1.239

0.105

0.32 7 0.72 8 0.10 9 0.19 7

0.092

18.167

0.001

8.11 7 2.22 2 7.99 6 3.47 4

0.04 4 0.52 8 0.04 6 0.32 4

0.268

1.785

0.182

0.126

0.408 0.185

0.588 2.23

0.072 0.14

0.12 1 6.83 2 1.66 3

0.033 0.046

6.844 10.489

0.144 0.033

0.128 0.265

4.209 3.212

0.08 0.073

0.193 0.169

0.268

0.154

0.037

0.121

14.217

0.007

0.173

2.213

0.137

0.14

CV= Cramers V

133

4.3.3.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE DEMOGRAPHIC CHARACTERISTICS OF NURSES While analysing the relationship of factors of Attraction and the demographic characteristics of the respondents such as age, family background, marital status, length of service, place of work and nature of employment, wherein the sex characteristic has been dropped as only one case of differentiation is there in the data. The three factors of attraction viz., Financial incentives / Rural allowances/ Performance incentives, Supportive supervision & mentoring and Reward and recognition system, have at least one of the variables has zero variance and there is only one variable in the analysis chi-square could not be computed for all pairs of variables, henceforth it has been dropped from the analysis. According to the table 48, it is found that there is a relationship between age group of the nurses and Career development opportunity {2(3, N = 98) = 2.443, p = 0.03, Cramers V=0.151} as lower age group nurses (20-30 yrs) has attraction of this factor, Training and skill development Opportunities {2(3, N = 98) = 3.928, p = 0.039, Cramers V=0.204} as lower age group nurses (20-40 yrs) has attraction of this, and Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) {2(3, N = 98) = 19.43, p = 0.001, Cramers V=0.43} as lower age group nurses (20-40 yrs) has attraction of this. Whereas, no association has been found of marital status and other attraction factors, except the Compulsion has a relationship {2(3, N = 98) = 4.665, p = 0.031, Cramers V=0.218}, 62.5% married nurses has agreed that they are in rural services on compulsion. Similarly, the length of services (group) has the relationship to Career development opportunity {2(4, N = 98) = 9.288, p = 0.05, Cramers V=0.289} as more of the lower group of the service length of 0-5 yrs has attracted for this reason, Compulsion {2(4, N = 98) = 24.473, p = 0.001, Cramers V=0.471} as more of the lower group of the service length of 0-10 yrs has attracted for this reason, Amenities like housing & conveyance provided {2(4, N = 98) = 11.919, p = 0.018, Cramers V=0.314}in which the group of 5-15 yrs of service length attracted due to this factor and current health facility is closer to town or closer to family and friends {2(4, N = 98) = 10.048, p = 0.040, Cramers V=0.331} as more of the higher group of the service length of 10-20 yrs has attracted for this reason.

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It is also found that the nature of employment has relationship with Career development opportunity {2(1, N = 98) = 9.863, p = 0.002, Cramers V=0.317} 35.6% contract nurses has attracted in comparison to 9.4% permanent nurses attracted of this factor; compulsion {2(1, N = 98) = 16.309, p = 0.001, Cramers V=0.408} have 66.7% contract nurses out of the total nurses opted for compulsion in comparison to the permanent nurses; Flexible working hour with minimal workload {2(1, N = 98) = 3.945, p = 0.047, Cramers V=0.201} as the permanent nurses are more attracted, 78.6% permanent nurses opted for this against the 21.4% contract nurses; Amenities like housing & conveyance provided {2(1, N = 98) = 6.401, p = 0.011, Cramers V=0.256} 13.2% of permanent nurses were attracted for this factor to the rural services and non of the contract nurses; and Current health facility is closer to town or closer to family and friends {2(1, N = 98) = 4.339, p = 0.037, Cramers V=0.210} this factor has attracted 34% of permanent nurses against 15% of contract nurses. However, we found no association between Place of work and other attraction factors other than the Availability of equipment, drugs and supplies {2(3, N = 98) = 4.665, p = 0.031, Cramers V=0.218}. Wherein, we did not found any relationship between the family backgrounds of the nurses with any other factors of attraction.

135

Table 48: Relationship between the factor for attraction or placement with the demographic attributes of nurses
With Age group Factor of Attraction Improved working condition Availability of equipment, drugs and supplies Career development opportunity Training and skill development Opportunities Compulsion Flexible working hour with minimal workload Amenities like housing, conveyance provided Teamwork and Interpersonal staffs relationship Safety at workplace Availability of good schools for children nearby town Current health facility is closer to town or Closer to family and friends (2) 0.704 0.342 2.443 3.928 p 0.872 0.958 0.03 0.039 CV 0.081 0.056 0.151 0.204 With Family Background (2) 1.609 0.384 4.731 2.443 p 0.205 0.536 0.486 0.118 CV 0.128 0.063 0.22 0.158 With Marital Status (2) 0.432 0.151 3.137 1.2 p 0.511 0.698 0.077 0.273 CV 0.066 0.039 0.179 0.111 With Length of service (group) p CV (2) 2.127 3.853 9.288 3.723 0.712 0.505 0.05 0.445 0.148 0.184 0.289 0.19 With Place of work (2) 3.144 10.509 4.205 0.689 p 0.208 0.005 0.122 0.709 CV 0.234 0.366 0.206 0.089 With nature of Employment p CV (2) 0.058 0.074 9.863 1.374 0.809 0.785 0.002 0.241 0.024 0.028 0.317 0.118

19.43 6.128 4.245 6.468

0.001 0.106 0.236 0.091

0.43 0.249 0.201 0.289

1.005 2.235 0.057 1.628

0.316 0.135 0.811 0.202

0.101 0.151 0.024 0.129

4.665 1.44 0.665 1.177

0.031 0.23 0.415 0.278

0.218 0.121 0.082 0.11

24.473 8.479 11.919 7.148

0.001 0.076 0.018 0.128

0.471 0.316 0.314 321

0.197 1.583 0.934 0.24

0.906 0.453 0.627 0.887

0.045 0.151 0.091 0.043

16.30 9 3.945 6.401 2.628

0.001 0.047 0.011 0.105

0.408 0.201 0.256 0.164

4.109 1.133

0.25 0.769

0.26 0.106

0.49 0.111

0.484 0.739

0.071 0.034

0.384 1.586

0.535 0.208

0.063 0.127

6.661 7.261

0.155 0.123

0.492 0.281

1.757 0.736

0.415 0.692

0.12 0.08

0.858 0.735

0.354 0.391

0.094 0.087

5.743

0.125

0.244

2.443

0.118

0.158

2.243

0.134

0.151

10.048

0.04

0.331

1.577

0.455

0.106

4.339

0.037

0.21

CV= Cramers V

136

4.3.3.3. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE DEMOGRAPHIC CHARACTERISTICS OF MID-WIVES While analysing the relationship of factors of Attraction and the demographic characteristics of the respondents such as age, family background, marital status, length of service, place of work and nature of employment, wherein the sex characteristic has been dropped as no case of differentiation is there in the data. The three factors of attraction viz., Financial incentives / Rural allowances/ Performance incentives, Supportive supervision & mentoring and Reward and recognition system, have at least one of the variables has zero variance and there is only one variable in the analysis chi-square could not be computed for all pairs of variables, henceforth it has been dropped from the analysis. According to the table 49, it is found that there is a relationship between age group of the nurses and Improved working condition {2(2, N = 123) = 9.745, p = 0.008, Cramers V=0.300}(the lower age group of 20-30 years of the mid-wives has attracted, 75% of the agreed nurses are of this category); Availability of equipment, drugs and supplies{2(2, N = 123) = 7.688, p = 0.021, Cramers V=0.359}(about 2550% of the age group which has agreed upon it); Training and skill development Opportunities {2(2, N = 123) = 1.788, p = 0.049, Cramers V=0..127}(about 66% of age group of 20-30 years attracted due to this factor); Compulsion {2(2, N = 123) = 26.462, p = 0.001, Cramers V=0.455} (57% of mid-wives being placed of this); Flexible working hour with minimal workload {2(2, N = 123) = 14.072, p = 0.001, Cramers V=0.375} (the higher age group of 57% agreed on this factor); Amenities like housing & conveyance provided {2(2, N = 123) = 17.693, p = 0.001, Cramers V=0.448} (as the age group of higher mid-wives) and Teamwork and Interpersonal staffs relationship {2(2, N = 123) = 11.696, p = 0.003, Cramers V=0.431}(the higher age group has attraction due to this factor). Similarly, we found relationship between Marital status of Mid-wives and Amenities like housing & conveyance provided {2(1, N = 123) = 5.861, p = 0.015, Cramers V=0.218} (more married mid-wives are attracted of this factor); Availability of good schools for children nearby town {2(1, N = 123) = 3.570, p = 0.050, Cramers V=0.170} (more married mid-wives are attracted of this factor); and Current health facility is closer to town or Closer to family and friends {2(1, N = 123) = 4.222, p = 0.040, Cramers V=0.185} (28% of married mid-wives and 12% of unmarried Mid-wives attracted due to this factor); while the Compulsion {2(1, N =
137

123) = 7.036, p = 0.008, Cramers V=0.239}(72% of unmarried and 48% of married mid-wives are in the rural health institute in compulsion). It is also found that the length of service has a relationship with factor of Availability of equipment, drugs and supplies{2 (4, N = 123) = 9.724, p = 0.045, Cramers V=0.358}(18-25% of 10-15 and 15-20 years of service years mid-wives were attracted); Continuing education/higher education Opportunities {2(4, N = 123) = 13.940, p = 0.007, Cramers V=0.368}(5% to 45% of 0-15 years of service length mid-wives have attracted); Training and skill development Opportunities {2(4, N = 123) = 6.601, p = 0.050, Cramers V=0.236}(11% to 36% of 0-20 years of service length has attracted); Flexible working hour with minimal workload {2(4, N = 123) = 23.991, p = 0.001, Cramers V=0.464}(25% to 100% of mid-wives who have service length of 5-25 years attracted to this factor); Amenities like housing, conveyance provided {2(4, N = 123) = 9.527, p = 0.049, Cramers V=0.285}(12% to 25% of 5-20 years of service length mid-wives have attracted by this factor); Availability of good schools for children nearby town {2(4, N = 123) = 11.478, p = 0.022, Cramers V=0.303}(about 20% of 5-15 years of service length has been attracted from this factor); Current health facility is closer to town or closer to family and friends {2(4, N = 123) = 14.758, p = 0.005, Cramers V=0.360} (27% to 100% of the higher age groups were attracted to this factor); besides these Compulsion {2(4, N = 123) = 28.792, p = 0.001, Cramers V=0.474} also have the relationship. Meanwhile, it is also found that the Place of work and the factors of attraction of Authority, independency and autonomy {2 (3, N = 123) = 12.719, p = 0.005, Cramers V=0.274}(15% of mid-wives presently posted in SCs have agreed to the point); Amenities like housing & conveyance provided {2(3, N = 123) = 23.766, p = 0.001, Cramers V=0.536}; Teamwork and Interpersonal staffs relationship {2(3, N = 123) = 10.417, p = 0.015, Cramers V=0.304} (10% to 20% of the mid-wives in CHCs and DHs have agreed that this factor also contributed), Current health facility is closer to town or closer to family and friends {2(3, N = 123) = 7.515, p = 0.050, Cramers V=0.240} (20%-40% of mid-wives at CHCs and DHs have agreed on this factor); and besides these the Compulsion {2(3, N = 123) = 13.904, p = 0.003, Cramers V=0.332} is the factor of placement in rural areas. Meanwhile, it is also found that the nature of employment also have relationship with the factors of attraction like Authority, independency and autonomy {2(1, N = 123) = 10.147, p = 0.001, Cramers V=0.287} (17% permanent mid-wives
138

are more attracted of this factor); Career development opportunity {2(1, N = 123) = 8.200, p = 0.004, Cramers V=0.258} (contract mid-wives (40%) to 14% of permanent mid-wives have attracted); Continuing education/higher education opportunities {2(1, N = 123) = 8.451, p = 0.004, Cramers V=0.262}(23% of permanent mid-wives, while 5% of contract mid-wives has attracted); Flexible working hour with minimal workload {2(1, N = 123) = 19.282, p = 0.001, Cramers V=0.396}(33% of permanent mid-wives and 4% contract mid-wives); Amenities like housing, conveyance provided {2(1, N = 123) = 13.370, p = 0.001, Cramers V=0.330}(17% of permanent mid-wives were attracted due to this factor); Teamwork and Interpersonal staffs relationship {2(1, N = 123) = 4.085, p = 0.028, Cramers V=0.198}(7% of permanent mid-wives were attracted due to this factor); Current health facility is closer to town or closer to family and friends {2(1, N = 123) = 6.772, p = 0.009, Cramers V=0.235}(27% of permanent and 9% contract midwives); besides the above factor Compulsion {2(1, N = 123) = 30.284, p = 0.001, Cramers V=0.496} also contribute to factor relationship. However, we found no association between Family Background and other attraction factors.

139

Table 49: Relationship between the factor for attraction or placement with the demographic attributes of mid-wives
With Age group (2) Factor of Attraction Improved working condition Availability of equipment, drugs and supplies Authority, independency and autonomy Career development opportunity Continuing education/higher education Opportunities Training and skill development Opportunities Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) Flexible working hour with minimal workload Amenities like housing, conveyance provided Teamwork and Interpersonal staffs relationship Safety at workplace Availability of good schools for children nearby town Current health facility is closer to town or Closer to family and friends p CV (2) With Family Background p CV With Marital Status (2) p CV With Length of service (group) (2) p CV With Place of work (2) p CV With nature of Employment (2) p CV

9.745 7.688 4.707 5.204 8.124 1.788 26.462

0.008 0.021 0.06 0.074 0.017 0.049 0.001

0.3 0.359 0.214 0.163 0.284 0.127 0.455

0.507 0.107 0.629 1.312 0.267 3.837 0.544

0.476 0.744 0.428 0.252 0.606 0.059 0.457

0.064 0.029 0.072 0.103 0.047 0.177 0.067

0.295 0.42 6.651 0.911 5.284 2.977 7.036

0.587 0.517 0.11 0.34 0.122 0.084 0.008

0.049 0.058 0.233 0.086 0.207 0.156 0.239

6.59 9.724 3.888 3.78 13.94 6.601 28.792

0.159 0.045 0.421 0.437 0.007 0.05 0.001

0.304 0.358 0.19 0.175 0.368 0.236 0.474

3.636 6.788 12.719 0.528 3.324 1.405 13.904

0.304 0.079 0.005 0.913 0.344 0.704 0.003

0.186 0.211 0.274 0.065 0.164 0.104 0.332

0.673 2.2249 10.147 8.2 8.451 0.411 30.284

0.412 0.134 0.001 0.004 0.004 0.522 0.001

0.074 0.135 0.287 0.258 0.262 0.08 0.496

14.072 17.693 11.696 3.254 1.846 5.458

0.001 0.001 0.003 0.196 0.397 0.047

0.375 0.448 0.431 0.207 0.124 0.223

0.394 0.097 0.001 0.001 0.372 0.616

0.53 0.756 0.976 0.976 0.542 0.433

0.057 0.028 0.003 0.003 0.055 0.071

3.577 5.861 2.106 2.106 3.57 4.222

0.059 0.015 0.147 0.147 0.05 0.04

0.171 0.218 0.131 0.131 0.17 0.185

23.991 9.527 8.746 8.877 11.478 14.758

0.001 0.049 0.068 0.064 0.022 0.005

0.464 0.285 0.321 0.332 0.303 0.36

0.872 23.766 10.417 7.555 2.251 7.515

0.832 0.001 0.015 0.056 0.522 0.05

0.085 0.536 0.304 0.246 0.103 0.24

19.282 13.37 4.085 4.805 3.677 6.772

0.001 0.001 0.028 0.128 0.055 0.009

0.396 0.33 0.198 0.198 0.173 0.235

CV= Carmers V

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4.3.4. FACTORS THAT MAY ATTRACT PHYSICIANS, NURSES AND MID-WIVES TO RURAL AREA- CHOICE OF CURRENT PHYSICIANS, NURSES AND MID-WIVES
This part of the section has attempted to explore the factors that may attract physicians, nurses and mid-wives to rural area. Eighteen (18) factors were included for the same. The determination of the factor that may majorly attract the physicians, nurses and mid-wives has considered on the Mean factor which would be statistically significant at Mean test value of (1.5), that means the selection was done by the majority (more than half) of the respondents and have an greater impact at large workforce. This helps in ascertaining the factors that may attract the larger part of the workforce. The Reliability analysis was done for the attraction factors consistency of responses to items. The Cronbachs alpha coefficient for the factor items is =(0.542) on item 18 and N=334. The top 10 factor that may attract the physicians, nurses and mid-wives can be derived from Table 50 are: 1) Higher Salary package in compare to urban posting (1.80), 2) Conducive working condition (1.74), 3) Training and skill development Opportunities (1.74), 4) Access to amenities like housing & conveyance (1.69), 5) Financial incentives / Rural allowances/ Performance incentives (1.68), 6) Safety at workplace (1.61), 7) Rotational Posting after completing minimum rural service tenure (1.59), 8) Career development opportunities (1.58), 9) Availability of good schools for children (1.40), 10) Good reward and recognition system (1.40). The lowest mean factors are: Current health facility is closer to town or Closer to family and friends (1.01), Flexible working hours with minimal workload (1.07), Opportunity for authority, independency and autonomy (1.07), Supportive supervision and mentoring supplies (1.28). The factors that may attract physicians, nurses and mid-wives for rural and remote services has the following percentage of selection from these health workforces: Higher Salary package in compare to urban posting-268 (80%); Conducive working condition -247 (74%); Training and skill development Opportunities-246 (74%); Access to amenities like housing & conveyance-231 (69%); The Financial incentives / Rural allowances/ Performance incentives-227 (68%); Safety at workplace -204 (61%);
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(1.25) and Availability of equipment, drugs and

Rotational Posting after completing

minimum rural service tenure -196 (59%) and Career development opportunities -195 (58%); Availability of good schools for children -135 (40%); Good reward and recognition system -134 (40%); Continuing education/higher education Opportunities -131 (39%); Better teamwork and good interpersonal staffs relationship -128 (38%); Job security-120 (36%); Availability of equipment, drugs and supplies -92 (28%); Supportive supervision and mentoring -84 (25%);Opportunity for authority, independency and autonomy-25 (7%); Flexible working hours with minimal workload -24 (7%); Current health facility is closer to town or Closer to family and friends -5 (1%). The detail percentage comparison is presented in table 51. While the Mean Test value reveals the following factors statistically significant- Higher Salary package in compare to urban posting, Conducive working condition, Training and skill development opportunities, Access to amenities like housing & conveyance, Financial incentives / Rural allowances/ Performance incentives, Safety at workplace, Rotational Posting after completing minimum rural service tenure and Career development opportunities. These factors are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(333)=13.858, p= .001, t(333)=9.959, p= .001, t(333)=9.798, p= .001, t(333)=7.571, p= .001, t(333)=7.025, p= .001, t(333)=4.146, p= .001, t(333)=3.218, p= .001 and t(333)=3.104, p= .002 respectively. Table 50: Descriptive Statistics of the factors that may attract the physicians, nurses and mid-wives in the rural and remote area Test Value = 1.5 Sig. Factor Std. (2Mean N Mean Dev. t df tailed) Diff. Higher Salary package in 334 1.80 .399 13.858 333 .001 .302 compare to urban posting Conducive working condition 334 1.74 .440 9.959 333 .001 .240 Training and skill 334 1.74 .441 9.798 333 .001 .237 development Opportunities Access to amenities like 334 1.69 .463 7.571 333 .001 .192 housing & conveyance Financial incentives / Rural 334 1.68 .467 7.025 333 .001 .180 allowances/ Performance incentives Safety at workplace 334 1.61 .488 4.146 333 .001 .111 Rotational Posting after 334 1.59 .493 3.218 333 .001 .087 completing minimum rural service tenure
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Career development opportunities Availability of good schools for children Good reward and recognition system Continuing education/higher education Opportunities Better teamwork and good interpersonal staffs relationship Job security Availability of equipment, drugs and supplies Supportive supervision and mentoring Opportunity for authority, independency and autonomy Flexible working hours with minimal workload Current health facility is closer to town or Closer to family and friends

334 334 334 334

1.58 1.40 1.40 1.39

.494 .491 .491 .489

3.104 333 -3.563 333 -3.678 333 -4.028 333

.002 .001 .001 .001

.084 -.096 -.099 -.108

334

1.38

.487

-4.383 333

.001

-.117

334 334 334 334

1.36 1.28 1.25 1.07

.481 .447 .435 .264

-5.352 333 -9.172 333 -10.452 333 -29.482 333

.001 .001 .001 .001

-.141 -.225 -.249 -.425

334 334

1.07 1.01

.259 .122

-30.253 333 -72.888 333

.001 .001

-.428 -.485

Table 51: Percentage of factors that may attract physicians, nurses and midwives in rural and remote areas Factors n [n(%)] Higher Salary package in compare to urban posting 268 (80%) Conducive working condition 247 (74%) Training and skill development Opportunities 246 (74%) Access to amenities like housing & conveyance 231 (69%) Financial incentives / Rural allowances/ Performance incentives 227 (68%) Safety at workplace 204 (61%) Rotational Posting after completing minimum rural service tenure 196 (59%) Career development opportunities 195 (58%) Availability of good schools for children 135 (40%) Good reward and recognition system 134 (40%) Continuing education/higher education Opportunities 131 (39%) Better teamwork and good interpersonal staffs relationship 128 (38%) Job security 120 (36%) Availability of equipment, drugs and supplies 92 (28%) Supportive supervision and mentoring 84 (25%) Opportunity for authority, independency and autonomy 25 (7%) Flexible working hours with minimal workload 24 (7%) Current health facility is closer to town or Closer to family & friends 5 (1%)

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4.3.4.1. FACTORS THAT MAY ATTRACT PHYSICIANS TO RURAL AREACHOICE OF CURRENT PHYSICIANS As it can be derived from Table 52, the results indicated the top 10 factors that may attract the physicians are: 1) Training and skill development opportunities (1.81), 2) Access to amenities like housing & conveyance (1.78), 3) Career development opportunities (1.72), 4) Financial incentives / Rural allowances/ Performance incentives (1.71), 5) Rotational Posting after completing minimum rural service tenure (1.69), 6) Conducive working condition, (1.65), 7) Good reward and recognition system (1.64), 8) Higher Salary package in compare to urban posting (1.63), 9) Continuing education/higher education Opportunities (1.51) and 10) Safety at workplace (1.50). The lowest mean factors are: 1) Current health facility is closer to town or Closer to family and friends (1.03), 2) Flexible working hours with minimal workload (1.13), 3) Opportunity for authority, independency and autonomy (1.14), 4) Job security (1.21), 5) Availability of equipment, drugs and supplies (1.30), 6) Supportive supervision and mentoring (1.34), 7) Availability of good schools for children (1.35) and 8) Better teamwork and good interpersonal staffs relationship (1.38). While the Mean Test value reveals the following factors significant- Training and skill development Opportunities, Access to amenities like housing & conveyance, Career development opportunities, Financial incentives / Rural allowances/ Performance incentives, Rotational Posting after completing minimum rural service tenure, Conducive working condition, Good reward and recognition system, Higher Salary package in compare to urban posting and Continuing education/higher

education opportunities. These factors are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(112)=8.547, p=.001, t(112)=7.107, p= .001, t(112)=5.093, p= .001, t(112)=4.840, p= .001, t(112)=4.355, p= .001, t(112)=3.447, p= .001, t(112)=3.019, p= .003, t(112)=2.810, p= .006 and t(112)=1.281, p= .009 respectively. The Percentage selection of Factor is presented in table 53.

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Table 52: Descriptive Statistics of the factors that may attract the physicians Test Value = 1.5 Sig. Factors (2Std. taile Mean N Mean Dev. t df d) Diff. Training and skill development 113 1.81 .391 8.547 112 .001 .314 Opportunities Access to amenities like 113 1.78 .417 7.107 112 .001 .279 housing & conveyance Career development opportunity 113 1.72 .453 5.093 112 .001 .217 Financial incentives / Rural 113 1.71 .457 4.840 112 .001 .208 allowances/Performance incentives Rotational Posting after 4.355 112 .001 .190 113 1.69 .464 completing minimum rural service tenure Conducive working condition 113 1.65 .478 3.447 112 .001 .155 Good reward and recognition 113 1.64 .483 3.019 112 .003 .137 system Higher Salary package in 2.810 112 .006 .128 113 1.63 .485 compare to urban posting Continuing education/higher 1.281 112 .009 .113 113 1.61 .479 education Opportunities Safety at workplace 113 1.50 .502 .094 112 .926 .004 Better teamwork and good 113 1.38 .488 -2.604 112 .010 -.119 interpersonal staffs relationship Availability of good schools 113 1.35 .480 -3.231 112 .002 -.146 for children Supportive supervision and 113 1.34 .475 -3.667 112 .001 -.164 mentoring Availability of equipment, 113 1.30 .461 -4.595 112 .001 -.199 drugs and supplies Job security 113 1.21 .411 -7.442 112 .001 -.288 Opportunity for authority, 113 1.14 .350 -10.880 112 .001 -.358 independency and autonomy Flexible working hours with 113 1.13 .341 -11.455 112 .001 -.367 minimal workload Current health facility is closer 113 1.03 .161 -31.168 112 .001 -.473 to town or Closer to family and friends The factor that may attract physicians for rural and remote services has the following percentage of selection from the physicians: Training and skill

development Opportunities (81%), Access to amenities like housing & conveyance (78%), Career development opportunities (72%), Financial incentives / Rural allowances/ Performance incentives (71%), Rotational Posting after completing minimum rural service tenure (69%), Conducive working condition (65%), Good
145

reward and recognition system (64%), Higher Salary package in compare to urban posting (63%), Continuing education/higher education Opportunities (51%), Safety at workplace (50%), Better teamwork and good interpersonal staffs relationship (38%), Availability of good schools for children (35%), Supportive supervision and mentoring (34%), Availability of equipment, drugs and supplies (30%), Job security (21%), Opportunity for authority, independency and autonomy (14%), Flexible

working hours with minimal workload (13%), Current health facility is closer to town or Closer to family and friends (3%). Table 53: Percentage of factors that may attract physicians in rural and remote areas Physicians Factors may attract n n% Training and skill development Opportunities 92 81% Access to amenities like housing & conveyance 88 78% Career development opportunities 81 72% Financial incentives / Rural allowances/ Performance incentives 80 71% Rotational Posting after completing minimum rural service tenure 78 69% Conducive working condition 74 65% Good reward and recognition system 72 64% Higher Salary package in compare to urban posting 71 63% Continuing education/higher education Opportunities 58 51% Safety at workplace 57 50% Better teamwork and good interpersonal staffs relationship 43 38% Availability of good schools for children 40 35% Supportive supervision and mentoring 38 34% Availability of equipment, drugs and supplies 34 30% Job security 24 21% Opportunity for authority, independency and autonomy 16 14% Flexible working hours with minimal workload 15 13% Current health facility is closer to town or Closer to family and friends 3 3% 4.3.4.2. ANALYSIS OF THE FACTORS THAT MAY ATTRACT NURSES TO RURAL AND REMOTE AREA- CHOICE OF CURRENT NURSES In this section, it is attempted to explore the factors that may attract nurses to rural area. The sixteen (18) point factors were included for the same. As it can be derived from table 54, the results indicated the top 10 factors that may attraction the nurses are: Higher Salary package in compare to urban posting (1.89), Conducive working condition (1.82), Access to amenities like housing & conveyance (1.79), Training and skill development Opportunities (1.74), Financial incentives / Rural allowances/ Performance incentives (1.69), Good reward and
146

recognition system (1.63), Safety at workplace (1.56), Career development opportunities (1.46), Rotational Posting after completing minimum rural service tenure (1.40) and Better teamwork and good interpersonal staffs relationship (1.40). The lowest mean factors are: Availability of good schools for children (1.37), Job security (1.35), Continuing education/higher education Opportunities (1.32), Availability of equipment, drugs and supplies (1.26), Supportive supervision and mentoring (1.20), Flexible working hours with minimal workload (1.08), opportunity for authority, independency and autonomy (1.04), Current health facility is closer to town or Closer to family and friends (1.01). It is found that the combination of seven factors are having statistically significant at Mean Test Value=1.5, 95% C.I, and the factors : Higher Salary package in compare to urban posting, Conducive working condition Access to amenities like housing & conveyance, Training and skill development Opportunities, Financial incentives / rural allowances/ Performance incentives, Good reward and recognition system and Safety at workplace. These factors are significant at t(97)=12.098, p= .001, t(97)=8.046, p= .001, t(97)=6.858, p= .001, t(97)=5.533, p= .001, t(97)=4.143, p= .001, t(97)=2.710, p= .008 and t(97)=1.201, p= .041 respectively. The Percentage selection of factor for Attraction or placed is place in table 55. Table 54 : Descriptive Statistics of the factors that may attracted the nurses Test Value = 1.5 Sig. Factors Std. (2Mean N Mean Dev. t df tailed) Diff. Higher Salary package in 98 1.89 .317 12.098 97 .001 .388 compare to urban posting Conducive working condition 98 1.82 .389 8.046 97 .001 .316 Access to amenities like 98 1.79 .412 6.858 97 .001 .286 housing & conveyance Training and skill development 98 1.74 .438 5.533 97 .001 .245 Opportunities Financial incentives / Rural 98 1.69 .463 4.143 97 .001 .194 allowances/ Performance incentives Good reward and recognition 98 1.63 .485 2.710 97 .008 .133 system Safety at workplace 98 1.56 .478 1.201 97 .041 .006 Career development opportunity 98 1.46 .501 -.807 97 .422 -.041 Rotational Posting after 98 1.40 .492 -2.053 97 .043 -.102 completing minimum rural service tenure
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Better teamwork and good 98 interpersonal staffs relationship Availability of good schools for 98 children Job security 98 Continuing education/higher 98 education Opportunities Availability of equipment, 98 drugs and supplies Supportive supervision and 98 mentoring Flexible working hours with 98 minimal workload Opportunity for authority, 98 independency and autonomy Current health facility is closer to 98 town or Closer to family & friends

1.40 1.37 1.35 1.32 1.26 1.20 1.08 1.04 1.01

.492 .485 .478 .467 .438 .405 .275 .199 .101

-2.053 -2.710 -3.167 -3.890 -5.533 -7.231 -15.049 -22.856 -48.000

97 97 97 97 97 97 97 97 97

.043 .008 .002 .001 .001 .001 .001 .001 .001

-.102 -.133 -.153 -.184 -.245 -.296 -.418 -.459 -.490

The factor that may attract nurses for rural and remote services has the following percentage of selection: Higher Salary package in compare to urban posting (89%), Conducive working condition (82%), Access to amenities like housing & conveyance (74%), Training and skill development Opportunities (79%), Financial incentives / Rural allowances/ Performance incentives (63%), Good reward and recognition system (69%), Safety at workplace (46%), Career development

opportunities (51%), Rotational Posting after completing minimum rural service tenure (40%), Better teamwork and good interpersonal staffs relationship (35%), Availability of good schools for children education/higher education Opportunities (32%), Job security (40%), Continuing

(37%), Availability of equipment, drugs (20%), for Flexible authority,

and supplies (26%), Supportive supervision and mentoring working hours with minimal workload (4%), Opportunity

independency and autonomy (8%) and Current health facility is closer to town or Closer to family and friends (1%) Table 55: Percentage selection of Factor that may attract nurses Factors may attract Higher Salary package in compare to urban posting Conducive working condition Access to amenities like housing & conveyance Training and skill development Opportunities Financial incentives / Rural allowances/ Performance incentives Good reward and recognition system Safety at workplace
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Nurses n n% 87 89% 80 82% 73 74% 77 79% 62 63% 68 69% 45 46%

Career development opportunities Rotational Posting after completing minimum rural service tenure Better teamwork and good interpersonal staffs relationship Availability of good schools for children Job security Continuing education/higher education Opportunities Availability of equipment, drugs and supplies Supportive supervision and mentoring Flexible working hours with minimal workload Opportunity for authority, independency and autonomy Current health facility is closer to town or Closer to family and friends

50 39 34 31 39 36 25 20 4 8 1

51% 40% 35% 32% 40% 37% 26% 20% 4% 8% 1%

4.3.4.3. ANALYSIS OF THE FACTORS THAT MAY ATTRACT MID-WIVES TO RURAL AND REMOTE AREA- CHOICE OF CURRENT MID-WIVES When the group of mid-wives is analysed, it is found that the top 10 factors can be derived from table 56 are: Higher Salary package in compare to urban posting (1.81), Access to amenities like housing & conveyance (1.78), Conducive working condition (1.72), Training and skill development Opportunities reward and recognition system (1.71), Good

(1.69), Rotational Posting after completing

minimum rural service tenure (1.65), Financial incentives / Rural allowances/ Performance incentives (1.64), Continuing education/higher education Opportunities (1.63), Career development opportunities (1.61), Safety at workplace (1.60). The lowest mean factors are: Better teamwork and good interpersonal staffs relationship (1.38), Availability of good schools for children (1.35), Supportive supervision and mentoring (1.34), Availability of equipment, drugs and supplies (1.30), Job security (1.21), Opportunity for authority, independency and autonomy (1.14), Flexible working hours with minimal workload (1.13) and Current health facility is closer to town or Closer to family and friends (1.03). While the combination of ten factors are having statistically significant at Mean Test Value=1.5, 95% C.I, and they are : Higher Salary package in compare to urban posting, Access to amenities like housing & conveyance, Conducive working condition, Training and skill development Opportunities, Good reward and recognition system, Rotational Posting after completing minimum rural service tenure, Financial incentives / Rural allowances/ Performance incentives, Continuing education/higher education Opportunities, Career development opportunities and Safety at workplace. These factors are significant at t(112)=8.547, p=.001, t(112)=7.107, p= .001, t(112)=5.093, p= .001, t(112)=4.840, p=.001, t(112)=4.355, p= .001, t(112)=3.447, p=.001, t(112)=3.019, p=.003, t(112)=2.810, p=.006,
149

t(112)=1.281, p=.009 and t(112)=1.094, p=.026 respectively. The Percentage selection of Factor for Attraction or placed is presented in table 57. Table 56: Descriptive Statistics of the factors that may attracted the Midwives Test Value = 1.5 Sig. Factors Std. (2Mean t df tailed) Diff. N Mean Dev. Higher Salary package in 113 1.81 .391 8.547 112 .001 .314 compare to urban posting Access to amenities like 113 1.78 .417 7.107 112 .001 .279 housing & conveyance Conducive working condition 113 1.72 .453 5.093 112 .001 .217 Training and skill 113 1.71 .457 4.840 112 .001 .208 development Opportunities Good reward and 113 1.69 .464 4.355 112 .001 .190 recognition system Rotational Posting after 113 1.65 .478 3.447 112 .001 .155 completing minimum rural service tenure Financial incentives / Rural 113 1.64 .483 3.019 112 .003 .137 allowances/Performance incentives Continuing education/higher 113 1.63 .485 2.810 112 .006 .128 education Opportunities Career development opportunity 113 1.61 .479 1.281 112 .009 .113 Safety at workplace 113 1.60 .475 1.094 112 .026 .010 Better teamwork and good 113 1.38 .488 -2.604 112 .010 -.119 interpersonal staffs relationship Availability of good schools 113 1.35 .480 -3.231 112 .002 -.146 for children Supportive supervision and 113 1.34 .475 -3.667 112 .001 -.164 mentoring Availability of equipment, 113 1.30 .461 -4.595 112 .001 -.199 drugs and supplies Job security 113 1.21 .411 -7.442 112 .001 -.288 Opportunity for authority, 113 1.14 .350 -10.880 112 .001 -.358 independency and autonomy Flexible working hours with 113 1.13 .341 -11.455 112 .001 -.367 minimal workload Current health facility is 113 1.03 .161 -31.168 112 .001 -.473 closer to town or Closer to family and friends

150

The factor that may attract mid-wives for rural and remote services has the following percentage of selection: Higher Salary package in compare to urban posting (82%), Access to amenities like housing & conveyance (76%), Conducive working condition (66%), Training and skill development Opportunities (67%), Good reward and recognition system (63%), Rotational Posting after completing minimum rural service tenure (64%), Financial incentives / Rural allowances/ Performance incentives (59%), Continuing education/higher education Opportunities (52%), Career development opportunities (46%), Safety at workplace (23%), Better teamwork and good interpersonal staffs relationship (34%), Availability of good schools for children (37%), Supportive supervision and mentoring (49%), Availability of equipment, drugs and supplies (27%), Job security (21%), Opportunity for authority, independency and autonomy (4%), Flexible working hours with minimal workload (1%) and Current health facility is closer to town or Closer to family and friends (1%). Table 57: Percentage of factors that may attract mid-wives in rural and remote areas Mid-wives Factors may attract n n% Higher Salary package in compare to urban posting 101 82% Access to amenities like housing & conveyance 93 76% Conducive working condition 81 66% Training and skill development Opportunities 83 67% Good reward and recognition system 77 63% Rotational Posting after completing minimum rural service tenure 79 64% Financial incentives / Rural allowances/ Performance incentives 73 59% Continuing education/higher education Opportunities 64 52% Career development opportunities 56 46% Safety at workplace 28 23% Better teamwork and good interpersonal staffs relationship 42 34% Availability of good schools for children 46 37% Supportive supervision and mentoring 60 49% Availability of equipment, drugs and supplies 33 27% Job security 26 21% Opportunity for authority, independency and autonomy 5 4% Flexible working hours with minimal workload 1 1% Current health facility is closer to town or Closer to family and friends 1 1% 4.3.4.4. VARIANCE IN CHOICE OF FACTOR THAT MAY ATTRACT THE PHYSICIANS, NURSES AND MID-WIVES While analysing the variance in the choice of the factors that may attract the physicians, nurses and mid-wives, it is found that there is difference in the groups in the view of factors that may attract to the rural and rural areas services. It is found
151

that the physicians may be attracted to the rural and remote when they found there is scope of training and skill development, a good working environment, accommodation facilities, incentives and recognition system with a competitive salary that is more than that of urban areas. It meant that the physicians first look at self development by training and development, living condition and to the monetary factors. While, the nurses and mid-wives have attraction of higher salary first, good work environment, accommodation training and development, recognition and Safety at workplace. It meant that the group of nurses and mid-wives are more attracted to financial benefits and then they look after the work and living condition and off-course to the Safety at workplace. Thus, it meant that the preference is not in the same order and the factor cannot be generalised for all the three groups. However, it is statistically found that the three groups differ in their choices in the following factors:- Higher Salary package in compare to urban posting at F(2, 331)=3.210, p= .042, Financial / rural/ Performance incentives at F(2, 331)=5.706, p= .004, Improved working condition at F(2, 331)=3.740, p= .025, Opportunity for authority, independency & autonomy at F(2, 331)=5.629, p= .004, Career development opportunities at F(2, 331)=6.409, p= .002, Continuing

education/higher education Opportunities at F(2, 331)=5.448, p= .005, Training and skill development Opportunities at F(2, 331) = 3.750, p= .025, Rotational Posting at F(2, 331)=5.952, p= .003, Job security at F(2, 331)=10.231, p= .001, Flexible working hours with minimal workload at F(2, 331)=7.193, p= .001, Supportive supervision & mentoring at F(2, 331)=3.304, p= .038, Access to amenities like housing & conveyance at F(2, 331)=3.914, p= .021, Safety at workplace at F(2, 331)=4.445, p= .012, Good reward & recognition system at F(2, 331)=24.334, p= .001. Detail analysis of variance is presented in table 58.

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Table 58 : Analysis of Variance in factor that may attract the physicians, nurses and mid-wives Factors df F Sig. Higher Salary package in compare to urban Between Groups 2 3.210 .042 posting Within Groups 331 Financial incentives / Rural allowances/ Between Groups 2 5.706 .004 Performance incentives Within Groups 331 Improved working condition Between Groups 2 3.740 .025 Within Groups 331 Availability of equipment, drugs and Between Groups 2 .298 .742 supplies Within Groups 331 Opportunity for authority, independency Between Groups 2 5.629 .004 and autonomy Within Groups 331 Career development opportunities Between Groups 2 6.409 .002 Within Groups 331 Continuing education/higher education Between Groups 2 5.448 .005 Opportunities Within Groups 331 Training and skill development Between Groups 2 3.750 .025 Opportunities Within Groups 331 Rotational Posting after completing Between Groups 2 5.952 .003 minimum rural service tenure Within Groups 331 Job security Between Groups 2 10.231 .001 Within Groups 331 Flexible working hours with minimal Between Groups 2 7.193 .001 workload Within Groups 331 Supportive supervision and mentoring Between Groups 2 3.304 .038 Within Groups 331 Access to amenities like housing & Between Groups 2 3.914 .021 conveyance Within Groups 331 Better teamwork and good interpersonal Between Groups 2 .068 .934 staffs relationship Within Groups 331 Safety at workplace Between Groups 2 4.445 .012 Within Groups 331 Good reward and recognition system Between Groups 2 24.334 .001 Within Groups 331 Availability of good schools for children Between Groups 2 1.264 .284 Within Groups 331 Current health facility is closer to town or Between Groups 2 .781 .459 Closer to family and friends Within Groups 331

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SECTION 4 ANALYSIS OF THE DIMENSION OF HR ISSUES IN RETENTION OF PHYSICIANS, NURSES AND MIDWIVES IN RURAL AND REMOTE AREAS OF THE STATE

154

4.4.1. INTRODUCTION
This part of the chapter describes the dimensions of retention of the Physicians, Nurses and Mid-wives in the rural and remote areas. An employee attitude survey measured the employee attitudes towards their job satisfaction, intention to migrate and what would motivate them to stand back in present rural and remote place. There are two propositions concerning the satisfaction and performance relationship. The first proposition which is based on the traditional view is that, satisfaction caused performance. The second proposition is that satisfaction is the effect rather than the cause of performance. This proposition says that effort in a job leads to rewards, which result in a certain level of satisfaction. In another proposition, both satisfaction and performance are considered to be functions of rewards (Sharma, 2000). Job satisfaction therefore is a function of satisfaction with different aspects of the job, such as, nature of job, promotional avenues, supervisors, co-workers role etc. and the particular importance one attaches to these respective components and it affects the retention and performance. Therefore, the exploration of the issues in retention of Physicians, Nurses and Mid-wives from the perspective of employees itself are presented in five sub-parts of: i) level of job satisfaction of current job in rural and remote area with individual contributing factors of level of satisfaction, ii) the intention to continue the present rural area service for at least another 3-5 years, iii) retention factors for continuing the rural service, iv) contributing push factors and iv) factors that may motivate them to retain the current job in rural and remote area. The determination of the factor that majorly attracted the physicians, nurses and mid-wives has considered on the Mean factor which would be statistically significant at Mean Test value of (1.5), that means the selection was done by the majority (more than half) of the respondents and have an greater impact at large workforce. This helps in ascertain the most relevant factors for the issue. Along with the employee perspectives, the management perspective is also presented in the following section.

155

4.4.2. OVERALL JOB SATISFACTION OF PHYSICIANS, NURSES AND MID-WIVES IN PRESENT RURAL AND REMOTE AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTES
Mobley (1982) (adapted from Yang, 2007) suggested that the reasons for turnover in general include dissatisfaction with work. The job satisfaction of the Physicians, Nurses and Mid-wives was measured on a scale of 1 to 5 with their present job in rural and remote area. The scale denotes 1 (one) as the highly dissatisfied to 5 (five) as highly satisfied. The mean of overall scale of job satisfaction of these employees is 2.26 (N=334), which shows an average lower scale of satisfaction. In the group comparison, the Physicians (2.53, N=113), Nurses (2.32, N=98) and Mid-wives (1.98, N=123) means respectively. The analysis shows that the groups of Mid-wives have the lowest scale of job satisfaction, followed by the group of nurses and the physicians. 21.2% of physicians are satisfied against 1.8% of them is highly satisfied and 3.5% have high dissatisfaction along with 64.6% of dissatisfied. In the counterpart the nurses have 16.3% satisfied and 64.3% are dissatisfied along with 10.2% highly dissatisfied. While, Mid-wives have 5.7% of satisfied group, 14.6% highly dissatisfied and 78.9% has dissatisfied. It seems that most of the groups are dissatisfied with the present job in rural and remote area. Table 59: Percentage showing Job Satisfaction of physicians, nurses and midwives in rural and remote area setting Scale of overall job satisfaction Neither Satisfied Nor Dissatisfied Highly Dissatisfied Dissatisfied Satisfied Highly Satisfied

Category of Respondents Physician Nurse Mid-Wife Total

4 (3.5%) 10 (10.2%) 18 (14.6%) 32 (9.6%)

73 (64.6%) 63 (64.3%) 97 (78.9%) 233 (69.8%)

10 (8.8%) 24 (21.2%) 9 (9.2%) 16 (16.%) 1 (0.8%) 7 (5.70%) 20 (6%) 47 (14.1%)

2 (1.8%) 0 (0%) 0 (0%) 2 (0.6%)

Total 113 98 123 334

While the analysis of variance shows that there is difference in the scale of job satisfaction among the three groups, the values of F(2, 331)=14.197, p =.001.

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Table 60: Descriptive statistics of Job Satisfaction of Physicians, Nurses and Mid-wives Std. Std. Category of Respondents N Mean Deviation Error Min Max Physician 113 2.53 .927 .087 1 5 Nurse 98 2.32 .869 .088 1 4 Mid-Wife 123 1.98 .620 .056 1 4 Total 334 2.26 .840 .046 1 5 Table 61: Analysis of Variance in Job Satisfaction among the Physicians, nurses and mid-wives Sum of Squares df Mean Square F Sig. Between Groups 18.552 2 9.276 14.197 .001 Within Groups 216.262 331 .653 Total 234.814 333 In the group comparison as per the Nature of Employment, the means of contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. This interprets as the contractual employees have lower job satisfaction in comparison to the permanent employees. If we analysed the situation in categorizing the workforce in nature of employment, we found that contract workforce are more dissatisfied than the permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2% are satisfied in the group of the contracts. Whereas, the permanent employees have 9.6% are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only 0.6% are highly satisfied. Table 62: Percentage showing Job Satisfaction of contractual and permanent physicians, nurses and mid-wives in rural and remote area setting Scale of overall job satisfaction Neither Satisfied Nor Dissatisfied Highly Satisfied Highly Dissatisfied Dissatisfied Satisfied Total 154 180 334

Nature of Employment Contract 27(17.5%) 110 (71.4%) 9 (5.8%) 8 (5.2%) 0(0.0%) Permanent 5 (2.8%) 123 (68.3%) 11 (6.1%) 39 (21.7%) 2(1.1%) Total 32 (9.6%) 233 (69.8%) 20 (6.0%) 47 (14.1%) 2(0.6%)

Two sample T-Test shows that it is statistical significant, the values are: t(332) = -5.835, p=.001. There is a difference in the job satisfaction between the groups. The mean difference is -.513 between the contractual and permanent employees.

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Table 63: Descriptive statistic of Job Satisfaction of contract and permanent Physicians, nurses and mid-wives Std. Error Nature of Employment N Mean Std. Deviation Mean Contract 154 1.99 .667 .054 Permanent 180 2.50 .900 .067 Table 64: Analysis of Variance of Job Satisfaction among contractual and permanent Physicians, nurses and mid-wives
Levene's Test for Equality of Variances t-test for Equality of Means Sig. (2Mean df tailed) Difference

Sig.

Std. Error Difference

Equal variances assumed Equal variances not assumed

54.929 .001

-5.835 -5.969

332 325.5 41

0 0

-0.513 -0.513

0.088 0.086

The Medical professions like doctor and nurses has been long among the most attractive and satisfied profession in the society, but when it is analysed in the context of rural and remote area services, the results suggests that these group of employees are increasingly getting dissatisfied with their jobs in rural and remote areas. The next topic of analysis and interpretation is on how the demographic attributes effect the job satisfaction of these groups in rural and remote area service setting. It is well known that the job satisfaction is effected by the demographic attributes of the employees. To explore the relationship of the Job satisfaction of Physicians, nurses and mid-wives in rural and remote area services with other demographic attributes like age, family background, marital status, length of service, place of posting and nature of employment, the statistical analysis has been done and interpreted. The variable, (sex) has been drooped from analysing for the relationship because there are male and female classification is only in the Physicians group, where as the nurses and mid-wives does not have the classification of male and female, except 1 (one) no. of male in the nurse group of employee. Correlation (Pearsons ratio or Spearman Correlation), paired sample T-Test were used to identify the attributes significantly related with job satisfaction. The pvalues of 0.05 were used as the level of significance.

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It is statistically significant that there is a positive relationship of job satisfaction with the age r(334)=.282, p=.001, length of service r(334)=.224, p=.001, place of posting r(334)=.053, p=.004 and nature of employment r(334) = .305, p=.001. However, the relationship is not strong between the variables because the association is under minimum values. Thus, it signifies that as higher age employee has higher job satisfaction, higher length of service has higher job satisfaction, employee posted at the higher level of health institute has higher job satisfaction and permanent employees have the higher job satisfaction than the contractual employees. There is negative relationship and statistically significant as well between the variables. The correlation between the marital status and job satisfaction is r(334)=(-).159, p=.004. Thus, in marital status it signifies that married employees has less job satisfaction. Wherein, it signifies that the more married employees the less satisfaction level in rural setting. There is no relationship between family background and job satisfaction of employees in rural setting. The correlation between the variables is not statistically significant r(334)=.028, p=.613. Thus, there is no effect of family background on job satisfaction of the employees. To sum up, statistically it seems that age, length of service, place of posting and nature of employment have the positive impact on job satisfaction in the rural setting. Table 65: Correlation between Job satisfaction and the demographic attributes of the employees (Physicians, Nurses and Mid-wives) Sl. No. Attributes Correlation coefficient P-Value 1. Age 0.282 0.001 2. Family Background 0.028 0.613 3. Marital Status -0.159 0.004 4. Length of Service 0.224 0.001 5. Nature of Employment 0.305 0.001 6. Place of Posting 0.053 0.004 4.4.2.1. JOB SATISFACTION OF PHYSICIANS IN RURAL AND REMOTE AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTES The job satisfaction of the physicians has been measured on a scale of 1 to 5 with their present job in rural and remote area. The scale denotes 1 (one) as the highly dissatisfied to 5 (five) as highly satisfied.

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The mean of overall scale of job satisfaction of physician is (2.53, N=113), which shows an average low scale of satisfaction. In the group comparison, the contractual physicians (2.24, N=34), permanent physicians (2.66, N=79). The analysis shows that the contractual physicians have the lowest scale of job satisfaction in comparison to the permanent physicians. Two sample T-Test (Paired) shows that it is statistical significant, the values are: t(111) = -2.266, p =0.025. It signifies that there is a difference in the job satisfaction between the groups. The mean difference is -.423 between the contractual and permanent physicians. Table 66 : Descriptive statistic of Job Satisfaction of contract and permanent Physicians. Category N Mean Std. Dev. Std. Error Min Max Contract 34 2.24 .741 .127 1 4 Permanent 79 2.66 .973 .109 1 5 Total 113 2.53 .927 .087 1 5 Table 67: Analysis of Variance of Job Satisfaction among contractual and permanent Physicians.
Levene's Test for Equality of Variances F Sig. t-test for Equality of Means df Sig. Mean (2Diff. tailed) -2.266 111 0.025 -0.423 -2.522 81.191 0.014 -0.423 t

14.522 .001 Equal variances assumed Equal variances not assumed

Std. Error Diff. 0.187 0.168

To explore the relationship of the Job satisfaction of Physicians in rural and remote area services with other demographic attributes like age, sex, family background, marital status, length of service and nature of employment, the statistical analysis has been done and interpreted. The variable place of posting is not considered for the aforesaid test, because the variable has fewer cases of different groups. Correlation (Pearsons) or paired sample T-Test was used to identify the attributes significantly related with job satisfaction. The p-values of 0.05 were used as the level of significance. It is statistically significant that there is a positive relationship of job satisfaction with the age r(113)=.213, p=.024, length of service r(113)=.223, p=.018, and nature of employment r(113) = .210, p = .025. However, the relationship is not strong between the variables because the association is under
160

minimum positive values. Thus, it signifies that as higher age employee has higher job satisfaction, higher length of service has higher job satisfaction and permanent employees have the higher job satisfaction than the contractual employees. There is negative relationship and statistically significant as well between the variables. The correlation between the sex and job satisfaction is negative r(113)=(-).178, p=.05 and the marital status is r(113)=(-).185, p=.05. Thus, it signifies that males (77%) out-numbered the female (23%) employees and the job satisfaction diminishes as the male employees goes up and male physicians have less job satisfaction in rural setting. Moreover, the negative relationship in marital signifies that married employees has less job satisfaction and it is statistically signifies. The married physicians (63%) are out-numbered the unmarried physicians (37%), and as the married physicians out-numbered, the satisfaction level will go down in rural setting. It is found that, there is no relationship between family background and job satisfaction of employees in rural setting. The correlation between the variables is not statistically significant r(113)=.042, p=.656. Thus, there is no effect of family background on job satisfaction of the employees. To sum up, statistically it seems that age, length of service and nature of employment have positive relationship with the job satisfaction of the Physicians. Table 68 : Correlation between Job satisfaction and the demographic attributes of Physicians Attributes Correlation coefficient P-Value Sl. No. 1. Age 0.213 0.024 2. Sex -0.178 0.050 3. Family Background 0.042 0.656 4. Marital Status -0.185 0.050 5. Length of Service 0.223 0.018 6. Nature of Employment 0.210 0.025 4.4.2.2. JOB SATISFACTION OF NURSES IN RURAL AND REMOTE AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTES The job satisfaction of the Nurses has been measured on a scale of 1 to 5 with their present job in rural and remote area. The scale denotes 1 (one) as the highly dissatisfied to 5 (five) as highly satisfied. The mean of overall scale of job satisfaction of Nurses is (2.32, N=98), which shows an average lower scale of satisfaction. In the group comparison, the contractual nurses (2.02, N=45), permanent nurses (2.57, N=53).
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The analysis shows that the contractual nurses have the lowest scale of job satisfaction in comparison to the permanent nurses. Two sample T-Test (Paired) shows that it is statistical significant, the values are: t(96) = -3.236, p =0.002. It signifies that there is a difference in the job satisfaction between the groups. The mean difference is -.544 between the contractual and permanent nurses. Table 69: Descriptive statistic of Job Satisfaction of contract and permanent nurses. N Mean Std. Dev. Std. Error Min Max Contract Permanent Total 45 53 98 2.02 2.57 2.32 .723 .910 .869 .108 .125 .088 1 1 1 4 4 4

Table 70 : Analysis of Variance of Job Satisfaction among contractual and permanent nurses
Levene's Test for Equality of Variances F Sig. t t-test for Equality of Means Sig. (2- Mean Std. Error df tailed) Diff. Diff.

Equal variances assumed 13.959 .001 -3.236 96 Equal variances not assumed -3.297 95.608

.002 -.544 .001 -.544

.168 .165

To explore the relationship of the Job satisfaction of Nurses in rural and remote area services with other demographic attributes like age, family background, marital status, length of service and nature of employment, the statistical analysis has been done and interpreted. The variable place of posting and sex is not considered for the aforesaid test, because the variable has fewer cases of different groups. Correlation (Pearsons) or paired sample T-Test was used to identify the attributes significantly related with job satisfaction. The p-values of 0.05 were used as the level of significance. It is statistically significant that there is a positive relationship of job satisfaction with the age r(98)=.225, p=.026, length of service r(98)=.227, p=.025, and nature of employment r(98) = .314, p = .002. However, the relationship is not strong between the variables because the association is under minimum positive values. Thus, it signifies that as higher age nurses has higher job satisfaction, higher length of service has higher job satisfaction and permanent nurses have the higher job satisfaction than the contractual nurses.

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The correlation between the marital status and job satisfaction is negative and statistically not significant r(98)=(-).173, p=.089. Also, there is no relationship between family background and job satisfaction of nurses in rural setting r(98)=.0.047, p=.644. Thus, there is no relationship of Marital Status and family background and Job Satisfaction in Nurses. To sum up, statistically it seems that age, length of service and nature of employment have positive effect on the job satisfaction of the Nurses. Table 71: Correlation between Job satisfaction and the demographic attributes of Nurses Sl. No. Attributes Correlation coefficient P-Value 1. Age 0.225 0.026 2. Family Background 0.047 0.644 3. Marital Status -0.173 0.089 4. Length of Service 0.227 0.025 5. Nature of Employment 0.314 0.002

4.4.2.3. JOB SATISFACTION OF MID-WIVES IN RURAL AND REMOTE AREA AND RELATIONSHIP WITH OTHER DEMOGRAPHIC ATTRIBUTES The job satisfaction of the Mid-wives has been measured on a scale of 1 to 5 with their present job in rural and remote area. The scale denotes 1 (one) as the highly dissatisfied to 5 (five) as highly satisfied. The mean of overall scale of job satisfaction of Nurses is (1.98, N=123), which shows a lower scale of satisfaction. In the group comparison, the contractual nurses (1.85, N=75), permanent nurses (2.17, N=48). The analysis shows that the contractual mid-wives have the lowest scale of job satisfaction in comparison to the permanent mid-wives. Two sample T-Test (Paired) shows that it is statistical significant, the values are: t(121) = -2.809, p= .006. It signifies that there is a difference in the job satisfaction between the groups. The mean difference is -.313 between the contractual and permanent mid-wives. Table 72: Descriptive statistic of Job Satisfaction of contract and permanent mid-wives. Category N Mean Std. Deviation Std. Error Min Max Contract Permanent Total 75 1.85 48 2.17 123 1.98 .562 .663 .620
163

.065 .096 .056

1 1 1

4 4 4

Table 73: Analysis of Variance of Job Satisfaction among contractual and permanent mid-wives
Levene's Test t-test for Equality of Means Sig. (2tailed) Mean Diff. Std. Error Diff.

Sig.

df

Equal variances assumed .042 .839 -2.809 121 Equal variances not assumed -2.709 88.315

.006 .008

-.313 -.313

.112 .116

To explore the relationship of the Job satisfaction of Mid-wives in rural and remote area services with other demographic attributes like age, family background, marital status, length of service and nature of employment, the statistical analysis has been done and interpreted. The variable place of posting and sex is not considered for the aforesaid test, because the variable has fewer cases of different groups. Correlation (Pearsons) or paired sample T-Test was used to identify the attributes significantly related with job satisfaction. The p-values of 0.05 were used as the level of significance. It is statistically significant that there is a positive relationship of job satisfaction with the age r(123)=.183, p=.043 and nature of employment r(123) = .247, p = .006 However, the relationship is not strong between the variables because the association is under minimum positive values. Thus, it signifies that as higher age mid-wives has higher job satisfaction and permanent mid-wives have the higher job satisfaction than the contractual mid-wives. The correlation between the length of service r(123)=.158, p=.081, marital status r(123)=(-).101, p=.265 and family background r(123)=.0.140, p=.123 with job satisfaction is statistically not significant, thus there is no relationship between these separate variables and job satisfaction of mid-wives in rural setting. To sum up, statistically it seems that age and nature of employment have positive effect on the job satisfaction of the Mid-wives. Table 74 : Correlation between Job satisfaction and the demographic attributes of mid-wives Sl. No. Attributes Correlation coefficient P-Value 1. Age 0.183 0.043 2. Family Background 0.140 0.123 3. Marital Status -0.101 0.265 4. Length of Service 0.158 0.081 5. Nature of Employment 0.247 0.006

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4.4.3. FACTORS OF JOB SATISFACTION OF PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND REMOTE AREA
Many managers subscribe to the belief that a satisfied worker is necessarily a good worker. In other words, if management could keep all the workers happy, good performance would automatically follow. Job satisfaction in relation to workers and organisation has been a fascinating area of scientific enduring right from the day of Taylor and his pessimistic philosophy that the workers are essentially stupid and phlegmatic and satisfied only with more economic return to a more realistic and complex approach to job satisfaction. It has come a long way. The studies of Hoppock (1935) and Samantray (1997) to mention some of the studies have added new dimensions of knowledge on job satisfaction. The studies in the Indian context between 1951 to 1983 as reviewed by Sayadain (2009) reveal that the economic factors play a significant role in job satisfaction of Indian workers followed by job security, fringe benefits and relationship with boss in that order. So, it is attempted to explore the dimension of factors of job satisfaction in this study. As it is mentioned job satisfaction is a composite of several variables that contributed to the overall satisfaction from the job. These variables contribute to the job satisfaction in different manner. One aspect or the variable can contribute to the job satisfaction and other may not be. So, the analysis of factors of job satisfaction is necessities here. In this study, job satisfaction among physicians, nurses and mid-wives is found to be at lower scale of satisfaction. Specifically in overall the mid-wives has the lowest satisfaction level and the contractual physicians, nurses and mid-wives have the lowest satisfaction level than the permanent employees of the same category. Therefore, in this section of the study, it is attempted to explore the factors contributed for job satisfaction of the physicians, nurses and mid-wives. The factors of job satisfaction of the physicians, nurses and mid-wives have been measured on 18 items related to the current job in the rural area setting. The items attempted to explore the contributing factors for job satisfaction of physicians, nurses and midwives from the current job in rural and remote area setting. The Cronbachs alpha coefficient for this factor items is =0.556 on item 18 and N=334, which is higher than 0.5. The analysed results indicated in table 75 shows that the factor means at - a) Social recognition and opportunities of public services/ care to patients (1.80) and b) Better Job Prospects in future (1.80), which is the highest with mean among the factor
165

list that contributed for job satisfaction of the physicians, nurses and mid-wives. The top 10 listed factor according to the compared mean out of the 18 point factors of job satisfaction are: i) Social recognition and opportunities of public services/ care to patients, ii) Better Job Prospects in future, iii) Training and skill development Opportunities, iv) Matching of skills and tasks, v) Support, supervision, management and mentoring, vi) Job security, vii) Teamwork and Interpersonal staffs relationship viii) Salary, ix) Appropriate Work load and x) Career development opportunities. The lowest mean factors are : Financial incentives linked to rural posting (1.00), Reward system and recognition (1.00), Non-financial benefits/allowances linked to rural posting (1.08), Safety at the workplace from external environment (1.10), Work environment (1.19), Access to free accommodation (Housing) (1.20), Adequacy of equipment, drugs and supplies (1.20), Opportunities of continuing (1.26),

education/higher education (1.25), Career development opportunities Appropriate Work load (1.43)

Table 75: Descriptive Statistics of Factors contributed for job satisfaction of the physicians, nurses and mid-wives Std. Factors N Mean Dev. Better Job Prospects in future 334 1.8 0.403 Social recognition and opportunities of public services/ care 334 1.8 0.399 to patients Training and skill development Opportunities 334 1.74 0.44 Matching of skills and tasks 334 1.73 0.444 Support, supervision, management and mentoring 334 1.66 0.473 Job security 334 1.59 0.493 Teamwork and Interpersonal staffs relationship 334 1.55 0.498 Salary 334 1.52 0.5 Appropriate Work load 334 1.43 0.496 Career development opportunities 334 1.26 0.441 Opportunities of continuing education/higher education 334 1.25 0.433 Adequacy of equipment, drugs and supplies 334 1.2 0.399 Access to free accommodation (Housing) 334 1.2 0.399 Work environment 334 1.19 0.396 Safety at the workplace from external environment 334 1.1 0.295 Non-financial benefits/allowances linked to rural posting 334 1.08 0.273 A simultaneous multiple linear regression analysis was conducted to find significant predictor at current time for the job satisfaction of physicians, nurses and mid-wives altogether in rural and remote area setting. The factor variables of job satisfaction explained about 17% of the variance in job satisfaction, F(16, 317)=
166

4.95; p < .05. As in table 76 shows, the factor model included 18 factors. The following variables are constants or have missing correlations, financial incentives linked to rural posting, Reward system and recognition, thus, they were deleted for the analysis. An examination of the T-Value indicates that Salary and Training & Skill development opportunities are the main contributors to Job satisfaction in current time of physicians, nurses and mid-wives altogether in rural and remote area setting. Salary found to be significant at (b=.324, t=4.508; p= .001) and Training and skill development opportunities found to be significant at (b=.108, t=2.017; p= .004). Table 76: Result of Regression Analysis of factors contributed for job satisfaction of the physicians, nurses and mid-wives. Factors (Constant) Salary Better Job Prospects in future Job security Career development opportunities Opportunities of continuing education/higher education Training and skill development Opportunities Work environment Adequacy of equipment, drugs and supplies Non-financial benefits/allowances linked to rural posting Appropriate Work load Matching of skills and tasks Support, supervision, management and mentoring Social recognition and opportunities of public services/ care to patients Teamwork and Interpersonal staffs relationship Safety at the workplace from external environment Access to free accommodation (Housing) Adjusted R Std. Error of R R Square Square the Estimate .415 .172 .131 .783 b .324 -.033 .018 .059 -.035 .108 .053 .065 .023 -.081 .060 .014 .086 -.010 .017 .050 t .419 4.508 -.639 .278 1.054 -.595 2.017 .970 1.199 .434 -1.435 1.092 .263 1.629 -.154 .320 .919 pvalue .675 .001 .523 .781 .293 .552 .044 .333 .231 .665 .152 .276 .793 .104 .878 .749 .359

The correlation matrix at table 77, indicates a positive relationship between Overall job satisfaction with Salary, Job security, Career development opportunities, Opportunities of continuing education/higher education, Training and skill development Opportunities, Matching of skills and tasks, Social recognition and opportunities of public services/ care to patients, Teamwork and Interpersonal staffs relationship, Access to free accommodation (Housing).
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Table 77: Correlation matrix of overall job Satisfaction with factor of job satisfaction for physicians, nurses and mid-wives Correlation p-value Salary .350** .001 Better Job Prospects in future -.018 .737 ** Job security .213 .001 Career development opportunities .169** .002 * Opportunities of continuing education/higher education .133 .015 Training and skill development Opportunities .089** .005 Work environment .089 .104 Adequacy of equipment, drugs and supplies .086 .116 a Financial incentives linked to rural posting . Non-financial benefits/allowances linked to rural posting .090 .100 Appropriate Work load -.028 .605 * Matching of skills and tasks .126 .021 Support, supervision, management and mentoring -.011 .837 a Reward system and recognition . . Social recognition and opportunities of public services/ care to .129* .018 patients Teamwork and Interpersonal staffs relationship .212** .001 Safety at the workplace from external environment .043 .430 ** Access to free accommodation (Housing) .158 .004
(**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). a. Cannot be computed because at least one of the variables is constant.)

4.4.3.1. FACTORS OF JOB SATISFACTION OF PHYSICIANS IN RURAL AND REMOTE AREA When we look into separately the factors that impact on job satisfaction of physicians at table 78, the 1) Social recognition and opportunities of public services/ care to patients (1.89) is the highest mean factor and Financial incentives linked to rural posting (1.00) is the lowest mean factor. The top 10 factors area : 1) Social recognition and opportunities of public services/ care to patients (1.89), 2) Better Job Prospects in future (1.81), 3)Training and skill development Opportunities (1.77), 4) Job security (1.75), 5) Matching of skills and tasks (1.72), 6) Salary (1.69), 7) Teamwork and Interpersonal staffs relationship (1.66), 8) Support, supervision, management and mentoring (1.65), 9) Opportunities of continuing education/higher education (1.50), 10) Career development opportunities (1.39), and the lowest mean factors are Financial incentives linked to rural posting (1.00), Reward system and recognition (1.00), Non-financial benefits/allowances linked to rural posting (1.14), Safety at the workplace from external environment (1.14), Work environment (1.22), Adequacy of equipment, drugs and supplies (1.23), Access to free accommodation (Housing) (1.23), Appropriate Work load (1.24).
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Table 78: Descriptive Statistics on Factors contributed for job satisfaction of the physicians.
Sl. No. Factors N Min Max Mean Std. Dev.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Social recognition and opportunities of public services/ care to patients Better Job Prospects in future Training and skill development Opportunities Job security Matching of skills and tasks Salary Teamwork and Interpersonal staffs relationship Support, supervision, management and mentoring Opportunities of continuing education/higher education Career development opportunities Appropriate Work load Access to free accommodation (Housing) Adequacy of equipment, drugs and supplies Work environment Safety at the workplace from external environment Non-financial benefits/allowances linked to rural posting Reward system and recognition Financial incentives linked to rural posting

113 113 113 113 113 113 113 113 113 113 113 113 113 113 113 113 113 113

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1

1.89 1.81 1.77 1.75 1.72 1.69 1.66 1.65 1.50 1.39 1.24 1.23 1.23 1.22 1.14 1.14 1.00 1.00

.309 .398 .423 .434 .453 .464 .475 .478 .502 .490 .428 .423 .423 .417 .350 .350 .000 .000

A simultaneous multiple linear regression analysis was conducted to find significant predictor at current time for the job satisfaction of physicians in rural and remote area setting. The factor variables of job satisfaction explained about 22% of the variance in physicians job satisfaction, F(16, 96)= 1.726; p < .05. As in table 79, the 18 factors were included. The following variables are constants or have missing correlations, financial incentives linked to rural posting, Reward system and recognition, thus, they were deleted for the analysis. An examination of the T-Value indicates that Salary, Training & skill development Opportunities and Safety at the workplace from external environment are the main contributors to the prediction of Job satisfaction in current time of physicians in rural and remote area setting. Salary found to be significant at (b=.364, t=2.839; p=.006), Training and skill development opportunities found to be significant at (b=.186, t=1.926; p=.05) and Safety at the workplace from external environment found to be significant at (b=.232, t=2.441; p= .016)
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Table 79: Result of Regression Analysis of factors contributed for job satisfaction of the physicians. Factors b t P (Constant) -.340 .734 Salary .364 2.839 .006 Better Job Prospects in future .004 .038 .970 Job security -.032 -.319 .751 Career development opportunities .024 .237 .813 Opportunities of continuing education/higher education -.105 -.969 .335 Training and skill development Opportunities .186 1.926 .05 Work environment .143 1.383 .170 Adequacy of equipment, drugs and supplies .101 .961 .339 Non-financial benefits/allowances linked to rural posting -.065 -.700 .486 Appropriate Work load -.166 -1.647 .103 Matching of skills and tasks .001 .012 .991 Support, supervision, management and mentoring .042 .439 .662 Social recognition & opportunities of public services .069 .706 .482 Teamwork and Interpersonal staffs relationship -.006 -.053 .958 Safety at the workplace from external environment .232 2.441 .016 Access to free accommodation (Housing) .016 .158 .874 Adjusted R Std. Error of R R Square Square the Estimate .473 .223 .094 .882 The correlation matrix at table 80, indicates a positive and strong relationship between Overall job satisfaction with Salary (r=.282), Training and skill development Opportunities (r=.110) and Safety at the workplace from external environment (r= .262). Table 80: Correlation matrix of overall job Satisfaction with factor of Job satisfaction of Physicians Factors r Salary .282** Better Job Prospects in future .041 Job security .019 Career development opportunities .111 Opportunities of continuing education/higher education .091 Training and skill development Opportunities .110* Work environment .132 Adequacy of equipment, drugs and supplies .141 Non-financial benefits/allowances linked to rural posting -.041 Appropriate Work load -.030 Matching of skills and tasks .106 Support, supervision, management and mentoring .055 Social recognition and opportunities of public services/ care to patients .043 Teamwork and Interpersonal staffs relationship .125 Safety at the workplace from external environment .262** Access to free accommodation (Housing) .118
**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).

p .002 .668 .839 .242 .339 .048 .162 .136 .665 .752 .263 .565 .653 .186 .005 .212

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4.4.3.2. FACTORS OF JOB SATISFACTION OF NURSES IN RURAL AND REMOTE AREA The factors that impact on job satisfaction of nurses can be seen at table 81, such that- 1) Social recognition and opportunities of public services/ care to patients (1.89) is the highest mean factor and Financial incentives linked to rural posting (1.00) is the lowest mean factor. The top 10 factors are: Social recognition and opportunities of public

services/ care to patients (1.91), Matching of skills and tasks (1.89), Better Job Prospects in future (1.82), Training and skill development Opportunities (1.72), Appropriate Work load (1.69), Support, supervision, management and mentoring (1.65), Teamwork and Interpersonal staffs relationship (1.61), Job security (1.60) Salary (1.53) and Career development opportunities (1.24). Work environment (1.23), Access to free accommodation (Housing) (1.21), Adequacy of equipment, drugs and supplies (1.17), Opportunities of continuing education/higher education (1.06), Non-financial benefits/allowances linked to rural posting (1.05), Safety at the workplace from external environment (1.04), Reward system and recognition (1.00) and Financial incentives linked to rural posting (1.00) are the main factors which have the lowest scores and contributes to the less job satisfaction of the nurses. Table 81: Descriptive Statistics on factors contributed for job satisfaction of the Nurses. Sl. Std. Factors No. N Min Max Mean Dev. 1 Social recognition and opportunities of public 98 1 2 1.91 .290 services/ care to patients 2 Matching of skills and tasks 98 1 2 1.89 .317 3 Better Job Prospects in future 98 1 2 1.82 .389 4 Training and skill development Opportunities 98 1 2 1.72 .449 5 Appropriate Work load 98 1 2 1.69 .463 6 Support, supervision, management and mentoring 98 1 2 1.65 .478 7 Teamwork and Interpersonal staffs relationship 98 1 2 1.61 .490 8 Job security 98 1 2 1.60 .492 9 Salary 98 1 2 1.53 .502 10 Career development opportunities 98 1 2 1.24 .432 11 Work environment 98 1 2 1.23 .426 12 Access to free accommodation (Housing) 98 1 2 1.21 .412 13 Adequacy of equipment, drugs and supplies 98 1 2 1.17 .381 14 Opportunities of continuing education/higher 98 1 2 1.06 .241 education

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15 16 17 18

Non-financial benefits/allowances linked to rural posting Safety at the workplace from external environment Reward system and recognition Financial incentives linked to rural posting

98 98 98 98

1 1 1 1

2 2 1 1

1.05 1.04 1.00 1.00

.221 .199 .000 .000

A simultaneous multiple linear regression analysis was conducted to find significant predictor at current time for the job satisfaction of nurses in rural and remote area setting. The factor variables of job satisfaction explained about 21% of the variance in nurses job satisfaction, F(16, 81)= 1.403; p > .05. However, it is statistically not significant, the p value is 0.161. As table 82 shows, the factor included 18 factors. The following variables are constants or have missing correlations, financial incentives linked to rural posting, Reward system and recognition, thus, they were deleted for the analysis. An examination of the T-Value indicates that no factors contribute to the prediction of Job satisfaction in current time of nurses in rural and remote area setting. None of the value found to be statistically significant. However, the one sample T-test at table 83 shows that the following factors have the Mean more than 1.5 and statistically significant in selection of factor of satisfaction according to the responses. Social recognition and opportunities of public services/ care to patients [t(97) = 13.920 p= .001], Matching of skills and tasks [t(97) = 12.098 p= .001], Better Job Prospects in future [t(97) = 8.046 p= .001], Training and skill development Opportunities t(97) = 4.949 p= .001,

Appropriate Work load [t(97) = 4.143 p= .001], Support, supervision, management and mentoring [t(97) = 3.167 p=.002], Teamwork and Interpersonal staffs relationship [t(97) = 2.269 p= .025] and Job security [t(97) = 2.053 p= .043]

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Table 82: Regression Analysis of factors contributed for job satisfaction of the nurses. Factors b t Sig. (Constant) 1.378 .172 Salary .209 1.354 .179 Better Job Prospects in future -.130 -1.228 .223 Job security -.004 -.031 .975 Career development opportunities -.024 -.203 .840 Opportunities of continuing education/higher education -.066 -.645 .521 Training and skill development Opportunities -.008 -.075 .941 Work environment -.031 -.281 .780 Adequacy of equipment, drugs and supplies .087 .780 .438 Non-financial benefits/allowances linked to rural posting .162 1.489 .140 Appropriate Work load -.097 -.862 .391 Matching of skills and tasks .045 .423 .674 Support, supervision, management and mentoring .051 .474 .637 Social recognition and opportunities of public services/ care -.016 -.148 .883 to patients Teamwork and Interpersonal staffs relationship .085 .635 .527 Safety at the workplace from external environment -.155 -1.445 .152 Access to free accommodation (Housing) .101 .879 .382 Adjusted R Std. Error of R R Square Square the Estimate .466 .217 .062 .841 Table 83: T-test results of factors contributed for job satisfaction of the nurses. Factors Test Value = 1.5 t df Sig. Mean (2Diff.
tailed)

Salary Better Job Prospects in future Job security Career development opportunities Opportunities of continuing/higher education Training & skill development Opportunities Work environment Adequacy of equipment, drugs and supplies Non-financial benefits/allowances linked to rural posting Appropriate Work load Matching of skills and tasks Support, supervision, management and mentoring Social recognition and opportunities of public services/ care to patients Teamwork and Interpersonal staffs relationship Safety at the workplace from external environment Access to free accommodation (Housing)

0.604 8.046 2.053 -5.843 -18.025 4.949 -6.165 -8.493 -20.096 4.143 12.098 3.167 13.92 2.269 -22.856 -6.858

97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97

0.547 0.001 0.043 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.002 0.001 0.025 0.001 0.001

0.031 0.316 0.102 -0.255 -0.439 0.224 -0.265 -0.327 -0.449 0.194 0.388 0.153 0.408 0.112 -0.459 -0.286

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The correlation matrix at table 84, indicates a positive and strong relationship between overall job satisfaction with Salary (r= .321), Teamwork and Interpersonal staffs relationship (r=.267) and Access to free accommodation (Housing) (r= .240), while the weakest relationship was found between Training and skill development Opportunities (r=.012). Table 84: Correlation matrix of overall job Satisfaction with factor of Job satisfaction of Nurses Correlation Factors with job satisfaction Salary .321** Better Job Prospects in future -.131 Job security .177 Career development opportunities .148 Opportunities of continuing education/higher education -.044 Training and skill development Opportunities .012** Work environment .036 Adequacy of equipment, drugs and supplies .082 Financial incentives linked to rural posting .a Non-financial benefits/allowances linked to rural posting .183 Appropriate Work load -.064 Matching of skills and tasks .018 Support, supervision, management and mentoring .044 Reward system and recognition .a Social recognition and opportunities of public services/ care to .047 patients Teamwork and Interpersonal staffs relationship .267** Safety at the workplace from external environment .255* Access to free accommodation (Housing) .240*

.001 .197 .081 .144 .665 .006 .728 .423 . .071 .529 .861 .670 . .645 .008 .011 .017

**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).

4.4.3.3. FACTORS OF JOB SATISFACTION OF MID-WIVES IN RURAL AND REMOTE AREA The factors that have impact on job satisfaction of mid-wives have the highest mean of the factors like- Training and skill development Opportunities (1.72), Support, supervision and management mentoring (1.68) and Better Job Prospects in future (1.64) which may be seen at table 85. The top 10 factors are: Training and skill development Opportunities (1.72), Support, supervision and management mentoring (1.68), Better Job Prospects in future (1.64), Social recognition and opportunities of public services/ care to patients (1.63), Matching of skills and tasks (1.62), Job security (1.42), Appropriate Work

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load (1.40), Teamwork and Interpersonal staffs relationship (1.40), Salary (1.37) and Adequacy of equipment drugs and supplies (1.19). Career development opportunities (1.16), Opportunities of continuing education/higher education (1.16), Access to free accommodation (Housing) (1.15), Work environment (1.14), Safety at the workplace from external environment

(1.10), Non-financial benefits/allowances linked to rural posting (1.05), Reward system and recognition (1.00), and Financial incentives linked to rural posting (1.00) have the lowest scores. Table 85: Descriptive Statistics on factors contributed for job satisfaction of the Mid-wives. Std. Factors N Min Max Mean Dev. Training and skill development Opportunities 123 1 2 1.72 .449 Support, supervision and management mentoring 123 1 2 1.68 .467 Better Job Prospects in future 123 1 2 1.64 .483 Social recognition and opportunities of public 123 1 2 1.63 .484 services/ care to patients Matching of skills and tasks 123 1 2 1.62 .488 Job security 123 1 2 1.42 .496 Appropriate Work load 123 1 2 1.40 .492 Teamwork and Interpersonal staffs relationship 123 1 2 1.40 .492 Salary 123 1 2 1.37 .484 Adequacy of equipment, drugs and supplies 123 1 2 1.19 .391 Career development opportunities 123 1 2 1.16 .371 Opportunities of continuing education/higher education123 1 2 1.16 .371 Access to free accommodation (Housing) 123 1 2 1.15 .363 Work environment 123 1 2 1.14 .347 Safety at the workplace from external environment 123 1 2 1.10 .298 Non-financial benefits linked to rural posting 123 1 2 1.05 .216 Reward system and recognition 123 1 1 1.00 .000 Financial incentives linked to rural posting 123 1 1 1.00 .000 A simultaneous multiple linear regression analysis was conducted to find significant predictor at current time for the job satisfaction of nurses in rural and remote area setting. The factor variables of job satisfaction explained about 24% of the variance in mid-wives job satisfaction, F(16, 106)= 2.1; p < .05. It is statistically significant, the p value is 0.013. As in table 86 shows, this included 18 factors. The following variables are constants or have missing correlations, financial incentives linked to rural posting, Reward system and recognition, thus, they were deleted for the analysis. An examination of the T-Value indicates that Salary and Training & skill development Opportunities and Safety at the workplace from external
175

environment are the main contributors to the prediction of Job satisfaction in current time of mid-wives in rural and remote area setting. Salary found to be significant at (b=.245, t=2.040; p= .044) and Training and skill development opportunities found to be significant at (b=.230, t=2.508; p= .014). Table 86: Regression Analysis of factors contributed for job satisfaction mid-wives. Factors b t (Constant) 2.464 Salary .245 2.040 Better Job Prospects in future -.055 -.620 Job security .241 1.973 Career development opportunities .019 .204 Opportunities of continuing education/higher education -.066 -.643 Training and skill development Opportunities .230 2.508 Work environment .113 1.187 Adequacy of equipment, drugs and supplies -.049 -.551 Non-financial benefits/allowances linked to rural posting .083 .884 Appropriate Work load .013 .127 Matching of skills and tasks .033 .312 Support, supervision, management and mentoring -.172 -1.766 Social recognition and opportunities of public services/ care .097 1.110 to patients Teamwork and Interpersonal staffs relationship -.160 -1.395 Safety at the workplace from external environment -.182 -1.910 Access to free accommodation (Housing) -.096 -1.017 Adjusted R Std. Error of R R Square Square the Estimate a .491 .241 .126 .580 of the Sig. .015 .044 .537 .051 .838 .522 .014 .238 .583 .379 .899 .755 .080 .269 .166 .059 .311

The correlation matrix at table 87, indicates a positive and strong relationship between overall job satisfaction with Salary (r=.303), Job security (r=.274) and while the weakest relationship was found between Access to free accommodation (Housing) (r= .053) and current job satisfaction. Table 87: Correlation matrix of overall job Satisfaction with factor of job satisfaction of Mid-wives Factors r Salary .303** Better Job Prospects in future -.021 Job security .274** Career development opportunities .089 Opportunities of continuing education/higher education .089 Training and skill development Opportunities .152 Work environment .092 Adequacy of equipment, drugs and supplies -.015 Financial incentives linked to rural posting .a
176

p .001 .814 .002 .329 .329 .093 .311 .871 .

Non-financial benefits/allowances linked to rural posting Appropriate Work load Matching of skills and tasks Support, supervision, management and mentoring Reward system and recognition Social recognition & opportunities of public services/ care to patients Teamwork and Interpersonal staffs relationship Safety at the workplace from external environment Access to free accommodation (Housing)

.131 .086 .159 -.140 .a .134 .086 -.120 .053*

.148 .345 .080 .122 . .140 .345 .186 .048

**. Correlation is significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. *. Correlation is significant at the 0.05 level (2-tailed).

4.4.3.4. FACTORS OF JOB SATISFACTION OF CONTRACTUAL AND PERMANENT PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND REMOTE AREA The past one decade has seen a growing tendency of contractual employment in the public health sector in the country and as well in the state, toward a fundamental restructuring for addressing the inadequacy issue. This section of the chapter explores the factors of job satisfaction of contractual and permanent physicians, nurses and mid-wives. A comparison of contractual and permanent job satisfaction factors significantly shows a difference in between the two groups of employees. As it is explored above that the contractual and permanent physicians, nurses and mid-wives have different level of job satisfaction, in which contractual have less job satisfaction level than that of the permanent physicians, nurses and midwives. In the group comparison as per the Nature of Employment, the means of contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. TTest shows that it is statistical significant, the values are: t(332) = -5.835, p =.001. There is a difference in the job satisfaction between the groups. The mean difference is -.513 between the contractual and permanent employees. While exploring to the factors of job satisfaction in between the contractual and permanent physicians, nurses and mid-wives, it is found as per table 88 and 89, with Salary (1.92), Job security (1.88), Social recognition and opportunities of public services/ care to patients (1.86), Teamwork and Interpersonal staffs relationship (1.84) and Better Job Prospects in future (1.80) are the five most influential factors for job satisfaction of permanent physicians, nurses and mid-wives. Whereas the factors like Training and skill development Opportunities (1.80), Better Job Prospects in future (1.79), Social recognition and opportunities of public services/ care to patients (1.73), Matching of skills and tasks (1.69), and Support, supervision, management mentoring (1.66) are for the contractual.
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Table 88 : Descriptive Statistics for factors for job satisfaction of permanent Physicians, nurses and mid-wives Std. Factors N Min Max Mean Dev. Salary 180 1 2 1.92 .277 Job security 180 1 2 1.88 .322 Social recognition and opportunities of public services/ 180 1 2 1.86 .347 care to patients Teamwork and Interpersonal staffs relationship 180 1 2 1.84 .369 Better Job Prospects in future 180 1 2 1.80 .401 Matching of skills and tasks 180 1 2 1.79 .409 Training and skill development Opportunities 180 1 2 1.69 .464 Support, supervision, management and mentoring 180 1 2 1.64 .480 Appropriate Work load 180 1 2 1.44 .498 Opportunities of continuing education/higher education 180 1 2 1.42 .495 Career development opportunities 180 1 2 1.39 .490 Access to free accommodation (Housing) 180 1 2 1.31 .462 Adequacy of equipment, drugs and supplies 180 1 2 1.22 .413 Work environment 180 1 2 1.21 .409 Non-financial benefits/allowances linked to rural posting 180 1 2 1.12 .322 Safety at the workplace from external environment 180 1 2 1.11 .308 Reward system and recognition 180 1 1 1.00 .000 Financial incentives linked to rural posting 180 1 1 1.00 .000 Table 89: Descriptive Statistics for factors for job satisfaction of contracts Physicians, nurses and mid-wives Factors Training and skill development Opportunities Better Job Prospects in future Social recognition and opportunities of public services/ care to patients Matching of skills and tasks Support, supervision, management and mentoring Appropriate Work load Job security Teamwork and Interpersonal staffs relationship Adequacy of equipment, drugs and supplies Work environment Career development opportunities Safety at the workplace from external environment Access to free accommodation (Housing) Salary Opportunities of continuing /higher education Non-financial allowances linked to rural posting Reward system and recognition Financial incentives linked to rural posting Std. N Min Max Mean Dev. 154 1 2 1.80 .402 154 1 2 1.79 .407 154 1 2 1.73 .443 154 154 154 154 154 154 154 154 154 154 154 154 154 154 154 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1.69 1.66 1.42 1.24 1.21 1.18 1.18 1.11 1.08 1.07 1.06 1.05 1.04 1.00 1.00 .465 .474 .496 .429 .412 .381 .381 .314 .279 .258 .247 .209 .194 .000 .000

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While exploring to the variance of factors of job satisfaction in between the contractual and permanent physicians, nurses and mid-wives, it is observed in table 90, that the following have statistically significant difference between the two groups of employees: Salary t(332) = -29.416, p= .001, Job security t(332) = -15.627, p= .001, Career development opportunities t(332) = -6.185, p= .001, Opportunities of continuing education/higher education t(332) = -8.793, p= .001, Training and skill development Opportunities t(332) = 2.290, p= .023, Non-financial

benefits/allowances linked to rural posting t(332) = -2.616, p= .009, Matching of skills and tasks t(332) = -2.617, p= .009, Social recognition and opportunities of public services/ care to patients t(332) = -2.942, p= .003, Teamwork and Interpersonal staffs relationship t(332) = -14.625, p= .001 and Access to free accommodation (Housing) t(332) = -5.586, p= .001. However, it is found that there is no significant difference of the following factors between the two groups: Better Job Prospects in future, t(332)= -.176 p= .861, Work environment t(332)= -.822 p= .412, Adequacy of equipment, drugs and supplies t(332)= -.944 p= .346, Appropriate Work load t(332)= -.308 p=.758, Support, supervision, management and mentoring t(332)=.845 p= .399,and Safety at the workplace from external environment t(332)= -.653 p= .514. Table 90: Analysis of variance in factors of Job satisfaction of Contractual and Permanent Physicians, nurses and mid-wives in rural and remote area t-test for Equality of Means Sig. Std. Factors (2Mean Error t df tailed) Diff. Diff. Salary -29.416 332 .001 -.852 .029 Better Job Prospects in future -.176 332 .861 -.008 .044 Job security -15.627 332 .001 -.643 .041 Career development opportunities -6.185 332 .001 -.284 .046 Opportunities of continuing -8.793 332 .001 -.377 .043 education/higher education Training and skill development 2.290 332 .023 .110 .048 Opportunities Work environment -.822 332 .412 -.036 .044 Adequacy of equipment, drugs and supplies -.944 332 .346 -.041 .044 Non-financial benefits/allowances linked to -2.616 332 .009 -.078 .030 rural posting Appropriate Work load -.308 332 .758 -.017 .055 Matching of skills and tasks -2.617 332 .009 -.127 .048 Support, supervision, management and .845 332 .399 .044 .052 mentoring
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Social recognition and opportunities of public services/ care to patients Teamwork and Interpersonal staffs relationship Safety at the workplace from external environment Access to free accommodation (Housing)

-2.942 -14.625 -.653 -5.586

332 332 332 332

.003 .001 .514 .001

-.127 -.625 -.021 -.234

.043 .043 .032 .042

4.4.4. LIKELIHOOD OF MIGRATION OF PHYSICIANS, NURSES AND MID-WIVES- CHOICE TO MIGRATE

Employees are the most valuable assets of organizations. Organisations need to retain them, as it would benefit them in many ways. Employees who serve the longest are best bets to win prizes for being the most productive and most reliable. Long service employees are often the ones that carry the company and account for a disproportionate share of its success. No doubt, turnover arising because of superannuation and fusion of fresh blood in organizations is unavoidable and welcomed. But constant change and flux in the labour force is wasteful. (Raju, 2003). Therefore the intention of the physicians, nurses and the mid-wives to leave the current job place or the job was explored with keeping the pay (salary) component at constant. The dimension of migration was preset - to continue for atleast 3-5 years in the present rural area posting or to shift to another rural health institute or to shift to another urban health institute or to shift to another job in some other State/sector. As per the position of the employees, the descriptive analysis in table 91, shows that 41.6% of Physicians willing to shift to urban area, 24.8% physicians willing to shift to other rural area health institute and only 26.5% wants to retain in the present health institution in rural area, while 7.1% Physicians wants to leave the public health service of the state. While, 50% of nurses willing to shift to urban area, 19.4% nurses willing to shift to other rural area health institute and only 25.5% wants to retain in the present health institution in rural area and 5.1% nurses wants to leave the public health service of the state. Similarly, 59.3% of mid-wives willing to shift to urban area, 27.6% mid-wives willing to shift to other rural area health institute and only 6.5% wants to retain in the present health institution in rural area and 6.5% nurses wants to leave the public health service of the state. Thus, we can interpret that more mid-wives are willing to shift to urban areas followed by nurses and physicians. Figure 40 and 43 represent the situation graphically.

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Management represenatatives have the concensus that there is lack of supply of equipments, drugs and other supplies at the health institutes and the working conditions are not conducive in the absence of adequate funding at all level. With minimun resource the planning is very difficult and almost as doing nothing with plan and the execution. For planning we need brain, discussion and laptop with a printer, but for execution of plan we need money the fund, which is not adequate; funding is needed for equipments, drugs and other supplies and infrastructure development at the rural and remote areas in the districts. Contributing factors are more, nothing is in its place, all mashed up. The workforce are not getting conducive environment to work on, and overall personal factors are also there which affects the turnover from the rural areas.-A management representative from the district. the enviorment is good in urban areas, wiith schools, good market and career development oppurtunites are there, on need the growth in the professional life, not just dumping itself in the rural areas, this reason could be the out flux of the physicians, nurses and mid-wives.-A management representative from the district. Table 91: Percentage showing the intention of migration of the physicians, nurses and mid wives Position of Respondent Total Migrating Destination Physician Nurse Mid-Wife N N% N N% N N% N N% To continue at least 3-5 years more in 30 26.5% 25 25.5% 8 6.5% 63 19% the present rural area posting To shift to another rural health institute 28 24.8% 19 19.4% 34 27.6% 81 24% To shift to another urban health 47 41.6% 49 50.0% 73 59.3% 169 51% institute To shift to another job in some other 8 7.1% 5 5.1% 8 6.5% 21 6% State/sector

Figure 40: Percentage of migrating intention of the physicians, nurses and mid wives
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Figure 41: Percentage of migrating intention of the physicians

Figure 42: Percentage of migrating intention of the nurses

Figure 43: Percentage of migrating intention of the mid-wives

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Table 92: Percentage showing the intention of migration of the contract and permanent workforce (physicians, nurses and mid wives) Migrating Destination Nature of Employment Contract Permanent N N% N N% To continue at least 3-5 years more in the present rural 16 10.4% 47 26.1% To shift to another rural health institute 38 24.7% 43 23.9% To shift to another urban health institute 79 51.3% 90 50.0% To shift to another job in some other State/sector 21 13.6% 0 .0% Similarly in table 92, 51.3% of contract physicians, nurses and mid-wives are willing to migrate to another urban health institution, whereas, only 50% of the permanent physicians, nurses and mid-wives have the intention to leave for urban area. More of the permanent employees are willing to continue the rural service in the same posting place rather than the contract counterpart. While none of the permanent employee are willing to shift to another job than that of 13.6% of contracts. Figure 44 and 45 represent the situation graphically.

Figure 44: Percentage of migrating intention of the contract workforce (Physicians, nurses and mid-wives)

Figure 45: Percentage of migrating intention of the Permanent workforce (Physicians, nurses and mid-wives)
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It is the job satisfaction of the employees which propel them to migrate. While analysed, it is known that the job satisfaction has impact on the migration decision of the employees. Job satisfaction and decision to stay: With Logistic regression analysis it is tried to explore the impact of job satisfaction as a predictor for stay at present posting rural area. The variable job satisfaction significant at p<.001, has an impact and predictive power for the decision of employees to stay at the present rural place of posting. By measuring job satisfaction we can predict with 97.6% accuracy of the decision of employees to stay at the present rural place of posting. A test of the full model against a constant was statistically significant, indicating that a set reliably distinguished between, in our case model chi square has 1 degrees of freedom, a value of 254.046 and a probability of p<0.001. Thus, the indication is that the predictors do have a significant effect. Here it is indicating that 53.3% of the variation in the decision to stay is explained by the logistic model. Nagelkerke R Square is .859, so, it is indicating a moderately strong relationship of 85.9% between the job satisfaction and the choice to stay. While, The Wald criterion demonstrated it has 1 degrees of freedom, a value of 56.505 and a probability of p<0.001 and signifies that job satisfaction contributed significantly to the prediction of decision of stay at the present job in rural and remote area of posting. EXP(B) value associated with Job satisfaction is 79.527. Hence when job satisfaction is raised by one scale the odds ratio is 79 times as large and therefore employees are 79 more times likely to stay. Job satisfaction and shift to another rural area: With Logistic regression analysis it is tried to explore the impact of job satisfaction as a predictor for employee shifting to another rural area from presently posted rural area. As the variable is not statistically significant, the p>.05, and if included would not have the predictive power and not able to contribute to the prediction. Hence, it is statistically proved that there is no significant relationship of job satisfaction and shifting of employee from one rural area to another rural area. Job satisfaction and shift to urban area: With Logistic regression analysis it is tried to explore the impact of job satisfaction as a predictor for employee shifting to urban area from presently posted rural area. The variable job satisfaction significant at p<.001, has an impact and predictive power for the decision of employees to urban
184

migration. By measuring job satisfaction we can predict with 71% accuracy of the decision of employees to migrate to urban area. A test of the full model against a constant was statistically significant, in our case model chi square has 1 degrees of freedom, a value of 75.551 and a probability of p<0.001. Thus, the indication is that the predictors do have a significant effect. Here it is indicating that 20.2% of the variation in the decision to migrate to urban area is explained by the logistic model. Nagelkerke R Square is .270, so, it is indicating a low relationship of 27% between the job satisfactions and migrates to urban area. While, The Wald criterion demonstrated it has 1 degrees of freedom, a value of 41.434 and a probability of p<0.001 and signifies that job satisfaction contributed significantly to the prediction of decision. EXP(B) value associated with Job satisfaction is .221. Hence when the figure is less that 1, any increase in the job satisfaction will leads to a drop in outcome occurring that migration to urban area. Job satisfaction and shift to other sector or state: With Logistic regression analysis it is tried to explore the impact of job satisfaction as a predictor for employee shifting out of the sector or the state. The variable job satisfaction significant at p<.001, has an impact and predictive power for the decision of employees to out sector or state migration. By measuring job satisfaction we can predict with 93.1% accuracy of the decision of employees to this migration. A test of the full model against a constant was statistically significant, in our case model chi square has 1 degrees of freedom, a value of 50.076 and a probability of p<0.001. Thus, the indication is that the predictors do have a significant effect. Here it is indicating that 13.9% of the variation in the decision to migrate to other sector or state is explained by the logistic model. Nagelkerke R Square is .172, so, it is indicating a low relationship of 17% between the job satisfactions and migrates to other sector or state. While, The Wald criterion demonstrated it has 1 degrees of freedom, a value of 38.758 and a probability of p<0.001 and signifies that job satisfaction contributed significantly to the prediction of decision. EXP(B) value associated with Job satisfaction is .039. Hence when job satisfaction is raised by one scale, employees are more times stopped migrating to other sector or state. However, migrating to other state or sector has low relationship of 17% only. Thus, the level of job satisfaction has a relationship and act as a predictor for pushing the physicians, nurses and mid-wives from rural areas to urban and to other
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sector. Whereas, it is not statically found that there is any association of job satisfaction and rural to rural migration. However, the other pushing factors also act as contributor for retention and migration of the workplace that too have an effect on job satisfaction. So, coming section explores the factor for retention and migration of this workforce. 4.4.4.1. CONTRIBUTING FACTOR OF LIKELIHOOD OF RETENTION OF PHYSICIANS, NURSES AND MID-WIVES- CHOICE TO STAY In this section, it is attempted to explore the factors that contributed for the decision of this workforce to stay back in same health institution at the rural area. The eighteen (18) preset factors were included for the same. The Cronbachs alpha coefficient for the factor items is =(0.559) on item 18 and N=63. Factor of likelihood of retention of Physicians, nurses and mid-wives: The factor that contributed to stay at the place of posting for more 3-5 years for both contract and permanent physicians, nurses and mid-wives for rural and remote services has the following top 10 selections: 1) Scope for training and skill development (1.71), 2) Career development opportunities (1.56), 3) Job Security (1.40),4) Improved working condition (1.33), 5) Satisfied with salary (1.32), 6) Scope for continuing education/higher education (1.29), 7) Anticipation of obtaining a regular position after contractual position (1.25), 8) More autonomy in current place of posting (1.24), 9) Adequate drugs/equipment at the rural health centre (1.22) and 10) Improved support, supervision and mentoring (1.17). Out of which, only one factor that is the Scope for training and skill development is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(62)= 3.735, p=.001. However, the selection is made only by 19% of the employee who wants to stay at the present posting place. Table 93: Descriptive Statistics of contributing factor of likelihood of retention of physicians, nurses and mid-wives Test Value = 1.5 Sig. Factors (2N Mean tailed Mean t df ) Diff. Scope for training and skill development 63 1.71 3.735 62 .001 .214 Career development opportunities 63 1.56 .880 62 .382 .056 Job Security 63 1.35 -2.491 62 .015 -.151 Improved working condition 63 1.33 -2.784 62 .007 -.167
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Satisfied with salary Scope for continuing /higher education Anticipation of obtaining a regular position after contractual position More autonomy in current place of posting Adequate drugs/equipment at the rural health centre Improved support, supervision and mentoring Adequate living conditions Good schools for children/ education prospects of children Strong Teamwork and interpersonal relationship Flexible working hours with minimal workload Geographical affinities(Hometown near)and familial associations Opportunity for both spouses to work and live in the same location Getting adequate financial incentives/ Rural allowances/performance incentives

63 1.32 -3.088 63 1.29 -3.735 63 1.25 -4.451 63 1.24 -4.842 63 1.22 -5.261 63 1.17 -6.749 63 1.13 -8.821 63 1.13 -8.821

62 62 62 62 62 62 62 62

.003 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001 .001

-.183 -.214 -.246 -.262 -.278 -.325 -.373 -.373 -.421 -.437 -.437 -.452 -.484

63 1.08 -12.253 62 63 1.06 -14.095 62 63 1.06 -14.095 62 63 1.05 -16.726 62 63 1.02 -30.500 62

Physicians: While, analysing the factors to stay at the place of posting for more 3-5 years by the categories of employee i.e., Physicians, nurses and mid-wives. The following 10 top factors for retention have been found for Physicians: 1)Scope for training and skill development (1.83), 2) Career development opportunities (1.60), 3)Satisfied with salary (1.53), 4) Scope for continuing education/higher education (1.43), 5) Improved working condition (1.40), 6) Job Security (1.40), 7) More autonomy in current place of posting (1.40), 8) Adequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.27), 9) Opportunity for both spouses to work and live in the same location (1.20), and 10)

Anticipation of obtaining a regular position after contractual position (1.17). Out of which, only one factor that is the Scope for training and skill development is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(29)= 4.817, p=.001.

187

Table 94: Descriptive statistics for contributing factor of likelihood of retention of physicians Test Value = 1.5 Sig. Factors (2Mea Mea Std. tailed n N n Dev. t df ) Diff. Scope for training and skill 30 1.83 .379 4.817 29 .001 .333 development Career development opportunities 30 1.60 .498 1.099 29 .281 .100 Satisfied with salary 30 1.53 .507 .360 29 .722 .033 Scope for continuing 30 1.43 .504 -.724 29 .475 -.067 education/higher education Improved working condition 30 1.40 .498 -1.099 29 .281 -.100 Job Security 30 1.40 .498 -1.099 29 .281 -.100 More autonomy in current place 30 1.40 .498 -1.099 29 .281 -.100 of posting Adequate drugs/equipment at the 30 1.27 .450 -2.841 29 .008 -.233 rural health centre Adequate living conditions 30 1.20 .407 -4.039 29 .001 -.300 Anticipation of obtaining a .001 -.333 30 1.17 .379 -4.817 29 regular position after contractual position Improved support, supervision 30 1.13 .346 -5.809 29 .001 -.367 and mentoring Good schools for children/ 30 1.13 .346 -5.809 29 .001 -.367 education prospects of children Geographical 30 1.10 .305 -7.180 29 .001 -.400 affinities(Hometown near)and familial associations Opportunity for both spouses to 30 1.10 .305 -7.180 29 .001 -.400 work and live in the same location Flexible working hours with 30 1.07 .254 -9.355 29 .001 -.433 minimal workload Strong Teamwork and 30 1.07 .254 -9.355 29 .001 -.433 interpersonal relationship Getting adequate financial 30 1.00 .000 incentives/ Rural allowances/performance incentives Achievement is recognized and 30 1.00 .000 rewarded Permanent physicians: While, the permanent physicians have the following top 10 factors for retention: 1) Scope for training and skill development (1.80), 2) Satisfied with salary (1.64), 3) Career development opportunities (1.52), 4) Improved working condition (1.48), 5) More autonomy in current place of posting (1.44), 6) Scope for
188

continuing education/higher education (1.32), 7) Job Security (1.32), 8) Adequate drugs/equipment at the rural health centre (1.32), 9) Adequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.24). Out of which, only one factor that is the Scope for training and skill development is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(24)= 3.674, p=.001. Table 95: Descriptive statistics for contributing factor of likelihood of retention of permanent physicians Test Value = 1.5 Sig. Mea Factors Std. (2n N Mean Dev. t df tailed) Diff. Scope for training & skill development 25 1.80 .408 3.674 24 .001 .300 Satisfied with salary 25 1.64 .490 1.429 24 .166 .140 Career development opportunities 25 1.52 .510 .196 24 .846 .020 Improved working condition 25 1.48 .510 -.196 24 .846 -.020 More autonomy in current place of .559 -.060 25 1.44 .507 -.592 24 posting Adequate drugs/equipment at the 25 1.32 .476 -1.890 24 .071 -.180 rural health centre Scope for continuing /higher education 25 1.32 .476 -1.890 24 .071 -.180 Job Security 25 1.32 .476 -1.890 24 .071 -.180 Adequate living conditions 25 1.24 .436 -2.982 24 .006 -.260 Geographical affinities(Hometown 25 1.12 .332 -5.729 24 .001 -.380 near)and familial associations Good schools for children/ education 25 1.12 .332 -5.729 24 .001 -.380 prospects of children Opportunity for both spouses to work 25 1.12 .332 -5.729 24 .001 -.380 and live in the same location Flexible working hours with minimal 25 1.08 .277 -7.584 24 .001 -.420 workload Improved support, supervision and 25 1.08 .277 -7.584 24 .001 -.420 mentoring Strong Teamwork and interpersonal 25 1.08 .277 -7.584 24 .001 -.420 relationship Getting adequate financial / Rural 25 1.00 .000 allowances/performance incentives Anticipation of obtaining a regular 25 1.00 .000 position after contractual position Achievement is recognized &rewarded 25 1.00 .000 Contract physicians: Likewise, the contract physicians have the following 8 factors found to relevant for retention: 1) Scope for training and skill development (2.00), 2) Anticipation of obtaining a regular position after contractual position (1.95), 3) Scope
189

for

continuing

education/higher

education (1.86),

4)

Career

development

opportunities (1.81), 5) Improved support, supervision and mentoring (1.80), 6) More autonomy in current place of posting (1.40), 7) Job Security (1.20), and 8) Good schools for children/ education prospects of children (1.20). Out of which, only two factors that is the Scope for training and skill development and Anticipation of obtaining permanent post is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(4)= 4.568, p=.001 and t(4)= 2.500, p= .001. Table 96: Descriptive statistics for contributing factor of likelihood of retention of contract physicians Test Value = 1.5 Sig. Factors (2Mea Std. tailed Mean N n Dev. t df ) Diff. Scope for training and skill development 5 2.00 .000 4.568 4 .001 .500 Anticipation of obtaining a regular 5 1.95 .218 2.500 4 .001 .452 position after contractual position Scope for continuing /higher education 5 1.86 .359 1.564 4 .100 .357 Career development opportunities 5 1.81 .402 1.525 4 .102 .310 Job Security 5 1.80 .447 1.500 4 .208 .300 Improved support, supervision and 5 1.40 .548 -.408 4 .704 -.100 mentoring Good schools for children/ education 5 1.20 .447 -1.500 4 .208 -.300 prospects of children More autonomy in current place of posting 5 1.20 .447 -1.500 4 .208 -.300 Satisfied with salary 5 1.00 .000 - Getting adequate financial/ Rural 5 1.00 .000 - allowances/performance incentives Improved working condition 5 1.00 .000 - Adequate drugs/equipment at the rural 5 1.00 .000 - health centre Flexible working hours with minimal 5 1.00 .000 - workload Strong Teamwork and interpersonal 5 1.00 .000 - relationship Adequate living conditions 5 1.00 .000 - Achievement is recognized &rewarded 5 1.00 .000 - Geographical affinities(Hometown 5 1.00 .000 - near)and familial associations Opportunity for both spouses to work 5 1.00 .000 - and live in the same location Nurses: While, analysing the factors to stay at the place of posting for more 3-5 years of the nurses. The following 10 top factors for retention have been found: 1) Scope
190

for training and skill development (1.64), 2) Career development opportunities (1.48), 3) Anticipation of obtaining a regular position after contractual position (1.32), 4) Job Security (1.32), 5) Improved working condition (1.28), 6) Improved support, supervision and mentoring (1.20), 7) Adequate drugs/equipment at the rural health centre (1.16), 8) Strong Teamwork and interpersonal relationship (1.12), Satisfied with salary (1.12) and 9) Good schools for children/ education prospects of children (1.12). Out of which, only one factor that is the Scope for training and skill development and Anticipation of obtaining permanent post is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(24)= 1.429, p=.006. Table 97: Descriptive statistics for contributing factor of likelihood of retention of nurses Factors
Std. N Mean Dev. Test Value = 1.5 Sig. Mean t df (2-tailed) Diff.

Scope for training and skill development 25 Career development opportunities 25 Job Security 25 Anticipation of obtaining a regular 25 position after contractual position Improved working condition 25 Improved support,supervision &mentoring 25 Adequate drugs/equipment at the rural 25 health centre Satisfied with salary 25 Strong Teamwork and interpersonal 25 relationship Good schools for children/ education 25 prospects of children Scope for continuing education/higher 25 education Flexible working hours with minimal 25 workload Adequate living conditions 25 Geographical affinities(Hometown 25 near)and familial associations Getting adequate financial incentives/ 25 Rural allowances/performance incentives Achievement is recognized & rewarded 25 Opportunity for both spouses to work 25 and live in the same location More autonomy in current place of 25 posting

1.64 1.48 1.32 1.32 1.28 1.20 1.16 1.12 1.12 1.12 1.08 1.08 1.08 1.04 1.00 1.00 1.00 1.00

.490 .510 .476 .476

1.429 -.196 -1.890 -1.890

24 24 24 24

.006 .140 .846 -.020 .071 -.180 .071 -.180 .024 -.220 .001 -.300 .001 -.340 .001 -.380 .001 -.380 .001 -.380 .001 -.420 .001 -.420 .001 -.420 .001 -.460 -

.458 -2.400 24 .408 -3.674 24 .374 -4.543 24 .332 -5.729 24 .332 -5.729 24 .332 -5.729 24 .277 -7.584 24 .277 -7.584 24 .277 -7.584 24 .200 -11.50 24 .000 .000 .000 .000 -

191

Permanent Nurses: While, analysing the factors to stay at the present place of posting, the following 10 top factors for retention have been found in case of permanent nurses: 1) Scope for training and skill development (1.53), 2) Career development opportunities (1.29), 3) Improved working condition (1.24),

4) Adequate drugs/equipment at the rural health centre (1.18), 5) Satisfied with salary (1.18), 6) Adequate living conditions (access to amenities like housing, water,

electricity, conveyance and communication) (1.12), 7) Strong Teamwork and interpersonal relationship (1.12), 8) Job Security (1.12), 9) Geographical affinities(Hometown near)and familial associations (1.06) and 10) Scope for continuing education/higher education (1.06). Out of which, only one factor that is the Scope for training and skill development is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(16)=1 .236, p= .017. Table 98: Descriptive statistics contributing factor of likelihood of retention of permanent nurses- Choice to stay in present rural area
Test Value = 1.5

Factors

Me N an

Std. Dev.

Sig. Mean df (2-tailed) Diff.

Scope for training & skill development 17 Career development opportunities 17 Improved working condition 17 Satisfied with salary 17 Adequate drugs/equipment at the rural 17 health centre Job Security 17 Strong Teamwork and interpersonal 17 relationship Adequate living conditions 17 Scope for continuing /higher education 17 Flexible working hours with minimal 17 workload Improved support,supervision &mentoring7 1 Geographical affinities(Hometown 17 near)and familial associations Good schools for children/ education 17 prospects of children Getting adequate financial / Rural 17 allowances/performance incentives Anticipation of obtaining a regular 17 position after contractual position Achievement is recognized& rewarded 17 Opportunity for both spouses to work 17 and live in the same location More autonomy in current placeof posting 17
192

1.53 1.29 1.24 1.18 1.18

.514 .470 .437 .393 .393

1.236 -1.807 -2.496 -3.395 -3.395

16 16 16 16 16 16 16 16 16 16 16 16 16 -

.017 .090 .024 .004 .004

.029 -.206 -.265 -.324 -.324

1.12 .332 -4.747 1.12 .332 -4.747 1.12 .332 -4.747 1.06 .243 -7.500 1.06 .243 -7.500 1.06 .243 -7.500 1.06 .243 -7.500 1.06 .243 -7.500 1.00 .000 1.00 .000 1.00 .000 1.00 .000 1.00 .000 -

.001 -.382 .001 -.382 .001 -.382 .001 -.441 .001 -.441 .001 -.441 .001 -.441 .001 -.441 -

Contract nurses: While, analysing the factors to stay at the present place of posting for more 3-5 years, the following 10 top factors for retention have been found in case of contract nurses: 1) Anticipation of obtaining a regular position after contractual position (2.00), 2) Scope for training and skill development (1.88), 3) Career development opportunities (1.88), 4) Improved support, supervision and mentoring (1.75), 5) Improved working condition (1.50), 6) Good schools for children/ education prospects of children (1.38), 7) Strong Teamwork and interpersonal relationship (1.25), 8) Flexible working hours with minimal workload (1.13), 9)

Scope for continuing education/higher education (1.13) and 10) Adequate drugs/equipment at the rural health centre (1.13). Out of which, three factors that is the Scope for training and skill development, Anticipation of obtaining permanent post and Career development opportunities are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(7)=5.342, p=.001. t(7)=3.000, p=.020 and t(7)=3.000, p=.020 respectively. Table 99: Descriptive statistics for contributing factor of likelihood of retention of contract nurses Test Value = 1.5 Std. Sig. Factors Mea Dev (2Mean . t df tailed) Diff. N n Anticipation of obtaining a regular 8 2.00 .000 5.342 7 .001 .500 position after contractual position Scope for training and skill development 8 1.88 .354 3.000 7 .020 .375 Career development opportunities 8 1.88 .354 3.000 7 .020 .375 Job Security 8 1.75 .463 1.528 7 .170 .250 Improved support, supervision and 8 1.50 .535 .000 7 1.000 .000 mentoring Improved working condition 8 1.38 .518 -.683 7 .516 -.125 Good schools for children/ education 8 1.25 .463 -1.528 7 .170 -.250 prospects of children Adequate drugs/equipment at the rural 8 1.13 .354 -3.000 7 .020 -.375 health centre Scope for continuing /higher education 8 1.13 .354 -3.000 7 .020 -.375 Flexible working hours with minimal 8 1.13 .354 -3.000 7 .020 -.375 workload Strong Teamwork and interpersonal 8 1.13 .354 -3.000 7 .020 -.375 relationship Satisfied with salary 8 1.00 .000 - Getting adequate financial incentives/ 8 1.00 .000 - Rural allowances/performance incentives Adequate living conditions 8 1.00 .000 - 193

Achievement is recognized and rewarded Geographical affinities(Hometown near)and familial associations Opportunity for both spouses to work and live in the same location More autonomy in current place of posting

8 1.00 .000 8 1.00 .000 8 1.00 .000 8 1.00 .000

Mid-wives: While, analysing the factors to stay at the present place of posting for more 3-5 years, the following 10 top factors for retention have been found in case of nurses: Scope for training and skill development (1.63), Anticipation of obtaining a regular position after contractual position (1.61), Scope for continuing (1.38),

education/higher education

(1.38), Career development opportunities

More autonomy in current place of posting (1.38), Improved working condition (1.25), Adequate drugs/equipment at the rural health centre (1.25), Job Security (1.25), Improved support, supervision and mentoring (1.25), Satisfied with salary (1.13). Out of which, two factors that is the Scope for training and skill development, Anticipation of obtaining permanent post are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(7)=.683, p=.016 and t(7)=.100, p=.043 respectively. Table 100: Descriptive statistics for contributing factor of likelihood of retention of Mid-wives Test Value = 1.5 Factors Std. Sig. (2- Mean N Mean Dev. t df tailed) Diff. Scope for training & skill development 8 1.63 .518 .683 7 .016 .125 Anticipation of obtaining a regular 8 1.61 .535 .100 7 .043 .11 position after contractual position Scope for continuing /higher 8 1.38 .518 -.683 7 .516 -.125 education Career development opportunities 8 1.38 .518 -.683 7 .516 -.125 More autonomy in current place of 8 1.38 .518 -.683 7 .516 -.125 posting Improved working condition 8 1.25 .463 -1.528 7 .170 -.250 Adequate drugs/equipment at the rural 8 1.25 .463 -1.528 7 .170 -.250 health centre Job Security 8 1.25 .463 -1.528 7 .170 -.250 Improved support, supervision and 8 1.25 .463 - mentoring Satisfied with salary 8 1.13 .354 -3.000 7 .020 -.375 Getting adequate financial /Rural 8 1.13 .354 -3.000 7 .020 -.375 allowances/performance incentives
194

Good schools for children/ education prospects of children Flexible working hours with minimal workload Strong Teamwork and interpersonal relationship Adequate living conditions Achievement is recognized &rewarded Geographical affinities(Hometown near)and familial associations Opportunity for both spouses to work and live in the same location

8 8 8 8 8 8 8

1.13 1.00 1.00 1.00 1.00 1.00 1.00

.354 -3.000 .000 -1.528 .000 .000 .000 .000 .000 -

7 .020 7 .170 -

-.375 -.250 -

Permanent Mid-wives: While, analysing the factors to stay at the present place of posting for more 3-5 years, the following 10 top factors for retention have been found in case of permanent mid-wives: 1) Scope for training and skill development (1.60), 2)Career development opportunities (1.40), 3) Job Security (1.40), 4) More autonomy in current place of posting (1.40), 5) Improved working condition (1.40), 6) Scope for continuing education/higher education (1.20), 7) Good schools for children/ education prospects of children (1.20), 8) Improved support, supervision and mentoring (1.20), 9) Adequate drugs/equipment at the rural health centre (1.20) and 10) Opportunity for both spouses to work and live in the same location (1.20). Out of which, only one factor that is the Scope for training and skill development, is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(4)=1.408, p= .004. Table 101: Descriptive statistics for contributing factor of likelihood of retention of Permanent Mid-wives Test Value = 1.5 Sig. Factors Std. (2Mean N Mean Dev. t df tailed) Diff. Scope for training and skill 5 1.60 .548 1.408 4 .004 .100 development Career development opportunities 5 1.40 .548 -.408 4 .704 -.100 Job Security 5 1.40 .548 -.408 4 .704 -.100 More autonomy in current place of 5 1.40 .548 -.408 4 .704 -.100 posting Satisfied with salary 5 1.20 .447 -1.500 4 .208 -.300 Getting adequate financial incentives/ 5 1.20 .447 -1.500 4 .208 -.300 Rural allowances/performance incentives Adequate drugs/equipment at the rural 5 1.20 .447 -1.500 4 .208 -.300 health centre
195

Scope for continuing education/higher education Improved working condition Improved support, supervision and mentoring Good schools for children/ education prospects of children Flexible working hours with minimal workload Strong Teamwork and interpersonal relationship Anticipation of obtaining a regular position after contractual position Adequate living Achievement is recognized and rewarded Geographical affinities(Hometown near)and familial associations Opportunity for both spouses to work and live in the same location

5 1.20 5 1.20 5 1.20 5 1.20 5 1.00 5 1.00 5 1.00 5 1.00 5 1.00 5 1.00 5 1.00

.447 .447 .447 .447 .000 .000 .000 .000 .000 .000 .000

-1.500 -1.500 -1.500 -1.500 -

4 4 4 4 -

.208 .208 .208 .208 -

-.300 -.300 -.300 -.300 -

Contract Mid-wives: While, analysing the factors to stay at the present place of posting for more 3-5 years, the following 7 factors for retention have been found relevant mean in case of contract mid-wives: 1) Anticipation of obtaining a regular position after contractual position (2.00), 2) Scope for training and skill development (2.00), 3) Career development opportunities (2.00), education/higher education 4) Scope for continuing

(1.67), 5) More autonomy in current place of posting

(1.33), 6) Improved support, supervision and mentoring (1.33) and 7) Adequate drugs/equipment at the rural health centre (1.33). Out of which, only two factors that is the Anticipation of obtaining a regular position after contractual position and Scope for training and skill development, are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(2)=.386, p=.001 and t(2)=.386, p=.001 respectively. Table 102: Descriptive statistics for contributing factor of likelihood of retention of contract Mid-wives Test Value = 1.5 Sig. Factors Std. (2Mea Dev d taile n N Mean . t f d) Diff. Anticipation of obtaining a regular 3 2.00 .000 .386 2 .001 .000 position after contractual position Scope for training and skill development 3 2.00 .000 .386 2 .001 .000
196

Career development opportunities Scope for continuing /higher education Adequate drugs/equipment at the rural health centre Improved support, supervision and mentoring More autonomy in current place of posting Satisfied with salary Getting adequate financial incentives/ Rural allowances/performance incentives Improved working condition Job Security Flexible working hours with minimal workload Strong Teamwork and interpersonal relationship Adequate living conditions Achievement is recognized and rewarded Geographical affinities(Hometown near)and familial associations Good schools for children/ education prospects of children Opportunity for both spouses to work and live in the same location

3 1.67 .577 3 1.67 .577 3 1.33 .577 3 1.33 .577 3 1.33 .577 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000 3 1.00 .000

.500 .500 .500 .500 .500 -

2 2 2 2 2 -

.667 .167 .667 .167 .667 -.167 .667 -.167 .667 -.167 -

4.4.4.2. PUSH FACTORS OF LIKELIHOOD OF MIGRATION OF PHYSICIANS, NURSES AND MID-WIVES- CHOICE TO MIGRATE In this section, it is attempted to explore the push factors that contributed for the decision to migrate from the present rural area health institution of the employees. The eighteen (16) preset factors were included for the same. The Cronbachs alpha coefficient for the factor items is =(0.607) on item 16 and N=271. Push factors for migration of Physicians, Nurses and Mid-wives: It is analysed and found that the top 10 factors that contributed for intention for migration of the physicians, nurses and mid-wives from the present rural area to other rural area, urban area or to leave the sector are: 1) Lack of adequate financial incentives/ Rural allowances/performance incentive (1.57), 2) Poor working condition (1.54), 3) Poor salaries (1.45), 4) Inadequate drugs/equipment (1.28), 5) Lack of Career development opportunities (1.24), 6) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.18), 7) Lack of scope

197

for continuing education/higher education

(1.13),

8)

Lack of others

cadres,

teamwork and interpersonal relationship (1.07), 9) Lack of Job security (1.07) and 10) Poor support, supervision and mentoring (1.04). Out of which, two factors that is the Lack of adequate financial incentives / Rural allowances/performance incentives and poor working condition is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(270)= 2.265, p=.024 and t(270)=1.400, p=.036. Table 103: Descriptive statistics for contributing push factors for physicians, nurses and mid-wives Test Value = 1.5 Std. Mea Sig. Factors Mea Dev n (2n . N t df tailed) Diff. 271 1.57 .496 Lack of adequate financial 2.265 270 .024 .068 incentives/ Rural allowances/performance incentives Poor working condition 271 1.54 .499 1.400 270 .036 .042 Poor salaries 271 1.45 .498 -1.769 270 .078 -.054 Inadequate drugs/equipment 271 1.28 .450 -8.031 270 .001 -.220 Lack of Career development 271 1.24 .428 -10.011 270 .001 -.260 opportunities Inadequate living conditions 271 1.18 .389 -13.365 270 .001 -.315 Lack of scope for continuing 271 1.13 .340 -17.775 270 .001 -.367 education/higher education Lack of others cadres, 271 1.07 .256 -27.665 270 .001 -.430 teamwork and interpersonal relationship Lack of Job security 271 1.07 .249 -28.610 270 .001 -.434 Poor support, supervision and 271 1.04 .206 -36.401 270 .001 -.456 mentoring Limited or no good schools for 271 1.04 .198 -38.253 270 .001 -.459 children/ education prospects of children Achievement not recognized 271 1.03 .170 -45.674 270 .001 -.470 Limited opportunity of training 271 1.02 .147 -53.365 270 .001 -.478 and skill development Unusual working hours and 271 1.02 .147 -53.365 270 .001 -.478 excess work load Lack of safety at workplace 271 1.02 .147 -53.365 270 .001 -.478 Lack of Autonomy 271 1.02 .147 -53.365 270 .001 -.478 Push factors for migration of Physicians: While analysing the responses, the top 10 factors found contributing for intention of migration of the physicians from the present rural area to other rural area, urban area or to leave the sector are: 1) Lack of adequate financial incentives/ Rural allowances/performance incentive (1.61), 2) Poor
198

working condition (1.51), 3) Lack of Career development opportunities (1.34), 4) Inadequate drugs/equipment (1.31), 5) Poor salaries (1.29), 6) Lack of scope for continuing education/higher education (1.23), 7), Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.22), 8) Lack of Job security (1.08), 9) Lack of Autonomy(1.05),10) Limited or no good schools for children/ education prospects of children (1.05). Out of which, only one factor that is the Lack of adequate financial incentives / Rural

allowances/performance incentives is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(82)= 2.129, p=.036. However, the poor working condition also seems to be one of the factors that influencing with Mean of 1.51. Table 104: Descriptive statistics for contributing push factor for physicians Test Value = 1.5 Sig. Factors (2Mea Mea Std. taile n t df N n Dev. d) Diff. Lack of adequate financial incentives/ 83 1.61 .490 2.129 82 .036 .114 Rural allowances/performance incentives Poor working condition 83 1.51 .503 .109 82 .913 .006 Lack of Career development opportunities 1.34 .476 83 -3.115 82 .003 -.163 Inadequate drugs/equipment 83 1.31 .467 -3.646 82 .001 -.187 Poor salaries 83 1.29 .456 -4.211 82 .001 -.211 Lack of scope for continuing 83 1.23 .423 -5.843 82 .001 -.271 education/higher education Inadequate living conditions 83 1.22 .415 -6.221 82 .001 -.283 Lack of Job security 83 1.08 .280 -13.545 82 .001 -.416 Lack of others cadres, teamwork and 83 1.05 .215 -19.103 82 .001 -.452 interpersonal relationship Limited or no good schools for children/83 1.05 .215 -19.103 82 .001 -.452 /education prospects of children Lack of Autonomy 83 1.05 .215 -19.103 82 .001 -.452 Unusual working hours and excess 83 1.04 .188 -22.504 82 .001 -.464 work load Poor support, supervision & mentoring 83 1.04 .188 -22.504 82 .001 -.464 Achievement not recognized 83 1.04 .188 -22.504 82 .001 -.464 Limited opportunity of training and 83 1.02 .154 -28.103 82 .001 -.476 skill development Lack of safety at workplace 83 1.02 .154 -28.103 82 .001 -.476 Push factors for migration of permanent Physicians: While analysing further breaking down to nature of employment as permanent physicians, it is found that the following factors contributed for intention of migration of the permanent physicians
199

from the present rural area to other rural area, urban area or to leave the sector: 1) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.68), 2) Poor working condition (1.47), 3) Inadequate drugs/equipment (1.28), 4) Lack of Career development opportunities (1.11), 5) Inadequate living conditions

(access to amenities like housing, water, electricity, conveyance and communication) (1.11), 6) Lack of scope for continuing education/higher education (1.08), 7) Lack of Autonomy relationship (1.06), 8) Lack of others cadres, teamwork and interpersonal (1.06), 9) Unusual working hours and excess work load (1.06) and

10) Limited or no good schools for children/ education prospects of children (1.02). Out of which, only one factor that is the Lack of adequate financial incentives / Rural allowances/performance incentives is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(52)= 1.243, p=.020. Table 105: Descriptive statistics for contributing push factor for permanent physicians Test Value = 1.5 Sig. Mea Factors Mea Std. (2n N n Dev. t df tailed) Diff. Lack of adequate financial incentives/ 53 1.68 .497 1.243 52 .020 .085 Rural allowances/performance incentives Poor working condition 53 1.47 .504 -.409 52 .684 -.028 Inadequate drugs/equipment 53 1.28 .455 -3.473 52 .001 -.217 Lack of Career development opportunities53 1.11 .320 -8.803 52 .001 -.387 Inadequate living conditions 53 1.11 .320 -8.803 52 .001 -.387 Lack of scope for continuing 53 1.08 .267 -11.589 52 .001 -.425 education/higher education Unusual working hours/excess work load 53 1.06 .233 -13.836 52 .001 -.443 Lack of others cadres, teamwork and 53 1.06 .233 -13.836 52 .001 -.443 interpersonal relationship Lack of Autonomy 53 1.06 .233 -13.836 52 .001 -.443 Limited opportunity of trng.& skill dev. 53 1.02 .137 -25.500 52 .001 -.481 Poor support, supervision and mentoring 53 1.02 .137 -25.500 52 .001 -.481 Limited or no good schools for children/ 53 1.02 .137 -25.500 52 .001 -.481 education prospects of children Poor salaries 53 1.00 .000 Lack of Job security 53 1.00 .000 Achievement not recognized 53 1.00 .000 Lack of safety at workplace 53 1.00 .000 Push factors for migration of contract Physicians: While analysing the responses of contract physicians, it is found that these factors contributed for intention of
200

migration of the contract physicians from the present rural area to other rural area, urban area or to leave the sector are: 1) Poor salaries (1.80), 2) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.77), 3) Lack of

Career development opportunities (1.73), 4) Poor working condition (1.57), 5) Lack of scope for continuing education/higher education (1.50), conditions 6) Inadequate living

(access to amenities like housing, water, electricity, conveyance and

communication)(1.40), 7) Inadequate drugs/equipment (1.37), 8) Lack of Job security (1.23), 9) Limited or no good schools for children/ education prospects of children (1.10) and 10)Achievement not recognized (1.10). Out of which, three factors that are the Poor salaries, lack of adequate financial incentives/ Rural

allowances/performance incentives and lack of Career development opportunities are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(29)= 4.039, p= .001, t(29)= 1.904, p=.037 and t(29)= 2.841, p=.008 respectively. Table 106: Descriptive statistics for contributing push factor for contract physicians Test Value = 1.5 Sig. Mean Factors Std. (2t df tailed) Diff. N Mean Dev. Poor salaries 30 1.80 .407 4.039 29 .001 .300 Lack of adequate financial incentives/ 30 1.77 .479 1.904 29 .037 .167 Rural allowances/performance incentives Lack of Career development 30 1.73 .450 2.841 29 .008 .233 opportunities Poor working condition 30 1.57 .504 .724 29 .475 .067 Lack of scope for continuing 30 1.50 .509 .000 29 1.00 .000 education/higher education Inadequate living conditions 30 1.40 .498 -1.099 29 .281 -.100 Inadequate drugs/equipment 30 1.37 .490 -1.490 29 .147 -.133 Lack of Job security 30 1.23 .430 -3.395 29 .002 -.267 Achievement not recognized 30 1.10 .305 -7.180 29 .001 -.400 Limited or no good schools for children/30 1.10 .305 -7.180 29 .001 -.400 education prospects of children Poor support, supervision and 30 1.07 .254 -9.355 29 .001 -.433 mentoring Lack of safety at workplace 30 1.07 .254 -9.355 29 .001 -.433 Limited opportunity of training &skill 30 1.03 .183 -14.00 29 .001 -.467 development Lack of others cadres, teamwork and 30 1.03 .183 -14.00 29 .001 -.467 interpersonal relationship Lack of Autonomy 30 1.03 .183 -14.00 29 .001 -.467 Unusual working hours and excess 30 1.00 .000 work load
201

Push factors for migration of Nurses: From the responses of the nurses, it is found that these factors contributed for intention of migration of the nurses from the present rural area to other rural area, urban area or to leave the sector are: 1) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.62), 2) Poor working condition (1.62), 3) Poor salaries (1.48), 4) Inadequate drugs/equipment (1.26), 5) Lack of Career development opportunities (1.18), 6) Inadequate living conditions

(access to amenities like housing, water, electricity, conveyance and communication) (1.16), 7) Lack of scope for continuing education/higher education (1.08), 8)Lack of others cadres, teamwork and interpersonal relationship (1.05), 9) Lack of Job security (1.05) and 10) Limited opportunity of training and skill development (1.05). Out of which, two factors, the Lack of adequate financial incentives/ Rural

allowances/performance incentives and Poor working condition are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(72)= 2.032, p= .046 both. Table 107: Descriptive statistics for contributing push factor for nurses Test Value = 1.5 Sig. (2Mea Std. tailed Mean N n Dev t df ) Diff. Lack of adequate financial incentives/ 73 1.62 .490 2.032 72 .046 .116 Rural allowances/performance incentives Poor working condition 73 1.62 .490 2.032 72 .046 .116 Poor salaries 73 1.48 .503 -.349 72 .728 -.021 Inadequate drugs/equipment 73 1.26 .442 -4.636 72 .001 -.240 Lack of Career development opportunities 73 1.18 .385 -7.140 72 .001 -.322 Inadequate living conditions 73 1.16 .373 -7.684 72 .001 -.336 Lack of scope for continuing 73 1.08 .277 -12.908 72 .001 -.418 education/higher education Limited opportunity of training and skill 73 1.05 .229 -16.600 72 .001 -.445 development Lack of Job security 73 1.05 .229 -16.600 72 .001 -.445 Lack of others cadres, teamwork and 73 1.05 .229 -16.600 72 .001 -.445 interpersonal relationship Poor support, supervision and mentoring 73 1.04 .200 -19.616 72 .001 -.459 Limited or no good schools for children/ 73 1.04 .200 -19.616 72 .001 -.459 education prospects of children Achievement not recognized 73 1.03 .164 -24.566 72 .001 -.473 Unusual working hours and excess work 73 1.01 .117 -35.500 72 .001 -.486 load Lack of safety at workplace 73 1.01 .117 -35.500 72 .001 -.486 Lack of Autonomy 73 1.00 .000 202

Push factors for migration of permanent nurses: While analysing further breaking down to nature of employment of nurses as permanent nurses, it is found from the responses, the following factors contributed for intention of migration of the permanent nurses from the present rural area to other rural area, urban area or to leave the sector: 1) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.64), 2) Poor working condition (1.61), 3) Inadequate drugs/equipment (1.22), 4) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.08), teamwork and interpersonal relationship children/ education prospects of children 5) Lack of others cadres,

(1.06), 6) Limited or no good schools for (1.06), 7) Limited opportunity of training 9)

and skill development (1.06), 8) Poor support, supervision and mentoring (1.03), Lack of Career development opportunities

(1.03) and 10) Unusual working hours

and excess work load (1.03). Out of which, only one factor that is the Lack of adequate financial incentives / Rural allowances/performance incentives is statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(35)= 1.711, p=.046. However, poor working condition also has seems contributing to the intention with Mean of 1.61. Table 108: Descriptive statistics for contributing push factor for regular nurses Test Value = 1.5 Mea Sig. Mea Std. n (2N n Dev t df tailed) Diff. Lack of adequate financial incentives/ Rural 36 1.64 .487 1.711 35 .046 .139 allowances/performance incentives Poor working condition 36 1.61 .494 1.348 35 .186 .111 Inadequate drugs/equipment 36 1.22 .422 -3.953 35 .001 -.278 Inadequate living conditions 36 1.08 .280 -8.919 35 .001 -.417 Limited opportunity of training and skill dev. 36 1.06 .232 -11.479 35 .001 -.444 Lack of others cadres, teamwork and 36 1.06 .232 -11.479 35 .001 -.444 interpersonal relationship Limited or no good schools for children/ 36 1.06 .232 -11.479 35 .001 -.444 education prospects of children Lack of Career development opportunities 36 1.03 .167 -17.000 35 .001 -.472 Unusual working hours and excess work load 36 1.03 .167 -17.000 35 .001 -.472 Poor support, supervision & mentoring 36 1.03 .167 -17.000 35 .001 -.472 Poor salaries 36 1.00 .000 Lack of scope for continuing /higher education36 1.00 .000 Lack of Job security 36 1.00 .000 Achievement not recognized 36 1.00 .000 Lack of safety at workplace 36 1.00 .000 Lack of Autonomy 36 1.00 .000 203

Push factors for migration of contract nurses: While analysing the responses of contract nurses, it is found that the following factors contributed for migration of the contract nurses from the present rural area to other rural area, urban area or to leave the sector: 1) Poor salaries (1.95), 2) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.62), 3) Poor working condition (1.59), 4) Lack of Career development opportunities (1.32), 5) Inadequate drugs/equipment (1.30), 6) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.24), 7) Lack of scope for continuing

education/higher education (1.16), 8) Lack of Job security (1.11), 9) Achievement not recognized (1.05) and 10) Lack of others cadres, teamwork and interpersonal relationship (1.05). Out of which, two factors that is the Poor salary and Lack of adequate financial incentives / Rural allowances/performance incentives are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(36)= 11.833, p= .001 and t(36)= 1.505, p=.041 respectively. Table 109: Descriptive statistics for contributing push factor for contract nurses Test Value = 1.5 Sig Factors (2Mea Std taile Mean N n Dev t df d) Diff. Poor salaries 37 1.95 .229 11.833 36 .001 .446 Lack of adequate financial incentives/ Rural 37 1.62 .492 1.505 36 .041 .122 allowances/performance incentives Poor working condition 37 1.59 .498 1.156 36 .255 .095 Lack of Career development opportunities 37 1.32 .475 -2.25236 .031 -.176 Inadequate drugs/equipment 37 1.30 .463 -2.66136 .012 -.203 Inadequate living conditions 37 1.24 .435 -3.59136 .001 -.257 Lack of scope for continuing 37 1.16 .374 -5.49936 .001 -.338 education/higher education Lack of Job security 37 1.11 .315 -7.57236 .001 -.392 Limited opportunity of training and skill 37 1.05 .229 -11.83336 .001 -.446 development Poor support, supervision and mentoring 37 1.05 .229 -11.83336 .001 -.446 Lack of others cadres, teamwork and 37 1.05 .229 -11.83336 .001 -.446 interpersonal relationship Achievement not recognized 37 1.05 .229 -11.83336 .001 -.446 Lack of safety at workplace 37 1.03 .164 -17.50036 .001 -.473 Limited or no good schools for children/ 37 1.03 .164 -17.50036 .001 -.473 education prospects of children Unusual working hours and excess work 37 1.00 .000 load Lack of Autonomy 37 1.00 .000 204

Push factors for migration of Mid-Wives: While analysing for the group of Midwives, it is found that the following factors contributed for migration from the present rural area to other rural area, urban area or to leave the sector: 1) Poor salaries (1.74), 2) Poor working condition (1.64), 3) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.50), 4) Inadequate drugs/equipment (1.27), 5) Lack of Career development opportunities (1.21), 6) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.17), 7) Lack of scope for continuing education/higher education (1.10), 8) Lack of others cadres, teamwork and interpersonal relationship (1.10), 9) Lack of Job security (1.06) and 10) Poor support, supervision and mentoring (1.05). Out of which, two factors that is the Poor salaries, and Poor working condition are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(114)= 1.838, p= .044 and t(114)= 1.465, p=.050 respectively. Table 110: Descriptive statistics for contributing push factor for mid-wives
Std. N Mean Dev Test Value = 1.5 Sig. (2- Mean t df tailed) Diff.

Poor salaries Poor working condition Lack of adequate financial incentives/ Rural allowances/performance incentives Inadequate drugs/equipment Lack of Career development opportunities Inadequate living conditions Lack of scope for continuing /higher education Lack of others cadres, teamwork and interpersonal relationship Lack of Job security Poor support, supervision and mentoring Limited or no good schools for children/ education prospects of children Achievement not recognized Lack of safety at workplace Unusual working hours and excess work load Lack of Autonomy Limited opportunity of training and skill development

1151.74 .601 1151.64 .502 1151.50 .402 1151.27 1151.21 1151.17 1151.10 1151.10 .446 .408 .381 .295 .295

1.838 114 .044 .239 1.465 114 .050 .142 .093 114 .926 .004 -5.545 -7.654 -9.186 -14.679 -14.679 114 .001 114 .001 114 .001 114 .001 114 .001 -.230 -.291 -.326 -.404 -.404

1151.06 .240 -19.610 114 .001 -.439 1151.05 .223 -21.502 114 .001 -.448 1151.03 .184 -27.109 114 .001 -.465 1151.03 1151.03 1151.02 1151.02 1151.00 .160 .160 .131 .131 .000 -31.745 -31.745 -39.418 -39.418 114 .001 114 .001 114 .001 114 .001 -.474 -.474 -.483 -.483 -

Push factors for migration of Permanent Mid-Wives: While analysing further breaking down from the bunch of Mid-wives, to nature of employment as permanent Mid-wives, it is found that the following 8 factors have valid mean and contributed
205

for migration of the permanent mid-wives from the present rural area to other rural area, urban area or to leave the sector: 1) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.65), 2) Poor working condition (1.63), 3) Inadequate drugs/equipment (1.16), 4) Inadequate living conditions (access to 5)

amenities like housing, water, electricity, conveyance and communication) (1.09),

Lack of others cadres, teamwork and interpersonal relationship (1.05), 6) Lack of Autonomy (1.02), 7) Limited or no good schools for children/ education prospects of children (1.02) and 8) Lack of Career development opportunities (1.02). Out of which, two factors that is the Lack of adequate financial incentives/ Rural

allowances/performance incentives and Poor working condition are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(42)= 2.055, p=.036 and t(42)= 1.715, p=.044 respectively. Table 111: Descriptive statistics for contributing push factor for permanent mid-wives Factors Lack of adequate financial incentives/ Rural allowances/performance incentives Poor working condition Inadequate drugs/equipment Inadequate living conditions Lack of others cadres, teamwork and interpersonal relationship Lack of Career development opportunities Limited or no good schools for children/ education prospects of children Lack of Autonomy Poor salaries Lack of scope for continuing education/higher education Limited opportunity of training and skill development Lack of Job security Unusual working hours and excess work load Poor support, supervision and mentoring Achievement not recognized Lack of safety at workplace
Std. N Mean Dev Test Value = 1.5 Sig. Mean (2t df tailed) Diff.

43 1.65 .482 43 43 43 43 1.63 1.16 1.09 1.05

2.055 42 .036

.151 .128 -.337 -.407 -.453 -.477 -.477 -.477 -

.489 1.715 42 .044 .374 -5.920 42 .001 .294 -9.080 42 .001 .213 -13.956 42 .001

43 1.02 .152 -20.500 42 .001 43 1.02 .152 -20.500 42 .001 43 1.02 .152 -20.500 42 .001 43 1.00 .000 43 1.00 .000 43 1.00 .000 43 43 43 43 43 1.00 1.00 1.00 1.00 1.00 .000 .000 .000 .000 .000 -

Push factors for migration of Contract Mid-Wives: While analysing further breaking down from the bunch of Mid-wives, to nature of employment as contract Mid-wives, it is found that the following top 10 factors contributed for migration of
206

the contract mid-wives from the present rural area to other rural area, urban area or to leave the sector: 1) Poor salaries (1.86), 2) Poor working condition (1.77), 3) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.42), 4) Inadequate drugs/equipment (1.33), 5) Lack of Career development opportunities (1.32), 6) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.22), 7) Lack of scope for continuing education/higher education (1.15), 8) Lack of others cadres, teamwork and interpersonal relationship (1.12), 9) Lack of Job security (1.10) and 10) Poor

support, supervision and mentoring (1.08). Out of which, two factors that is poor salaries and Poor working condition are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(71)= 8.798, p= .001 and t(71)= 1.705, p= .048 respectively. Table 112: Descriptive statistics for contributing push factor for contract midwives
Std. N Mean Dev Test Value = 1.5 Sig. Mean (2t df tailed) Diff.

Factors Poor salaries Poor working condition Lack of adequate financial incentives/ Rural allowances/performance incentives Inadequate drugs/equipment Lack of Career development opportunities Inadequate living conditions Lack of scope for continuing education/higher education Lack of others cadres, teamwork and interpersonal relationship Lack of Job security Poor support, supervision and mentoring Achievement not recognized Lack of safety at workplace Limited or no good schools for children/ education prospects of children Unusual working hours & excess workload Lack of Autonomy Limited opportunity of training and skill development

72 1.86 .348 72 1.77 .502 72 1.42 .496 72 72 72 72 1.33 1.32 1.22 1.15 .475 .470 .419 .362

8.798 71 .001 .361 1.705 71 .048 .205 -1.424 71 .159 -.083 -2.979 -3.263 -5.630 -8.132 71 71 71 71 .004 .002 .001 .001 -.167 -.181 -.278 -.347

72 1.13 .333 72 72 72 72 72 1.10 1.08 1.04 1.04 1.04 .298 .278 .201 .201 .201

-9.554 71 .001 -.375 -11.456 -12.703 -19.327 -19.327 71 71 71 71 .001 .001 .001 .001 -.403 -.417 -.458 -.458

72 1.03 .165 -24.213 71 .001 -.472 72 1.01 .118 -35.000 71 .001 -.486 72 1.00 .000 -

207

4.4.4.3. PUSH FACTORS OF LIKELIHOOD TO MIGRATE ACCORDING TO THE CHOICE OF PLACE The above section tells us in detail the migration intention of the physicians, nurses and mid-wives according to the category and nature of employment. In this section it is aimed to explore the issue of intention to migrate according to the place of choice. The exploration is based on finding the issue that, why the employees have the choice for either vertical or the horizontal movements that is from rural to rural areas, from rural to urban and migrates to other sector or to other places outside the state. This effort is needed to track the issues of these health workforce migration and understanding of factors contributing to it and may perhaps have these health workforce retained in rural and remote areas of Arunachal Pradesh or country at large. Migrating from rural area to another rural area: This section explores the intention of migration of physicians, nurses and mid-wives from the present rural health institute to any other rural health institute. The exploration of the preset factors from the responses is presented below in table 113. The top 10 factors that contributed to the intention of the migration of another rural health institute of these employees are: 1) Lack of others cadres, teamwork and interpersonal relationship (1.65), 2) Lack of Autonomy (1.59), 3) Poor support, supervision and mentoring (1.07), 4) Poor working condition (1.05), 5) Unusual working hours and excess work load (1.05), 6) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.04), 7) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.04), 8) Lack of scope for continuing education/higher education (1.02), 9) Lack of safety at workplace (1.02) and 10) Inadequate drugs/equipment (1.02). Out of which, two factors, the lack of others cadres, teamwork and interpersonal relationship, lack of Autonomy are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(80)= 4.238, p= .001 and t(71)= 3.546, p= .001 respectively. Table 113: Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to another rural area
Test Value = 1.5

Factors
N Mean

Std. Dev.

Sig. (2t df
tailed)

Mean Diff.

Lack of others cadres, teamwork and interpersonal relationship Lack of Autonomy Poor salaries

81 1.65 .331

4.238 80

.001

.151

81 1.59 .264 3.546 80 81 1.31 .465 -3.705 80

208

.001 .090 .001 -.191

Limited opportunity of training and skill development Poor support, supervision and mentoring Lack of adequate financial incentives/ Rural allowances/performance incentives Unusual working hours and excess work load Lack of Career development opportunities Lack of scope for continuing education/higher education Inadequate living conditions Poor working condition Inadequate drugs/equipment Lack of Job security Achievement not recognized Lack of safety at workplace Limited or no good schools for children/ education prospects of children

81 1.05 .218 -18.602 80 81 1.05 .218 -18.602 80 81 1.04 .190 -21.926 80

.001 -.451 .001 -.451 .001 -.463

81 1.04 .190 -21.926 80 81 1.02 .156 -27.395 80 81 1.02 .156 -27.395 80 81 81 81 81 81 81 81 1.02 1.01 1.01 1.00 1.00 1.00 1.00 .156 -27.395 80 .111 -39.500 80 .111 -39.500 80 .000 .000 .000 .000 -

.001 -.463 .001 -.475 .001 -.475 .001 -.475 .001 -.488 .001 -.488 -

Migrating from rural area to urban area: This section explores the intention of migration of physicians, nurses and mid-wives from the present rural health institute to any other urban area health institute. The exploration of the preset factors from the responses is presented below in table 114. The top 10 factors that contributed to the intention of the migration of urban area health institute of these employees are: 1) Poor working condition (1.83), 2) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.79), 3) Poor salaries (1.45), 4) Inadequate

drugs/equipment (1.38), 5) Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) (1.28), 6) Lack of Career development opportunities (1.25), 7) Lack of scope for continuing education/higher education (1.11), 8) Limited or no good schools for children/ education prospects of children (1.07), 9) Lack of others cadres, teamwork and interpersonal relationship (1.05) and 10) Poor support, supervision and mentoring (1.05). Out of which, two factors, the Poor working condition and Lack of adequate financial incentives/ Rural allowances/performance incentives are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(168)= 11.290, p= .001 and t(168)= 9.369, p= .001 respectively.

209

Table 114: Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to rural to urban
Std. Dev Test Value = 1.5 Sig. Mean (2t df tailed) Diff.

N Mean

Poor working condition 169 Lack of adequate financial incentives/ 169 Rural allowances/performance incentives Poor salaries 169 Inadequate drugs/equipment 169 Inadequate living conditions 169 Lack of Career development 169 opportunities Lack of scope for continuing 169 education/higher education Limited or no good schools for children/ 169 education prospects of children Lack of others cadres, teamwork and 169 interpersonal relationship Poor support, supervision and mentoring 169 Lack of safety at workplace 169 Unusual working hours & excess workload 169 Limited opportunity of training and skill 169 development Lack of Job security 169 Achievement not recognized 169 Lack of Autonomy 169

1.83 .378 11.290 168 .001 .328 1.79 .406 9.369 168 .001 .293 1.45 1.38 1.28 1.25 .499 .487 .452 .433 -1.310 -3.241 -6.208 -7.543 168 168 168 168 .192 .001 .001 .001 -.050 -.121 -.216 -.251

1.11 .309

-16.533168 .001 -.393

1.07 .247 -22.852 168 .001 -.435 1.05 .225 -25.788 168 .001 -.447 1.05 1.04 1.02 1.01 .213 .186 .132 .108 -27.629 168 -32.535 168 -47.337 168 -58.511 168 .001 .001 .001 .001 -.453 -.464 -.482 -.488 -

1.00 .000 1.00 .000 1.00 .000

Migrating to other sector or outside state: This section explores the intention of migration of physicians, nurses and mid-wives from the present rural health institute to any other sector or outside the state. The exploration of the preset factors from the responses is presented below in table 115. The top 8 factors found to be with valid mean that contributed to the intention of the migration to other sectors or outside state are: 1) Lack of Career development opportunities (2.00), 2) Poor salaries (1.95), 3) Lack of Job security (1.86), 4) Lack of adequate financial incentives/ Rural allowances/performance incentives (1.81), 5) Lack of scope for continuing education/higher education (1.76), 6) Inadequate drugs/equipment (1.52), 7)

Achievement not recognized (1.38) and 8) Poor working condition (1.29). Out of which, five factors, the Lack of Career development opportunities, Poor salaries, Lack of Job security, Lack of adequate financial incentives/ Rural allowances/performance incentives and Lack of scope for continuing education/higher education are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(20)=
210

11.568, p= .001, t(20)= 9.5, p= .001, t(20)= 4.564, p= .001, t(20)= 3.525, p= .002 and t(20)= 2.750, p= .012 respectively. Table: 115: Descriptive statistics of push factors for migration of physicians, nurses and mid-wives to other employer or outside state
Std. N Mean Dev Test Value = 1.5 Sig. (2- Mean t df tailed) Diff.

Lack of Career development 21 opportunities Poor salaries 21 Lack of Job security 21 Lack of adequate financial incentives/ 21 Rural allowances/performance incentives Lack of scope for continuing 21 education/higher education Inadequate drugs/equipment 21 Achievement not recognized 21 Poor working condition 21 Limited opportunity of training and skill 21 development Unusual working hours & excess workload21 Poor support, supervision and mentoring 21 Lack of others cadres, teamwork and 21 interpersonal relationship Inadequate living conditions 21 Lack of safety at workplace 21 Limited or no good schools for children/ 21 education prospects of children Lack of Autonomy 21

2.00 .000 11.568 20 .001 .500 1.95 .218 1.86 .359 1.81 .402 1.76 .436 1.52 1.38 1.29 1.00 9.500 20 .001 .452 4.564 20 .001 .357 3.525 20 .002 .310 2.750 20 .012 .262

.512 .213 20 .833 .024 .498 -1.096 20 .286 -.119 .463 -2.121 20 .047 -.214 .000 -

1.00 .000 1.00 .000 1.00 .000 1.00 .000 1.00 .000 1.00 .000 1.00 .000

4.4.4.4. RELATIONSHIP OF DEMOGRAPHIC AND SATISFACTION ATTRIBUTES WITH THE MAJOR INTENTION TO MIGRATE TO URBAN AREAS It is known from the study that the intention to migrate is having relationship with job satisfaction. Hence, the exploration is attempted along with the exploration with demographic attributes like age, sex, family background, marital status, length of service, hierarchy level of place of posting and nature of employment of the employees on intention to migrate to urban areas. The variable (sex) has been drooped from interpretation for the relationship because there are few cases of male and female classification in the data, and classification is only in the Physicians group, where as the nurses and mid-wives does not have the classification of male and female, except 1 (one) no. of male in the nurse group of employee.
211

From the study, it is found that there is no relationship exists between the demographic attributes of age (2=1.523, p=.677), family background (2=0.008, p=.929), marital status (2=0.927, p=.336), nature of employment (2=0.056, p=.813), and place of posting (2=0.820, p=.845) with urban migration. Only the attribute of length of service (2=10.825, p=.029), is significant and revealed the relationship with the migration to urban areas. And job satisfaction has been statistically significance relationship at (2=84.930), p=.001), with the intention of migration to urban area. Table 116: Relationship of demographic attributes to intention to migrate in physicians, nurses and mid-wives Demographic and Satisfaction Attributes P Sl. Chi-Square (2) No. 1 Age 1.523 .677 2 Family Background 0.008 .929 3 Marital Status 0.927 .336 4 Length of Service 10.825 .029 5 .845 Hierarchy level of Health institutes-place of 0.820 6 Nature of Employment 0.056 .813 7 Job Satisfaction 84.930 .001 While analysing by separating the positions of the workforce as Physicians, it is found that there is no relationship exists between the demographic attributes of age (2=3.729, p=.292), Sex (2=0.007, p=.933), family background (2=1.299, p=.245), marital status (2=0.337, p=.562), nature of employment (2=0.598, p=.439), and place of posting (2=1.981, p=.576), length of service (2=4.062, p= .398), except job satisfaction has statistically significance relationship at (2=33.227), p< .001), with the intention of migration to urban area. Table 117: Relationship of demographic attributes to intention to migrate in physicians Sl. No Demographic and Satisfaction Attributes P Chi-Square (2) 1 Age 3.729 .292 2 Sex 0.007 .933 3 Family Background 1.299 .254 4 Marital Status .337 .562 5 Length of Service 4.062 .398 6 Hierarchy level of Health institutes-place of 1.981 .576 posting of Employment 7 Nature .598 .439 8 Job Satisfaction 33.227 .001 While analysing separating the positions of the workforce as Nurses, it is found that there is no relationship exists between the demographic attributes of age
212

(2=1.341, p=.719), family background (2=.001, p=1.00), marital status (2=.051, p=.821), nature of employment (2=.041, p=.839), and place of posting (2=4.668, p=.097), length of service (2=5.384, p=.250), except job satisfaction has statistically significance relationship at (2=33.797), p< .001), with the intention of migration to urban area. Table 118: Relationship of demographic attributes to intention to migrate in nurses Sl. No Demographic and Satisfaction Attributes P Chi-Square (2) 1 2 3 4 5 6 7 Age Family Background Marital Status Length of Service Hierarchy level of Health institutes-place of posting Nature of Employment Job Satisfaction 1.341 .001 .051 5.384 4.668 .041 33.797 .719 1 .821 .250 .097 .839 .001

While analysing separating the positions of the workforce as Mid-wives, it is found that there is no relationship exists between the demographic attributes of family background (2=1.153, p=.238), marital status (2=1.886, p=.176), nature of employment (2=1.747, p=.186), and place of posting (2=2.334, p=.506) with urban migration and significant relationship has been found with age (2=9.110, p=.011) and length of service (2=10.552, p=.032). And job satisfaction has statistically significance relationship at (2=13.048), p=.005), with the intention of migration to urban area. Table 119: Relationship of demographic attributes to mid-wives Demographic and Satisfaction Attributes Sl. No 1 Age 2 Family Background 3 Marital Status 4 Length of Service 5 Hierarchy level of Health institutes-place of posting 6 Nature of Employment 7 Job Satisfaction intention to migrate in Chi-Square (2) 9.110 1.153 1.886 10.552 2.334 1.747 13.048 P .011 .238 .176 .032 .506 .186 .005

213

4.4.5. FACTORS THAT MAY MOTIVATE THE PHYSICIANS, NURSES AND MID-WIVES TO RETAIN IN CURRENT JOB IN RURAL AND REMOTE AREA- WHAT IS THEIR CHOICE?
The use of financial incentives as important motivators has been over emphasised in the recent past. However, research in human relations and behaviour sciences has shown that where as money incentive had not proved effective, psychic rewards worked (Gellerman, 1963). Later research by Herzberg (1968) & Lawler (1971) confirmed the fact that pay has very little to do with motivation. However, several research studies in India have indicated the positive relationships between pay and employee performance (Dwivedi, 1980). Therefore, the need is to understand the various factors which motivate physicians, nurses and mid-wives to retain themselves in the present rural posting. Taking all these factors into consideration, financial as well as non-financial incentives can be planned. So forth, in this section, it is attempted to explore the preset factors that may motivate the physicians, nurses and mid-wives to retain themselves in the present rural area health institution. The responses of these employees reveal the motivational factors for retain themselves for the rural services. However, this section is based on all responses of 334 health workforce and the eighteen (19) preset factors were included in the section of the questionnaire. The Cronbachs alpha coefficient for the factor items is =(0.603) on item 19 and N=334. Factors that may motivate the physicians, nurses and mid-wives : While

exploring the motivational factors that may motivate the physicians, nurses and midwives to retain themselves in the present rural area health institution. The responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial incentives for rural posting/ Rural allowances/performance incentives (1.93), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (1.87), Career development opportunities recognition system 3)

(1.63), 4) Good reward and achievement

(1.55), 5) Training and skill development Opportunities (1.53),

6) Improved working condition (1.49), 7) Adequacy of equipment, drugs and supplies at Health centre (1.48), 8) Increase salary by half (1.34), 9) Opportunities of

continuing education/higher education (support for further education) (1.33) and 10) Job Security (1.32). Out of which, four factors, financial incentives/ Rural
214

allowances/performance incentives, improved living condition, career development and Good reward and achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(334)= 31.938, p= .001, t(334)=20.598, p= .001 and t(334)= 4.984, p= .001 and t(334)= 2.867, p= .043 respectively. Table 120 : Descriptive statistics of factors that may motivate the physicians, nurses and mid-wives to retain in current job in rural and remote area Factors
Std. N Mean Dev. Test Value = 1.5 Sig. t df
(2tailed)

Mean Diff.

Financial incentives for rural posting/ Rural 334 1.93 allowances/performance incentives Improve living conditions 334 1.87 Career development opportunities 334 1.63 Good reward & achievement recognition 334 1.61 system Training & skill development Opportunities 334 1.53 Improved working condition 334 1.49 Adequacy of equipment, drugs and supplies 334 1.48 at Health centre Increase salary by half 334 1.34 Opportunities of continuing 334 1.33 education/higher education (support for further education) Job Security 334 1.32 Good teamwork and good interpersonal 334 1.30 staffs relationship Security & Safety at workplace 334 1.23 Supportive supervision, management & 334 1.19 mentoring Adequate patients/clients at current facility 334 1.16 Increase salary by double 334 1.12 Rotational posting 334 1.11 Availability of good schools for children 334 1.11 Opportunity of autonomy 334 1.03 Flexible working hours with minimal workload334 1.01

.248 .332 .483 .489 .500 .501 .506 .474 .470

31.938 333.001 .434 20.598 333.001 .374 4.984 333.001 .132 2.867 333.043 .111 .985 333.325 .027 -.437 333.662 -.012 -.865 333.388 -.024 -6.236 333.001 -.162 -6.758 333.001 -.174

.466 .457

-7.160 333.001 -.183 -8.135 333.001 -.204

.420 -11.859 333.001 -.272 .389 -14.755 333.001 -.314 .366 .329 .314 .314 .171 .122 -17.047 -20.978 -22.630 -22.630 -50.333 -72.888 333.001 333.001 333.001 333.001 333.001 333.001 -.341 -.377 -.389 -.389 -.470 -.485

4.4.5.1. FACTORS THAT MAY MOTIVATE THE PHYSICIANS TO STAY Getting a more refined picture, the analysis was done according to the category of these groups of health workforce. While, exploring the motivational factors that may motivate the physicians to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial
215

incentives for rural posting/ Rural allowances/performance incentives Improve living conditions

(1.90), 2)

(Access to amenities like housing, water, electricity,

conveyance and communication) (1.79), 3) Career development opportunities (1.73), 4) Improved working condition (1.66), 5) Good reward and achievement recognition system (1.65), 6) Training and skill development Opportunities (1.53), 7) Adequacy of equipment, drugs and supplies at Health centre (1.50), 8) Opportunities of

continuing education/higher education (support for further education) (1.46), 9) Good teamwork and good interpersonal staffs relationship (1.38) and 10) Adequate patients/clients at current facility (1.36). Out of which, five factors, Financial incentives for rural posting/ rural allowances/performance incentives, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication), Career development opportunities, 4) Improved working condition and Good reward and achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(112)= 14.376, p= .001, t(112) 7.442, p= .001, t(112)= 5.620, p= .001, t(112)= 3.667, p= .001 and t(112)= 2.035, p= .030 respectively. Table 121: Descriptive statistics of factors that may motivate the physicians to retain in current job in rural and remote area Factors
Std. N Mean Dev Test Value = 1.5 Sig. t df
(2tailed)

Mean Diff.

Financial incentives for rural posting/ 1131.90 Rural allowances/performance incentives Improve living conditions 1131.79 Career development opportunities 1131.73 Improved working condition 1131.66 Good reward and achievement recognition 1131.65 system Training & skill development Opportunity 1131.53 Adequacy of equipment, drugs and 1131.50 supplies at Health centre Opportunities of continuing /higher 1131.46 education Good teamwork and good interpersonal 1131.38 staffs relationship Adequate patients/clients at current facility 1131.36 Supportive supervision,management&mentoring 1131.22 Increase salary by half 1131.21 Job Security 1131.20 Availability of good schools for children 1131.11 Rotational posting 1131.10
216

.298 14.376 112 .001 .403 .411 .444 .475 .490 .501 .502 .501 .488 7.442 5.620 3.667 2.035 112 112 112 112 .001 .001 .001 .030 .288 .235 .164 .159

.657 112 .513 .031 .094 112 .926 .004 -.846 112 .400 -.040 -2.604 112 .010 -.119 .003 .001 .001 .001 .001 .001 -.137 -.279 -.288 -.296 -.394 -.403

.483 -3.019 112 .417 -7.107 112 .411 -7.442 112 .404 -7.792 112 .309 -13.528 112 .298 -14.376 112

Security & Safety at workplace Increase salary by double Opportunity of autonomy Flexible working hours with minimal work load

1131.10 1131.09 1131.06 1131.00

.298 -14.376 112 .001 -.403 .285 -15.334 112 .001 -.412 .242 -19.231 112 .001 -.438 .000 -

Factors that may motivate the contract physicians: Getting a more refined picture, the analysis was done according to the nature of employment inside the category of groups of Physicians. While, exploring the motivational factors that may motivate the contract physicians to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Career development opportunities (2.00), 2) Opportunities of continuing education/higher education (support for further education) (1.97), 3) Financial incentives for rural posting/ Rural

allowances/performance incentives (1.82), 4) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (1.76), 5)

Increase salary by half (1.71), 6) Job Security (1.68), 7) Training and skill development Opportunities (1.62), 8) Improved working condition (1.53) (1.59), 10)

9)Adequacy of equipment, drugs and supplies at Health centre

and

Good teamwork and good interpersonal staffs relationship (1.50). Out of which, six factors, Career development opportunities, Opportunities of continuing

education/higher education (support for further education), Financial incentives for rural posting/ Rural allowances/performance incentives , Improve living conditions (Access to amenities like housing, water, electricity, conveyance and

communication), Increase salary by half and Job Security are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(33)= 18.00, p= .001, t(33)= 16.00, p= .001, t(33)= 4.875, p= .001, t(33)= 3.585, p= .001, t(33)= 2.596, p= .014, and t(33)= 2.167, p= .038, respectively. Table 122: Descriptive statistics of factors that may motivate the contract physicians to retain in current job in rural and remote area Factors
Std. N Mean Dev Test Value = 1.5 Sig. (2- Mean t df tailed) Diff.

Career development opportunities 34 2.00 .000 18.000 33 .001 .500 Opportunities of continuing education/higher 34 1.97 .171 16.000 33 .001 .471 education (support for further education) Financial incentives for rural posting/ Rural 34 1.82 .387 4.875 33 .001 .324 allowances/performance incentives
217

Improve living conditions 34 Increase salary by half 34 Job Security 34 Training and skill development Opportunities 34 Improved working condition 34 Adequacy of equipment, drugs and supplies 34 at Health centre Good teamwork and good interpersonal 34 staffs relationship Good reward &achievement recognition system34 Adequate patients/clients at current facility 34 Increase salary by double 34 Security & Safety at workplace 34 Supportive supervision, management and 34 mentoring Availability of good schools for children 34 Rotational posting 34 Opportunity of autonomy 34 Flexible working hours with minimal workload 34

1.76 1.71 1.68 1.62 1.59 1.53

.431 .462 .475 .493 .500 .507

3.585 2.596 2.167 1.391 1.030 .339

33 33 33 33 33 33

.001 .014 .038 .174 .311 .737

.265 .206 .176 .118 .088 .029

1.50 .508 1.44 1.32 1.29 1.29 1.26 1.18 1.09 1.09 1.00 .504 .475 .462 .462 .448

.000 33 1.00 .000 -.681 -2.167 -2.596 -2.596 -3.064 33 33 33 33 33 .501 -.059 .038 -.176 .014 -.206 .014 -.206 .004 -.235

.387 -4.875 33 .001 -.324 .288 -8.340 33 .001 -.412 .288 -8.340 33 .001 -.412 .000 - -

Factors that may motivate the permanent physicians: Similarly, while exploring the motivational factors that may motivate the permanent physicians to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial incentives for rural posting/ Rural

allowances/performance incentives (1.94), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (1.80), 3) Improved working condition (1.70), 4) Career development opportunities

(1.62), 5) Good reward and achievement recognition system (1.62), 6) Training and skill development Opportunities (1.52), 7) Adequacy of equipment, drugs and supplies at Health centre (1.49), 8) Adequate patients/clients at current facility (1.38), 9) Good teamwork and good interpersonal staffs relationship (1.33),

and 10) Opportunities of continuing education/higher education (support for further education) (1.24). Out of which, five factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions (Access to

amenities like housing, water, electricity, conveyance and communication), Improved working condition, Career development opportunities and Good reward and

achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(78)= 15.840, p= .001, t(78)= 6.537, p= .001, t(78)= 3.768, p= .001 , t(78)= 2.188, p= .032 and t(78)= 2.188, p= .032 respectively.
218

Table 123: Descriptive statistics of Factors that may motivate the permanent physicians to retain in current job in rural and remote area
Test Value = 1.5

Factors

Std. N Mean Dev

Sig Mean df (2-tailed) Dif.

Financial incentives for rural posting/ Rural 79 allowances/performance incentives Improve living conditions 79 Improved working condition 79 Career development opportunities 79 Good reward &achievement recognition system79 Training and skill development Opportunities 79 Adequacy of equipment, drugs and supplies at 79 Health centre Adequate patients/clients at current facility 79 Good teamwork and good interpersonal staffs 79 relationship Opportunities of continuing education/higher 79 education (support for further education) Supportive supervision, management and 79 mentoring Rotational posting 79 Availability of good schools for children 79 Opportunity of autonomy 79 Security & Safety at workplace 79 Increase salary by half 79 Increase salary by double 79 Job Security 79 Flexible working hours with minimal workload 79

1.94 .245 15.840 78 .001 .437 1.80 1.70 1.62 1.62 1.52 1.49 .404 .463 .488 .488 .503 .503 6.537 3.768 2.188 2.188 .336 -.112 78 78 78 78 78 78 .001 .001 .032 .032 .738 .911 .297 .196 .120 .120 .019 -.006

1.38 .488 -2.188 78 .032 -.120 1.33 .473 -3.212 78 .002 -.171 1.24 .430 -5.362 78 .001 -.259 1.20 .404 -6.537 78 .001 -.297 1.10 1.08 1.05 1.01 1.00 1.00 1.00 1.00 .304 .267 .221 .113 .000 .000 .000 .000 -11.67 -14.13 -18.10 -38.500 78 78 78 78 .001 .001 .001 .000 -.399 -.424 -.449 -.487 -

4.4.5.2. FACTORS THAT MAY MOTIVATE THE NURSES TO STAY Getting a more refined picture, the analysis was done for the group of the nurses. While, exploring the motivational factors that may motivate the nurses to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial incentives for rural posting/ Rural

allowances/performance incentives (1.93), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (1.88), 3) Career development opportunities (1.71), 4) Training and skill development 6)

Opportunities (1.53), 5) Good reward and achievement recognition system (1.48),

Adequacy of equipment, drugs and supplies at Health centre (1.47), 7) Improved working condition (1.46), 8) Increase salary by half (1.35), 9)
219

Job

Security

(1.34) and 10) Good teamwork and good interpersonal staffs relationship (1.33). Out of which, three factors, Financial incentives for rural posting/ Rural

allowances/performance incentives, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) and Career development opportunities are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(97)= 16.389, p= .001, t(97)= 11.344, p= .001, t(97)= 4.672, p= .001 respectively. Table 124 : Descriptive statistics of factors that may motivate the nurses to retain in current job in rural and remote area Factors
Std. N Mean Dev Test Value = 1.5 Sig. d Mean (2t f tailed) Diff.

Financial incentives for rural posting/ Rural 98 allowances/performance incentives Improve living conditions 98 Career development opportunities 98 Training and skill development Opportunities 98 Good reward& achievement recognition system 98 Adequacy of equipment, drugs and supplies 98 at Health centre Improved working condition 98 Increase salary by half 98 Job Security 98 Good teamwork and good interpersonal 98 staffs relationship Security & Safety at workplace 98 Opportunities of continuing education/higher 98 education (support for further education) Supportive supervision,management&mentoring 98 Availability of good schools for children 98 Increase salary by double 98 Rotational posting 98 Adequate patients/clients at current facility 98 Flexible working hours with minimal work 98 load Opportunity of autonomy 98

1.93 .259 1.88 1.71 1.53 1.48 1.47 1.46 1.35 1.34 1.33 .329 .454 .502 .502 .522 .501 .478 .475 .471

16.38997 .001 .429 11.34497 4.67297 .60497 -.40297 -.58197 -.80797 -3.16797 -3.40297 -3.64397 .001 .001 .547 .688 .563 .422 .002 .001 .001 .378 .214 .031 -.020 -.031 -.041 -.153 -.163 -.173

1.23 .426 1.20 .405 1.19 1.14 1.11 1.10 1.08 1.03 .397 .352 .317 .304 .275 .173

-6.16597 .001 -.265 -7.23197 .001 -.296 -7.62697 -10.05297 -12.09897 -12.94897 -15.04997 -26.83697 .001 .001 .001 .001 .001 .001 -.306 -.357 -.388 -.398 -.418 -.469

1.01 .101 -48.00097 .001 -.490

Factors that may motivate the Contract Nurses: Getting a more refined picture within the group of nurses, the analysis was done for the group of the contract nurses. While, exploring the motivational factors that may motivate the contract nurses to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial incentives
220

for

rural

posting/

Rural

allowances/performance incentives (2.00), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (2.00), 3)Career development opportunities (1.93), 4) Increase salary by half (1.76), 5) Job Security (1.73), 6) Training and skill development Opportunities (1.56), 7) Adequacy of equipment, drugs and supplies at Health centre (1.56), 8) Improved working condition (1.56), 9) Good reward and achievement recognition system (1.51) and 10) Good teamwork and good interpersonal staffs relationship (1.42). Out of which, five factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions (Access to amenities like housing, water,

electricity, conveyance and communication), Career development opportunities , Increase salary by half and Job Security are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(44)=12.543, p= .001, t(44)=12.543, p= .001, t(44)=11.523, p= .001, t(44)=3.944, p= .001 and t(44)=3.500, p= .001, respectively. Table 125: Descriptive statistics of factors that may motivate the contract nurses to retain in current job in rural and remote area
Test Value = 1.5

Factors

Std. N Mean Dev

df

(2-tailed)Diff.

Sig Mean

Financial incentives for rural posting/ Rural 45 allowances/performance incentives Improve living conditions 45 Career development opportunities 45 Increase salary by half 45 Job Security 45 Improved working condition 45 Adequacy of equipment, drugs and supplies at 45 Health centre Training and skill development Opportunities 45 Good reward & achievement recognition 45 system Good teamwork and good interpersonal staffs 45 relationship Security & Safety at workplace 45 Opportunities of continuing education/higher 45 education (support for further education) Increase salary by double 45 Availability of good schools for children 45 Supportive supervision,management& mentoring5 4 Rotational posting 45 Adequate patients/clients at current facility 45 Flexible working hours with minimal workload 45 Opportunity of autonomy 45
221

2.00 .000 2.00 1.93 1.76 1.73 1.56 1.56 .000 .252 .435 .447 .503 .503

12.54344 .001 .500 12.54344 11.52344 3.94444 3.50044 .74244 .74244 .001 .001 .001 .001 .462 .462 0.5 .433 .256 .233 .056 .056

1.56 .503 1.51 .506 1.42 .499 1.33 .477 1.31 .468 1.24 1.24 1.22 1.11 1.04 1.02 1.00

.74244 .462 .056 .14744 .883 .011 -1.04544 .302 -.078 -2.34544 .024 -.167 -2.70644 .010 -.189 -.256 -.256 -.278 -.389 -.456 -.478 -

.435 -3.94444 .001 .435 -3.94444 .001 .420 -4.43244 .001 .318 -8.20844 .001 .208 -14.66344 .001 .149 -21.50044 .001 .000 - -

Factors that may motivate the Permanent Nurses: Getting a more refined picture within the group of nurses, the analysis was also done for the group of the permanent nurses. While, exploring the motivational factors that may motivate the permanent nurses to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: Financial incentives for rural posting/ Rural

allowances/performance incentives (1.87), Improve living conditions

(Access to

amenities like housing, water, electricity, conveyance and communication) (1.77), Good reward and achievement recognition system (1.63), Training and skill development Opportunities (1.51), Career development opportunities (1.45),

Adequacy of equipment, drugs and supplies at Health centre (1.40), Improved working condition (1.38), Good teamwork and good interpersonal staffs relationship (1.25), Supportive supervision, management and mentoring (1.17) and Security & Safety at workplace(1.15). Out of which, three factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication), Good reward and achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(52)= 7.836, p= .001, t(52)= 4.715 p= .001 and t(52)= 2.409, p= .044 respectively. Table 126: Descriptive statistics of factors that may motivate the permanent nurses to retain in current job in rural and remote area Factors
N Mean Std. Dev Test Value = 1.5 Sig. Mean (2t df tailed) Diff.

Financial incentives for rural posting/ Rural allowances/performance incentives Improve living conditions Good reward and achievement recognition system Training and skill development Opportunities Career development opportunities Adequacy of equipment, drugs and supplies at Health centre Improved working condition Good teamwork and good interpersonal staffs relationship Supportive supervision, management and mentoring Security & Safety at workplace
222

53 1.87 .342 53 1.77 .423 53 1.63 .504 53 1.51 .505

7.836 52 .001 .368 4.714 52 .001 .274 2.409 52 .044 .130 .136 52 .892 .009

53 1.45 .503 -.683 52 .497 -.047 53 1.40 .531 -1.422 52 .161 -.104 53 1.38 .489 -1.824 52 .074 -.123 53 1.25 .434 -4.269 52 .001 -.255 53 1.17 .379 -6.342 52 .001 -.330 53 1.15 .361 -7.031 52 .001 -.349

Opportunities of continuing education/higher education (support for further education) Adequate patients/clients at current facility Rotational posting Availability of good schools for children Flexible working hours with minimal work load Opportunity of autonomy Increase salary by half Increase salary by double Job Security

53 1.11 .320 -8.803 52 .001 -.387

53 53 53 53 53 53 53 53

1.11 1.09 1.06 1.04 1.02 1.00 1.00 1.00

.320 .295 .233 .192

-8.803 -10.008 -13.836 -17.493

52 52 52 52

.001 .001 .001 .001

-.387 -.406 -.443 -.462

.137 -25.500 52 .001 -.481 .000 .000 .000 -

4.4.5.3. FACTORS THAT MAY MOTIVATE THE MID-WIVES TO STAY Getting a more refined picture, the analysis was done for the group of the Midwives also. While, exploring the motivational factors that may motivate the midwives to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural services: 1) Financial incentives for rural posting/ Rural

allowances/performance incentives (1.97), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (1.95), 3)

Good reward and achievement recognition system (1.63), 4) Training and skill development Opportunities (1.50), 5) Career development opportunities (1.47), 6) Adequacy of equipment, drugs and supplies at Health centre (1.46), 7) Increase salary by half (1.45), 8) Job Security (1.41), 9) Improved working condition (1.35) and 10) Security & Safety at workplace (1.34). Out of which, three factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) and Good reward and achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(122)= 29.110, p= .001, t(122)= 23.137 p= .001 and t(122)= 2.877, p= .005 respectively. Table 127 : Descriptive statistics of Factors that may motivate the Mid-wives to retain in current job in rural and remote area
Test Value = 1.5

Factors

Std N Mean Dev.

Sig. Mean df (2-tailed) Dif.

Financial incentives for rural posting/ Rural 1231.97 .178 allowances/performance incentives Improve living conditions 1231.95 .216
223

29.110 122.001 .467 23.137 122.001 .451

Good reward and achievement recognition system Training and skill development Opportunities Career development opportunities Adequacy of equipment, drugs and supplies at Health centre Increase salary by half Job Security Improved working condition Security & Safety at workplace Opportunities of continuing /higher education (support for further education) Good teamwork and good interpersonal staffs relationship Increase salary by double Supportive supervision, management and mentoring Rotational posting Availability of good schools for children Adequate patients/clients at current facility Opportunity of autonomy Flexible working hours with minimal work load

1231.63 .486 1231.50 .502 1231.47 .501 1231.46 .500 1231.45 1231.41 1231.35 1231.34 1231.30 .499 .493 .479 .476 .460

2.877 122.005 .126 .090 122.929 .004 -.630 122.530 -.028 -.992 122.323 -.045 -1.174 -2.102 -3.484 -3.693 -4.797 122.243 122.038 122.001 122.001 122.001 -.053 -.093 -.150 -.159 -.199

1231.20 .398

-8.497 122.001 -.305

1231.16 .371 -10.099 122.001 -.337 1231.15 .355 -11.052 122.001 -.354 1231.13 1231.09 1231.03 1231.02 1231.02 .338 .287 .178 .127 .127 -12.146 -15.892 -29.110 -42.246 -42.246 122.001 122.001 122.001 122.001 122.001 -.370 -.411 -.467 -.484 -.484

Factors that may motivate the Contract mid-wives: Getting a more refined picture within the group of mid-wives, the motivational factors that may motivate the contract mid-wives to retain themselves in the present rural area health institution, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural service: 1) Financial incentives for rural posting/ Rural allowances/performance incentives (2.00), 2) Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) (2.00), 3) Increase salary by half (1.73), 4) Job Security (1.67), 5) Good reward and achievement recognition system (1.65), 6) Career development opportunities (1.61), 7) Training and skill development Opportunities (1.57), 8) Security & Safety at workplace (1.53), 9) Adequacy of equipment, drugs and supplies at Health centre (1.44) and 10) Opportunities of continuing education/higher education (support for further education) (1.43). Out of which, six factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication), Increase salary by half, Job Security, Good reward and achievement recognition system and Career development opportunities are statistically significant at Mean Test
224

Value=1.5, 95% C.I, it is significant at t(74)= 10.534, p= .001, t(74)= 10.534, p= .001, t(74)= 4.539, p= .001, t(74)= 3.041, p= .003, t(74)= 2.772, p= .007 and t(74)= 2.002, p= .049 respectively. Table 128: Descriptive statistics of factors that may motivate the contract Midwives to retain in current job in rural and remote area N Mean Std. Test Value = 1.5 Factors
Dev. t df Sig. Mean (2Diff. tailed)

Financial incentives for rural posting/ Rural allowances/performance incentives Improve living conditions Increase salary by half Job Security Good reward and achievement recognition system Career development opportunities Training and skill development Opportunities Security & Safety at workplace Adequacy of equipment, drugs and supplies at Health centre Opportunities of continuing education/higher education (support for further education) Improved working condition Increase salary by double Rotational posting Good teamwork & good interpersonal staffs relationship Supportive supervision, management &mentoring Availability of good schools for children Adequate patients/clients at current facility Opportunity of autonomy Flexible working hours with minimal work load

75 2.00 .000 10.534 74 .001 .500 75 75 75 75 75 75 75 75 2.00 .000 10.534 74 .001 .500 1.73 .445 4.539 74 .001 .233 1.67 .475 3.041 74 .003 .167 1.65 .479 2.772 74 .007 .153 1.61 .490 2.002 74 .049 .113 1.57 .498 1.275 74 .206 .073 1.53 .502 .575 74 .567 .033 1.44 .500 -1.040 74 .302 -.060

75 1.43 .498 -1.275 74 .206 -.073 75 75 75 75 75 75 75 75 75 1.37 .487 1.27 .445 1.20 .403 1.19 .392 -2.253 74 .027 -.127 -4.539 74 .001 -.233 -6.452 74 .001 -.300 -6.918 74 .001 -.313

1.12 .327 -10.059 74 .001 -.380 1.08 .273 -13.318 74 .001 -.420 1.04 .197 -20.193 74 .001 -.460 1.01 .115 -36.500 74 .001 -.487 1.00 .000 - -

Factors that may motivate the permanent mid-wives: Similarly, exploring the motivational factors that may motivate the permanent mid-wives to retain themselves in the present rural area, the responses of these employees reveal the following top 10 motivational factors for retain themselves for the rural service: 1) Financial incentives for rural posting/performance incentives (1.92), 2) Improve living conditions (1.88), 3) Good reward and achievement recognition system (1.78), 4) Adequacy of equipment, drugs and supplies at Health centre (1.48), 5) Training and skill

development Opportunities (1.40), 6) Improved working condition (1.31), 7) Career development opportunities (1.25), 8) Good teamwork and good interpersonal staffs relationship (1.21), 9) Supportive supervision, management and mentoring (1.21) and
225

10) Availability of good schools for children (1.19). Out of which, three factors, Financial incentives for rural posting/ Rural allowances/performance incentives, Improve living conditions and Good reward and achievement recognition system are statistically significant at Mean Test Value=1.5, 95% C.I, it is significant at t(47)=10.335, p= .001, t(47)= 7.774, p= .001 and t(47)=3.159, p=.022 respectively. Table 129: Factors that may motivate the permanent Mid-wives to retain in current job in rural and remote area N Mean Std. Test Value = 1.5 Factors
Dev t df
tailed)

Sig Mean (2- Diff.

Financial incentives for rural posting/ Rural 48 allowances/performance incentives Improve living conditions 48 Good reward & achievement recognition 48 system Adequacy of equipment, drugs and supplies at 48 Health centre Training and skill development Opportunities 48 Improved working condition 48 Career development opportunities 48 Good teamwork & good interpersonal staffs 48 relationship Supportive supervision, management 48 &mentoring Opportunities of continuing /higher education 48 Availability of good schools for children 48 Flexible working hours with minimal workload 48 Security & Safety at workplace 48 Rotational posting 48 Opportunity of autonomy 48 Adequate patients/clients at current facility 48 Increase salary by half 48 Increase salary by double 48 Job Security 48

1.92 .279 1.88 .334 1.78 .398 1.48 .505 1.40 1.31 1.25 1.21 .494 .468 .438 .410

10.33547 .001 .417 7.77447 .001 .375 3.15947 .022 .283 -.28647 .776 -.021 -1.46047 -2.77347 -3.95847 -4.92447 .151 .008 .001 .001 -.104 -.188 -.250 -.292

1.19 .394 1.10 1.10 1.04 1.04 1.02 1.02 1.02 1.00 1.00 1.00 .309 .309 .202 .202 .144 .144 .144 .000 .000 .000

-5.48947 .001 -.313 -8.88347 -8.88347 -15.72547 -15.72547 -23.00047 -23.00047 -23.00047 .001 .001 .001 .001 .001 .001 .001 -.396 -.396 -.458 -.458 -.479 -.479 -.479 -

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SECTION 5 ANALYSIS OF THE REFORM INITIATIVES FOR DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS, NURSES AND MID-WIVES

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4.5.1. REFORM INITIATIVES FOR RECRUITMENT AND DEPLOYMENT (DISTRIBUTION)

This section of the chapter addresses the descriptive finding of reform initiatives in respect of the human resources in the public health sector, specifically the initiatives related to distribution, attraction and retention of physicians, nurses and mid-wives in the rural and remote areas for ensuring primary health care with especial emphasize on maternal and child health. This part of the descriptive analysis also presents the views of physicians, nurses and mid-wives on reform initiatives. 4.5.1.1. REFORM INITIATIVES TO ADDRESS THE ISSUE OF NUMERICAL INADEQUACY OF HEALTH WORKFORCE (PHYSICIANS, NURSES & MIDWIVES) IN THE STATE a) Emphasized on contractual appointments for rural and remote area: While it is true that human resource is one of the biggest challenges in Indian public health sector, Government of India has brought the thrust on human resource in centre stage. The serious issue in human resource management is huge gaps in critical health manpower in government health institutions, particularly in rural areas, that provide healthcare to the poorer segments of population. A large number of vacant posts of physicians, nurses and mid-wives are reported at the primary level in government hospitals. Also, almost all of the specialist positions in government hospitals in rural areas in the state are lying vacant. Most of the management representatives have pointed out for the difficulty in getting physicians, Nurses for the health posts. The management representatives pointed out the crisis is more for the GNMs and the physicians for rural and remote areas. It is may be due to lower graduates of medicines and nursing candidates. They also revealed that they have many post lying vacant in search of the GNMs (Nurses) and some of them are even personally arranging these cadres for the rural health services. It is also pointed out by the management representatives that in the light of very limited candidates for the posts they have to compromise on the technical expertise and experience of the candidates and have to appoint them for the rural and remote areas which obviously affect the quality of the services in the rural and remote areas. The situation at the secondary and tertiary level is somewhat better, as doctors generally prefer to reside in urban areas.

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Increasing the number of health worker is a major challenge in improving the health system, to address the issue of numerical adequacy with cost effectiveness is contracting the human resource-State Level Official. The past one decade has seen a growing tendency of contractual employment in the public health sector in the state, toward a fundamental restructuring for addressing the inadequacy issue under National Rural Health Mission (NRHM). A significant change in placement of human resource has been seen since 2005 in the country. Several measures were initiated to fill the wide gaps of health workforce shortage in the state under the Reform process in human resource for health sector. Within the scope of this flagship programme one of the measures that have been adapted by the state with vis--vis to the national policy is of recruiting the health workforce is in contract appointment. This process has involved recruiting the health workforce to minimize the gaps of numerical inadequacy and supported the tremendous growth in contract employment in this sector in Arunachal Pradesh along with rest of the states in the country. In the last seven years of Government of India flagship programme National Rural Health Mission in the state has tried reforms with resources available. Measures were initiated to fill the vacant posts of Medical officers, Nurses and Mid-wives in the state with higher preference to rural and remote areas. The NRHM division of the state undertakes the recruitment and placement of Physicians including the Specialist cadres, Nurses and Mid-wives. According to the statistics of MoHFW, Govt. of India and Govt. of Arunachal Pradesh, 1 no. of Specialist , 57 nos. of Doctors , 21 nos. AYUSH Doctors , 15 Dental Surgeons, 196 nos. of Staff Nurses and 158 nos. of ANM have been appointment by the State Govt. on contract for the health institutes in Arunachal Pradesh. Similarly, in the country an addition of total numbers of 2460 Specialist, 8624 MBBS doctors, 7692 Ayush Doctors, 26793 Staff Nurses, 46690 ANM and 14490 other Para Medics have been recruited in contract employment. Management Perspective: Pros and cons of recruiting in contract I. Pros : i) Cost Effectiveness: The contractual employees are cheaper than the permanent employees, it cost the department in much less than permanent employees, as there are no provision of other financial benefits other than a consolidated salary.- Management Representative from the state. The remuneration structure
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is affected through the department using the services of a contractual employee. Thus, there is no burden upon the government for benefits like-insurance, medical, leave encashment and retirement benefits etc. as it is given to the permanent employee. It is also a viable alternative to the sector as long as downsizing/restructuring is concern. Using the contract employees the health department gets the ability to grow in size to meet the demand in large scale without large scale effect on financial burdens. ii) Flexibility: To a large extent the provision of contractual employee is a resource balancing exercise of the sector. Fitting the human resource requirement in existing resource pool of salary structure, when a permanent employment in respect of higher rate pay is a problematic. iii) Availability of manpower for higher days Less employees on long leaves: No burden for paying benefits to these employees- District Management Representative. This group of employees is not entitled to all range of leaves as it is entitled to the permanent employees. This group gets very short term leaves and not entitled to long term leaves and thus ensures the availability of manpower for higher days in a year. iv) Simplified way of recruitment and reduce cost on recruitment and selection process: The contractual employees are recruited by walk-in-interview process in the state, which reduces the cost of recruitment process-Management Representative from the state. In the state of Arunachal Pradesh, all the vacancies under NRHM, both new and recurring are immediately filled up through open advertisement in the local newspapers at the district level. In order to ensure rational deployment of contractual manpower, recruitment is done at district level and appointments are made for specific health centres without provision of transfer. The appointments are district and facility specific and non transferable. However, intra district relocation is allowed in certain exceptions. v) Reduce unemployment percentage: All the contractual staff under NRHM is normally employed for the entire NRHM period, subject to renewal of annual contract based on performance, unless otherwise terminated on grounds of breach of contract -Management Representative from the state. By engaging a huge numbers of employees in contract has reduce the unemployment percentage. It has to an extent solved the unemployment problem, though it is a temporary arrangement and valuable to the current short-term development.
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II. Cons : i) Investment on training and development of contractual employees: Under this programme in public health sector, huge investments in the employees are done in the form of training and development opportunities. In the terms of stability of the trained employee is less, as the employees are contractual and may leave the sector in order to ensure their stability in other work/job. In order to ensure a return on those investments, it is the public health sector that stands at instability. Under NRHM different types of skill up-gradation training such at Skill Birth Training, Medical Termination of Pregnancy, Life Saving Anesthesia Training, Emergency Obstetrics Care, Neo-natal care etc. which are provided irrespective of contract or permanent employee- -Management Representative from the state. ii) Performance: The issue of the performance of the contract employees was divided into two different opinions of the management representatives. The opinion on performance cannot be generalizing the two groups of employees contract and permanent. Those favored the best performance by contract employee is due to the fear of non renewal of contract and compulsion to show the performance. Those who support the worst performance by contract employees had echoed the comments that due to the insecurity of job, discrimination as a contract employee in pays and perks may be one of the reasons the productivity issue could be compromised. iii) Employee Turnover or attrition: Some contract employees had left contract jobs over dissatisfaction with the low pay and lack of benefits- comment by a state level management representative. In the interests of stability of employment, contractual employees may shift their job to other sector who offers employment stability and to take steps to reduce turnover and re-filling of vacant position may cost the department. However, there is no concrete data on attrition; the management representatives estimate it to 05-10% attrition per year. iv) Short term arrangement (Less long-term feasibility): The contractual arrangement of employees in public health sector only provides a short-term solution for the inadequacy in human resource. The management representatives also favor the statement, as it is time bound specific program for architectural correction of health delivery system and it only provides the short term solution of the problem unless the employees are made a permanent employee in the sector.
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The contract employees felt no attachment to their employers' long-term strategies because they are on short-term contracts. Employee Perspective: view on contracting the pros and cons Almost all of those interviewed were positive about their experience at this sector, only in positivity in thinking in future they will be turned out to be a permanent employee in the sector and they come up at par to the other existing permanent employees. The following section focuses on findings of interaction and questionnaire responses with the physicians, nurses and mid-wives). I. Pros: i) Solved unemployment problem of the employee: The contractual employment has solved the unemployment problem of this group of peoples and now they are engaged in employment activity to earn their livelihood and atleast solved financial hardship. ii) Access to simplified process of recruitment process- Walk-in-interviews: Most of the contractual employees those who were part of the study were appointed through walk-in-interview. Some of them were appointed through double stage of recruitment and selection process of written examination and interview process. It is observed that major portion of the employees were appointed in contract were simple process of Walk-in-interview. This process of recruitment and selection process takes less time and efforts in respect of the prospect candidates to be appointed on contract. iii) Flexibility in job shifting/ Easy on job shifting: The existing norms for leaving the job are very simple for the contractual employees. Giving one month advance notice to the employer or in lieu of one month salary a contractual employee can terminate the contract and leave the job. The job shifting is easy in terms of contract norms. I can easily leave the job if I get a new job that lead to an offer to be brought on board full-time as a regular.- A physician. iv) Training opportunity: Majority of contract employees stated in response to the questionnaire that they are getting full opportunity for skill up-gradation trainings from the department. There is no discrimination regarding the status of employment for proving various skill up-gradation training. Availability of

training opportunities can be seen as a factor of attraction and retention of the contractual employees. They are getting opportunity for skill acquisition and have
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the access to all type of training in the department as per their eligibility. They are provided with a wide variety of training opportunity and provide exposure to different type skill up-gradation of their related work and techniques. It can also be developmental in a wider sense of developing both technical and professional skills. v) Contracting jobs may ultimately lead to a permanent offer : The physicians and nurses generally expected employer will give them permanent offer. This is one of the advantage and retention factor. Number of the earlier contract physician and nurses were offered and regularized from the contract pool to the state govt. permanent posts- A Physician. Most of the respondents believed that they will be significantly regularized if they remain in government service. II. Cons: i) Provides a short-term and temporary solution: This is a temporary solution to their employment needs. Contract employees shared that they are going to be short-term tend to be invisible as per the health program in which they are appointed. There is a huge contractual employee in the state, which may be difficult for the government to regularize us in a short period of time, they tend to be treated by many as just not really there-A Nurse. ii) Feeling of job in-security: Security issues were important for many contract physicians, nurses and mid-wives. They commented on the lack of security and less reliable working arrangement for them. It doesnt provide the security and benefits of full-time employment. Thus, the level of security that employment offers insecurity arose as an issue. iii) Financial and other Pay: Different pay scale is followed for a contract which is not at par with the permanent employee. They are paid less than those of permanent employees performing the same tasks and they were without other employment benefits, pension contribution/retirement benefits/plans, medical benefits, life insurance, paid vacation, educational reimbursement etc. and opportunities for employment. One of the respondent shared-the bank is not going to loan you money because I am a contract employee. This puts additional stress factors in their lives that are absent in permanent employees' lives. Contract employees were less satisfied with certain aspects of their jobs, such as compensation and benefits at par with the existing contract employees. Different set of pay and conditions can create an environment where conflict is possible.
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One of the example of agitation in India is from Rajasthan No other benefits Strike by Rajasthan contractual employee under NRHM for other benefits. iv) Lack of opportunity for career advancement: The ladder of career is absence in the scenario of contract employment. Career advancement and promotion avenue are almost absent for contract employees- A Mid-wive. The respondents stated that they do not have the avenues for career advancement and promotional ladder unless and until they are regularized in the department. v) Lack of coordination and discrimination as in contract between Regular & Contractual employee: The contract employee respondents stated that permanent employee may not invite them in to their inner circle or share as much information. There is always a discrimination of being contract workers in the middle of the circle of permanent employee- A nurse. In addition to individual level problems with perceived inequity, group level problems have also been identified. It is observed that the contract employees are treated differently in the workplace by employer, by management, by human resource policies, and by permanent coworkers. vi) Lack of loyalty, commitment and lack of motivation: They also stated that they have less commitment towards their employer. The commitment is less and they felt no attachment to their employers long-term or short-term strategies. Their short-term contract meant they probably would not be employed long enough to see long-term objectives achieved. A hard feeling among contract employees has been observed. All contract employees admitted suffering stress connected to contract employment and less motivation. 4.5.1.2. EMPHASIZING ON PROFESSIONAL TRAINING INSTITUTES FOR ENHACING THE NUMBERS OF TECHNICAL HUMAN RESOURCE IN THE STATE Enhancing the pool of physicians, nurses and mid-wives within the state is a alarming issue. It has not been kept pace with the need, especially with the physicians, nurses and mid-wives. Absence of adequate training institutes for medical and nursing courses results in low numbers of medics and paramedics produced for the state. Till today, there is no medical college in public sector or in private sector for Allopathic disciplines besides a Homeopathy Medical College in private sector. Yearly a fixed numbers of students according to the Govt. of India quota seats, are placed in various Medical colleges all over India. 32 seats in First nomination 2010 and 34 seats in first

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nomination 2011 has been allotted to the students for the MBBS course in various Medical Colleges in India (DHTE, 2010 & DHTE, 2011). For the training of nursing personnel, the state runs a lone Nursing School for ANMs at General Hospital, Pasighat, East Siang District of Arunachal Pradesh. The institute runs training programs on midwifery (ANM) nursing courses. There are no fix numbers of ANM admission seats per year in this ANM School, in the year 2009-10, the number was 70, a year before in 2008-09, it was 47. The variation depends on Government of Arunachal Pradesh continuing changing policy. In the state there is a chronic and serious shortage of GNMs, as there is no GNM training school in govt. sector in Arunachal Pradesh. A few number of GNMs are produced in GNM School at Ramakrishna Mission Hospital, Itanagar. With this inadequacy in teaching schools, insufficient numbers of professionally trained personnel to compensate the situation. Under the reform process the state government is keen to address this issue, and at this moment one nursing school at Daporijo, the Headquarter of Upper Subansiri District and 3 ANM schools at Tawang at Tawang District, Aalo (Along) at West Siang District and Namsai at Lohit District are on project execution level and expected to be completed in 2013-14. The Govt of India has recently released first instalment fund for establishment of one GNM school in Upper Subansiri district. As per the civil works norms framed by the Indian Nursing Council, the construction projects are being undertaken through Works department of the state government. The construction is going on. The projects are expected to take 1 year for completion and the nursing schools will start functioning from the financial year 2013-14. This is expected to augment the supply of nurses and reduce the deficiency confronted by the State health sector presently. The HRTC at Pasighat is the lone institute in the entire State for the training of para medical staff which is fully functional. The institute trains ANM and Health Assistants. GoI has sanctioned 3 Para medic schools during 2010-11. The constructions are going on at Tawang, Aalo and Namsai (ANM School). (Source : SPIP, 12-13). Regarding medical education in the state, Arunachal Pradesh Government, in the month of September 2011, signed a tripartite memorandum of understanding (MOU) with Union Health Ministry and Hospital Services Consultancy Cooperation (HSCC) India Limited, for strengthening and up-gradation of Arunachal State Hospital at Naharlagun. The health and family welfare ministry, Govt. of India is
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supporting the up-gradation of the 140 bedded hospitals to a 300 bedded multidisciplinary hospital. MoHFW had sanctioned the Rs. 185 crore 300-bedded hospital projects on priority with a target time of 24 months for its upgrading to a medical college subsequently. (With inputs from Arunachal Times, 23rd Sept 2011). However, it will take a couple of years to completely established Medical College, after fulfilment of several formalities. The State level training Centre is under implementation through funding support from GoI at a cost of Rs 2 Crores. The construction work of the training centre is presently in full swing. Once completed, this is expected to reduce the dependence of the health department on other department for conducting training activities. Comprehensive training course materials, training methods and equipment in place to ensure quality of training. (SPIP, 2012-13) Most of the management representatives have pointed out for the difficulty in getting physicians, Nurses for the health posts. The management representatives pointed out the crisis is more for the GNMs and then the physicians for rural and remote areas. It is may be due to lower graduates of medicines and nursing candidates. They also revealed that they have many post lying vacant in search of the GNMs (Nurses) and some of them are even personally arranging these cadres for the rural health services. 4.5.1.3. INITIATIVES FOR HR POLICIES FOR RECRUITMENT AND DEPLOYMENT OF DOCTORS, NURSES AND MID-WIVES: There is no comprehensive HR Policy in Public health sector in Arunachal Pradesh. There are recruitment rules for different category of health workforce. The recruitment and other service conditions for staff in health services of the state government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The regular doctors and specialist cadre comes under the purview of service rule of APHS. The State health department has in place a concrete system for career progression for physicians, nurses and mid-wives, where all have promotional avenues as per seniority and availability of vacancies. The recruitment rules are the specific instrument of the state govt. for recruitment, classification, method of

recruitment/promotion including constitution of departmental promotion committee, salary etc. However, there is no specific HR Policy for contractual physicians, nurses and midwives and other health workers.

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The state Govt. is preparing a 5 year strategies and policy document for augmentation and maximization of Human Resources. This includes sustainable HRD and policy reform from restructuring/ rationalization of HR deployment. The vibrant HR policy includes terms of recruitment / filling up of vacancies, rationalising posting, specific tenure of posting, career progression and incentives. The policy is focussing on improving maternal and child health indicators through posting of required manpower for maximising performance at identified functional facilities. (SPIP-NRHM Arunachal Pradesh, 2012-13). In order to ensure rational deployment of contractual physicians, nurses and mid-wives, recruitment is done at district level and appointments are made for specific health centres without provision of transfer. The contractual position is on facility based need and recruitment is only for that facility other than district health society. The appointments are district and facility specific and non transferable. However, intra district relocation is allowed in certain exceptions. The state is also contemplating rational transfer of permanent physicians and nurses & mid-wives on rotation after completion of atleast 3 years in a particular posting place. The measures include compulsory rural posting for certain period, earmarking certain percentage of postgraduate seats for doctors who have served in rural areas, and provision of rural service allowance, etc.
Thus, the state Govt. is preparing a 5 year strategies and policy document for

augmentation and maximization of Human Resources. This includes sustainable HRD and policy reform from restructuring/ rationalization of HR deployment. The HRD issues related to contractual manpower under NRHM is in placed that include the following: 1. The contractual manpower has been put in place following gap analysis through facility survey report. 2. All the contractual appointments are decentralized to the District Health Society. 3. The recruitment process is done transparently through advertisement in the newspaper. 4. The process of selection is based on the performance of the candidate in the walk in interview. 5. The contractual position is on facility based need and recruitment is only for that facility other than district health society. 6. The appointment is only for a period ending in the 31st year of the year.
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7. The appointment is purely temporality and non transferable. However, intra district rational relocation as required by the District Health Society is allowed in exceptional cases. 8. The extension of contractual services is subject to good performance and recommendation by the appraisal board. 9. An undertaking is sign by the contractual appointee to abide by the appointee for the period of appointment. 10. A new indicators based appraisal format is being used for ANM for further extension of the services. 11. Monthly appraisal of all the PMSU staff is in place for regular monthly appraisal. 12. In term of carrier progression/incentive, the State Govt. is regularizing their job into the state health services especially for technical manpower from time to time. 13. Further improvement in the working condition and careers progression will be put in place during 2012-13 and years to come. 4.5.1.4. DECENTRALIZATION OF HR ACTIVITIES UNDER REFORM PROCESS Health service decentralization is being pursued by Government of India under National Rural Health Mission at all levels, decentralization of authority, responsibility, and resources for personnel functions is delegated in a decentralized way in reform process. It is important to achieve effective human resource management and to improve staff performance. However, decentralization itself entails large-scale development of capacity at the local level for health planning, financing, allocation and accounting for resources, and HR management functions including staff recruitment, payroll and allowance documentation, and maintenance of personnel records. The Human Resource Management functions including recruitment and deployment are decentralized to the districts level. The recruitment transfer and posting of manpower are done at the District level. The District is ensuring rationality, appropriate placing of manpower to the facilities to make functional. As per the District requirement, manpower is sanctioned from the state level and District are recruiting & posting as per the guidelines and requirement. The recruitment reform process is only for the contractual workforce with non-transferable and district specific and with their performance appraisal. Though decentralization is used as an ornamental word into the reform process, the actual implementation in the view of low capacity at the lower level is a
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concern. The new decentralized organizational structures mean that the role of district authority as employer is transferred from state level, but to configure the new structure of decentralized environment there is no provision reform process for HRM system and HRM personnel in the organisation at state or the district level, that to strategically support the initiation. The transfer of human resources functions from State level to district level without a comprehensive design and structure is quite a big challenge for the district administration. Over all in the absence of an appropriate HR policy at state and district level on human resource, is still provide a big deal of challenge for the district authority. Decentralization brings considerable new skill needs, particularly in management competencies. District managers capacity to respond to these and other performance gaps through training is, however, there is a budget constraint. The new structures of administration, new budgeting style and reporting mechanisms, under reform process is the side of decentralization, but the local capacity of absorptions is always a matter of concern. District health managers have a range of new responsibilities, depending on the powers that have been decentralized to them. Decentralization makes district health managers responsible for improving the way health services are targeted to meet priority health needs, organized, and managed within the available budget. To do this, they need a workforce whose staff numbers and mix are as appropriate as possible to these needs, and whose cost is affordable. However, the study finds that in the reform process in Arunachal Pradesh, decentralization in many field including HR management issues have be percolated down up-to the district level and to some extend to the health institutes, but there is a need of far greater attention to HR skill deficits. The decentralization has been done in respect of power and resources to the district level and lower level of health administration for HR administration and management. Under this decentralised process, the recruitment is done with the District Recruitment Board, as formed at the district level to perform the functions of Recruitment and selection. The main human resource management roles at the district level were to identify staff requirements i.e., Human Resource planning, and their training needs and to ensure that health facilities had the minimum staffing requirements. In addition, the powers to recruit, exercise disciplinary control, and to remove persons from district service were delegated to the District. Pay determination is heavily centralized at state level and national level, as part of broad based culture as other public sector. Decentralized the district autonomy is facilitating the local
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preference and to retain the workforce in the district. However, as mentioned earlier to manage the decentralized activities there is shortage of HR management personnel in the district level, which create a challenging environment at this and subsequent level of administration. As to increase the requirement for administrative and managerial staff in the system and likely to associated increase requirement for performance management also.

4.5.2. REFORM INITIATIVES FOR ATTRACTION AND RETENTION

4.5.2.1. ADOPTION OF SIMPLIFIED WAY OF RECRUITMENT AND SELECTION PROCESS The contractual employees are recruited by walk-in-interview process in most of the districts, which reduces the cost of recruitment process. The process of selection is based on the performance of the candidate in the walk in interview. All the vacancies for contractual appointments both new and recurring are immediately filled up through open advertisement in the local newspapers at the district level in a decentralised manner. The appointments are made for a period of 1 year on contractual basis, with the provision for renewal of contract further for another year on the basis of previous years performance. 4.5.2.2. EMPHASIZED ON TRAINING AND DEVELOPMENT OPPORTUNITIES Training and development is vital for every organization to cope with changes from time to time and perform well. This helps in honing of skills, developing versatility and adaptability. In this content Mark Twains statement is crucial which states. There is nothing that training cannot do. Nothing is above its reach or below it(Ramani, 2003). In case of growing and learning organizations the importance of training is even much more crucial. Andragogy (the science of adult learning) demands tremendous effort from the trainer what should be more effective and purposeful (Rao, 2003). There is tremendous efforts can be seen in the reform process for skill upgradation of the training and the physicians, nurses and mid-wives are satisfied with the process and most of the workforce are attracted and retain themselves due to this factor in the sector. A major pre-requisite for providing quality health care service is upgrading the skills and knowledge of all health personnel as well as this is an integral factor for retaining technical human resource in rural and remote areas. The
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Government is providing frequent scope for programme based training with time to time refresher training to all level of functionaries including ANMs, GNMs & Medical Officers. Huge investments on the employees are done in the form of training and development opportunities. There are different types of skill up-gradation training such at Skill Birth Training, Medical Termination of Pregnancy, Life Saving Anesthesia Training, Emergency Obstetrics Care, Neo-natal care etc. which are provided to physicians, nurses & midwives in primary and secondary level of health institutes. There is no discrimination regarding the status of employment for proving various skill up-gradation training. Availability of in service training opportunities can be seen as a factor of attraction and retention of the employees in primary and secondary health institutes in rural and remote areas. They are getting opportunity for skill acquisition and have the access to all type of training in the department as per their eligibility and location of the health institutes. They are provided with a wide variety of training opportunity and provide exposure to different type skill upgradation of their related work and techniques. It can also be developmental in a wider sense of developing both technical and professional skills. The multi-skill trainings & capacity building of the workforce are emphasized on physicians, nurses & mid-wives from the rural and remote area. Skill up-gradation is an essential component of in-service training programmes. The skill up-gradation varies enormously depending upon the qualifications of the personnel and the institution where he/she is working. For optimum utilization of human resources, skill and competence enhancement is of paramount importance. Therefore, with the objective to maintain the skill and competence level of the employees as well as to improve upon these skills, different training programmes are designed and undertaken in Health Sector under NRHM. Table 130: Gist of various training under NRHM for physicians, nurses and mid-wives Sl. Type of Training Category of participants Duration No. 1 SBA SN/ANM/LHV 3-6 weeks 2 EmOC MOs 16 weeks 3 Life Saving Skills in MOs 18 weeks Obs. Anesthesia 4 Blood storage MOs, Lab. Tech. 3 days 5 RTI/STI MO/SN/ANM/LHV 2 days 6 MTP including MVA MOs 15 days 7 IMNCI MO/ANM/LHV/AWW etc 8 days
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8 9 10

Immunization MiniLap Lap. Sterilization

11 IUCD 12 NSV 13 Adolescent Health 14 PDC 15 PMU Source : MoHFW, Govt. of India

Health Workers MOs for CHCs/FRU &DH Gynecologist, Surgeon with OT nurse and Assist. ANM/LHV MOs Mos/ANM CMO/Civil sur./hospital suptd.

2 days 12 working days 12 working days 5 days 5 days 5 days 10 weeks 5 days

Under this training and development component for the technical workforce of physicians, nurses and mid-wives, the achievement from 2005 to 2012 under NRHM is presented detail in table 131. Training programmes are conducted on specific thrust areas of maternal health, child health and family planning. Table 131: Achievement cumulative Training for Maternal and Child Health (March 2005-2012) Type of Achievement cumulative Training for Maternal and Child Health till March 2012 LSAS 7 EmOC 8 BEmOC 12 SBA (MO/GNM/ANM) 256 MTP (MO) 124 RTI/STI (MO/GNM/ANM) 258 IMNCI (MO) 184 IMNCI (SN) 79 IMNCI (ANM) 208 F-IMNCI (MO) 69 F-IMNCI (SN) 108 NSSK (MO) 203 NSSK (SN) 156 NSSK (ANM) 16
Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

4.5.2.3. OPPORTUNITY FOR CAREER ADVANCEMENT The State health department has in place a concrete system for career progression for permanent physicians, nursing staff where physicians and nurses have promotional avenues as per seniority and availability of vacancies. The ladder of career is also not absence in the scenario of contract employment of physicians and nurses & mid-wives. The State Govt. provides avenue for career advancement for contractual doctors and nurses by absorbing them into permanent service subject to availability of vacancies and based on the satisfactory performance and placed at the rural and remote areas. Thus, contracting jobs for physicians, nurses and Mi-wives
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may ultimately lead to a permanent offer. A good number of the contract physician and nurses were offered and regularized from the contract pool to the state govt. permanent posts. In Arunachal Pradesh it has compulsory for all the medical graduates to serve in rural areas for a duration varying from 2 - 3 years and also has made it mandatory for all the graduates to complete two to three years of rural service for admission to the PG degree programs. In the state of Arunachal Pradesh Medical Officers on completion of two years of rural service in permanent capacity are eligible to be sponsored by the State, which will cover all expenses of their PG training. 4.5.2.4. FINANCIAL AND OTHER INCENTIVE SCHEMES Consolidated pay rates have been revised on the lines of the rates fixed by the 6th Pay Commission so as to attract contractual physicians, nurses and mid-wives to rural jobs. Salary increments are periodically enhanced subject to availability of fund in the NRHM budget. It is proposed to enhance the pay by about 5% every year from 2013-14. According to the Arunachal Pradesh State Programme Implementation Plan, 2011-12 and 12-13, in order to ensure stay of Health workers in difficult rural and remote areas, the state proposed incentive schemes. Incentive for Difficult Area (A Category) @Rs 2000 per month to 83 ANM, 41 MO, 2 Specialist, 57 Pharmacist, 1 Radiographer, 24 Lab. Tech, and 115 Staff Nurse. For Most Difficult Area (B Category) @Rs 4000 per month to 57 ANM, 16 MO, 21 Pharmacist, 4 Lab. Tech, and 41 Staff Nurse. For Inaccessible Area (C Category) @Rs 6000 per month, 74 ANM, 13 MO, 13 Pharmacist, 5 Lab. Tech, and 26 Staff Nurse are proposed. Among the inaccessible areas, the state has further identified 11 health facilities as most difficult to access. Over and above their salary and incentives proposed above, the health staff will get special package - Medical officer@ Rs 10,000 per month and Nurses @Rs 5,000/- per month. However, the incentives are yet to be seen materialized, it may be due to financial constraints in the state. Table 132: Categorization of rural and remote area for incentive scheme for workforce Sl. Staff Difficult Area Most difficult area Inaccessible area Total No. Category (A Category) (B Category) (C category) 1 Specialist 2 2 2 MO 41 16 13 70 4 Staff Nurse 115 41 26 182 6 ANM 83 57 74 214 Total 323 139 131 593
Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh 243

4.5.2.5. AVAILABILITY OF EQUIPMENTS FOR HEALTH WORKFORCE IN RURAL AND REMOTE AREAS Availability of essential equipments is an imperative for functionalising a health centre as per IPHS and attracts and retain health workforce in rural services. There are several health centres devoid of the essential functional equipments. In view of this, under reform initiatives fully equip PHC and CHC are ensured through regular needs assessment. A robust system of indenting and procurement in respect of medical equipment are in process of development and put in place. Identification of non repairable / functional equipments is done annually and unserviceable equipments are condemned and disposed off to scrapes. As far as possible, the state is looking into awarding of AMC for all categories of equipments and instruments. (Source: SPIP 2012-13) 4.5.2.6. SUPPORTIVE SUPERVISION Supervision of supporting nature has been found relatively more effective. It supportive supervision includes identification of the gap and subsequent immediate best possible immediate solution on the spot with an objective to strengthening the capacity of person being supervised on one hand and obtaining the result through smooth implementation of the programme. The State and District level supervisory monitoring team are regularly visiting the field up to the community level besides facility on the way. The periodical meetings of all concern from the field at district and the State level are also accelerating the pace of both way communications resulting the minimising of impediments in case there is any. 4.5.2.7. INFRASTRUCTURE DEVELOPMENT INITIATIVES INCLUDING ACCOMMODATION FACILITIES AT RURAL AND REMOTE AREAS FOR UNDER REFORM PROCESS Chronically there is inadequacy of residential quarters for workforce at rural and remote areas. For ensuring deploying, attraction and retention of physicians, nurses and especially Mid-wives in rural and remote area, the reform process is emphasizing to develop the residential facilities all over the state. However within the limited resources, prioritization is done to provide residential quarters in the health facilities phase-wise. The identification of the health facilities has been done linking the HR availabilities and acceptable infrastructure. Table 133 to 138 put more light on the infrastructure development in the state regarding residential quarters.

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Table 133: Information on new Constructions of infrastructure in the state under reform process
Health New Construction sanctioned New Construction sanctioned under Facility under NRHM so far in Non High Focus NRHM so far in High Focus Districts Districts
2007-08 2009-10 2010-11 2011-12 2007-08 2009-10 2010-11 2011-12 2008-09 2008-09

Total

CHCs 1 SCs 6 4 0 4 3 44 21 0 11 Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

12

1 105

Table 134: Information on Upgradations of infrastructure in the state under reform process
Health Facility New Construction sanctioned under NRHM so far in High Focus Districts New Construction sanctioned under NRHM so far in Non High Focus Districts 2011-12 2008-09 2011-12 2007-08 2009-10 2010-11

2007-08

2009-10

2010-11

DH

2 3 (Staff Qtr.) (C/o. of Store House) 2 2 (C/o of (C/o of residential residential Qtr.) Qtr.)

7 (Staff Qtrs). 10

3 (Staff Qtr.)

14 (C/o. of Store House) 6 (C/o of residential Qtr.) 3 (C/o. of LR) 1 (C/o. of OT) 16 (C/o of residential Qtr.) 9 (C/o. of LR) 17 (Provision of waiting room & Furniture) 2 (C/o of residential Qtr.)

29

CHCs

22

PHCs

2
(Upgra dation)

1 (Upgradati on) 2 (Staff Qtr.)

4
(Staff Qtts.)

7 (C/o of residential Qtr.) 2 (C/o. of LR) 3 (Provision of waiting room & Furniture)

3 3 (C/o of (Upgrada resident tion) ial Qtr.) 6 (Staff Qtr)

3 (Staff Qtr.)

11 (C/o of residential Qtr.)

89

Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh Table 135: New Constructions of infrastructure in the state under reform process 2012-13

Sl.No
1 2

Type of Health Institute

District Hospital CHC

3 PHC 4 SC 5 Training Centre Source: PIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh
245

New Construction Physic al Target 13 (Qtrs) 4 (Residential Qtr.), 2 LRs, 10 (Residential Qtr.) 28 (Residential Qtr.), 5 LRs 34 1(On going)

Total

2008 -09

Table 136: Identified District Hospitals where New Residential Quarters to be constructed in 2012-13 District Hospitals Existing Qtrs Nos. of New Residential Qtrs proposed Tawang 18 1 Bomdila 24 1 Seppa 15 1 Ziro 21 1 Aalo 25 1 Daporijo 20 1 GH-Pasighat 31 1 Yingkiong 18 1 Roing 25 1 Anini 8 1 Tezu 22 1 Changlang 22 1 Khonsa 20 1 299 Total 13
Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 137: Identified List of facilities (PHCs) that are proposed for new construction of Residential Quarters in 2012-13 District West Kameng E/ Kameng P/ Pare L/Subansiri Kurung Kumey West Siang East Siang U/Siang LD Valley D/Valley Lohit Anjaw Changlang Tirap Upper Subansiri Name of PHCs Thrizino, Sinchung Bameng, Bana, Pakke kesang Jote Poru Sangram, Yangte Gensi, Tirbin, Kaying Yembung, Namsing, Borguli, Koyu Jeying Anpum Etalin New Mohong Wallong Khimiyong, Kharsang Wakka, Panchou Maro

Source: SPIP 2012-13, NRHM Division, Govt. of Aruanchal Pradesh

Table 138 : Identified CHCs for Construction of Residential Quarters in 2012-13 District Name of CHCs West Siang Tirap Upper Siang Papumpare East Siang East Kameng Lower Subansiri Rumgong, Likabali Deomali, Longding Geku Balijan Ruksin Seijosa Yazali
246

Additional 30 nos. of SCs with ANM quarters were constructed from state govt. financial resources in the year 2010-11.

4.5.3. EXPLORING THE VIEWS ON HEALTH SECTOR REFORM FROM THE PERSPECTIVE OF PHYSICIANS, NURSES AND MID-WIVES
To explore the views of the physicians, nurses and mid-wives upon the ongoing reform processes which include the HR activities related to public health sector. The questionnaire was included with seventeen (17) nos. of preset statements on a scale of 1 to 5 of degree of agreement [1) Strongly Disagree 2) Disagree 3) Undecided 4) Agree 5) Strongly agree]. The analysis of the responses has the following descriptive. The analysis of the responses, it is revealed that these three categories have different views on the health sector reform process on Human resource activities. The analysis of the all responses with the preset variable factors is presented pointwise below: 1. Statement : The Reform has made the Human Resource Policies clear and understandable at all level The first question in this part of questionnaire was to explore that the employees are clear about the human resource policies of the organization and that is also it their own context and level. All the employees are quite reserved at this, that they are clear about the HR policies of the organization, the mean of the response is only 2.06 in the scale of 5, which is lower and signifies that there is more disagreement to the statement that reform has succeeded to clear presentation of the HR policies in the context of the physicians, nurses and mid-wives. The responses revealed that there is difference between the groups, the values of F(2, 331) = 6.093, p = .003. The Physicians have the mean of 2.25 for the responses, 2.03 for the nurses and 1.92 for the mid-wives. It seems the physicians are little understanding, but we cannot say this group is also in favour that the reform has made the Human Resource Policies clear and understandable at your level. However, the mean of the responses are the lowest we cannot say that the reform process has made human resource policies understandable at all level and contributed to the HR function of the organisation.

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2. Statement: Reforms have made the placement, transfer and promotion transparent, fairer and unbiased All the employees are quite reserved and disagreed on this statement; the mean of the responses is only 2.05 in the scale of 5, which is lower at side. The responses revealed that there is no significant difference between the groups, the values of F(2, 331) = 1.110, p=.331 and the groups thinks in similar way. The physicians have the mean of 2.12, nurses have 2.04 and the mid-wives only 1.92. The mean scores clearly indicating in the scale of five, that there is no change in the scenario and still no existing of transparent, fairer and unbiased placement, transfer and promotion. The groups have the view that the reform has failed to make placement, transfer and promotion to transparent, fairer and unbiased. 3. Statement: The reform has made your job description clear All the employees agreed in some extent of agreement but the agreement is not so strong on this statement; the mean of the responses is only 3.73 in the scale of 5. The responses revealed that there is statistically significant difference between the groups, the values of F(2, 331) = 3.450, p= .033 and the groups have difference on this. The physicians have the mean of 3.83; nurses have 3.79 and the mid-wives only 1.99. The mean scores clearly indicating, that there is differences in agreement on the statement and the physicians and nurses are likely to agree upon, but no agreement from the mid-wives. Thus, it is found that the physicians and nurses are familiar with their job description clear as they agree upon the statement, but not so strongly. Whereas, the mid-wives has no agreement on the statement and it seems, may be they are not so clear about the job description of the mid-wives and has no agreement. 4. Statement: The reform has increased your chances of being promoted No agreement could be seen in all the employee responses, they are quite reserved and disagreed on this statement; the mean of the responses is only 2.15 in the scale of 5, which is lower at side. The responses revealed that there is statistically significant difference between the groups, the values of F(2, 331) = 5.344, p= .005. The physicians have the mean of 2.35, nurses have 2.04 and the mid-wives only 2.07. The mean scores clearly indicating in the scale of five, that the reform process has not increased the change of their promotion. Thus, it is found that the physicians, nurses and mid-wives do not think that they are getting promotional chances strongly.
248

5. Statement: The reform has made the Salary structure Competitive for rural area posting No agreement could be seen as well for this statement also. No groups agree upon that the reform process has created the salary structure competitive for the rural area posting. There is no difference between the groups, the values of F(2, 331) = 1.211, p= .299. The mean of the responses is only 2.85 in the scale of 5, which is lower at side. The responses revealed that there is statistically no significant difference between the groups. The physicians have the mean of 2.93, nurses have 2.88 and the mid-wives only 2.76. Thus, it is found that the reform process has failed to achieve a competitive salary structure for the rural area postings. 6. Statement: The reform has made regular and adequate financial incentives and allowances for rural area posting The statement that reform has made available regular and adequate financial incentives for rural areas physicians, nurses and mid-wives has no agreement between the group responses. The groups have differences, the values of F(2, 331) = 12.479, p=.001. The mean of the responses is only 2.21 in the scale of 5, which is lower at side. The responses revealed that there is statistically significant difference between the groups. The physicians have the mean of 2.21, nurses have 2.43 and the midwives only 2.11. The group of nurses has little higher mean than that of the two other groups. Thus, reform has failed to made regular and adequate financial incentives and allowances for physicians, nurses and mid-wives who are posted in remote and rural areas. 7. Statement: The reform has increased the activities for your performance appraisal and positive action them All the employees are disagreed or undecided on this statement; the mean of the responses is only 2.29 in the scale of 5. The responses revealed that there is no significant difference between the groups, the values of F(2, 331) = 1.510, p=.222 and the groups thinks in similar way. The physicians have the mean of 2.37, nurses have 2.28 and the mid-wives only 2.24. The mean scores clearly indicating in the scale of five, that there are no increase activities for actual performance appraisals and positive actions on them.

249

8. Statement: The reform has made an improvement in working condition in your work place This statement that reform has made an improvement in working condition at the respondents posted health institutes has agreement in group responses, though the mean of the responses is 3.40, quite no so impressive, but we can say that the statement have a favorable response. The groups have differences, the values of F(2, 331) = 23.958, p=.001. The mean of the responses is 3.40 in the scale of 5. The responses revealed that there is statistically significant difference between the groups. The physicians have the mean of 3.53, nurses have 3.69 and the mid-wives only 3.05. The group of mid-wives has little lower mean than that of the two other groups. Thus, it seems at the lower level of the health care delivery system where the Mid-wives are largely posted are deviated of improving the working conditions. However, the other two groups have also do not have the highest mean, which also revealed that there is no sufficient improvement of work conditions at their workplace. 9. Statement: The reform has increased the training & skill development opportunity This statement that reform has increased the training and skill development opportunities for the respondents posted rural health institutes has agreement in group responses, though the mean of the responses is 3.72, which shows the statement have a favorable response. The groups have statistically significant differences, the values of F(2, 331) = 4.958, p=.008. The physicians have the mean of 3.55, nurses have 3.86 and the mid-wives only 3.78. The group of physicians has little lower mean than that of the two other groups. Thus, it seems at the physicians do not get more chance for training and development opportunities in comparison to the nurses and mid-wives. Thus, it reveals that the reform has failed to address the need of training and development in equal manner to all the groups of the employees. 10. Statement: The reform has improved the availability of equipment, drugs and supplies essential to perform your assigned tasks This statement that reform has improved the availability of equipments, drugs and essential supplies for performing the assigned tasks for the respondents posted rural health institutes has been agreed in group responses, though the mean of the responses is 3.35, however, the favor is not so strong. The groups have statistically significant differences, the values of F(2, 331) = 47.220, p=001. The physicians have the mean of 3.59, nurses have 3.81 and the mid-wives only 2.76. The group of mid250

wives has lowest mean than that of the two other groups. Thus, it seems at the midwives do not get adequate equipments, drugs and essential supplies and the reform has failed to provide them as well, in comparison to the physicians and nurses. Thus, it reveals that the reform has failed to address 360 degrees of these needs too. 11. Statement: The reform has improved mix of other cadres in your workplace This statement that reform has improved the mix of cadres in respondents posted rural health institutes has low agreement, thats the mean of the responses is 3.28, however, the favor is not so strong. The groups have statistically significant differences, the values of F(2, 331) = 13.465, p= .001. The physicians have the mean of 3.39, nurses have 3.58 and the mid-wives only 2.93. The group of mid-wives has lowest mean than that of the two other groups. Thus, it seems at the mid-wives do not get team-work on with other cadres, while physicians and nurses also revealed that they are also not so adequately gets improved atmosphere of team. Thus, it reveals that the reform has failed to address 360 degrees of these needs too. 12. Statement: The reform has made your workload more manageable There was no agreement revealed from the responses from the groups, the mean of the responses is 2.25. The groups have statistically significant differences, the values of F(2, 331) = 4.144, p=017. The physicians have the mean of 2.39, nurses have 2.24 and the mid-wives only 2.09. The group of mid-wives has lowest mean than that of the two other groups. Thus, it seems at the mid-wives are more affected bythe reform process, but all the groups still have the same situation rather high or low. They do not agree upon that the reform process has made their work load manageable but rather they think more unmanageable at their level. The disagreement increases at the lower level of the groups. Thus, it reveals that the workload are more unmanageable to all level due to the reform process. 13. Statement: The reform has made improvement in supportive supervision, management and mentoring form higher authority This statement that reform has made improvement in supportive supervision, management and mentoring form higher authority, has an agreement mean of the responses is 3.65. The groups have statistically significant differences, the values of F(2, 331) = 3.850, p=.022. The physicians have the mean of 3.50, nurses have 3.68 and the mid-wives only 3.76. Thus, the responses reveals that there is an improvement of supervision and mentoring due to the reform process, and the trend is higher to the
251

lower health institutes because the mean of the mid-wives is higher than that of the two other higher groups. While putting light from the management representative interview responses that the supervision services also suffers from the financial constraints, geographical constraints and overall suffers from the skill scarcity that is scarcity of supervisors. The supervision structures starts from very state level to the lowest layer of SCs, the SCs are supervised by the Medical Officers (Physicians) at PHCs or CHCs and these PHCs/CHCs by the district level. The matter is more concern upon lot of higher institutes is without the supervisors and if they are also, they are concern with the clinical abilities and lacks the managerial skills like supervision and monitoring at various levels. 14. Statement: The reform has made work independent and more autonomy When the responses are analyzed the mean comes to 3.06, which revealed that there is more undecided or neutral about the statement rather agreement or no agreement. While the responses are analyzed separately according to the different groups, physicians have Mean of 3.55, which shows an agreement but a weak one. Other two groups, nurses have 2.49, which reveal that they have disagreement and mid-wives are undecided on this statement thus making the group in neutral position with Mean of 3.07. The responses revealed that there is significant difference between the groups, the values of F(2, 331) = 27.992, p=.001. The mean scores clearly indicating in the scale of five, that there is more autonomy to physicians rather than that of nurses and mid-wives in the reform process. 15. Statement: The reform has made improvement in housing and other amenities at your workplace When overall responses are analyzed the mean comes to 2.53, which revealed total disagreement with the statement that reform has shown an improvement in housing and other amenities at the workplace of the respondents. While the responses are analyzed separately according to the different groups, physicians have Mean of 3.24, which shows an agreement but a weak one. Other two groups, nurses have 2.13 and 2.20 for mid-wives, which reveal that they have disagreement on this statement thus making the group significant different, the values of F(2, 331) = 41.599, p=.001. The mean scores clearly indicating in the scale of five, that there is an improvement in housing and other amenities at the workplace of the physicians that is at the higher
252

level of health institute rather in the lower health institute where the nurses and midwives are posted. 16. Statement: The reform has made rural health care services an attraction for the potential physicians, nurses and mid-wives to work in rural and remote area The response to this statement reveals that none of the respondents think that the reform process has succeeded or made rural health care services an attraction for the potential physicians and nurses to work in rural and remote area. When overall responses are analyzed the mean comes to 2.01, which is the worst side of the response, which revealed total disagreement with the statement that reform has made the rural service an attraction for the physicians, nurses and mid-wives. While the responses are analyzed separately according to the different groups, physicians have Mean of 2.08, nurses have 2.11 and 1.87 for mid-wives, which reveal that they have disagreement and highly disagreement on this statement thus making the group significant different, the values of F(2, 331) = 3.171, p=.043. The mean scores clearly stated that there is no attraction on rural health services for physicians, nurses and mid-wives and reform process has failed to attend so. 17. Statement: The reform has made overall HR practice effective and conducive in the organization Reform process has the HR dimension along with other activities on the pipeline also. The responses revealed that the reform had failed to attend the contribution to make the overall HR practice effective and conductive for the organization and to the physicians, nurses and mid-wives. The Mean is 1.99 for all the responses, which is strongly disagreement with the statement. While the responses are analyzed separately according to the different groups, physicians have Mean of 2.21, nurses have 1.95 and 1.81 for mid-wives, which reveal that they have disagreement and strong disagreement on this statement. The group has significant difference, the values of F(2, 331) = 10.716, p=.001. The mean scores clearly stating that reform has less attended overall HR practice effective and conducive in the organization for physicians, nurses and mid-wives. It also revealed that the reform process failed to give attention to the HR front rather giving attention to the other components of reform process in the state. The table 139 to 143 has the descriptive tables for putting more light on these issues point-wises.
253

Table 139 : Descriptive Statistics of views on health sector reform process on HR by physicians, nurses and mid-wives Mean Sl. Attributes Stati Std. Std. No. N MinMax stic Error Dev. 1 The reform has made the Human Resource 334 1 4 2.06 .041 .743 Policies clear and understandable at your level 2 The reform has made the placement, transfer 334 1 4 2.05 .037 .685 and promotion transparent, fairer and unbiased 3 The reform has made your job description clear 334 2 5 3.73 .042 .772 4 The reform has increased your chances of being 334 1 4 2.15 .043 .781 promoted 5 The reform has made the Salary structure 334 1 5 2.85 .046 .834 Competitive for rural area posting 6 The reform has made regular and adequate 334 1 4 2.21 .034 .617 financial incentives and allowances for rural area posting 7 The reform has increased the HR activities for 334 1 4 2.29 .034 .613 your performance appraisal 8 The reform has made an improvement in 334 1 5 3.40 .043 .779 working condition in your work place 9 The reform have increased the training and skill 334 1 5 3.72 .042 .761 development Opportunities 10 The reform have improved the availability of 334 1 5 3.35 .053 .968 equipment, drugs and supplies essential to perform your assigned tasks 11 The reform have supported to create and 334 1 5 3.28 .055 .997 improvement in good mix of other cadres in your workplace 12 The reform has made your workload more 334 1 5 2.25 .041 .756 manageable 13 The reform has made improvement in 334 1 5 3.65 .042 .763 supportive supervision, management and mentoring form higher authority 14 The reform has made work independent and 334 1 5 3.06 .060 1.10 more autonomy 5 15 The reform has made improvement in housing 334 1 5 2.53 .062 1.13 and other amenities at your workplace 0 16 The reform has made rural health care services 334 1 5 2.01 .044 .798 an attraction for the potential physicians and nurses to work in rural and remote area 17 The reform has made overall HR practice 334 1 5 1.99 .038 .689 effective and conducive in the organization

254

Table 140: Descriptive Statistics of views on health sector reform process on HR by physicians Sl. Mean No. Stati Std. Std. N MinMax stic Error Dev. 1 The reform has made the Human Resource 113 1 4 2.25 .068 .726 Policies clear and understandable at your level 2 The reform has made the placement, transfer and 113 1 4 2.12 .059 .629 promotion transparent, fairer and unbiased 3 The reform has made your job description clear 113 2 5 3.83 .065 .693 4 5 6 The reform has increased your chances of being 113 1 promoted The reform has made the Salary structure 113 1 Competitive for rural area posting The reform has made regular and adequate 113 1 financial incentives and allowances for rural area posting The reform has increased the HR activities for 113 1 your performance appraisal The reform has made an improvement in 113 1 working condition in your work place The reform have increased the training and skill 113 1 development Opportunities The reform have improved the availability of 113 1 equipment, drugs and supplies essential to perform your assigned tasks The reform have supported to create and 113 2 improvement in good mix of other cadres in your workplace The reform has made your workload more 113 1 manageable The reform has made improvement in supportive 113 1 supervision, management and mentoring form higher authority The reform has made work independent and 113 1 more autonomy The reform has made improvement in housing 113 1 and other amenities at your workplace The reform has made rural health care services 113 1 an attraction for the potential physicians and nurses to work in rural and remote area The reform has made overall HR practice 113 1 effective and conducive in the organization 4 4 4 2.35 .086 .914 2.93 .071 .753 2.43 .059 .625

7 8 9 10

4 5 5 5

2.37 .056 .601 3.53 .070 .745 3.55 .096 1.018 3.59 .081 .862

11

3.39 .080 .850

12 13

5 5

2.39 .085 .901 3.50 .084 .888

14 15 16

5 5 5

3.55 .092 .982 3.24 .119 1.270 2.08 .077 .814

17

2.21 .076 .807

255

Table 141 : Descriptive Statistics of views on health sector reform process on HR by nurses Sl. Mean No. Attributes Stati Std. Std. N Min Max stic Error Dev. 1 The reform has made the Human Resource 98 1 4 2.03 .073 .724 Policies clear and understandable at your level 2 The reform has made the placement, transfer 98 1 4 2.04 .071 .702 and promotion transparent, fairer and unbiased 3 The reform has made your job description 98 2 5 3.79 .071 .707 clear 4 The reform has increased your chances of 98 1 3 2.04 .065 .641 being promoted 5 The reform has made the Salary structure 98 1 5 2.88 .092 .911 Competitive for rural area posting 6 The reform has made regular and adequate 98 1 4 2.11 .063 .624 financial incentives and allowances for rural area posting 7 The reform has increased the HR activities 98 1 3 2.28 .059 .588 for your performance appraisal 8 The reform has made an improvement in 98 2 5 3.69 .072 .709 working condition in your work place 9 The reform have increased the training and 98 2 5 3.86 .058 .574 skill development Opportunities 10 The reform have improved the availability 98 2 5 3.81 .068 .668 of equipment, drugs and supplies essential to perform your assigned tasks 11 The reform have supported to create and 98 2 5 3.58 .072 .717 improvement in good mix of other cadres in your workplace 12 The reform has made your workload more 98 1 4 2.24 .058 .645 manageable 13 The reform has made improvement in 98 2 5 3.68 .075 .741 supportive supervision, management and mentoring form higher authority 14 The reform has made work independent and 98 1 5 2.49 .103 1.01 more autonomy 15 The reform has made improvement in 98 1 4 2.13 .079 .782 housing and other amenities at your workplace 16 The reform has made rural health care 98 1 5 2.11 .093 .918 services an attraction for the potential physicians and nurses to work in rural and remote area 17 The reform has made overall HR practice 98 1 4 1.95 .042 .415 effective and conducive in the organization

256

Table 142: Descriptive Statistics of views on health sector reform process on HR by Mid-wives Sl. Mean No. Attributes Stati Std. Std. N Min Max stic Error Dev. 1 The reform has made the Human Resource 123 1 4 1.92 .067 Policies clear and understandable at your level 2 The reform has made the placement, transfer 123 1 4 1.99 .065 .719 and promotion transparent, fairer and unbiased 3 The reform has made your job description clear 123 2 5 3.59 .078 .868 4 The reform has increased your chances of 123 1 3 2.07 .065 .721 being promoted 5 The reform has made the Salary structure 123 1 5 2.76 .076 .840 Competitive for rural area posting 6 The reform has made regular and adequate 123 1 3 2.07 .049 .546 financial incentives and allowances for rural area posting 7 The reform has increased the HR activities for 123 1 4 2.24 .058 .641 your performance appraisal 8 The reform has made an improvement in 123 2 4 3.05 .066 .734 working condition in your work place 9 The reform have increased the training and 123 2 5 3.78 .051 .566 skill development Opportunities 10 The reform have improved the availability of 123 1 5 2.76 .088 .976 equipment, drugs and supplies essential to perform your assigned tasks 11 The reform have supported to create and 123 1 5 2.93 .108 1.199 improvement in good mix of other cadres in your workplace 12 The reform has made your workload more 123 1 4 2.09 .068 .675 manageable 13 The reform has made improvement in 123 2 5 3.76 .057 .628 supportive supervision, management and mentoring form higher authority 14 The reform has made work independent and 123 1 5 3.07 .096 1.069 more autonomy 15 The reform has made improvement in housing 123 1 5 2.20 .082 .905 and other amenities at your workplace 16 The reform has made rural health care services 123 1 4 1.87 .059 .652 an attraction for the potential physicians and nurses to work in rural and remote area 17 The reform has made overall HR practice 123 1 5 1.81 .063 .694 effective and conducive in the organization

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Table 143: Analysis of Variance of views on health sector reform process on HR by physicians, nurses and mid-wives Sl. Sum of Mean Attributes No. Squares df SquareF Sig. 1 The reform has made the Human Between 6.523 2 3.261 6.093 .003 Resource Policies clear and Groups understandable at your level Within 177.157 331 .535 Groups 2 The reform has made the Between 1.041 2 .520 1.110 .331 placement, transfer and Groups promotion transparent, fairer and Within 155.094 331 .469 unbiased Groups 3 The reform has made your job Between 4.048 2 2.024 3.450 .033 description clear Groups Within 194.159 331 .587 Groups 4 The reform has increased your Between 6.356 2 3.178 5.344 .005 chances of being promoted Groups Within 196.856 331 .595 Groups 5 The reform has made the Salary Between 1.685 2 .842 1.211 .299 structure Competitive for rural Groups area posting Within 230.127 331 .695 Groups 6 The reform has made regular and Between 8.887 2 4.443 12.47 .001 adequate financial incentives and Groups 9 allowances for rural area posting Within 117.859 331 .356 Groups 7 The reform has increased the HR Between 1.132 2 .566 1.510 .222 activities for your performance Groups appraisal Within 124.113 331 .375 Groups 8 The reform has made an Between 25.574 2 12.78 23.95 .001 improvement in working Groups 8 condition in your work place Within 176.665 331 .534 Groups 9 The reform have increased the Between 5.603 2 2.802 4.958 .008 training and skill development Groups Opportunities Within 187.055 331 .565 Groups 10 The reform have improved the Between 69.262 2 34.63 47.22 .001 availablity of equipment, drugs Groups 0 and supplies essential to perform Within 242.753 331 .733 your assigned tasks Groups 11 The reform have supported to Between 24.911 2 12.45 13.46 .001 create and improvement in good Groups 5 mix of other cadres in your Within 306.194 331 .925 workplace Groups

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12 The reform has made your workload more manageable

13

14

15

16

17

Between Groups Within Groups The reform has made Between improvement in supportive Groups supervision, management and Within mentoring form higher authority Groups The reform has made work Between independent and more autonomy Groups Within Groups The reform has made Between improvement in housing and Groups other amenities at your Within workplace Groups The reform has made rural health Between care services an attraction for the Groups potential physicians and nurses Within to work in rural and remote area Groups The reform has made overall HR Between practice effective and conducive Groups in the organization Within Groups

4.651

2 2.325 4.144 .017

185.724 331 .561 4.411 2 2.205 3.850 .022

189.604 331 .573 2 29.42 27.99 .001 2 347.952 331 1.051 2 42.69 41.59 .001 9 339.743 331 1.026 3.985 2 1.992 3.171 .043 85.395 58.851

207.967 331 .628 2 4.803 10.71 .001 6 148.347 331 .448 9.605

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SECTION 6 ANALYSIS OF THE HR POLICIES AND PRACTICES ON ATTRACTION, DISTRIBUTION AND RETENTION OF PHYSICIANS, NURSES AND MIDWIVES FOR RURAL AND REMOTE AREA IN THE STATE

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4.6.1. INTRODUCTION
As the human resource practices is related to the day-to-day HR activities of job responsibilities, included administrative duties and recruitment; supervision (including performance appraisals, conflict resolution, and mentoring); training; staff deployment (including placement, transfer and benefits functions); and HR planning and policy (covering policy-making, budgeting, and advising senior management). HRM practices, which play a central role in the exchange relationships between the organisation's management and its employees, are connected to every stage of the employment circle, and through these engagements employees obtain valuable information about the organisation and the way it is managed. These activities show employees, in practice, what is valued in general, and how the organisation views them in particular. When employees deal with customers they bring to the interaction their perceptions of HRM practices (Ulrich, Halbroock, Meder, Stuchlick & Thorpe 1991). This section is particularly for exploring and discussion on the HR policies and practices related to Attraction, distribution and retention. It also presents the satisfaction level of the physicians, nurses and mid-wives of these practices.

4.6.2. POLICIES FOR HR PLANNING, RECRUITMENT (ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION
Manpower planning or human resource planning is essentially the process of getting the right number of qualified people into the right job at the right time. It is a system of matching the supply of people (existing employees and those to be hired or searched for) with opening the organization expects over a given time frame. (Rao, 2000). Further the efficient utilization of resources, manpower or other does not just happen. It requires a careful planning. According to Sikula (1976) maximum productive use of any organization input can only be attained through the conscious and prolonged attention to planning details. Hence, raised the need and importance of Human Resource Planning (HRP). Every organization has a view of the people it employs. It is fact that no organization can rise above the calibre of its personnel. It is no accident, therefore, that the managements emphasis must be laid with acquisition of right personnel. But acquisition of right personnel is not an easy task (Samantray & Pradhan, 1998).The selection, promotion and placement process includes all those activities related to the internal movement of people across positions and external hiring into the
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organisation. The essential process is one of matching available resources to jobs in the organisation. It entails defining the organisations human needs for particular positions and assessing the available pool of people to determine the best fit. (Fombrun, C., et al. (1984). There is no comprehensive HR Policy in Public health sector in Arunachal Pradesh. There are recruitment rules for different category of health workforce. The recruitment and other service conditions for staff in health services of the state government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The regular doctors and specialist cadre comes under the purview of service rule of APHS. The State health department has in place a concrete system for career progression for physicians, nursing staff where physicians and nurses have promotional avenues as per seniority and availability of vacancies. The recruitment rules are the specific instrument of the state govt. for recruitment, classification, method of

recruitment/promotion including constitution of departmental promotion committee, salary etc. However, there is no specific HR Policy for contractual physicians, nurses and midwives and other health workers. The state Govt. is preparing a 5 year strategies and policy document for augmentation and maximization of Human Resources. This includes sustainable HRD and policy reform from restructuring/ rationalization of HR deployment. The vibrant HR policy includes terms of recruitment / filling up of vacancies, rationalising posting, specific tenure of posting, career progression and incentives. The policy is focussing on improving maternal and child health indicators through posting of required manpower for maximising performance at identified functional facilities. Absence of appropriate and concrete human resources policies on deployment, there is always a hindrance in managing people at work (interviewee from district- 1 to 16). Moreover, the 5 year strategies and policy document for augmentation and maximization of Human Resources. This includes sustainable HRD and policy reform from restructuring/ rationalization of HR deployment. In order to ensure rational deployment of contractual physicians, nurses and mid-wives, recruitment is done at district level and appointments are made for specific health centres without provision of transfer. The contractual position is on facility based need and recruitment is only for that facility other than district health society. The appointments are district and facility specific and non transferable as far as the documents. However, intra district relocation is allowed in certain exceptions
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on mutual transfer and postings. The state is also contemplating rational transfer of permanent physicians and nurses & mid-wives on rotation after completion of atleast 3 years in a particular posting place (State interviewee). The measures include compulsory rural posting for certain period, earmarking certain percentage of postgraduate seats for doctors who have served in rural areas, and provision of rural service allowance, etc. For the regular groups of employees the intra-district transfer and posting are handled by the District Medical Officer and inter-districts transfer is handled by the Director of Health Services. The recruitment and other service conditions for staff in health services of all the state government are regulated by the respective central or state services recruitment rules. These rules are elaborate and provide clear cut guidelines for recruitment, promotions etc. Effective recruitment, selection practices are cohesively depends on the HR policies and in the absence of the same, a number of difficulties have been highlighted in the interview. Thus, in the absence of the human resource policies, personnel decisions like recruitment, placement, transfer and promotion are the major problems. The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for Policies for placement, transfer and promotion is not very low and above the average of the scale (N=334, mean=3.28) in the scale of 1 to 5. Table 144: Scale of satisfaction on Policies for planning, placement, transfer and promotion by position of Respondents Category Highly Dissatisfied Neither Satisfied Highly Dissatisfied Satisfied Nor Satisfied Dissatisfied Physicians 0 (0%) 6(5.3%) 33(29%) 74(65.1%) 0 Nurses 3(3.06%) 13(13.2%) 29(29.59% 53(54.08%) 0 Mid-wives 4(3.2%) 34(27.64%) 50(40.6%) 35(28.4%) 0 Total 7(2.09%) 53(15.8%) 112(33.5%) 162(48.5%) 0 The separate analysis of the scale of satisfaction of this component by the group of these employees, the mid-wives have the lowest level of satisfaction that is mean=2.94, whereas physicians and nurses have mean=3.60 and 3.35 respectively, and the Contract employee has mean of 3.2 and Permanent Employee has 3.36. The ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331)= 22.743, p =.001.
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Table 145: Descriptive statistics on scale of satisfaction on policies for planning, placement, transfer and promotion by position of respondents Category N Mean Std. Dev. Std. Error Min Max Physician 113 3.60 .591 .056 2 4 Nurse 98 3.35 .826 .083 1 4 Mid-Wife 123 2.94 .833 .075 1 4 Total 334 3.28 .805 .044 1 4 Table 146: Analysis of Variance for scale of satisfaction on policies for placement, transfer and promotion among the physicians, nurses and midwives among the group of respondents Sum of Squares Df Mean Square F Sig. Between Groups 26.094 2 13.047 22.743 .001 Within Groups 189.885 331 .574 Total 215.979 333

4.6.3. HR PLANNING, RECRUITMENT AND SELECTION PROCESS

The core HRM practices for fairness in the distribution according to the norms are based on HR planning, recruitment and selection process in the organisation. HRP as a process is essentially a careful thought-out strategy with a futuristic lookout of the kind of human resource requirements of an organization. Planning the health workforce is not only a technical process, but also a political one, as decisions on the number, types and distribution of health workers depend on the political choices and values enshrined in the organization of national health systems (Fulop and Roemer 1987; Dussault et al. 1997). As the question itself is indicating towards the Health Human Resources Planning that further aimed at having the right number of people with the right skills in the right place at the right time to provide the right services to the right people (Birch 2002, adapted from Birch et al, 2007). Planning is most important in every sectors including health sector especially in manpower recruitment and placing. It involves comparing estimates of future requirements for and supplies of human resources and considering policy options for addressing any differences between requirements and supplies (Lomas et al. 1985adapted from Birch et al, 2007). Research Observation shows that accurate information systems on staffing trends and conditions are not in place-e.g., there is more difficulty in part of knowing the sanction post in the district or in the state, also there is no tradition of research on workforce issues in the state. HR planning under NRHM division is theoretically based on decentralized system, however, in the absence of proper information, and trends of staffing makes HR planning more
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exhaustive and difficult. While, the HR planning in permanent physicians, nurses and mid-wives are done by the Health Directorate and based on vacancies and annual operating plans. It is also found that there is lack of extensive co-ordination between the two divisions for planning. As manpower planning involves assessment of current and future demand & supply and analyzing the gap and formulating short and long term strategies for ensuring availability of sustainable levels of staff. The states do not have a formal mechanism in place to undertake manpower planning on a continuous basis except the Annual Action Plans. Planning exercise in the department of health is primarily focused on creation of new infrastructure/institutions. The recruitment and selection process of physicians, nurses and mid-wives after the initiation of Reproductive and Child Health programme in 1997 and subsequently National Rural Health Mission in 2005 has been concentrated to the contractual manpower and the process is decentralised to the district level since 201011. The decentralisation of this process is only for the contractual physicians, nurses and mid-wives. For the recruitment of the permanent employee of this category, the contractual employees are regularised and continued their services as regular employees, the process is basically based on the sanctioned post vacancies and seniority based and the process is undertaken by the Directorate of Health Services headed by the Director of Health Services. However, decentralization of recruitment and selection process to the district included HR planning, recruitment; transfer and maintenance of human resource have at the district level only for the contractual physicians, nurses and mid-wives. District authority is now had to play a new role as employers, often without the appropriate technical abilities to do so. The recruitment process under the decentralised arrangement in the district is closely linked to the instruction and financial provision at the state level. The implementation of the decentralisation policy is only for the contractual manpower in the district. Whereas, the appointment and deployment of the permanent physicians, nurses and mid-wives are not comes under the decentralised recruitment and deployment. So, it does not left any room for majority of the recruitment process and deployment. Thus, the recruitment under centralisation, whereby the state level would post permanent physicians, nurses and mid-wives to district may be without taking into consideration the specific needs of each district. Thus districts requiring
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more physicians, nurses and mid-wives could not get the required number or the willed workforce. Management representatives Interviewees from all the districts have the common consensus that they do not have the sufficient pool of the candidates and suffered from the shortage of entry level physicians and nurses (GNM). However, two of the district (3, 8) faced problems in Mid-wives pool also. Hughes (2002) has pointed out that when supply is scarce; the development of an effective recruitment and selection strategy becomes significantly more challenging and imperative. Interviewees from Districts (3, 6, 8 and 11) put light on recruitment & selection of less skilled candidates in the light of the scare pool of the candidates. The majority of the management representatives emphasized that there is a need for a division of responsibilities between the districts and the state level in matters related to recruitment and distribution of health workers, to gain a favourable impact on recruiting and deploying the physicians, nurses and mid-wives in rural and remote areas. In order to select the skilled physicians, nurses and mid-wives, various recruitment sources are utilised by the districts. Advertising in state level newspapers, local newspapers, office notice board publications and informal way of word of mouths of present employees (district 1,2, 5, 8, 10, 13, 16) are used as the medium for recruitment of these category of employees. The recruitment advertisement for the contractual vacancies is only undertaken for this kind of process in the districts. The recruitment advertisement for permanent positions is placed in the newspaper and office board by the Directorate of Health Services. However, the internal source of recruitment is widely used, whenever a sanctioned regular post is vacant. This process of recruitment of internal candidates for regular posts supports career development opportunities for internal contractual employees. Selection is basically a matching process. How well an employee is matched to a job affects the amount and quality of a employees work. Improper job placement affects his moral as well. Ultimately, it costs an organization a great deal of money, time and trouble. Effective human resource management requires constant monitoring of the fit between person and job. (Rao, 2000). As rightly pointed out, If a systematic selection procedure (test, patterned interview and so forth) prevented one or two selection errors a year, it would represent a substantial return on investment (Durbin, 1981). Now a-days some new methods like walk-in-interview are
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becoming so popular that many corporations are adopting it. In this process the venue is just checked out from the advertisement and if one becomes successful in the interview, he gets a plum job and pay package within two and half hours. More and more companies recruiting for entry-level and front-line jobs are opting for the walkin method (Beach, 1980). So forth, the selection processes is based on Walk-in-interview (districts-2, 8, 12, 16), Written-test and panel interview (district-1,3,4,5,6,7,9,10,11,13,14,15) across districts for these categories of contractual employees. In every district, a standing recruitment and selection board is in place, which is headed by Deputy Commissioner of the District and involved in every recruitment and selection process in the individual districts. The section process is based on merit in written test and technical and skill knowledge, personality and attitude assessment of the candidates in panel interview. For final selection, the selection committee assess the comparative merits of each candidate in terms of his / her qualifications, experience if any and on the basis of performance in the selection tests as per criteria laid down and come to a conclusion as to whether or not the candidate would measure up to the requirements of the job. However wherever marks are assigned, committee members give marks on the basis of criteria laid down. Finally, candidates found suitable are empanelled in order of merit. The panel / merit list so prepared are subject to the approval of the competent authority and remain valid for a period of six months from the date of such approval. If required the authority may extend the validity of the panel for a further period not exceeding six months. Lastly, after the final selection of the candidates, appointment offers are issued to the required number of candidates from the panel in order of merit with the approval of the competent authority. All the appointment offers are centrally issued by the establishment section. The assessment of the requirement of Physicians, Nurses and Mid-wives particularly for rural and remote areas is done annually in the form of Health Action Plan based on the service based facility planning and it is a recurring planning in nature. But these requirement planning are based for contractual employees. While assessment of requirement of permanent Physicians, nurses and mid-wives, under Annual Operating Plan in Directorate of Health Services under Planning and Development Branch is done. However, the planning is done to create sanction post.

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Thus, the recruitment and selection process of the employee in the state public health system is a traditional approach and lack the professional forefront in this process. The system of recruitment and selection methods may be judged as the traditional, and the advertisement, walk-in-interview, written-test with panel interview as the dominant tools in use. However, the system failed to use a good recruitment and selection techniques or the process for the recruitment of right skill and the right number of employees in the system. It seems, the transfer of human resources functions from State level to district level without a comprehensive design and structure is quite a big challenge for the district administration. To manage the decentralized activities there is no proper system of professional HR management personnel in the district level or in the state level, which create a challenging environment at this and subsequent level of administration. The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for Recruitment and selection process is low (N=334, mean=2.43) in the scale of 1 to 5. It may be there is no concrete HR policy for recruitment and selection process, and may lead to favouritism, political dictates, and nepotism in the recruitment and selection process. Table 147: Scale of satisfaction on Recruitment and Position of Respondent Category Highly Dissatisfied Neither Dissatisfied Satisfied Nor Dissatisfied Physicians 3 (2.6%) 66(58.4%) 31(27.4%) Nurses 6(6.1%) 61 (62.2%) 28(28.5% Mid-wives 15(12.1%) 50(40.6%) 41(33.3%) Total 24(7.18%) 177(52.9%) 100(29.9%) selection process and Satisfied Highly Satisfied 0 0 0 0

13(11.5%) 3(3.06%) 17(13.8%) 33(9.8%)

The separate analysis of the scale of satisfaction of this component by the group of these employees, the nurses have the lowest level of satisfaction that is mean=2.29, whereas physicians and mid-wives have mean=2.48 and 2.49 respectively, and the Contract employee has mean of 2.51 and Permanent Employee has 2.35. The ANOVA test shows that there is a no significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 2.318, p =0.1.

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Table 148: Descriptive statistics on scale of satisfaction on Recruitment and selection process by position of respondents Std. Deviation .733 .626 .881 .766 Std. Error .069 .063 .079 .042

Physician Nurse Mid-Wife Total

N Mean 113 2.48 98 2.29 123 2.49 334 2.43

Min 1 1 1 1

Max 4 4 4 4

Table 149: Analysis of variance for Scale of satisfaction on Recruitment and selection process among the group of respondents Sum of Squares Df Mean Square F Sig. Between Groups 2.702 2 1.351 2.318 .100 Within Groups 192.926 331 .583 Total 195.629 333

4.6.4. HR PRACTICE FOR PLACEMENT, TRANSFER AND PROMOTION

The deployment of contractual physicians, nurses and mid-wives are done according to the recruitment done for the particular vacancies for the specific health institution. However, the deployments are interchange able on mutual consent of the employees or the management decisions at the district level. The deployment of the regular cadre employee is done according to the requirement of the district and the District Medical Officer looks the matter and depends on the physical infrastructure and basic amenities in the health institution e.g. accommodation. The common tenure following transfer posting is of minimum 3 years of posting in one location, however, which is not followed at the district level or the state level. The current practices however are non systematic and non transparent in many district. Promotion acts as an important motivational factor even when it is not accompanied by substantial monetary benefits. The contractual groups do not have any scope of promotion, as they are considered as the temporary employees. Promotion as an internal source of recruitment is a long established policy in the department. As per the recruitment rules the states follow the promotional avenues for their permanent workforce. However, time bound promotions are not practices for several reasons to these categories of staff. However, seniority-cum-merit promotions are followed by the state.
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The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for fairness of HR Practice for placement, transfer and promotion is low (N=334, mean=2.11) in the scale of 1 to 5. The result revealed that there may exists some extent of favouritism and unfairness in practicing related to the placement, transfer and promotional avenues to the employees. Table 150: Scale of satisfaction on fairness in HR Practice for placement, transfer and promotion and Position of Respondent Category Highly Dissatisfied Neither Satisfied Highly Dissatisfied Satisfied Nor Satisfied Dissatisfied Physicians 16 (14%) 77(68%) 14(12.3%) 6(5.3%) 0 Nurses 10(10.2%) 65 (66%) 17(17.3% 6(6.12%) 0 Mid-wives 23(18.6%) 78(63.3%) 14(11.3%) 8(6.5%) 0 Total 49(14.6%) 220(65.8%) 45(13.4%) 20(5.9%) 0 The separate analysis of the scale of satisfaction of this component by the group of these employees, the mid-wives have the lowest level of satisfaction that is mean=2.06, whereas physicians and nurses have mean=2.01 and 2.19 respectively. The ANOVA test shows that there is a no significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p =.346. Table 151: Descriptive statistics on scale of satisfaction on fairness of HR Practice for placement, transfer and promotion by the position of respondents Category N Mean Std. Deviation Std. Error Min Max Physician Nurse Mid-Wife Total 113 98 123 334 2.09 2.19 2.06 2.11 .689 .698 .750 .715 .065 .071 .068 .039 1 1 1 1 4 4 4 4

Table 152 : Analysis of Variance for the scale of satisfaction on fairness of HR Practice for placement, transfer and promotion among the group of respondents Sum of Squares Df Mean Square F Sig. Between Groups 1.087 2 .543 1.064 .346 Within Groups 169.033 331 .511 Total 170.120 333 The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for magnitude of management favouritism and political interference in transfer and posting is low (N=334, mean=2.36) in the scale of 1 to 5. The result revealed that, the employees feel that there may existence of management favouritism and political interference in the transfer and posting of these groups of employees.
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Table 153: Scale of satisfaction on Magnitude of management favouritism and political interference in transfer and posting among the group of respondents Category Highly Dissatisfied Neither Satisfied Highly Dissatisfied Satisfied Nor Satisfied Dissatisfied Physicians 10 (8.8%) 64(56.6%) 32(28.3%) 7(6.1%) 0 Nurses 10(10.2%) 43 (43.8%) 36(36.7% 9(9.18%) 0 Mid-wives 12(9.7%) 68(55.2%) 35(28.4%) 8(6.5%) 0 Total 32(9.5%) 175(52.39%) 103(30.8%) 24(7.18%) 0 The separate analysis of the scale of satisfaction of this component by the group of these employees, the physicians and mid-wives have the lowest level of satisfaction that is mean=2.32, whereas nurses have mean=2.45. And the Contract employee has mean of 2.41 and Permanent Employee has 2.31. The ANOVA test shows that there is a no significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 1.052, p =0.350. Table 154: Descriptive statistics on scale of satisfaction on magnitude of management favouritism and political interference in transfer and posting by the position of respondents N Mean Std. Deviation Std. Error Min Max Physician Nurse Mid-Wife Total 113 98 123 334 2.32 2.45 2.32 2.36 .723 .801 .739 .753 .068 .081 .067 .041 1 1 1 1 4 4 4 4

Table 155: Analysis of Variance for the scale of satisfaction on Magnitude of management favouritism and political interference in transfer and posting among the group of respondents Sum of Df Mean Square F Sig. Squares Between Groups 1.192 2 .596 1.052 .350 Within Groups 187.410 331 .566 Total 188.602 333 The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for magnitude of response of

administration/management on your placement, transfer and promotional grievances is low (N=334, mean=2.39) in the scale of 1 to 5. The result revealed that, the employees feel that there exists a delay in response of administration/management on your placement, transfer and promotional grievances of these groups of employees.

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Table 156:Scale of satisfaction on response of administration/management on your placement, transfer and promotional grievances Satisfied Highly Category Highly Dissatisfied Neither Dissatisfied Satisfied Satisfied Nor Dissatisfied Physicians 10 (8.8%) 46(40.7%) 40(35.3%) 16(14.1%) 1 (0.8%) Nurses 10(10.2%) 59 (60.2%) 23(23.4% 6(6.1%) 0 Mid-wives 18(14.6%) 57(46.3%) 38(30.8%) 10(8.1%) 0 Total 38(11.3%) 162(48.5%) 101(30.2 %) 32(9.5%) 1 (0.29%) The separate analysis of the scale of satisfaction of this component by the group of these employees, the nurses have the lowest level of satisfaction that is mean=2.26, whereas physicians and nurses have mean=2.58 and 2.33 respectively. And the Contract employee has mean of 2.36 and Permanent Employee has 2.41. The ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 4.663, p =.01. Table 157: Descriptive statistics on scale of satisfaction on response of administration/ management on your placement, transfer and promotional grievances by the position of respondents Std. Std. N Mean Deviation Error Minimum Maximum Physician 113 2.58 .874 .082 1 5 Nurse 98 2.26 .722 .073 1 4 Mid-Wife 123 2.33 .825 .074 1 4 Total 334 2.39 .823 .045 1 5 Table 158: Analysis of Variance for the scale of satisfaction on Response of administration/management on your placement, transfer and promotional grievances among the group of respondents Sum of Squares Df Mean Square F Sig. Between Groups 6.176 2 3.088 4.663 .010 Within Groups 219.225 331 .662 Total 225.401 333 Likewise, the analysis of employee attitude survey revealed that the Level of satisfaction of these employees for participation and involvement in the decision making of employees placement and transfer is low (N=334, mean=2.32) in the scale of 1 to 5. The result revealed that, the employees feel non existence of participation and involvement of employees in placement and transfer decisions.

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Table 159: Scale of satisfaction on Participation decision making of your placement and transfer Category Highly Dissatisfied Neither Dissatisfied Satisfied Nor Dissatisfied Physicians 13 (11.5%) 57(50.4%) 39(34.5%) Nurses 4 (4.08%) 51 (52%) 40(40.8% Mid15(12.1%) 68(55.2%) 35(28.4%) wives Total 32(9.5%) 176(52.6%) 114(34.1%)

and involvement in the Satisfied Highly Satisfied

4(3.5%) 3(3.06%) 5(4.06%) 12(3.5%)

0 0 0 0

The separate analysis of the scale of satisfaction of this component by the group of these employees, the mid-wives have the lowest level of satisfaction that is mean=2.24, whereas physicians and nurses have mean=2.30 and 2.43 respectively. And the Contract employee has mean of 2.36 and Permanent Employee has 2.28. The ANOVA test shows that there is a no significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331)=1.991, p=0.138. Table 160: Descriptive statistics on scale of satisfaction on participation and involvement in the decision making of your placement and transfer by the position of respondents N Mean Std. Std. Error Minimum Maximum Deviation Physician 113 2.30 .718 .068 1 4 Nurse 98 2.43 .626 .063 1 4 Mid-Wife 123 2.24 .717 .065 1 4 Total 334 2.32 .694 .038 1 4 Table 161: Analysis of variance for the scale of satisfaction on Participation and involvement in the decision making of your placement and transfer among the group of respondents Sum of Squares Df Mean Square F Sig. Between Groups 1.906 2 .953 1.991 .138 Within Groups 158.453 331 .479 Total 160.359 333

4.6.5. HR PRACTICE FOR RETENTION - FINANCIAL & NONFINANCIAL INTERVENTIONS

There is no provision of financial and non-financial incentives for rural and remote area deployment and retention. In the light of no provision of such incentives for the physicians, nurses and mid-wives for rural area services and the compensation package also is same irrespective of the place of posting. Other non financial benefits
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such quarters with electricity, water facilities etc. are minimum in the system to retain the workforce in those underserved areas. Moreover, other rewards system linked to performance is also not the system, may resulted to the low job satisfaction and motivation of the workforce. The reward and recognition for the performance and achievement is also there in the system which could boost the satisfaction and motivation to perform by the workforce. The study findings seem that the workforce is dissatisfied with these components in the system. The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for financial incentives as retention interventions is low (N=334, mean=2.13) in the scale of 1 to 5. The result revealed that there is no satisfaction regarding the HR Practice for retention taking financial incentives as an intervention. Table 162: Scale of satisfaction of HR Practice for retentions Financial Interventions Category Highly Satisfied Highly Dissatisfied Neither Dissatisfied Satisfied Satisfied Nor Dissatisfied Physicians 36 (31.9%) 50(44.2%) 15(13.3%) 12(10.6%) 0 Nurses 24 (24.5%) 46 (46.9%) 20(20.4% 8(8.2%) 0 Mid28 (22.8%) 52(42.3%) 28(22.8%) 15(12.2%) 0 wives Total 88(26.3%) 148(44.3%) 63(18.9%) 35(10.5%) 0 The separate analysis of the scale of satisfaction of this component by the group of these employees, the physicians have the lowest level of satisfaction that is mean=2.03, whereas mid-wives and nurses have mean=2.24 and 2.12 respectively. The ANOVA test shows that there is a no significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 1.064, p =0.195. Table 163: Descriptive statistics on scale of satisfaction of HR Practice for retentions Financial Interventions by the position of respondents Category Physician Nurse Mid-Wife Total N 113 98 123 334 Mean Std. Deviation Std. Error Minimum Maximum 2.03 .940 .088 1 4 2.12 .877 .089 1 4 2.24 .944 .085 1 4 2.13 .925 .051 1 4

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Table 164: Analysis of variance for the Scale of satisfaction of HR Practice for retentions Financial Interventions among the group of respondents Mean Sum of Squares df Square F Sig. Between Groups 2.803 2 1.402 1.644 .195 Within Groups 282.134 331 .852 Total 284.937 333 The analysis of employee attitude survey revealed that the Level of satisfaction of these employees for non-financial incentives as retention interventions is low (N=334, mean=2.36) in the scale of 1 to 5. The result revealed that, the employees feel that there exists management favouritism and political interference in the transfer and posting of these groups of employees. Table 165: Scale of satisfaction of HR Practice for retentions NonInterventions Category Highly Dissatisfied Neither Satisfied Dissatisfied Satisfied Nor Dissatisfied Physicians 2 (1.8%) 33(29.2%) 42(37.2%) 36 (31.9%) Nurses 24 (24.5%) 26 (26.5%) 25(25.5%) 23(23.5%) Mid-wives 15 (12.2%) 65(52.8%) 33(26.8%) 10(8.1%) Total 41(12.3%) 124(37.1%) 100(29.9%) 69(20.7%) Financial Highly Satisfied 0 0 0 0

The separate analysis of the scale of satisfaction of this component by the group of these employees, the nurses and mid-wives have the lowest level of satisfaction that is mean=2.48 and 2.31, whereas physicians have mean=2.99. The ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 17.722, p =.001. Table 166: Descriptive statistics on scale of satisfaction of HR Practice for retentions Non Financial Interventions by the position of respondents Category Physician Nurse Mid-Wife Total N 113 98 123 334 Mean Std. Deviation Std. Error 2.99 .829 .078 2.48 1.105 .112 2.31 .791 .071 2.59 .950 .052 Min 1 1 1 1 Max 4 4 4 4

Table 167: Analysis of variance of Scale of satisfaction of HR Practice for retentions Non Financial Interventions among the workforce among the group of respondents Mean Sum of Squares df Square F Sig. Between Groups 29.095 2 14.547 17.722 .001 Within Groups 271.710 331 .821 Total 300.805 333
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4.6.6. HR PRACTICE FOR RETENTION DEVELOPMENT

TRAINING AND

In this context Mark Twains statement is crucial which states. There is nothing that training cannot do. Nothing is above its reach or below it (Ramani, 2003). Andragogy (the science of adult learning) demands tremendous effort from the trainer what should be more effective and purposeful (Rao, 2003). Skill up-gradation and multi skilling practices are much emphasizes in the sector. Lot of skill up-gradation and multi skilling training are undertaken and the physicians, nurses and mid-wives are satisfied with the process and most of the workforce are attracted and retain themselves due to this factor in the sector. A major pre-requisite for providing quality health care service is upgrading the skills and knowledge of all health personnel as well as this is an integral factor for retaining technical human resource in rural and remote areas. The Government is providing frequent scope for programme based training with time to time refresher training to all level of functionaries including ANMs, GNMs & Medical Officers. Huge investments on the employees are done in the form of training and development opportunities. There are different types of skill up-gradation training such at Skill Birth Training, Medical Termination of Pregnancy, Life Saving Anesthesia Training, Emergency Obstetrics Care, Neo-natal care etc. which are provided to physicians, nurses & midwives in primary and secondary level of health institutes. There is no discrimination regarding the status of employment for proving various skill upgradation training. Availability of in service training opportunities can be seen as a factor of attraction and retention of the employees in primary and secondary health institutes in rural and remote areas. They are getting opportunity for skill acquisition and have the access to all type of training in the department as per their eligibility and location of the health institutes. They are provided with a wide variety of training opportunity and provide exposure to different type skill up-gradation of their related work and techniques. It can also be developmental in a wider sense of developing both technical and professional skills. The multi-skill trainings & capacity building of the workforce are emphasized on physicians, nurses & mid-wives from the rural and remote area. Skill up-gradation is an essential component of in-service training programmes. The skill up-gradation varies enormously depending upon the qualifications of the personnel and the institution where he/she is working. For optimum utilization of human resources, skill
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and competence enhancement is of paramount importance. Therefore, with the objective to maintain the skill and competence level of the employees as well as to improve upon these skills, different training programmes are designed and undertaken in Health Sector. The analysis of employee attitude survey revealed that the Level of satisfaction of training and development as retention interventions is low (N=334, mean=3.22) in the scale of 1 to 5. The result revealed that, the employees are to the extent satisfied with the training and development practices of the organisation. Table 168: Scale of Satisfaction of Training and Development Category Highly Dissatisfied Neither Satisfied Dissatisfied Satisfied Nor Dissatisfied Physicians 2 (1.8%) 27 (23.9%) 27(28.4%) 48 (42.5%) Nurses 5 (5.1%) 26 (26.5%) 33(34.7%) 34(34.7%) Mid-wives 6 (4.9%) 17(13.8%) 35(36.8%) 59(48.0%) Total 13(3.9%) 70 (21%) 95(28.4%) 141(42.2%)

Highly Satisfied

9(8%) 0 6 (4.9%) 15(4.5%)

The separate analysis of the scale of satisfaction of this component by the group of these employees, the nurses have the lower level of satisfaction that is mean=2.98, whereas physicians and mid-wives have mean=3.31 and 3.34. The ANOVA test shows that there is a significant difference in the scale of satisfaction for this theme among the three groups, the values of F(2, 331) = 4.658, p =.010. Table 169: Descriptive statistics on scale of satisfaction of HR Practice of Training and Development by position of the respondents N Mean Std. Deviation Std. Error Min Max Physician 113 3.31 .983 .092 1 5 Nurse 98 2.98 .908 .092 1 4 Mid-Wife 123 3.34 .948 .085 1 5 Total 334 3.22 .959 .052 1 5 Table 170: Analysis of variance of Scale of Satisfaction of Training and Development among the group of respondents Sum of Squares df Mean Square F Sig. Between Groups 8.382 2 4.191 4.658 .010 Within Groups 297.777 331 .900 Total 306.159 333 The overall descriptive table on satisfaction of employees on HR practice of planning, recruitment and placement in respect of physicians, nurses and mid-wives is presented in table: 171 to 173.
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Table 171 : Descriptive statistics on level of satisfaction on HR practice of planning, recruitment & placement in respect of physicians, nurses & mid-wives Sl. No. N Scale Mean SD Dimensions 1 2 3 4 5 6 7 8 9 Recruitment and selection process Policies for placement, transfer and promotion Fairness of HR Practice for placement, transfer and promotion Magnitude of management favouritism and political interference in transfer and posting Response of administration/management on your placement, transfer and promotional grievances Participation and involvement in the decision making for placement and transfer Practice for retentions Financial Interventions Practice for retentions Non Financial Interventions Training and Development Practices 334 334 334 2.43 .766 3.28 .805 2.11 .715

334 1 to 5 2.36 .753 333 334 334 334 334 2.39 .824 2.32 .694 2.13 .925 2.59 .950 3.22 .959

Table 172 : Descriptive statistics on level of satisfaction of Contractual employees on HR practice of planning, recruitment and placement Attributes N Mean Recruitment and selection process 154 2.51 Policies for placement, transfer and promotion 154 3.20 Fairness of HR Practice for placement, transfer and promotion 154 2.01 Magnitude of management favouritism and political interference in 154 2.41 transfer and posting Response of administration/management on your placement, transfer 154 2.36 and promotional grievances Participation and involvement in the decision making for placement 154 2.36 and transfer Practice for retentions Financial Interventions 154 2.16 Practice for retentions Non Financial Interventions 154 2.38 Training and Development Practices 154 3.36

SD

.834 .858 .657 .772 .847 .729 .937 .951 .861

Table 173: Descriptive statistics on level of satisfaction of Permanent employees on HR practice of planning, recruitment and placement N Mean SD Attributes Recruitment and selection process 180 2.35 .697 Policies for placement, transfer and promotion 180 3.36 .752 Fairness of HR Practice for placement, transfer and promotion 180 2.19 .753 Magnitude of management favouritism and political interference in 180 2.31 .735 transfer and posting Response of administration/management on your placement, transfer 180 2.41 .804 and promotional grievances Participation and involvement in the decision making for placement 180 2.28 .662 & transfer Practice for retentions Financial Interventions 180 2.12 .917 Practice for retentions Non Financial Interventions 180 2.77 .916 Training and Development Practices 180 3.11 1.024
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CHAPTER- 5 MAJOR FINDINGS, SUGGESTIONS AND CONCLUSION

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SECTION 1 MAJOR HR ISSUES IN DISTRIBUTION OF PHYSICIANS, NURSES AND MIDWIVES

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5.1.1. INTRODUCTION
After having an analysis and descriptive interpretational previous chapter, this chapter presents the major findings on distribution, attraction and retention of physicians, nurses and mid-wives in rural and remote areas. Section 1 highlights the major findings of HR issues on Distribution, Section 2 highlights major HR issues on Attraction and Section 3 highlights major HR issues on retention and Section 4 provides a preview of the specific findings on Health Sector Reform initiatives and Section 5 presents the major issues in HR Practice related to attraction, distribution and retention of physicians, nurses and mid-wives in rural and remote areas. Thereafter, Section 6 highlights possible options in form of suggestion on the major issues and followed by Section 7 the Conclusion of the study.

5.1.2.MAJOR HR ISSUES IN DISTRIBUTION OF PHYSICIANS, NURSES AND MIDWIVES

5.1.2.1. DISPARITIES IN ESTABLISHMENT OF HEALTH INSTITUTIONS: ISSUE OF HEALTHCARE DELIVERY SYSTEM WHICH LINK DIRECTLY TO HR ISSUES. Over the last few decades the establishment of health institutions in rural areas of the state are haphazard and not kept pace with adhering to the norms. The state has created 468 numbers of Sub-centres out of which only 286 no. of SCs are functional likewise 119 PHCs were established, whereas functional 24x7 PHC is 29, and functional CHC are 49 numbers, where as functional as FRUs is only one (1). Moreover, the figures of the health institution at the rural areas are different in the central database and the state figures. Health institution SC PHC CHC Central Figure (RHS, 2010) 286 97 48 State Figure 468 119 49

However, the government have attempted the disparities and on the verge of rectification and de-notification of many of the SCs in the rural areas, which were created randomly. The average population covered by the health institutions district wise has no similarities and the nurses were not followed it ranges from 6064 to 781 population for a Sub-centre in the districts. However, at the state level the figure is 2954 which is better than that of the norms for a SC. While a PHC covers a population from 22048
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to 1590 in the district and the state figure is 11619 which is also a better figure at the state level. Similarly, CHC covered a population from 8822 to 48513 and the state level figure is 28217 which is also a better figure than that of the norms. This trends show that the institution were randomly created without thinking the consequences of human resource requirement and without keeping in mind the Govt. of India norms. It seems the inter district disparities are there in respect of creation of the health institution, which in repulsion create the problem of inadequacy of human resource and inadequacy of importance. 5.1.2.2. THE HUMAN RESOURCE CRISIS IN RURAL AREA: NUMERICAL INADEQUACY OF PHYSICIANS, NURSES AND MID-WIVES The ramped and unplanned creation of health institution in the state has created a demand of Physicians, nurses and mid-wives. There is huge gaps of demand and supply, placement of Physicians, nurses and mid-wives in the region. Consequently, many rural communities/areas are deprived of the primary health care and desperately need the attention. However, the population norms of establishment of the health institutions does not fit in the state like Aruanchal Pradesh, because the state have lesser population in comparing to the other states in India. The state has the lowest density of population in the country. However, the norms are norms and should be followed by the state. Besides, the in-equities in distribution of Physicians, nurses and mid-wives, there is huge gaps and shortage of these category of health workforce, to cater the maternal and child health needs as well as primary health care in the state. This study found that there are geographical imbalances and shortages of Physicians, nurses and mid-wives. The inequities in the geographic distribution of Physicians, nurses and mid-wives, itself has meant too many rural and remote areas with the shortage of Physicians, nurses and mid-wives. This is a major reason for Arunachals weak health sector performance is due to the crisis in the health workforce. There is a critical shortage of skilled manpower like doctors, nurses and midwives. There are also shortages of personnel trained in concerned disciplines like various specialists, we can say this deals with number and the composition of health workforce, major public health issues. The health systems of the region were characterized by an insufficient number of medical specialists, MBBS doctors, and other professionals such as nurses and mid-wives. Other level of problem is that at many places posts are vacant in wants of appropriate candidate or procedural delays in appointing staff.
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Shortage of human resources is a major problem facing Arunachals Health sector, where more than 80% of the population lives in rural areas. Most of the districts have the rural population, maximum of the districts are having urban areas only in their District HQ and the rest are comprises of rural areas. Every District is having a district level hospital in its HQ, but these hospitals are also having acute shortage of manpower especially the graduate doctors, PG doctors and staff nurses. Whereas, the availability of ANMs in the state is quite good but this category of workforce is having an artificial crisis. However, under NRHM, doctors, staff nurses and mid-wives are currently recruited on a contractual basis. Among the newly recruited doctors, many of them do not join the service and some numbers leave the job within short span of time. As per the existing practices, staff nurse are recruited from those having passed out of nursing college and the nursing schools at the state and off-course from outside state. Although, the existing pool are not adequate to fill the vacant posts. Further, new requirements have come up after the launch of central government flagship programmes. There is demand for additional positions under these programmes in many of the district out of their sanctioned posts. The vacancy rates are particularly high for skills that are mostly needed. However, the determination of sanctioned post and vacancies there on, is also not cleared at the district as well as the state level. Most health occupations are highly interdependent when carrying out their tasks. Problems in one professional category may spill over into another. For example, a shortage of nurses resulting from inadequate planning may have adverse effects on the work of doctors. The shortfall of Physicians, nurses and mid-wives are continues to represent one of the major constraints to the development of health services and access to basic health care in Arunachal Pradesh. According to the Indian Public Health Standards, the availability of HR is one of the vital prerequisites for competency in the rural health care delivery system in the country. It is also very important where 77% of the population lives in rural and remote areas and poverty is the dominating factors among the population. Requirement based on the IPHS norms for Physicians, nurses and mid-wives for existence health institution are 570 midwives with current shortage of 51%, 926 Nurses with current shortage of 70% and 510 Physicians with current shortage of

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53%. The shortage of mid-wives among the districts ranges from 6% to 82%, nurses from 37% to 92% and 1% to 85% of physicians for all the existing health institution. Similarly, the requirement for rural and remote area is similarly high. We find that the requirement of mid-wives is 714 nos. with current shortfall of 65%, nurses is 747 nos. with current shortfall of 78% and physicians are 545 with current shortage of 66%. The situation is critical in respect of the requirement and the shortfall in rural and remote areas. This is a serious indicator of inadequacy of Physicians, nurses and mid-wives in rural and remote areas in comparison to the urban areas. The requirement is more because of the concentration of more Physicians, nurses and midwives in urban areas, which creates inequity in the distribution as well as the shortage of Physicians, nurses and mid-wives. Therefore, it is found that there is acute shortage of Physicians, nurses and mid-wives in the region and especially in rural and remote areas, while the urban areas have more concentration though there is also have the shortage in some numbers. While, the disparity of distribution of Physicians, nurses and mid-wives in rural and urban co-exists and contributing to the shortage and the huge gaps in the region. Thus, the poor availability of Physicians, nurses and mid-wives co-exists and creating an imbalance and a problem with debilitating health care delivery system in the region. The shortage of these categories of the health workforce is reaching the crisis proportion and should be the centre of attraction of the government machineries. 5.1.2.3. PRODUCTION ISSUES OF PHYSICIANS, NURSES AND MIDWIVES Generation of health workers is another issue in the state. It has not been kept pace with the need, especially with the physicians (MBBS) and nurses (GNMs). Absence of adequate training institutes for medical and nursing courses results in low numbers of medics and paramedics produced for the state. There is no medical college in public sector or in private sector for Allopathic disciplines besides a Homeopathy Medical College in private sector. Yearly a fixed numbers of students according to the Govt. Of India quota seats, are placed in various Medical colleges all over India. 32 seats in First nomination 2010 and 34 seats in first nomination 2011 has been allotted to the students for the MBBS course in various Medical Colleges in India (DHTE, 2010 & DHTE, 2011). For the training of nursing personnel, the state runs a lone
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Nursing School for ANMs at General Hospital, Pasighat, East Siang District of Arunachal Pradesh. The institute runs training programs on midwifery (ANM) nursing courses. There are no fix numbers of ANM admission seats per year in this ANM School, in the year 2009-10, the number was 70, a year before in 2008-09, it was 47. The variation depends on Government of Arunachal Pradesh continuing changing policy. There exists a chronic and serious shortage of Nureses (GNMs) at present time, as there is no GNM training school in govt. sector in Arunachal Pradesh. A few number of GNMs are produced in GNM School at Ramakrishna Mission Hospital, Itanagar. With this inadequacy in teaching schools, insufficient numbers of professionally trained personnel to compensate the situation. 5.1.2.4. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVES AMONG THE DISTRICTS: GEOGRAPHIC INEQUITY Adding to the acute shortage of manpower in the health sector in Arunachal Pradesh, the issues and options for deploying health workforce is always a big deal of concern. Mal-distribution, that is the distribution of health workforce is characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from a district perspective also. Urban/rural imbalance in the distribution of health workers is a problem in the past and present also, and it may be worsening more. There is an over-concentration of qualified health personnel in urban hospitals and urban centres, coupled with shortages in poor neighbourhood districts and rural areas that are not equally distributed, especially to manage change in the health sector. Health workforce especially the nursing staffs, the physicians are concentrated to the urban hospitals. Doctors and nurses are reluctant to relocate to remote areas and forest locations that offer poor communications with the rest of the main land and few amenities for health professionals and their families. Urban areas in the states are good and convenient to health care professionals for their comparative social, cultural and professional advantages. The Health workforce have been reluctant to work in rural and remote areas in the state, possibly because of little support at these areas, a lack of material resources for them, poor working and living conditions, isolation from professional colleagues and possibly less opportunities for self professionally developed and Silently the education opportunities for their (workforce) children. Moreover, there is a poor distribution of doctors as well as an acute shortage of midwives outside the capital city, particularly in remote areas and sparsely populated communities.
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Doctors and nurses are currently recruited on a contractual basis under NRHM, among the newly recruited doctors and nurses do not join the service if they are posted in remote and inaccessible areas in the state and some of them leave the job within short span of time on being regularized or of other reasons. The percentage of such doctors varies from district to district. Furthermore, there is no financial

incentive for Working in rural, remote and inaccessible areas, thats why the problem of geographic mal-distribution of health workers persists. The majority of skilled health service providers are concentrated in urban areas and the mal-distribution is concern for artificial crisis of health workforce in the rural and inaccessible areas in the state. The accessibility of Physicians, nurses and mid-wives has been threatened mostly in the rural and remote area of the state. While 77% of the population lives in rural and remote areas, only 63% of physicians, 54% of nurses and 72% of mid-wives are serving in rural and remotes areas of the state. This creates urban and rural imbalance in distribution. The phenomenon of urban skewness and mal-distribution among the districts are there, consequently, many rural and remote areas are in desperate need of the physicians, nurses and mid-wives. Thus, creating inequities in the geographical distribution of physicians, nurses and mid-wives have meant a wide range of rural & remote area are deprived of the primary healthcare at the doorsteps. In Arunachal Pradesh, the depth of inequities in the distribution of physicians, nurses and mid-wives in urban and rural area is truly a breathtaking. It is also found that the distribution of physicians, nurses and mid-wives is skewed among the districts. It is observed that the physicians, nurses and mid-wives concentrated to the districts which are with good accessibility and communication. The specialist cadre essential for the maternal and child health- Paediatrician, Gynaecologist and Anaesthetist are almost zero in the rural and remote areas and only concentrated to the urban areas. The 449 nos. of physicians are distributed across the health institutions having 1:3079 of doctor population ratio, which is poor than that of the norms. The doctor population ratio among the districts have different and ranges from 1506 to 8972 population per physicians (doctor). It is observed that the concentration of the physicians to the district is asymmetrical and maximum of them are concentrated to the three district with good communication and with more urban and semi urban area and easy rural area accessibility. The distribution of the physicians ranges from 17%

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to 1% among the districts, which creates a wide gap in the distribution. The remotest and harder districts have lesser number of physicians. Similarly, the nurses share the same situation. 390 number of nurses area distributed across the geographical boundary of the state. It is observed that the similar situation like the physicians to nurses. The nurse population ratio is 1:3545 for the state and does not fulfil the norms. The nurses are also concentrated to the same three districts as similar to the physicians. These three districts have good communication and urban areas. The distribution of nurses among the districts ranges from 23% to 1% among the districts. This trend resulted in Nurse Population ratio ranging from 1597 to 9802. It is observed that the nurses are also concentrated to the easy and good districts, whereas the hard and the remotest districts are deprived of the adequacy of the nurses in rural area. There are 542 numbers of Mid-wives and this category of health workers are to be placed in SCs, which is the lowest and the first contract points to the population. The mid-wives population ratio is 1:2551 in the state, which is also a worst among the ratio norms. The density of min-wives among the districts has the inequities ranging from 1 mid-wife serving 883 to 4722 populations. It is also observed similar to the other two categories physicians and nurses, that the distribution is also skewed among the district. The district with good communication and urban concentration has the highest mid-wives. The distribution ranges from 12% to 2% of the mid-wives across the districts. The distribution pattern of the mid-wives in the region shares the similar situation as the physicians and nurses have and concentrated to the same three districts. Thus, we found that there is poor distribution of physicians, nurses and midwives, wherein the ratio and percentage of distribution varies across the districts. 5.1.2.5. MAL-DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVES IN RURAL AND REMOTE AREAS AMONG THE DISTRICTS There are 283 numbers of Physicians, 210 numbers of nurses and 390 nos. of mid-wives distributed across the rural and remote areas of the state. This accounted for 32% of physicians, 24% of nurses and 44% of mid-wives in this pool. Physicians outnumbered the nurses, whereas in norms the nurses should outnumber the physicians. Whereas, the nursing cadre in rural area consists of 35% of nurses and 65% of mid-wives.

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The total 283 numbers of physicians are distributed among the rural health institutes across districts. The highest numbers are concentrated to the three districts, which have easy to access rural areas from the urban areas. The percentage distribution ranges from 13% to 2%, the deviation exist in the remotest and hardest districts. While the doctor population ratio in the rural areas is 1:3797, which is 74% deviation from the norms and wider that the state ratio of 1:3079. The district ratio ranges from 1:1506 to 1:8972. The better ratio can be observed in the district with smaller populated district followed by the same three districts which have highest numbers of Physicians, nurses and mid-wives and have the good communication and easy access of the rural areas. Similarly, the distribution of nurses has almost the same picture as of physicians. The 210 numbers of nurses are distributed asymmetrically among the districts. The average rural population serve by the nurses is 5117, which is 90% deviated from the norms. The distribution ranges from 16% to 1% among the districts. The ratio ranges from 2164 to 15039 among the district. The better ratio among the districts is of the three districts. Out of these, two districts are of good communication and easy access of rural areas. While, it is observed that 390 nos. of mid-wives are distributed asymmetrically among the districts. The distribution pattern ranges from 9% to 2% among the districts. The average rural population served by mid-wives is 2755 against the 2551 of the state, which deviates to 82% of the norms. The mid-wives ratio ranges from 883 to 6332 among the districts. The lowest population districts are having the good ratio among the districts and followed by the good accessible districts. Thus, we find that there is also poor distribution of Physicians, nurses and mid-wives among the districts in the rural and remote areas. 5.1.2.6. URBAN AND RURAL DISPARITY IN THE DISTRIBUTION OF PHYSICIANS, NURSES AND MID-WIVES IN WITHIN THE DISTRICTS: A CHRONIC PROBLEM The inequitable distribution of physicians, nurses and mid-wives found between districts. Almost all districts display serious disparities between levels of physicians, nurses and mid-wives between urban and rural areas. Most of the management representatives have a common consensus that the difficulty in distribution of the workforce particularly in the district level. The process of the transfer and posting are a challenging matter in the absence of the residential quarters
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and basic amenities at the rural and remote areas. They also pointed out that in the absence of comprehensive HR policy it is very difficult to rationalise the distribution. Overall, the shortage of the staffs is the main challenges in rational distribution of staffs in the rural areas. It is a matter of concern that the urban areas are also running out of the staffs and it is very difficult on their part to get equitable distribution. It is also pointed out that there are many cases of personal and medical reasons in which the management representative cannot force the staffs to be in the remote and rural areas for long durations. It is also sensed from the interview that there is influence of political pressure for the distributional process. However, it is not outspoken by the management representatives. Thus, the urban-rural disparity in distribution is observed within the districts. The analysis of urban and rural distributional disparity was done in the previous chapter, where the urban and rural areas were also defined in conceptual framework section in chapter of literature review, as being based in a hospital in urban areas especially only the institute in the district headquarter. Urban areas have 37% of physicians in urban areas and 63% in rural areas. The figures ranges from 14% of physicians to 57% of physicians concentrated to the urban health institutions within the districts. The tendency of urban concentration has been observed in the study of distribution of the physicians, out of 16 districts, 8 districts have more than 40% of physicians concentrated to the urban health institutions of the districts, wherein only one health institution is established in almost of the entire districts in the state. This signals inefficiencies in the distribution of physicians, nurses and midwives. The situation is grimmer in the cases of the nurses. The percentage of urban rural distribution is 46% and 54% respectively. It is observed the nurses are more concentrated to the urban health institutions. The figures of urban concentration ranges from 79% of nurses to 16% of nurses in the districts. The highest number of concentration of 79% of nurses is in the capital district of the state. There are more than 8 districts having more than 40% of nurses concentrated to the urban health institution within the districts. This creates a huge gap in rural and urban disparities in the distribution of nurses within the districts. Moreover, the distribution pattern of mid-wives is 28% in urban and 72% in rural areas in the state. However, the urban concentration of the mid-wives is observed within the districts. It ranges from the 59% of urban concentration to 7% of urban concentration. Basically mid-wives are meant for rural areas and meant for
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especially the SCs in huge numbers. But huge numbers are concentrated to the urban health institutions. 8 nos. of the districts have more than 20% of mid-wives concentrated to urban areas, creating a havoc situation in the rural areas. The most of the mid-wives are concentrated to the higher health institutions in the urban areas. Thus, we find a disparity in the distribution of Physicians, nurses and midwives in urban rural areas within the districts. These trends of Physicians, nurses and mid-wives to gravitate in urban health institutions where urban areas have facilities of good communication, accommodation and other basic amenities, this has create a vacuum in rural area and left the primary health care in the mercy of god and this in turn compels the rural mass to seek services to the urban tertiary level health institutes. This situation has also created the patient crowd in the urban level health institutions. 5.1.2.7. DECENTRALISATION OF DISTRIBUTIONAL FUNCTIONS Decentralisation of HR functions like distribution and deployment of Physicians, nurses and mid-wives had a twin context, in the sense that the function of distribution, deployment of contractual manpower is in the hand of district authority, rather the deployment criteria centralised to state level for regular employees. The second context was the transformation of roles in the health sector in response to crisis in local level only. So, matters relating to the deployment and distribution are a part of district authority as well as the state level authority. The core HRM practices for the distribution according to the norms are based on recruitment and selection process in the organisation. The recruitment and selection process of physicians, nurses and mid-wives after the initiation of Reproductive and Child Health programme in 1997 and subsequently National Rural Health Mission in 2005 has been concentrated to the contractual manpower and the process is decentralised to the district level since 2010-11. The decentralisation of this process is only for the contractual physicians, nurses and mid-wives. For the recruitment of the permanent employee of this category, the contractual employees are regularised and continued their services as regular employees, the process is basically based on the sanctioned post vacancies and seniority based and the process is undertaken by the Directorate of Health Services headed by the Director of Health Services. However, decentralization of recruitment and selection process to the district included HR planning, recruitment; transfer and maintenance of human resource have

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at the district level only for the contractual physicians, nurses and mid-wives. District authority is now had to play a new role as employers, often without the appropriate technical abilities to do so. The recruitment process under the decentralised arrangement in the district is closely linked to the instruction and financial provision at the state level. The implementation of the decentralisation policy is only for the contractual manpower in the district. But the appointment and deployment of the permanent physicians, nurses and mid-wives are not comes under the decentralised recruitment and deployment. So, it does not left any room for majority of the recruitment process and deployment. Thus, the recruitment under centralisation, whereby the state level would post permanent physicians, nurses and mid-wives to district may be without taking into consideration the specific needs of each district. Thus districts requiring more physicians, nurses and mid-wives could not get the required number or the willed workforce. 5.1.2.8. OTHER ISSUES In addition to the above major issues, the other persistent issues remain on eyes. The issues are of data inconsistency on HR deployment, use of the data for planning. In this study it is found that the information on human resource is in consistence among the state and district level, while it is also found that the inconsistency between the divisions of the health department. The official figures are very difficult to match on and come to any conclusive and concrete data on the human resource placement records, especially in the state level. This makes difficulty in estimating and establishment of facts and plan accordingly. The situation is grimmer in the state level taking the HR deployment data in the district level. There is absence of data base related to deployment of physicians, nurses and mid-wives, which could give the planner help.

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SECTION 2 MAJOR HR ISSUES IN ATTRACTION OF PHYSICIANS, NURSES AND MIDWIVES

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5.2.1. MAJOR HR ISSUES IN ATTRACTION OF PHYSICIANS, NURSES AND MIDWIVES

5.2.1.1. COMPULSION OF STAY IN THE RURAL AND REMOTE LOCATION The study revealed that the workforces who are presently working in the rural and remote areas of the state are either working to finish their minimum rural service tenure for PG courses especially the physicians, or on non-transferable positions like contractual employees or either they in transferred from other urban or rural areas by the Management and political pressure or demand. The cases are different but altogether they are staying at compulsion. It is found that 58% of the workforce is service in rural and remote areas in the compulsion, either they are in hurry to complete minimum rural service tenure or the nature of the position is nontransferable or Management relocations or in political pressure. When the groups of physicians, nurses and mid-wives are compared separately, 66% out of total physicians, 74% out of contract physicians and 63% out of permanent physicians agreed that they are in compulsion posting. Whereas, the group of nurses have, 49% out of total nurses, 71% out of contract nurses and 30% out of permanent nurses are agreed on the compulsion posting. While, the group of mid-wives have 58% out of total mid-wives, 77% out of contract mid-wives and 27% out of permanent mid-wives have agreed the compulsion. It is found that the situation is worst in the case of Physicians as more of them are in compulsion. When it is compared of permanent and contract workforce, the situation is worst on the part of the contractual. Secondly, the situation of the midwives is also a matter of concern; this group have more percentages of compulsion posting. The situation of compulsion posting among the workforce is a matter of concern and contributes to a high challenge for attraction and retention in the rural and remote areas. In addition, attracting physicians to rural areas has been a longstanding challenge (Rao, et al, 2009). In this study also we found that the situation is more alarming of the Physicians. Evidence on compulsory service from the previous studies seems to be unfavourable to the organisation. It seems to be less motivation and less commitment of these workforces and it may result in weak health indicators and low quality in the services. There are unanimous agreements in several studies that the compulsory
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positing does attract doctors, nurses and mid-wives to rural areas but there is no guarantee of commitment and improved service in the rural areas. International evidence on compulsory rural service has not been very favourable. Thus, such
compulsion was not well received and has not really succeeded in solving the long

term problem. At best, it is seen to address health worker mal-distribution in the short term, but tends to alienate people from the medical profession itself (WHO 2009). A recent review of compulsory education schemes recorded that such schemes rarely got support from health professionals, and health workers rarely continued on the same job after the compulsory stint was over affecting continuity of care (Seble F et al 2010). Many international studies point out that compulsory rural service programmes should be accompanied by support and incentives given to the health personnel (Liaw, et al 2005, Omole, et al 2005). Whereas, in India, compulsory rural service is not well-received by medical students. The level of opposition to this compulsion suggests that implementation is a huge challenge especially with the currently weak governance structures. Further, there exists little evidence of the effectiveness of compulsory rural service initiatives. (Rao & Ramani, 2011). Compulsory rural

service schemes (with no incentive attached) may not be the best way to face doctors in rural areas- such schemes have little appeal among doctors and adherence to such schemes has been found to be lacking. The effectiveness of compulsory placement has been assessed by descriptive surveys with inconclusive results (it addresses the short-term mal-distribution, but is criticized for alienating people from the profession, and for the difficulties in administration and enforcement) (Dolea 2009). In the Indian context, linking Post Graduate (PG) programmes to rural service appears to be a particularly influential incentive for attracting doctors to rural posts. There is a strong desire for specialization among doctors after their first degree (MBBS). (Rao, et al 2011). So, the main element in the attraction of the physicians, nurses and mid-wives in the rural and remote area of Arunachal Pradesh here is compulsion rural postings, and other factors contributes less among these groups of employees. Since, more of them are in compulsion, that may lack in commitment towards work, team working, absenteeism, lack of motivation and so on and so forth, which will create a non performing environment within the system and resulted in to low indicator of health services.
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5.2.1.2. LACK OF CAREER DEVELOPMENT OPPORTUNITY Lack of career development opportunities seems to be one of the issues in the attraction of these workforces. With the option of career development opportunity only 23% of physicians, 21% of nurses and 29% mid-wives are attracted to the rural area services in the state. The figures are alarming and it tells us that there is limited scope of career development in the rural service in public health sector. The lack of this component in the public health services in the rural and remote areas keeps the physicians, nurses and mid-wives from the rural areas than that of the urban areas in the state. The missing component of career development along with the promotion opportunities in the rural health service seems to push away the physician, nurses and mid-wives from the rural areas to urban which gives that a potentiality for personal growth in profession, career development and they can be in job hunting if they are in the urban areas in comparing to the rural areas. Career progression and development is always an important point while dealing with the new and young physicians, nurses and mid-wives. Thus, it seems from the selection of the respondents that there is no enough scope of career progression that has attracted them to rural area and for new entrants and it is also revealed that the nurses, mid-wives and especially physicians are reluctant to work in rural areas as opportunities for career development were typically less than in urban areas. So, the study found that the physicians, nurses and mid-wives are at the present posting place at rural and remote areas not for that they have the opportunity to progress. 5.2.1.3. INACTIVE RECRUITMENT STRATEGY Recruitment strategy for the physicians, nurses and mid-wives for rural and remote areas are not attractive and lack strategic recruitment and selection process. It is found that the organisation is not utilizing other means of recruitment advertisement other than that of newspaper advertisement. It seems that the strategy is only to lure the local candidates for the services in the rural areas, whereas to attract it is necessary for a wider circulation of the recruitment notices for a greater pool of potential candidates who are interested for the rural areas services for either reason. The organisation is not utilising the other strategy of recruitments and only relies on days old form of recruitment and selection tactics. There is little information for HR policy for the state or for the district. Absence of appropriate human resources policies, there is always a hindrance in managing people at work. Effective recruitment, selection practices are cohesively depends on the HR policies and in the absence of the same, a
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number of difficulties have been highlighted in the interview. The recruitment and selection process in the sector is characterised as traditional way of approach, only newspaper medium is used, no practical test, no scientific selection techniques used and overall there is no written policies that the contractual positions will be regularised if there is any relevant vacancies. The policy of the recruitment approach focused on the same geographic areas where staffs were needed, in the expectation that people would be less likely to want to transfer if they worked close to home. But, unfortunately this not in reality, the findings revealed that the factor for attraction in this study for preference for rural areas home town that is the current health facility is closer to town or Closer to family and friends does have only minimum selection as one of the factor of attraction are 16% for mid-wives, 20% for Physicians and 26% for nurses. Moreover, in the absence of HR Policy in the sector is great hurdle on recruitment and selections procedures. As many research studies concludes that in the absence of the comprehensive state HR Policies the personnel decisions are too often guided by favouritism, political dictates, and nepotism. As it is also seems that recruitment of right people through scientific recruitment and selection process is a significant aspect of HRM. The experience of the yesteryears in this sector in the above context is traumatic. As the "new" employment structure requires new/or modified HRM system to deal with the new organizational types and structure but the researcher could establish the traditional way of acquiring and managing employees are stand till date, there is still existence concept of personnel management rather through the new concept of Human resource management and Human Capital management. The study has revealed that recruitment of physicians, nurses and midwives under a decentralised arrangement has only been characterised by complex bureaucratic procedures and political influences and adversely affect the attraction of this workforce of the government service in the rural areas. 5.2.1.4. LACK OF HOSPITAL INFRASTRUCTURE & RESOURCE AVAILABILITY IN RURAL AREA AND POOR WORKING CONDITIONS The study found that, the attraction factor of availability of equipment, drugs and supplies for the smooth duty discharge of physicians, nurses and mid-wives is very low. It comes to 8% of physicians, 4% of nurses and 3% of mid-wives that are attracted to the rural and remote health care service in the state. It reveals that the hospital infrastructure and resource availability is scares at the rural and remote areas.

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While looking at the data of the state public health sector, it is very depressing and from no angle it seems the rural health service an attraction to this workforce. Out of 486 SCs only 286 SCs are functional all together deviated from one or other requirements. Taking 486 SCs at stock, 114 SCs are only with staff quarter, 212 SCs are without proper water supply, 263 SCs does not have electricity. Out of 119 PHCs, only 97 are functional (as per RHS, 2010) in which taking all 119 PHCs in stock, 52 nos. are without Labour room, 108 nos. are without minor operation theatre, 59 nos. have indoor facilities and 53 nos. of PHCs are without electricity. Whereas in the 49 CHCs, 3 nos. does not have labour room, 12 nos. does not have OT rooms, 11 nos. not having laboratories, X-ray machines in only 13 CHCs, only 3 of the CHCs have quarter facilities for specialist for the CHC and none of the CHCs have atleast 30 beds. Overall none of the health facilities are functioning as per IPHS. The situation of the poor health infrastructure and resource availability in the rural areas is a matter of concern and which is an issues on attraction of physicians, nurses and mid-wives. In the event of lack of equipments, drugs and supplies, it is very hard for a physician, nurse or a mid-wife to discharge their duty adequately, it is just like a soldier without arms in a battlefield. So, this is a very discouraging event for the physicians, nurses and mid-wives to attract towards the rural area services. However, this factor of attraction is not the only which can attract the physicians, nurses and mid-wives by its alone. While, the above points do have an impact on the working condition by which the attraction of the physicians, nurses and mid-wives could have attraction. The attraction from the improve working condition in the system in rural areas have attracted only 10% mid-wives, 8% nurse and 10% physicians. In the absence of hospital infrastructure and resource availability, it is obvious that the working condition will be poor in nature and have an adverse effect on the attraction of the physicians, nurses and mid-wives. Here in the system in rural areas, the working condition is characterised by poor working conditions and lack of corresponding inputs, which also contribute to the disillusionment of the health workforce. Workforce in the different districts and health institutes in Arunachal Pradesh are facing poor work environment and security at the workplace. Work conditions are characterised by absence of proper facilities at the health centre, ill-equipments, inadequate drugs and supplies, unusual working hours and excess work load, inaccessibility of accommodation, water and electricity etc.
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5.2.1.5. LACK OF OTHER CADRES, TEAMWORK AND INTERPERSONAL STAFFS RELATIONSHIP Teamwork and interpersonal relationship is always a contributing factor for attraction or leaving the job for any jobs positions. It is revealed that 2% of Midwives, 3% of Nurses and 4% of Physicians have selected as one of the factor that attracted to the rural and remote areas service. So, the organisation climate internally is no conducive for the employees. In the absence of adequate cadres in the fields are one of the non-attracting factors in the sector. It is also found in this study that the lack of others cadres, teamwork and interpersonal relationship with Mean of 1.65 has the highest mean among the factors for migration in rural to rural health institutes. Good mixer of cadres is absent in many of the health institutes, as compared to requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM at SCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians & Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know from the interview of the management representative that many of the health posts in the rural area are manned by the less skilled workers like nursing assistant and other semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and mid-wives or rather they are staying at urban areas. The impact of this maldistribution on health care delivery in rural areas is profound, at times resulting in primary health care facilities being staffed mostly by other staffs. As per primary data available for this study, there are total no. of sanctioned sub centres are 468, out of which only 301 have existing infrastructure, 222 No. of SCs having only one ANM each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3 ANMs, none of the CHCs except are having full complement of specialists i.e. Gynaecologist, Anaesthetist and Paediatrician. And it is also revealed in this study that there is no good interpersonal relationship between the permanent employees and the contractual. The contractual are always look down and lack recognition. So, the lack of good mixer of cadres, team work and interpersonal seems to be an issue and concern in the rural and remote areas.
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5.2.1.6. POOR REWARDING, RECOGNIZING AND APPRECIATION OF ACHIEVEMENT IN THE SYSTEM The reward and recognition for the performance and achievement is not there in the system which could attract the physicians, nurses and mid-wives in the rural area service. The study findings revealed that none of the respondents have attracted to the rural and remote areas due to this reason. There is no distinction of the performer and non-performer and it is known by everybody in the system and outside system in the public health sector in the state. The analysed results indicated that the lowest mean factors with the lowest score. That means the absence of reward and recognition for performance is one of the major issues for attraction of physicians, nurses and mid-wives. It is well know factor in several studies that only the financial incentives could not attract the health workers to the rural and remote areas. Almost all (90%) of studies discussed the importance of financial incentives on health worker motivation. However, it was noted that financial incentives should be integrated with other incentives, particularly with regard to migration where it was concluded that financial incentives alone would not keep health workers from migrating (Shattuck, et al., 2008). The reward and recognition and appreciation of service is a important component of attraction in the rural area service, which is absent in the system in the state. 5.2.1.7. POOR USE OF FINANCIAL (IN TERMS OF SALARY OR INCENTIVES) MEANS OF ATTRACTION For the attraction of the physicians, nurses and mid-wives for the rural and remote areas services the state does not have any concrete policies and implementation. There are no financial rural incentives for the physicians, nurses and mid-wives, however, there is a provision of hard area allowances under state govt. norms for only for the harder areas but the allowances are so little that it is negligible. The study revealed that none of the respondent has selected this option as one of the reason behind the attraction. It is found that the factors that may motivate the workforce to stay back commonly seem are financial incentives/ rural So forth, the same

allowances/performance incentives along with other factors.

situational factors may attract the physicians, nurses and mid-wives. Nevertheless, low salaries were found to be particularly de-motivating as health workers felt that their skills were not valued. Furthermore, they became overworked when taking a second job to supplement their income (Shattuck, et al.,

299

2008). Likewise the salary is also not competitive; there is no gaps or no difference in the urban posting or rural posting and even more no difference in the salary of performer or non performer. It is found in this study that the contractual appointments are done majorly to man the rural posts and the salary for the contractual are not competitive in compare to the permanent workforce and associated with a low and stagnant salaries especially for the contractual workforce. Further, the lack of a linkage between the skills and experience of staff to their remuneration package is absence the system. While, the compensation level of the workforce place in the rural and remote area and the urban areas are paid the same remuneration. The study found no difference in the pay range in the same category of the health workforce, whether being posted in remote rural area or the urban areas of the state. As here one can interpret that the remuneration and financial incentives for rural and remote areas are not competitive than of the urban areas, resulted in non attraction of the rural area services. Thus, the issue of low remuneration or salary and non existence of the financial incentives, which could in either, attract the physicians, nurses and midwives in rural areas. 5.2.1.8. TRAINING AND SKILL DEVELOPMENT ISSUES The study revealed that only 19% of the respondents have training and skill development opportunities in their list of attraction. While, the data revealed that only 16% of Physicians, 26% of nurses and 17% of Mid-wives have selected the factors as one of the factors of attraction for rural and remote areas. This seems that this factor has a limited scope of attraction especially to Physicians and the Mid-wives than that of the Nurses, however, the gaps are not wide and can be generalised that the factor have no much contribution for the attraction of this workforce. This creates a vacuum in the efforts of the health sector reform to greatly emphasize in the skill up-gradation and multi-skilling training practices. The non-attraction by this factor could be that the trainings are not given in regular intervals, with right access of the needs of the employees etc. The main issues found in the study is there is no random access of training needs, the planning of training and the execution of the same have a random mismatch in the district and as well as in the state level. The training needs are basically planned according to the services to be provided or it is in the health

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institutes, its no way access the personal training needs of these workforces that could also enhance their skills in personal fronts and interest. Overall, it is also found that the post evaluation of the training is not done and not in the process and not in implementation at the ground level. 5.2.1.9. LACK OF SUPERVISION IN CERTAIN AREAS Poor supervision and mentoring is always associated to the public sector. The same situation can be seen in the public health sector in the state. It is found that none of the respondents have attracted due to this factor. That means the factor have no contribution to the attraction of this workforce. It is also highlighted by the management representatives that in the absence of adequate workforce with trained in the matter at the higher level of health institution also contributed to this issue and it is a concern for the management. In reform initiatives the structural changes had taken place but the situation of the supervision could not be changed or improved. While putting light from the management representative interview responses that the supervision services also suffers from the financial constraints, geographical constraints and overall suffers from the skill scarcity that is scarcity of supervisors. The supervision is lack in the upper health institutes than that of SCs, however, whole of the workforce are not getting comprehensive supervision and mentoring. Thus, this component does not have the weightage in the sector that could attract physicians, nurses and mid-wives at the present scenario. 5.2.1.10. OTHER FINDINGS 5.2.1.10.1. FACTORS THAT ATTRACTED: CURRENT DETERMINANTS OF ATTRACTION AND PLACEMENTS It is found that the compulsion posting is the major determinant of physicians, nurses and mid-wives in rural and remote areas in the state. The other few factors are career opportunity, health facility is closer to town or family and training and skill development. However, the majority influential factor is Compulsion and it is statistically significant at mean test of 1.5. The study also revealed that the factor that attracted physicians is basically on Compulsion. Beside this factor, other few factors are -Continuing education/higher education Opportunities, Career development opportunity. In the case of nurses also compulsion is the factor, by which they are at the rural and remote areas. Beside the compulsion other few factors are- Current health facility is closer to town or closer to family and friends, Training and skill development Opportunities. In the case of Mid-wives also the have the same factor,
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the compulsion. Beside the compulsion, Career development opportunity, Training and skill development Opportunities etc. Compulsion is only the factor which is statistically significant at Mean Test Value=1.5 for all of the three groups. 5.2.1.10.2. RELATIONSHIP OF FACTORS OF ATTRACTION WITH THE DEMOGRAPHIC CHARACTERISTICS The study revealed the relationship of factors of Attraction and the demographic characteristics of physicians. It is found that there is a relationship

between age group of the physicians and attraction factors like availability of equipment, drugs and supplies,; Authority, independency and autonomy, Amenities like housing & conveyance provided, Safety at workplace and Current health facility is closer to town or closer to family and friends. Similarly, Family background of the physicians has the relationship to availability of good schools for children nearby town. It is also found that the Marital Status of the physicians has relationship with amenities like housing & conveyance provided; safety at workplace and availability of good schools for children nearby town. Relationship also found of Length of service and availability of equipment, drugs and supplies, Authority, independency and autonomy, Compulsion, Amenities like housing & conveyance provided, Teamwork and Interpersonal staffs relationship, Availability of good schools for children nearby town and Current health facility is closer to town or closer to family and friends. Similarly, it is found that there is a relationship between Nature of Employment of physicians and attraction factors like Availability of equipment, drugs and supplies, Authority, independency and autonomy, Career development opportunity, Amenities like housing, conveyance provided. Wherein, we did not found any relationship between the factors and sex of the physicians. While analysing the relationship of factors of Attraction and the demographic characteristics of Nurses, it is found that there is a relationship between age group of the nurses and Career development opportunity, Training and skill development Opportunities and Compulsion. No association has been found of marital status and other attraction factors. Similarly, the length of services (group) has the relationship to Career development opportunity, Compulsion, Amenities like housing & conveyance provided and Current health facility is closer to town or closer to family and friends. It is also found that the nature of employment has relationship with Career development opportunity, Compulsion, Flexible working hour with minimal

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workload, Amenities like housing & conveyance provided and Current health facility is closer to town or closer to family and friends. While analysing the relationship of factors of Attraction and the demographic characteristics of Mid-wives, it is found that there is a relationship between age group of the nurses and improved working condition, Availability of equipment, drugs and supplies, Training and skill development Opportunities, Compulsion, Flexible working hour with minimal workload, Amenities like housing & conveyance provided and Teamwork and Interpersonal staffs relationship. Similarly, we found relationship between Marital status of Mid-wives and Amenities like housing & conveyance provided, Availability of good schools for children nearby town, Current health facility is closer to town or closer to family and friends, besides the Compulsion. The length of service has a relationship with the factor of attraction like -Availability of equipment, drugs and supplies, Continuing education/higher education Opportunities, Training and skill development Opportunities, Flexible working hour with minimal workload, Amenities like housing, conveyance provided, Availability of good schools for children nearby town, Current health facility is closer to town or Closer to family and friends, besides the Compulsion. Meanwhile, it is also found that the nature of employment also have relationship with the factors of attraction like Authority, independency and autonomy, Career development opportunity, Continuing education/higher education Opportunities, Flexible working hour with minimal workload, Amenities like housing, conveyance provided, Teamwork and Interpersonal staffs relationship, Current health facility is closer to town or Closer to family and friends, besides the above factor Compulsion also contribute to factor relationship. However, we found no association between Family Background and other attraction factors. 5.2.1.10.3. FACTORS THAT MAY ATTRACT - CHOICE OF CURRENT PHYSICIANS, NURSES AND MID-WIVES The few highest percentage selection of the factors are Higher Salary package in compare to urban posting, Conducive working condition, Training and skill development Opportunities, Access to amenities like housing & conveyance, Financial incentives / Rural allowances/ Performance incentives, Safety at workplace, Rotational Posting after completing minimum rural service tenure and Career development opportunities. These factors are statistically significant at Mean Test Value (1.5). While the Mean Test value revealed the following factors significant
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factors for Physicians- Training and skill development Opportunities, Access to amenities like housing & conveyance, Career development opportunities, Financial incentives / Rural allowances/ Performance incentives, Rotational Posting after completing minimum rural service tenure, Conducive working condition, Good reward and recognition system, Higher Salary package in compare to urban posting and Continuing education/higher education Opportunities. While the combination of seven factors are having statistically significant for Nurses: Higher Salary package in compare to urban posting, Conducive working condition Access to amenities like housing & conveyance, Training and skill development Opportunities, Financial incentives / rural allowances/ Performance incentives, Good reward and recognition system and Safety at workplace. While the combination of ten factors are having statistically significant being found for Mid-wives: Higher Salary package in compare to urban posting, Access to amenities like housing & conveyance, Conducive working condition, Training and skill development Opportunities, Good reward and recognition system, Rotational Posting after completing minimum rural service tenure, Financial incentives / Rural allowances/ Performance incentives, Continuing education/higher education

Opportunities, Career development opportunities and Safety at workplace. While analysing the variance in the choice of the factors that may attract the physicians, nurses and mid-wives, it is found that there is difference in the groups in the view of factors that may attract to the rural and rural areas services. It is found that the physicians may be attracted to the rural and remote area service when they see there is scope of training and skill development, a good working environment, accommodation facilities, incentives and recognition system with a competitive salary that is more than that of urban areas. That meant that the physicians first look at self development by training and development, living condition and to the monetary factors. While, the nurses and mid-wives have attraction of higher salary first, good work environment, accommodation training and development, recognition and Safety at workplace. That meant that the group of nurses and mi-wives are more attracted to financial benefits and then they look after the work and living condition and offcourse to the Safety at workplace. Thus, it meant that the preferences are not in the same order and the factor cannot be generalised for all the three groups.

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SECTION 3 MAJOR HR ISSUES IN RETENTION OF PHYSICIANS, NURSES AND MIDWIVES

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5.3.1. MAJOR HR ISSUES IN RETENTION OF PHYSICIANS, NURSES AND MIDWIVES

5.3.1.1. ISSUES OF INTENTION OF INTERNAL MIGRATION AND RETENTION The study revealed that the factors that hindering the states effort to retain physicians, nurses and mid-wives in rural and remote areas are the migration of these health workforces within the state, very negligible amongst them are intent to search for an alternative employer. The major problem within the board is the problem of rural-urban migrations than that of rural to rural migration or outside migration. The study reveals that only 19% of them want to continue with their present rural posting place. 24% wants to shift to another rural health institute, 51% wants to shift to another urban health institute and 6% wants to shift to another job in some other State/sector in search of an alternative employer. This shows that the physicians, nurses and mid-wives are eager to shift their current locations. It was also revealed in the attraction findings that more than half of the workforce that is 58.1% of these groups is located in the present rural and remote locations in compulsions and it is obvious that these groups are very eagerly intended to shift their locations. This is an issue for the group of the physicians that 41.6 % of them intend to migrate to urban area, 24.8% physicians willing to migrate to other rural area and 7.1% Physicians willing to search for an alternative employer. Wherein, 50% of nurses are willing to migrate to urban area, 19.4% nurses willing to migrate to other rural area and only 25.5% wants to retain in the present health institution in rural area and 5.1% nurses intend to search for an alternative employer. Similarly, 59.3% of mid-wives intend to migrate to urban area, 27.6% mid-wives willing to migrate to other rural area and 6.5% nurses intend to migrate in search of new employer. Similarly, at the other side of the coin which is also an important angle to access the issue of migration that is the nature of the employment of these groups. The finding are 51.3% of contract physicians, nurses and mid-wives are intend to migrate to urban area, whereas, 50% of the permanent physicians, nurses and mid-wives have that intention. So, more of the contractual are intended to migrate. This study also revealed that the intention of migration of this workforce is related with the level of job satisfaction of these groups of health workforce and propel them to migrate. The variable job satisfaction is significant at p<.001, has an impact on the decision of employees to stay at the present rural place of posting.
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While, the study revealed that there is no significant relationship of job satisfaction and parallel migration from one rural area to another rural area. It is also explore that there is a strong relationship of the job satisfaction and urban migration. The variable job satisfaction significant at p<.001, has an impact and predictive power for the decision of employees to urban migration. Job satisfaction also has significant relationship and predictive for migrating in search of an alternative employers. This intention of migration of physicians, nurses and mid-wives is attributed by several factors within the health system and its co-exist external environment. The Factors that contributed for migration of the physicians, nurses and mid-wives as a whole, from the present rural area to other rural area, urban area or to leave the sector have two factors significant that are the Lack of adequate financial incentives / rural allowances/performance incentives and poor working condition. The Factors contributed for intention of migration of the permanent physicians have the Lack of adequate financial incentives. While, contract physicians have three factors significant that are the Poor salaries, lack of adequate financial incentives and lack of Career development opportunities. For intention of migration of the nurses have two factors, the Lack of adequate financial incentives and Poor working condition. In which, permanent nurses have the Lack of adequate financial incentives / rural allowances/performance incentives. While, contract nurses have two factor that is the Poor salary and Lack of adequate financial incentives. The Factors contributed for intention of migration of the mid-wives have two factors, the Poor salaries and Poor working condition. In which, permanent mid-wives have two factors that is the Lack of adequate financial incentives and Poor working condition. While, contract mid-wives have two factors that is poor salaries and Poor working condition. The issue of intention to migrate according to the place of choice is that the highest number of 51% of them is intended to migrate to urban areas. The factors that contribute highest to migration of this workforce to urban areas have two factors, the Poor working condition and Lack of adequate financial incentives. While, factors that contributed to the intention of migration to another rural health institute had the lack of others cadres, teamwork and interpersonal relationship and lack of Autonomy. Similarly, five factors found for migrating outside the state, the Lack of Career development opportunities, Poor salaries, Lack of Job security, Lack of adequate financial incentives and Lack of scope for continuing education/higher education.
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The need is to understand the various factors which motivate physicians, nurses and mid-wives to retain themselves in the present rural posting for taking decisions into consideration for planning the financial as well as non-financial incentives, thus, the factors that may motivate the physicians, nurses and mid-wives to retain themselves in the present rural area have the four factors -financial incentives, improved living condition, career development and Good reward and achievement recognition system. For the physicians are financial incentives for rural postings, Improve living conditions, Career development opportunities, improved working condition and Good reward and achievement recognition system. While, contract physicians have six factors, Career development opportunities, Opportunities of continuing education/higher education, financial incentives for rural posting, Improve living conditions, Increase salary by half & Job Security. Similarly, the permanent physicians have five factors, financial incentives for rural posting, Improve living conditions, improved working condition, Career development opportunities and Good reward and achievement recognition system. The motivational factors that may motivate the nurses have three factors, Financial incentives for rural posting, Improve living conditions and Career development opportunities. While, the contract nurses have five factors, financial incentives for rural posting, improve living conditions, Career development opportunities, Increase salary by half and Job Security are statistically significant. Similarly, the permanent nurses have three factors, financial incentives for rural posting, improve living conditions, Good reward and achievement recognition system. The factors that may motivate the mid-wives have three factors, financial incentives for rural posting, improve living conditions and Good reward and achievement recognition system. While, the contract mid-wives have six factors, financial incentives for rural posting, improve living conditions, Increase salary by half, Job Security, Good reward and achievement recognition system and Career development opportunities are statistically significant. Similarly, the permanent midwives have three factors, financial incentives for rural posting, Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication) and Good reward and achievement recognition system are statistically significant.

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Thus, the issue of migration is a major issue in the sector, more of the workforce wanted to migrate to urban area. So, the major problem within the board is the problem of rural-urban migrations than that of rural to rural migration or outside migration and Job satisfaction as a decision maker theme. 5.3.1.2. ISSUES OF DECLINE AND VARIANCE IN JOB SATISFACTION In this study finding, in addition to the other issues and concerns, there is a growing dissatisfaction among the physicians, nurses and mid-wives in presently working in the rural and remote areas. The mean of overall scale of job satisfaction of these entire workforce is 2.26 (N=334) in a scale of 1-5, which shows an average low scale of satisfaction. In the group comparison, the Physicians (2.53, N=113), Nurses (2.32, N=98) and Mid-wives (1.98, N=123) means respectively. This shows a lower job satisfaction in the groups this workforce. Low job satisfaction and motivation can lead to non-adherence to guidelines, dangerous practices, or negative attitudes towards patients (Rowe et al, 2005 as cited in Logie et al, 2008). The analysis also shows that the groups of Mid-wives have the lowest scale of job satisfaction, followed by the group of nurses and the physicians. The satisfaction of Physicians are little higher than that of the other two groups and the trend of declining job satisfaction is seen according to the category of employment as the lower groups is having declining job satisfaction. This may be that the lower group are being posted at the lower health institute and they represent a more remote and rural location. The Medical professions like doctor and nurses has been long among the most attractive and satisfied profession in the society, but when it is analysed in the context of rural and remote area services, the results suggests that these group of employees are increasingly dissatisfied with their jobs in rural and remote areas. It is already explained at the above point of migration and the intention of migration of this workforce is also related with the level of job satisfaction of these groups of health workforce and propels them to migrate. It is one of the determinants of the retention and migration of the physicians, nurses and mid-wives. It is well known that the job satisfaction is effected by the demographic attributes of the employees. It is found statistically significant that there is a positive relationship of job satisfaction with the age, length of service, place of posting and nature of employment. It is found that as higher age employee has higher job satisfaction, higher length of service has higher job satisfaction, employee posted at the higher level of health institute has higher job satisfaction and permanent employees have the
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higher job satisfaction than the contractual employees. It is also found the correlation between the marital status and job satisfaction. However, it is found that there is no relationship between family background and job satisfaction of employees in rural setting. Thus, statistically it seems that age, length of service, place of posting and nature of employment has the positive impact on job satisfaction in the rural setting. While in the group of Physicians, it is found that there is a positive relationship of job satisfaction of physicians with the age, length of service, and nature of employment. No relationship found between family background and job satisfaction of employees in rural setting. While in the group of nurses, it is found that there is a positive relationship of job satisfaction with the age, length of service and nature of employment. While in the group of mid-wives, it is statistically significant that there is a positive relationship of job satisfaction with the age and nature of employment and the correlation between the lengths of service. No significance found in marital status and family background with job satisfaction. However, in entire group of the workforce the common demographic in context of the nature of employment has a relationship with the job satisfaction or dissatisfaction in rural setting. It is found that Salary and Training & Skill development opportunities are the main contributors to the Job satisfaction in current time of physicians, nurses and mid-wives altogether in rural and remote area setting. Thus, there is a growing dissatisfaction among the physicians, nurses and midwives in presently working in the rural and remote areas, more on there is an issue of job satisfaction differentiation between the groups of physicians, nurses and midwives and the job satisfaction if diminishes according the lower category and it also revealed that there is a gap of job satisfaction between the contract workforce and permanent workforce at large. Only the components like Salary and Training & skill development opportunities found to be the main predictors of job satisfaction and no other factors found to significantly contributing to the job satisfaction in these categories of health workforce at the present time in the rural setting. 5.3.1.3. LACK OF ADEQUATE FINANCIAL, RURAL ALLOWANCES AND PERFORMANCE INCENTIVES As it is mentioned in earlier sections that the Health workforce are reluctant to work in rural and remote areas in the state, possibly because of little support in these areas, a lack of material resources for them, poor working and living conditions, isolation from professional colleagues and possibly less opportunities for self
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professionally development. To fuel on this the study found that there is no financial rural incentives for the physicians, nurses and mid-wives, however, there is a provision of hard area allowances under state govt. norms for only for the harder areas but the allowances are so little that it is negligible. Whereas, such allowances for the contractual health workforce are not recorded in this study. The questionnaire survey with the options has not selected by any of the respondents that has contributed their attraction factors or retention factors. It is found that the factors that many motivate the workforce to stay back commonly seem are financial incentives/ rural allowances/performance incentives along with other factors. In the light of no provision of such incentives for the physicians, nurses and mid-wives for rural area services and the compensation package also is same irrespective of the place of posting. Other non financial incentives such quarters with electricity, water facilities etc. are also not in the system to retain the workforce in those underserved areas. Moreover, other rewards system linked to performance is also not the system, resulted to the low morale and motivation of the workforce. The below statement was found in the documents of the state govt. but till now there is no sign of such incentives in the field. To motivate the manpower located at remote and hard areas will be given incentives. The incentives will be conditional on regular staying and performance based. The incentives will be given through respective RKS at facility level. Detail incentive policies are addressed under NRHM Additionalities-(Govt. of Arunachal Pradesh, 2009, SPIP 2010-11) Staff job satisfaction has been affected through rapid change, and the perception of health workers that their compensation levels and working conditions have been negatively obviously affected the motivational level of physicians, nurses and mid-wives. Thus, it is one of the major issues; a mixer of interventions both financial and non-financial is not in place for retention of human resource. Though, the health need related issues are looked into by the individual states and Govt. of India supports financially. All the states prepare annual plans to include this intervention in human resource issues, but still there are no accounts for these incentives in the field. Few statements on incentives by the respondents are: Furthermore, there is no provision of extra incentives till date for us living in rural area and even did nt heard about this in my 3-4 years of rural posting". A Physician.
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Financial incentives only will not be adequate for us, what do here in rural and remote area.. if we cannot make use of that money in a productive and entertaining way, no basic amenities like good housing, regular water and electricity supply, good road connectivity is not there. A Physician. According to the State Programme Implementation Plan, 2011-12 of all the states, in order to ensure stay of Health workers in difficult rural and remote areas, the states proposed incentive schemes. However, the incentives are yet to be seen materialized, it may be due to financial constraints in the state. 5.3.1.4. ISSUE OF EQUITY IN COMPENSATION: It is found in this study the public health service is associated with a low and stagnant salaries especially for the contractual workforce. The issue of low remuneration or salary is consistent for the health workforce especially for the contractual employees, the recent pay enhancement corresponding to the Pay Commission recommendation in the state has been only implemented to the regular staffs and it has also created a wide gap in the pay parity of contractual staffs and the regular staffs, but the compensation level was enhanced little to this groups in the year 2011-12, but no how it reaches the level of the regular workforce in the same working conditions and the nature of job. As here one can interpret that the contractual health workforce in Arunachal Pradesh are underpaid, poorly motivated and very dissatisfied and may have an adverse impact on the health delivery system. Further, the lack of a linkage between the skills and experience of staff to their remuneration package is absence the system. While, the compensation level of the workforce place in the rural and remote area and the urban areas are paid the same remuneration. The study found no difference in the pay range in the same category of the health workforce, whether being posted in remote rural area or the urban areas of the state. Moreover, the workforces that are posted in the urban areas have other options for earning if they will to do so. There are greater opportunities in urban areas for additional incomes to supplement the ever increasing inflation that that of rural and remote areas. This creates a burn out in the rural and remote area physicians, nurses and mid-wives and adversely affects their retention intention. Moreover, as a result of poor compensation, the available workforce such as physicians, specialist, nurses and mid-wives do not want to join the duty and serve in rural areas for longer duration. There is no clear cut policy implementation regarding duration of service in rural areas by these categories of
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workforce. Over all it is also mentioned in the earlier point that there is no financial incentive for working in rural, remote areas. Low pay ranges is also a major reason for the sector to face difficulty in attracting and retaining staff along with there are no differences in the compensation packages for serving in urban, rural, inaccessible areas. Thus, the state is failed to use the Salary component as means of retention of physicians, nurses and mid-wives in rural and remote areas. The government has failed to raise the real value of compensation differentiation on the basis place of posting to be using it as a retention strategy. Here, it is also understandable on the part of the government to unable to raise the salaries but the govt. is no doubt capable of being develop a policy implication on different pay structures for the urban and rural with remote areas for retention of the physicians, nurses and mid-wives. 5.3.1.5. DISPARITY IN REGULAR AND CONTRACT WORKFORCE, AFFECTING ADVERSELY IN JOB SATISFACTION AND RETENTION: We found that contract workforce is more dissatisfied from the job than the permanent workforce. In the group comparison as per the Nature of Employment, the means of contractual employees (1.99, N=154) and permanent (2.50, N=180) respectively. This interprets as the contractual employees have low job satisfaction in comparison to the permanent employees. There is a difference in the job satisfaction between the groups. The mean difference is -.513 between the contractual and permanent employees. If we analysed the situation in categorizing the workforce in nature of employment, we found that contract workforce are more dissatisfied than the permanent workforce. 17.5% are highly dissatisfied, 71.4% are dissatisfied, and 5.2% are satisfied in the group of the contracts. While, the permanent employees have 9.6% are highly dissatisfied, 69.8% are dissatisfied, 14.1% are satisfied with only 0.6% are highly satisfied. Thus, permanent employees have the higher job satisfaction than the contractual employees. The job characteristics of contractual employment are very much responsible for motivating factors to the contractual employee, the factors such as job security, low pay, no benefits and other factors are fuelling the low satisfaction and low motivation in the employees. Contract employees are less satisfied with certain aspects of their jobs, than permanent employees. Contract people are also in job stress from workload and lack of opportunity for career advancement. Contractual
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employees receive fewer fringe benefits, have no promotional opportunities, and receive little or no long training opportunities. Therefore, a job with fewer of these characteristics would reduce the person's job satisfaction. While exploring to the variance of factors of job satisfaction in between the contractual and permanent physicians, nurses and mid-wives, it is observed the components like salary, job security, career development opportunities, opportunities of continuing education/higher education, Teamwork and Interpersonal staffs relationship and Access to free accommodation (Housing) have the differentiation. While talk about there is differentiation in the compensation package another issue of job security is one of the most significant issues in contractual employments, which may create a greater sense of insecurity in short-term and long-term. Moreover, the work life balance is tough in the context of this contract workforce, who gets only few days of causal leave with no other kinds of paid leave as compare to the permanent employees, the contract employees face the difficulties to maintain the family and work life balance. There is no flexibility for contract employees for leaves to dispose of their family duties. Juggling between family and contractual is very difficultone of contractual employee said while informally discussing the topic. Financially the compensation is less, when they compared their incomes to those of permanent employees. Contract employee is not eligible for benefits, other employment benefits, pension plans, medical and dental benefits, life insurance, educational reimbursement and training etc. Even the bank is not providing loan to me as I am a contractual employee one of contractual employee said while discussing the topic. Human resource policies define how an employee is treated in the workplace, which is absence in the reform process in the sector. There is an inequity in perception in respect of contractual employees in respect of opportunity within the organisation, with fuelling of no definite path of career advancement and most of them are of younger generation and concern about their career advancement as well. There also an existing of a cold ill treatment of contractual employees by the fellow permanent employees at the work place. This makes contractual employee stress, and affects the working ability of the employee. The more stress comes when under to meet the demands of contract employment. All contract employees (who were informally interviewed including) admitted suffering stress connected to contract employment. I felt discriminated when I sat with other permanent employees of the

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department and when they talk about enhanced pay package and accumulated arrears being paid to them- one of contractual mid-wife said while discussing the topic. So, these staff motivation has been affected through rapid change, and the perception of health workers that their compensation levels and working conditions have been negatively affected the satisfaction level converted to low motivational level. 5.3.1.6. POOR WORKING CONDITION: It has long been known that employees behaviour and attitudes are affected by the nature of the work they do and the environment they do it in. Much experimentation and research have taken place in attempts to discover optimal designs of work and workplaces for maximizing results in organizational improvement and quality of working life. The studies of Kagi (1985) and Surti (1986), confirms the desire of workers for better working conditions. Working conditions in the absence of necessities for human resource in health sector in Arunachal is yet another major issue in this confront. The working condition is characterised by poor working conditions and lack of corresponding inputs, which also contribute to the disillusionment of the health workforce. Workforce in the different districts and health institutes in Arunachal Pradesh are facing poor work environment and security at the workplace. Work conditions are characterised by absence of proper facilities at the health centre, ill-equipments, inadequate drugs and supplies, unusual working hours and excess work load, inaccessibility of accommodation, water and electricity etc. Work required certain supplies and logistics which are currently inadequate. These supplies and logistics should be made available adequately thus ensuring steady and better service delivery. Added to the ill health infrastructure, absence of proper equipments and proper office infrastructure, there is no proper toilet facilities in maximum of the health facilities especially for the woman workforce, which may adversely affect. Often poor working condition resulted in frustration, low motivation less effectiveness, and sustainability among the workforce especially in woman workforce. Thus, poor working conditions and lack of corresponding inputs also contribute to the disillusionment of the health workforce. According to Rural Health Statistics (2010), in the state out of 286 SCs only 114 (39.9%) are with quarter facilities, 12 (4.2%) are without regular water supply, 63 (22%) without electricity and out of 97 functioning PHCs, 31 (32%) is without

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electricity, 29 (29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are having residential facility for specialist physicians. Few statements by the respondents on work condition are: We are overburden, not with our clinical practice.there are hardly 5-10 patients in this place daily, which is not a matter of concern for us. But what I am writing about is the managerial and programme management works entrusted upon us. We are technical and clinical persons, but various health programs including the health institutions management are to be look after by us alone with little support of staffs for these works.-Physician. My requirements for works are clinical equipments, adequate medicines and finance. My requirement was of Rs. 4 lakhs but they provided me as little as 50,000/- to 80,000/-. So, how can I work in this situation.-Physicians. We are teaches for patients care- putting IV fluids, injections, medicines, bed and ward management. But here I have to work for all these including maintaining huge registers daily, preparing reports in many numbers for all health programmes and also management of this health institution.-Nurse. "We are performing without adequate supplies and equipments, working condition should be crucial at the work place."-A Physician respondent. We can interpret the above statements by the respondents that they are very much involved and concerned about their working environment. They are entangled between the clinical and programme management work at present environment. They also emphasized for adequate supplies, equipments and adequate funding for discharging their duties of rural health care services. "Urban areas in counterpart are rich living standards and better income opportunities. I can even practice privately after my duty hours, where I can earn a little to support my financial earnings. Overall I am fade up of the less patient load, sometimes it comes to nil. I cant keep pace with my clinical side I m forgetting all my learning of practice here now I am becoming a dak (official letter) runner or above that I am becoming a good clerk. This is the situation where I am becoming isolated from my profession. With the above comment of the respondent, it is known that not only the work environment characterized with over burden, which makes an effect on the interest of the respondent. But as a professional they are worried about the patient load in their health institutes in rural area. They cant keep pace with their clinical side practice in some of the rural areas. So, overburden as well as under-work makes an effect on the situational preference of rural services. Many medical, technical, and managerial positions in health programs and facilities are needed in a health sector reform environment, and scarce medical personnel are misused for management tasks at various levels. The supply of professional staff is now severely constrained at the leadership and managerial levels.
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Shortage of human resource for health with ill-equipped, both technical and managerial workforce at various levels often resulted in duality of roles, overburden and workload to the existing health workforce. Staff shortages have increased the workloads and stress levels, further de-motivating the physicians, nurses and midwives. The formal as well as informal discussion with the staffs for this study shows that the staffs are frustrated for the duality or roles, over burden with the works and the workload, with additional with lack of equipment to discharge their duties. As many of the technical/ clinical health workforce have to do the managerial, health data information works and other financial management works for which they not appointed. In this situation they have to often discharge a duality of role in the existing system and they have to divide themselves for clinical works and other managerial works, which often have an adverse impact on the discharge to their own duty of primary health care for the mass. Health workers described their workload as being relatively to the data and financial related work and often lead them to work stress. It is the result of new structures, practices, and technologies are imposing a heavy strain on an already weak human resource base in the health sector. While with the quantitative data findings revealed the factors that may attract physicians, nurses and mid-wives for rural and remote services has the working condition component and followed the percentage of selection of 74%. It is analysed and found that the factors that contributed for intention of migration of the physicians, nurses and mid-wives- from the present rural area to other rural area, urban area or to leave the sector have the factor of Poor working condition after Lack of adequate financial incentives/ rural allowances/performance incentive. The factor of poor working condition and inadequate equipments, drugs and supplies have accounted as top factors for intention of migration among the physicians, nurses and mid-wives. While the impact of health sector reform on work condition is a matter of concern. They do not agree upon that the reform process has made their work load manageable but rather they think more unmanageable at their level. Thus, it reveals that the workload is more unmanageable to all level due to the reform process. The statement that reform has improved the availability of equipments, drugs and essential supplies for performing the assigned tasks for the respondents posted rural health institutes has been agreed in group responses. The group of mid-wives has lowest mean than that of the two other groups. Thus, it seems at the mid-wives do not get adequate equipments, drugs and essential supplies and the reform has failed to
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provide them as well, in comparison to the physicians and nurses. Thus, it reveals that the reform has failed to address 360 degrees of these needs too. 5.3.1.7. POOR LIVING CONDITIONS Poor living condition is directly not comes under an HR issues but it affects the availability of workforce in the rural and remote areas of the state which have lack of road network, hilly terrains, lack of communication, transport, other communication facilities and lack of accommodation facilities, lack of television and radio services and other recreation facilities, lack of effective communication systems like telephones and mobile service at the place of posting resulted in lack of proper living environment. The physicians, nurses and mid-wives have disinclined to rural services, primarily due to absence of accessibility of communication and basic amenities in rural and remote areas. Some of the places are only reachable on foot and more of the rural and remote areas living standards are characterized by poor basic facilities and amenities, for which reluctances in workforce can be seen. RHS, 2010, in the state, out of functional 286 SCs, 95 (33.2%) is without all-weather motor able approach road. Out of 97 functional PHCs, 11 (11.3%) without all-weather motor able approach road, 13 PHCs (13.4%) only with telephone facilities and none of the PHCs having computer access facilities. While, out of 286 SCs only 114 (39.9%) are with quarter facilities, 12 (4.2%) are without regular water supply, 63 (22%) without electricity and out of 97 functioning PHCs, 31 (32%) is without electricity, 29 (29.9%) without water supply, 11 (11.3%). Out of 48 CHCs, 3 are having residential facility for specialist physicians. Absence of accessibility and basic amenities in rural areas is more emphasized by the respondents in this study. Few statements by the respondents on the accessibility and amenities are:
"Urban areas are good and convenient because they provide us with basic facilities and amenities which are needed for a human being in todays world. But here posted in rural and inaccessible area, where we are disconnected to outer world due to the natural and topographic reason. This deprived me of basic facilities like good accommodation quarter, electricity, and over all connectivity like regular mobile and internet facilities. This is also having an adverse effect on my preparation of entrance for PG, I do not have internet access which is a basic need for an academics preparing for entrance.-A Physicians. I m an ANM (mid-wife) at Sub centre, but I m attached to a PHC and working for the PHC and visits once a week to the SC area. This is only because of, there is no provision of residential quarter in that health facility and overall being a lady there is always a safety and security issue, so why do I prefer the rural posting. - Nurse.
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Even if we appoint the physicians for rural areas especially specialist cadre, they are more reluctant to join the area, they did not even join the place. This may be because of the reason that the places are deprived of the material resources, poor living standards in the village/rural level and possibly less opportunities for their practice and educational opportunities for their children.". They are shows reluctance to work in rural and remote areas in the state (Arunachal Pradesh), often they come to state headquarters for seeking transfer and posting to capital and district headquarters areas.some presents their health issues, family problems and other genuine reasons for to be shifted to the urban areas.-Key Informant Official. "We have no quarters for accommodation, good school for our children, so we are staying in a rent house in nearby urban area and daily I have to cover total 40 KMs in Bus to attend my duty, which cost me physically and financially".- A Nurse respondent. "I always will look for basic facilities and amenities like housing, water supply, electricity and communication facilities at my preferred work place. These also will include a good school for my child."-A Physician respondent. I am frustrated only because I was not posted to my home village, which is in the same district, I could have been stayed at my own home and attends the duty.-A Physician.

We can interpret the above statements by the respondents that the doctors and nurse including the mid-wives disinclined to rural services in the state, primarily due to absence of accessibility of communication and basic amenities in rural and remote areas. Thus, living standards are characterized by poor basic facilities and amenities in the area where the health institutes are situated, for which reluctances in workforce can be seen. Moreover, many of the staff prefer to and are allowed to stay in a nearby town from where they commute to their place of work; it is obviously in the absence of basic amenities in the posting place. This means that the health services are not available 24 hours at the health centers as planned. At lower levels health institute, there is no one to provide care at the time of need after duty hours, or when staff is on leave. To add to this, many workers do not go to their place of work regularly. There are also many other interruptions in the regular work such as review meetings, various camps, and trainings. However, the staffs that stay at their place of posting and provide 24 hour service get the same salary as staff that are absent or are available for only three to four hours a day. Other unavoidable situation of staff absenteeism are due to illness of themselves or their family members, some are due to chasing their salaries, allowances, and other bureaucratic tasks at the HQ, etc. 5.3.1.8. LACK OF GOOD MIXER OF CADRES, TEAM WORK AND INTERPERSONAL RELATIONSHIP Teamwork in health care occurred throughout the 20th century and, more recently, effective inter-professional teamwork has been identified as an appropriate
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response to the complex issues in many health care settings. Effective teamwork has been identified as enhancing staff motivation (Wood et al. 1994), including increased job satisfaction and improved mental health (Borrill et al. 2000; Peiro et al. 1992), and improving retention and reducing turnover (Borrill et al. 2001). It is found in this study that the intention of migration of physicians, nurses and mid-wives from a rural area health institute to another rural health institute is propelled mainly by the factor of team work and interpersonal relationship in the present place of work. So, the rural to rural migration is mainly due to the factor of absence of teamwork and interpersonal relationship in the workplace. Good mixer of cadres is absent in many of the health institutes, as compared to requirement according to RHS, (2010), there was a shortfall of 27 nos. of ANM at SCs taking into consideration of 286 SC in RHS, 2010, whereas, the number of SCs without ANM out of 286 SCs were 56 SCs. There was 140 nos. of shortfall of Nurses in PHC/CHCs. The shortfall Doctors at PHCs were 5 in 2010 with PHCs without doctors were 10 out of 97 PHCs. There was a shortfall of 48 nos. of Obstetricians & Gynecologists in CHCs, 47 nos. of Pediatricians in CHCs. It is also came to know from the interview of the management representative that many of the health posts in the rural area are manned by the less skilled workers like nursing assistant and other semi-skilled or unskilled fourth grade staffs, this because of shortages in nurses and mid-wives or rather they are staying at urban areas. The impact of this maldistribution on health care delivery in rural areas is profound, at times resulting in primary health care facilities being staffed mostly by other staffs. As per primary data available for this study, there are total no. of sanctioned sub centres are 468, out of which only 301 have existing infrastructure, 222 No. of SCs having only one ANM each, only 33 SCs have 2 nos. each ANMs. 22 nos. of PHCs does not have Medical Officer i.e., the physician. 12 PHCs only have the full strength of 3 staff nurses or 3 ANMs, none of the CHCs except are having full complement of specialists i.e. Gynaecologist, Anaesthetist and Paediatrician. Most of the management representatives have a common consensus that the difficulty in distribution of the workforce particularly in the district level. The process of the transfer and posting are a challenging matter in the absence of the residential quarters and basic amenities at the rural and remote areas. They also pointed out that in the absence of comprehensive HR policy it is very difficult to rationalise the distribution. Overall, the shortage of the staffs is the main challenges in rational
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distribution of staffs in the rural areas. It is a matter of concern that the urban areas are also running out of the staffs and it is very difficult on their part to get equitable distribution. It is also pointed out that there are many cases of personal and medical reasons in which the management representative cannot force the staffs to be in the remote and rural areas for long durations. It is also sensed from the interview that there is influence of political pressure for the distributional process. However, it is not outspoken by the management representatives. So, the lack of good mixer of cadres, team work and interpersonal seems to be a issue and concern in the rural and remote areas. 5.3.1.9. LACK OF JOB SECURITY AND CAREER DEVELOPMENT FOR CONTRACTUAL PHYSICIANS, NURSES AND MID-WIVES Lack of job Security in the health sector for contractual physicians, nurses and mid-wives have adverse effect on the job satisfaction and thereon the motivation to stay and work in rural and remote areas in the state. There is no provision of job security for this group of workforce in the sector. The whole workforce under NRHM is contractual and liable to terminate at any time without assigning any reason with one month prior notice or in lieu one month salary. This is also a factor for low job satisfaction and motivations of contractual health workforce. The service of the employees is renewal every one year on performance based. However, the performance appraisal process is also not effective due to various reasons. Moreover, there is no career path or career development for these employees for which the motivational factor could be high. The study explores the intention of migration of physicians, nurses and mid-wives from the present rural health institute to any other sector or other employer. The exploration of the preset factors from the responses job security option and indicate that this is one of the major issues which propelling the workforce for quite from the state health sector services in rural areas. The views above of the workforce are quite claimed to be of concern in the part of management who expresses fear about the issue. To talk about the issue of intention to migrate in search of other sector and other employer in the same sector, we found five factors significant that are the Lack of Career development opportunities, Poor salaries, Lack of Job security, Lack of adequate financial incentives and Lack of scope for continuing education/higher education. However, in order to give a boost to contractual employment, the state govt. started pulling senior contract physicians,

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nurses and mid-wives for permanent vacant posts, but in reality the incumbents have to act upon on. While, exploring the motivational factors that may motivate the physicians, nurses and mid-wives to retain themselves in the present rural area health institution, the responses of these employees revealed that Career development opportunities and Job Security as one of the factor for retention. While, exploring the motivational factors that may motivate the contract physicians to retain, the responses of these employees revealed factors which include-Career development opportunities and Job Security. In the group of the contract nurses also includes Job Security as one of the motivating factor. In the group of contract mid-wives have also Job Security as one of the motivating factor. Therefore, the issue of job security and career development is an alarming and major issue in the retention of the contractual physician, nurses and mid-wives in the rural and remote areas in the state. 5.3.1.10. WEAK AND IN-EFFECTIVE PERFORMANCE APPRAISAL SYSTEMS There are not concrete and effective performance appraisal systems on board. Historically, the permanent physicians, nurses and mid-wives have service book and annual confidential report on the performance conduct of the permanent workforce. However, the system is not effective and does not do anything with the performance in the field and does not have any link with the rewards or incentives upon them. Neither there is any mechanism which can monitor the daily activities undertaken by each workforce, only some clinical services provided are monitored under monthly reports, which is not at all have any connection with rectification of the performance or anything to reward or incentives. While, the contractual part of the workforce are altogether face annual performance appraisal, that is only for the further extension of the contract, which in no way is used effectively for review of the contract. This performance systems on the board is seems only to be the formalities in the nuisance public health environment. However, the performance appraisal of permanent physicians, nurses and mid-wives are used in the service book for pay roll increments, transfers, and other additional determinants in the service life of the incumbents. Discussions with the management representatives expressed doubts about

performance appraisal systems and the reports by the concern supervisors that they give the right feedbacks, which could be used for real performance appraisal for any
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rewards or any rectification. Moreover, the performance benchmarks were not put in place at the time of initiating the contracts or start of services in the rural areas. Thus, although the performance appraisal system is placed in the sector but the system is almost defunct and to be very weak. Little evidence exists on their effective use at hospital, district and health facility levels in the state. 5.3.1.11. TOTAL ABSENCE REWARDING AND RECOGNIZING ACHIEVEMENT SYSTEM: The use of financial incentives as important motivators has been over emphasised in the recent past. However, research in human relations and behaviour sciences has shown that where as money incentive had not proved effective, psychic rewards worked (Gellerman, 1963). Later research by Herzberg (1968) & Lawler (1971) confirmed the fact that pay has very little to do with motivation. However, several research studies in India have indicated the positive relationships between pay and employee performance (Dwivedi, 1980). The reward and recognition for the performance and achievement is not there in the system which could boost the satisfaction and motivation to performance in the workforce. The study findings seem that the workforce is dissatisfied with this component in the system. There is no distinction of under performer or good performer in the system. The variable Reward system and recognition have constants or have missing correlations in the responses of the respondents. The analysed results indicated that the lowest mean factors of job satisfaction and retention have one of the factors that are Reward system and recognition system (1.00) which is the lowest scores. That means the absence of reward and recognition for performance is one of the major contributors to the dissatisfaction and migration of the physicians, nurses and midwives. Out of the top 8 factors found that contributed to the intention of the

migration to outside the sector, the factor of Achievement not recognized or rewarded with Mean 1.38 can be seen. That means the factor is not in selection for the internal migrations because the respondents know that there is no such provision now and they doubt it could be in future in the system. Thats why who are intended to go out of the system are only selecting this factor as a factor of migration. Therefore, the need is to understand the various factors which motivate physicians, nurses and mid-wives to retain themselves in the present rural posting. Taking all these factors into consideration, financial as well as non-financial incentives can be planned.
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5.3.1.12. LACK OF SUPERVISION IN CERTAIN AREAS While the analysis of the factors that contributed to stay at the place of posting for more 3-5 years for both contract and permanent physicians, nurses and mid-wives for rural and remote services was done it is found that the selection of improved support, supervision and mentoring with a Mean of 1.17 is only there, which is a lower mean of contribution. That means the factor failed to contribute to the factor of stay back in rural and remote place. It shows that there is a system of poor supervision and support. It is also highlighted by the management representatives that in the absence of adequate workforce with trained in the matter at the higher level of health institution also contributed to this issue and it is a concern for the management. In reform initiatives the structural changes had taken place but the situation of the supervision could not be changed or improved. However, the statement that reform has made improvement in supportive supervision, management and mentoring form higher authority, has an agreement from the respondents. The physicians have the mean of 3.50, nurses have 3.68 and the mid-wives only 3.76. Thus, the responses revealed that there is an improvement of supervision and mentoring due to the reform process, and the trend is higher to the lower health institutes because the mean of the mid-wives is higher than that of the two other higher groups. While putting light from the management representative interview responses that the supervision services also suffers from the financial constraints, geographical constraints and overall suffers from the skill scarcity that is scarcity of supervisors. The supervision structures starts from very state level to the lowest layer of SCs, the SCs are supervised by the Medical Officers (Physicians) at PHCs or CHCs and these PHCs/CHCs by the district level. The matter is more concern upon lot of higher institutes is without the supervisors and if they are also, they are concern with the clinical abilities and lacks the managerial skills like supervision and monitoring at various levels. The supervision is lack in the upper health institutes than that of SCs, however, whole of the workforce are not getting comprehensive supervision and mentoring. Many staff, particularly those working in the upper health institution in periphery according to the above analysis of Mean factors of all the health groups revealed are deprived of the supervision and mentoring activities. For this reason it can be resulted in lower job satisfaction and retention in rural and remote areas. Ideally, supervision is a formalized HRM instrument to correct shortcomings and to support good practice, on the basis of which recommendations
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are provided to help improve individual and facility performance. The weak supervision at all levels may result in lack of availability and accountability of the staff at the working place. The supervision system is placed in the system but it is weak as the supervisors only monitor the work of their subordinates through the reports they submit of the numerical achievements of targets at the end of the month. Moreover, it is also mentioned performance appraisal is also very weak. Appraisal systems in use are basically and practically tend to be based on an assessment of personal characteristics rather than on achievements against agreed-upon work objectives or targets. 5.3.1.13. OTHER MINOR FINDINGS RELATED TO DEMOGRAPHIC ATTRIBUTES The Medical professions like doctor and nurses has been long among the most attractive and satisfied profession in the society, but when it is analysed in the context of rural and remote area services, the results suggests that these group of employees are increasingly getting dissatisfied with their jobs in rural and remote areas. The analysis shows that the groups of Mid-wives have the lowest scale of job satisfaction, followed by the group of nurses and the physicians, similarly contractual employees have low job satisfaction in comparison to the permanent employees. We found that there is a positive relationship of job satisfaction with the age, length of service, place of posting and nature of employment. It is significantly found in the study that the higher age of these groups of workforce has higher job satisfaction, higher length of service has higher job satisfaction, and employee posted at the higher level of health institute has higher job satisfaction in rural setting. It is also found about negative relationship between the marital status and job satisfaction. Wherein, it signifies that the more married employees the less satisfaction level in rural setting. And there is no relationship between family background and job satisfaction of employees in rural setting. Thus, there is no effect of family background on job satisfaction of the employees. Only the Salary and Training & Skill development opportunities are the main contributors to the prediction of Job satisfaction in current time of physicians, nurses and mid-wives altogether in rural and remote area setting which is a matter of concern. It is known from the study that the intention to migrate is having relationship with job satisfaction. Here it is explore the effect of the demographic attributes of the employees on intention to migrate to urban areas. From the study, it is found that
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there is no relationship exists between the demographic attributes of age, family background, marital status, nature of employment, and place of posting. Only the length of service is significant and reveals the relationship with the migration to urban areas. And job satisfaction has been statistically significance relationship with the intention of migration to urban area. While analysing separating the positions of the workforce as Physicians, it is found that there is no relationship exists between the demographic attributes of age, Sex, family background, marital status, nature of employment and place of posting and length of service with the intention of migration to urban area. As in the case of Nurses, it is found that there is no relationship exists between the demographic attributes of age, family background, marital status, nature of employment, place of posting and length of service with the intention of migration to urban area. While in Mid-wives, it is found that there is no relationship exists between the demographic attributes of family background, marital status, nature of employment and place of posting with urban migration but found a significant relationship with age and length of service. Thus, it is found that the demographic factors do contribute to job satisfaction and intention to migrate.

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SECTION 4 MAJOR REFORM INITIATIVES AND ISSUES THEREON

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5.4.1. MAJOR REFORM INITIATIVES AND ISSUES THEREON

5.4.1.2. THE RISE OF CONTRACTUAL EMPLOYMENT: ESTABLISHED NEW EMPLOYMENT SYSTEMS AND CONDITIONS OF SERVICE WHICH LINK DIRECTLY TO HR ISSUES. The vital ingredient in human resource management in health system consists of workforce management, skill mix, workforce performance capacity building and the numerical adequacy. To address the issue of numerical adequacy with cost effectiveness is contracting the human resource. In Arunachal Pradesh along with the country, increasing the number of health worker is a major challenge in improving the health system. The past one decade has seen a growing tendency of contractual employment in the public health sector in the state, toward a fundamental restructuring for addressing the inadequacy issue under reform process. A significant change in placement of human resource has been seen since 2005 in the state. The task of ensuring the availability of physicians, specialists and nurses to human resource pool by contracting of them is only short-term solution for the inadequacy. One of the greatest drawbacks is possibility of attrition, non-commitment of the employee in compulsion of performance which is very real risk in long run for both employer and employer in the public health sector. In this way, contracting is no better than engaging permanent employee in the sector in long run. The health services are a continuous need of the community and can only be delivered with the adequacy in numbers of the health care provider and supports competitive strategies in long run. Contracting is more likely to be successful only when there is a competitive strategy in long run to convert the contract employment into permanent in a stipulated time period because healthcare sector is highly dependency on key professionals like physicians, nurses and mid-wives. It should also be supported by appropriate policies and guidelines regarding this for the attraction and retention of the healthcare providers. Contract employment is offered for performance under pressure to an employee, which may adversely affect both the employee and employer. It also leads to perceptions of inequity among the co-workers. They also faced a certain degree of uncertainty and change, regardless of their choice. Thus, the permanent employment status should be supported by administrative systems and processes that enable the relationship to operate smoothly in long run. While, the nature of the contract is also not cleared and the basic framework of expectations and obligations are also is not cleared in the system.
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Health professionals choice regarding contract employment, in this study, was conditioned by job security and compensation at par with the permanent employee in the sector. The contract employees were placed in a position of having insecurity and short-terms and conditions of employment of one year. They were forced to choose the contracting job as there is no other options remains within the state. Contract employees are treated differently in the workplace than permanent employees. They faced a certain degree of uncertainty and change, regardless of their choice of being permanent employee. Contract employees have a different attitude to the workplace and their position. Bringing the management perspective contract employees are off-course manageable and cost less to the department but it does not seems long run sustainability and free from HR issues arising out of it. 5.4.1.3. EMERGING ISSUES OF PROFESSIONAL MEDICAL EDUCATION IN ARUNACHAL PRADESH IN REFORM PROCESS There is existing issues of access, growth and expansion within the agenda of health sector reform in Arunachal Pradesh, which could to some extend helpful in solving the problem of inadequacy of physicians, nurses and mid-wives in the state in long run. Arunachal Pradesh is lagging behind in the field of medical education in comparison to other states of the country. Production of the graduate doctors, nurses and mid-wives in comparison to expanding health infrastructure is becoming a matter of concern and a challenge for the public health sector in the state and its inclusion under agenda of health sector reform is most an issue and a challenge. There is no medical college in govt. sector or private sector for Allopathic disciplines, and it is not adequately addressed by the reform process. It is observed that the aggregate number of seats for medical and para-medical education for the state is not inadequate comparing to the requirement of physicians, nurses and mid-wives especially in the rural and remote areas of the state. State Public Funding for Medical Colleges, Nursing schools is a matter of concern and it is not widely addressed in the reform process. In the light of resource constraints of the state government, state funding for establishment of Medical Institutes is a matter of concern and challenge. The growth and expansion is only possible with the interventions of central govt. public funding or attracting private funds. The government, which is the major funder of medical education institutes for the state has failed to develop training institutes for medical, nursing, and related professions in the state. This may be subjected to lack of funds. The growth of
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potential teaching hospitals for establishment of new medical schools and nursing school in itself is a challenging issue in the reform process. Wherein, in the entire state only two hospitals namely State Hospital, Naharlagun with bed strength of 148 nos. and General Hospital, Pasighat with bed strength of 150 are nearly in shape that can be upgraded to Medical Colleges but proper initiation under the reform process has not been taken up. 5.4.1.4. ISSUES REGARDING DEVELOPMENT OF COMPREHENSIVE HR POLICY IN THE HEALTH SECTOR OF ARUNACHAL PRADESH UNDER REFORM PROCESS There is no comprehensive HR Policy in Public health sector in Arunachal Pradesh. There are recruitment rules for different category of health workforce. The recruitment and other service conditions for staff in health services of the state government is regulated by the APHS (Arunachal Pradesh Health Service) rules and central recruitment rules are followed. However, there is no specific HR Policy for recruitment, deployment, retention of the physicians, nurses and mid-wives and other health workers especially for remote and rural areas. This issue is not adequately addressed in reform process, the state govt. is preparing a 5 year strategies and policy document for augmentation and maximization of Human Resources as per the management representative, but it is no way would be soon available and its sustainability, as it is well known in the public sector all comes late. And it is also found that the policies regarding recruitment, deployment and retention is much more emphasized on contractual employees only leaving a loose tight on permanent employees. 5.4.1.5. ISSUE OF HR FUNCTIONS DECENTRALIZATION UNDER REFORM PROCESS: CHALLENGES FOR LOCAL CAPACITY The process of decentralization in the reform process has its own issue. Decentralization of authority, responsibility, and resources for personnel functions is delegated in a decentralized way in reform process to the district level. It is important to achieve effective human resource management and to improve staff performance. However, decentralization itself entails large-scale development of capacity at the local level for health planning, financing, allocation and accounting for resources, and HR management functions including staff recruitment, payroll and allowance documentation, and maintenance of personnel records. The Human Resource

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Management functions including recruitment and deployment are decentralized to the districts level. Though decentralization is used as an ornamental word into the reform process, the actual implementation in the view of low capacity at the lower level is a concern. The new decentralized organizational structures mean that the role of district authority as employer is transferred from state level, but to configure the new structure of decentralized environment there is no provision reform process for HRM system and HRM personnel in the organisation at state or the district level, that to strategically support the initiation. The transfer of human resources functions from State level to district level without a comprehensive design and structure is quite a big challenge for the district administration. Over all in the absence of an appropriate HR policy at state and district level on human resource, is still provide a big deal of challenge for the district authority. The study finds that in the reform process in Arunachal Pradesh, decentralization in many field including HR management issues have been percolated down up-to the district level and to some extend to the health institutes, but there is a need of far greater attention to HR skill deficits. The decentralization has been done in respect of power and resources to the district level and lower level of health administration for HR administration and management. Under this decentralised process, the recruitment is done at the district level, Human Resource planning, and their training needs and to ensure that health facilities had the minimum staffing requirements. In addition, the powers to recruit, exercise

disciplinary control, and to remove persons from district service were delegated to the District. Pay determination is heavily centralized at state level and national level, as part of broad based culture as other public sector. Decentralized the local autonomy is facilitating the local preference and to retain the workforce in the district. However, as mentioned earlier to manage the decentralized activities there is shortage of HR management personnel in the district level, which create a challenging environment at this and subsequent level of administration. As to increase the requirement for administrative and managerial staff in the system and likely to associated increase requirement for performance management also. 5.4.1.6. ISSUES OF RECRUITMENT AND SELECTION PROCESS The reform process more emphasized on the contractual employees and the policies are developed only for the same. The recruitment process adapted in the
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reform process

is

inadequate and

lack professionalism.

Only newspaper

advertisement, walk-in-interviews are utilized and no other options are ever tried to explore to include for better recruitment and selection process in the system of reform. The recruitment and selection processes are often guided by the personal bias and favouritism in the system. After that the appointments are made and no proper performance appraisals are done and many of the physicians, nurses and mid-wives get regularisation. It is also found that the performance appraisal in the system of reform process is not effective and comprehensive. Most of the management representatives have pointed out for the difficulty in getting physicians, Nurses for the health posts. The management representatives pointed out the crisis is more for the GNMs and then the physicians for rural and remote areas. It is may be due to lower graduates of medicines and nursing candidates. They also revealed that they have many post lying vacant in search of the GNMs (Nurses) and some of them are even personally arranging these cadres for the rural health services. It is also pointed out by the management representatives that in the light of very limited candidates for the posts they have to compromise on the technical expertise and experience of the candidates and have to appoint them for the rural and remote areas which obviously affect the quality of the services in the rural and remote areas. 5.4.1.7. ISSUES IN TRAINING AND DEVELOPMENT SYSTEM UNDER REFORM PROCESS Skill up-gradation and multi skilling practices are much emphasizes in the sector. Lot of skill up-gradation and multi skilling training are undertaken and the physicians, nurses and mid-wives, but the main issues is there is no random access of training needs, the planning of training and the execution of the same have a random mismatch in the district and as well as in the state level. The training needs are basically planned according to the services to be provided or it is in the health institutes, its no way access the personal training needs of these workforces that could also enhance their skills in personal fronts and interest. Overall, it is also found that the post evaluation of the training is not done and not in the process and not in implementation at the ground. The reform process has failed to addressed the access of training needs and post evaluation of the training in the field and in personal front of the employees.

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5.4.1.8. ISSUES IN FINANCIAL AND NON-FINANCIAL INTERVENTIONS The reform process has tried to address the issue of financial and non financial incentive for the rural and remote areas physicians, nurses and mid-wives. But the process had failed to comprehensively plan and execute the same. No adequate emphasized on making use of provision of financial and non-financial incentives for rural and remote area posting and retention is there. Over all the reform process has failed to give emphasizing the compensation equity in the workforce and their differentiation according to the urban and rural posting. Moreover, other rewards system linked to performance is also not the system, resulted to the low morale and motivation of the workforce. The reward and recognition for the performance and achievement is also not there in the system. 5.4.1.9. ISSUES IN INFRASTRUCTURE DEVELOPMENT INITIATIVES INCLUDING ACCOMMODATION FACILITIES AT RURAL AND REMOTE AREAS FOR UNDER REFORM PROCESS However, the infrastructure development is directly a HR activity, but is no doubt it contribute to HR practice in the organisation, particularly in health sector. Chronically there is inadequacy of residential quarters for workforce at rural and remote areas. For ensuring deploying, attraction and retention of physicians, nurses and especially Mid-wives in rural and remote area, the reform process is emphasizing to develop the residential facilities all over the state, but it has failed to do it with proper planning and wide coverage. However within the limited resources, prioritization is done to provide at-least residential quarters in the health facilities phase-wise. The identification of the health facilities has been done linking the HR availabilities and acceptable infrastructure. 5.4.1.10. THE VIEW OF WORKFORCE ON HEALTH SECTOR REFORM IN ARUNACHAL PRADESH The exploration of health sector reform process on physicians, nurses and midwives has pointed out some of the issues in understanding of health sector reform process and the employees. It is revealed that these three categories have different views on the health sector reform process on Human resource activities. All the employees are quite reserved at human resource policies of the organization, that they are clear about the HR policies of the organization, the mean of the response is only 2.06 in the scale of 5, which can be interpreted that reform has not succeeded to clear presentation of the HR policies (whatever is there exists at present) in the context of
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the Physicians, nurses and mid-wives. It seems the physicians are having little understanding of this, but we cannot say all other groups are equally aware of this component. However, the mean of the responses are the lowest we cannot say that the reform process has made human resource policies understandable at all level and contributed to the HR function of the organisation. All the employees emphasized on that there is no change in the scenario of transparency, fairness and unbiased placement, transfer and promotion. The groups have the view that the reform has failed to make placement, transfer and promotion to transparent, fairer and unbiased. However, it is found that the physicians and nurses are familiar with their job description clear they agree upon the statement, but not so strongly. Whereas, the mid-wives has no agreement on the statement and may be they are not so clear about the job description of the mid-wives. It is also found that the physicians, nurses and mid-wives do not think that they are getting promotional chances are strong in the light of reform process. According, the responses of the respondents, the reform process has also failed to make the compensation a competitive one for rural and remote area posting, as the salary structure have no differentiation for urban or rural areas. No groups have agreed upon that the reform process has created the salary structure competitive for the rural area posting. Moreover, the physicians, nurses and mid-wives have the views that the reform has failed to made regular and adequate financial incentives and allowances for physicians, nurses and mid-wives who are posted in remote and rural areas. They also agreed on that there are no increase activities for actual performance appraisals and positive actions on them. On the front of improvement in working condition at the respondents posted health institutes has agreement in group responses, though the mean of the responses is 3.40, quite no so impressive. However, more on the issue, we can say that the lower levels of the health care delivery system where the Mid-wives are largely posted are deviated of improving the working conditions. The workforce has agreed that reform has increased the training and skill development opportunities for the respondents posted rural health institutes, but the group of physicians has little lower mean than that of the two other groups. Thus, it seems at the physicians do not get more chance for training and development opportunities in comparison to the nurses and mid-wives. Thus, it reveals that the
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reform has failed to address the need of training and development in equal manner to all the groups of the employees. While on the front that reform has improved the availability of equipments, drugs and essential supplies for performing the assigned tasks for the respondents posted rural health institutes has been agreed in group responses, though the mean of the responses is 3.35.The group of mid-wives has lowest mean than that of the two other groups. Thus, it seems at the mid-wives do not get adequate equipments, drugs and essential supplies and the reform has failed to provide them as well, in comparison to the physicians and nurses. Thus, it reveals that the reform has failed to address of these needs too. Reform has also failed to improved the mix of cadres in respondents posted rural health institutes and has made the work load unmanageable. The disagreement increases at the lower level of the groups. Thus, it reveals that the workloads are more unmanageable to all level due to the reform process. Reform has made improvement in supportive supervision, management and mentoring form higher authority. It is also found that, there is an improvement in housing and other amenities at the workplace of the physicians that is at the higher level of health institute rather in the lower health institute where the nurses and midwives are posted. In overall, the physicians, nurses and mid-wives, concludes that the reform process has failed or has not succeeded for making rural health care services an attraction for the potential physicians and nurses to work in rural and remote area. And it is also revealed in overall that the reform process failed to give attention to the HR front rather giving attention to the other components of reform process in the state.

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SECTION 5 MAJOR ISSUES IN HR PRACTICE RELATED TO ATTRACTION, DISTRIBUTION AND RETENTION OF PHYSICIANS, NURSES AND MID-WIVES

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5.5.1. MAJOR ISSUES IN HR PRACTICE FOR ATTRACTION, DISTRIBUTION AND RETENTION OF PHYSICIANS, NURSES AND MID-WIVES
5.5.1.1. INTRODUCTION In addressing the three dimensions of HR Practice for Attraction, distribution (deployment) and retention of physicians, nurses and mid-wives, the researcher could establish that the HRM system and practice in the organisation is mere personnel management functions rather a strategic human resource management approach in a reform environment. In this study researcher could established that the HR practices for attraction, distribution and retention are to an extent not utilized optimally to improve organizational performance and to retain the physicians, nurses and midwives. The study found that the HRM practice for Attraction, distribution (deployment) and retention of physicians, nurse and midwives in rural and remote areas is not a comprehensive one and its design, the platform is weak. It is found that from the policies to implementation, there is no concrete and strategic management is followed. The major findings may be outlined as - There is inadequate Human resource capacity as there is no dedicated HRM staffs, department and the staffs handling the HR activities are having limited experience in the organisation; Annual HR plans exists but it is an exhaustive process in the organisation, but it is not further evaluated for effectiveness; Comprehensive HRD policy in Arunachal Pradesh is very weak; Employee data such as number of staff, location, skill, education, gender, age, year of hire, and the salary level are maintained manually and partially at the district level; performance appraisal system is in place, it is done periodically at the interval of one year, but it does not include the work plans of individual employees and performance objectives jointly developed with the staff, it is rather a traditional singular downward appraisal; skill up-gradation training is an integral part of the programme, however, there is little space for induction trainings and further training and development of employee is a concern with follow up of training. Further, Key ways to motivate employees are also inadequate in the system. Nor was there recognition of the importance of employee empowerment as a powerful mean of developing a serviceoriented culture.

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5.5.1.2. ISSUES IN POLICIES FOR HR PLANNING, RECRUITMENT (ATTRACTING), PLACEMENT, TRANSFER AND PROMOTION There is no comprehensive HR Policy in Public health sector in Arunachal Pradesh. There are recruitment rules for different category of health workforce. The recruitment and other service conditions for staff in health services of the state government is regulated by the APHS (Arunachal Pradesh Health Service) rules. The regular doctors and specialist cadre comes under the purview of service rule of APHS. However, there is no specific HR Policy for contractual physicians, nurses and midwives and other health workers. Absence of appropriate and concrete human resources policies on deployment, there is always a hindrance in managing people at work as the entire district agreed to this. However, the state Govt. is preparing a 5 year strategies and policy document for augmentation and maximization of Human Resources. This includes sustainable HRD and policy reform from restructuring/ rationalization of HR deployment. The vibrant HR policy includes terms of recruitment / filling up of vacancies, rationalising posting, specific tenure of posting, career progression and incentives. The policy is focussing on improving maternal and child health indicators through posting of required manpower for maximising performance at identified functional facilities. In order to ensure rational deployment of contractual physicians, nurses and mid-wives, recruitment is done at district level and appointments are made for specific health centres without provision of transfer. For the regular groups of employees the intra-district transfer and posting are handled by the District Medical Officer and inter-districts transfer is handled by the Director of Health Services. However, the system is not so transparent and lack in proper implementation. Most of the management representatives have a common consensus that the difficulty in distribution of the workforce particularly in the district level. The process of the transfer and posting are a challenging matter in the absence of the residential quarters and basic amenities at the rural and remote areas. They also pointed out that in the absence of comprehensive HR policy it is very difficult to rationalise the distribution. Overall, the shortage of the staffs is the main challenges in rational distribution of staffs in the rural areas. It is a matter of concern that the urban areas are also running out of the staffs and it is very difficult on their part to get equitable distribution. It is also pointed out that there are many cases of personal and medical reasons in which the management representative cannot force the staffs to be in the remote and rural
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areas for long durations. It is also sensed from the interview that there is influence of political pressure for the distributional process. However, it is not outspoken by the management representatives. 5.5.1.3. ISSUES IN HR PLANNING, RECRUITMENT AND SELECTION PROCESS Research Observation shows that accurate information systems on staffing trends and conditions are not in place. There is no tradition of research on workforce issues in the state. HR planning for contractual employees is theoretically based on decentralized system, however, in the absence of proper information, and trends of staffing makes HR planning more exhaustive and difficult. While, the HR planning in permanent physicians, nurses and mid-wives are done by the Health Directorate and based on vacancies and annual operating plans. It is also found lack of extensive coordination among the two divisions regarding HR planning. The sector does not have a formal mechanism in place to undertake manpower planning on a continuous basis except the Annual Action Plans. Planning exercise in the department of health is primarily focused on creation of new infrastructure/institutions. Decentralization of recruitment and selection process to the district is often undertaken without the appropriate technical abilities to do so. There are no staffs specifically to develop and implement HRM system in the organisation. District and state level offices do not have staff adequately trained in personnel administration, nor do they have simple or robust systems for managing personnel affairs. HR management structures and systems at the district level are weak; District offices are inadequately staffed and are poorly resourced. There are staffs generally meant for other services are engaged to look after the HRM activities in the organisation at state and district level. But these sections of staffs are having limited experience related to this field such as personnel recruitment, management or have other functions in the organisation as well as HRM functions. Over all they are at the level of only to maintain basic procedures and record keeping functions, which cannot be comparable to the full functions of HRM system in the organisation. The recruitment process under the decentralised arrangement in the district is closely linked to the instruction and financial provision at the state level. The implementation of the decentralisation policy is only for the contractual manpower in the district. Whereas, the appointment and deployment of the permanent physicians, nurses and mid-wives are not comes

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under the decentralised recruitment and deployment. So, it does not left any room for majority of the recruitment process and deployment. Utilization of various recruitment sources is under-utilised only newspaper advertising is the source. The recruitment advertisement for the contractual vacancies is only undertaken for this kind of process in the districts. The recruitment advertisement for permanent positions is placed in the newspaper and office board by the Directorate of Health Services. However, the internal source of recruitment is widely used, whenever a sanctioned regular post is vacant. This process of recruitment of internal candidates for regular posts supports career development opportunities for internal contractual employees. The selection processes is based on Walk-in-interview across the districts for contractual employees and for permanent employees it is found the contractual physicians, nurses and mid-wives are taken up to fill the vacancies. Thus, the recruitment and selection process of the employee in the state public health system is a traditional approach and lack the professional forefront in this process, and the newspaper advertisement, walk-in-interview, written-test with panel interview as the dominant tools in use. 5.5.1.4. ISSUES IN HR PRACTICE FOR PLACEMENT, TRANSFER AND PROMOTION The deployment of contractual physicians, nurses and mid-wives are done according to the recruitments are done for the particular vacancies for the specific health institution. However, the deployments are interchange able on mutual consent of the employees or the management decisions at the district level. The deployment of the regular cadre employee is done according to the requirement of the district and the district medical officer looks the matter and depends on the physical infrastructure and basic amenities in the health institution. The common minimum tenures are not followed along with the time bound promotions are not practices for several reasons to these categories of staff. 5.5.1.5. ISSUES IN HR PRACTICE FOR RETENTION - FINANCIAL NONFINANCIAL INTERVENTIONS There is no use of provision of financial and non-financial incentives for rural and remote area posting and retention. In the light of no provision of such incentives for the physicians, nurses and mid-wives for rural area services and the compensation package also is same irrespective of the place of posting.
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Other non financial

incentives such quarters with electricity, water facilities etc. are also not in the system to retain the workforce in those underserved areas. Moreover, other rewards system linked to performance is also not the system, resulted to the low morale and motivation of the workforce. The reward and recognition for the performance and achievement is also not there in the system. 5.5.1.6. ISSUES IN HR PRACTICE FOR RETENTION - TRAINING AND DEVELOPMENT Skill up-gradation and multi skilling practices are much emphasizes in the sector. Lot of skill up-gradation and multi skilling training are undertaken and the physicians, nurses and mid-wives are satisfied with the process and most of the workforce are attracted and retain themselves due to this factor in the sector. But the issues is there is no random access of training needs, the planning of training and the execution of the same have a random mismatch in the district and as well as in the state level. The training needs are basically planned according to the services in the health institutes and likely to starting of the services, its no way access the personal training needs of these workforces that could also enhance their skills in personal fronts and interest. Overall, it is also found that the post evaluation of the training is not done and not in the process and not in implementation at the ground. The trainings are undertaken only the sake of performance in the training activities, but the real evaluation of the trainings is not done. The trainings are once done, the achievement of the training achieved and no further plans for evaluation. Expensive and important skill-up-gradation trainings are given to these groups especially to the physicians, but the matching of posting place and their performance after the training is not accessed. This creates a gap in the training skilled acquired and utilisation for the benefit of the organisation, society and self development of these workforces. The multi-skill trainings & capacity building of the workforce are emphasized on physicians, nurses & mid-wives from the rural and remote area. Multi-skilling training is randomly given to a concentrated workforce and makes them jack of all trade, master of nothing. There are many cases the research could establish that a single physician is trained in many skills which makes him confused and specialized in nothing and it does not helped in their self development.

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SECTION 6 SUGGESTION

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5.6.1. INTRODUCTION
This section of the chapter puts lights on the broad suggestions on the issue of distribution, attraction and retention of Physicians, nurses and mid-wives. It is found in the study that most of the workforce is on compulsion to stay at the rural and remote areas and these workforces have low level of satisfaction and resulted in low commitment and motivation towards the service. The contributions of other factors for attraction are very less and seems that the sector has not given due importance and tried to improve the other bricks of the wall. Most of the workforce is intended to migrate to urban or to other sector, it is more of the environmental issues and organisational issues more than that of the personal issues at the current time. The factors that can attract and motivate them to stay at the rural and remote areas have been found in this study. The factors like salary in comparison to the urban areas, conducive working condition, training and development opportunities,

accommodation, financial incentives/rural allowances, rotational postings, safety at the workplace and career development opportunity. While, the following factors have been found for the retention of theses workforces: financial incentives, improved living condition, career development, good reward and recognition system. These factors for attraction and retention seem to be a blend of financial & non-financial benefits. The distributional issues have an impact on the shortage of staffs in rural and remote areas with mal-distribution. The HR practices having many loop holes and the reform process have failed grossly to take the train on the track smoothly. The situation of the Rural Public Health Sector in Arunachal Pradesh is Like riding a tiger, not knowing how to get off without being eaten-(Cappelli, et al, 2011). While the suggestion should be 50 miles to a gallon (Cappelli, et al, 2011). Based on the research findings, retention strategies need to include creating a more positive work environment for rural availability of physicians, nurses and midwives. To fill the gap of mal-distribution, recruitment and retention in rural community in the state is dependent on the perception of the workforce's nonmonetary and monetary needs. A blend of interventions into professional fulfilment, financial remuneration and lifestyle needs are to be taken into consideration while making policies or plans. There should be a strategic planning to address the three fulfilments of manpower. Recruiting and selecting the right people with making conducive working environment will help greatly with retention in rural areas.

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Professional fulfilments include the need of adequate supplies, equipments and fund. Conducive working condition at the work place with a good mixture of other cadres at the posting place is the some requirements. Due to highly regulated environment in which health sector operates, professional training needs, career development and opportunity for continuous education of the workforce must be kept into account for attraction and retention of the workforce and their interest on the job and the organisation. Training and multi-skilling will also facilitate the production issues and professional needs, advancement of the workforce and willingness to continue their works in the rural sector. The respondents put light on the workload also; the workload is unlikely due to other management works of a health institution, which can be minimized by posting of clerical or managerial cadres in health institutes. Rotational posting of the physicians and nurses are to be taken into

consideration, to increase exposure to rural conditions and overstaying of one staff in rural areas. One of the factors that we saw in this study is compensation, benefits and incentives needs, which will enhance attraction and retention of workforce in rural areas. Likewise, the planners must now recognize the importance of non-monetary incentives and recognition, special award; career path of the workforce along with the incentives for rural posting. This study suggests giving importance to the lifestyle needs of the workforce in today's time for retention. The development of rural infrastructure of basic facilities and amenities is great need of the time. For example housing, water supply, electricity and third party's work for development of communication and other facilities in rural areas should be given emphasize on long run. Policies and retention strategies needs to consider rural manpower family lives. Retention strategies should also include recreation and education opportunities for workforce's children. Factors affecting rural recruitment and retention are complex and inter-linked; hence a package of interventions is likely to work better than any incentive in isolation. So keeping the points above, the following broad suggestion is presented for this study.

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5.6.2. BROAD SUGGESTION

5.6.2.1. EMPHASIZE ON RURAL HEALTH INSTITUTE AND PRODUCTION ISSUE Building strong institutions for education is essential to secure the numbers and qualities of health workers required by the health system (WHO, 2006). Creation of medical and nursing schools for enhanced seats for medical and nursing studies should be ensured. It should be emphasized that the establishment of the institution in rural areas, so to create a pool of workforce for rural areas. The options for taskshifting can also be put into the system. The MBBS physicians can be replaced by a Registered Medical Practitioner (which is adopted by the State of Assam and other state in India), State can undertake experimentation in medical education by introducing 3 year course of Bachelor of Rural Medicine and Surgery to fill the deficiency of physicians in villages. However, one arguments can be that, 3 course would produce poor quality doctors. Other in favor argument would be full duration of MBBS course is not necessary for educating the public about health, hygiene and treating preliminary ailments in village level. Likewise the inadequacy of nurses can be filled up by the Mid-wives after getting adequate Nurse training and the vacant post of Mid-wives can be filled up after the training of the eligible Village Health worker with education and experience. This will ensure the creation of rural health workers pool to minimize the gap in the inadequacy. 5.6.2.2. ENHANCING CAPACITY OF MEDICAL EDUCATION THROUGH PUBLIC-PRIVATE PARTNERSHIP Access of Medical Education by prospective students within the state is a great challenge at this time. There is a need of widening of access of medical education within the state. The state is on the process to setup one Medical college with upgrading one of its hospitals in recent time. It is important here to consider that, in a study by Hall (Hall, 1998) shows that a 10% rise in the number of students registering with medical schools will produce only a 2% increase in the supply of doctors after 10 years. So, the requirement of aspirations and capacities of the increased number of potential students and to meet up the requirement of physicians seems difficult with establishing only one Medical College in the state. A healthy Public/Private partnership can do much in this regard. The state should explore the PPP models to establishment of more Medical colleges in the state. However, it should be based on
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accountability and evidence based regulations by both the medical council and the state. The issue of fees and seats should be monitored by the government. Moreover, the areas which are not capable of attracting private funds should be supported sufficiently well from public funds. 5.6.2.3. STRENGTHENING HRM POLICYMAKING, PLANNING AND SYSTEMS THE REFORM PRIORITES SHOULD BE! Getting HR policy right in order to create a well motivated, appropriately skilled and deployed workforce needs to be at the core of any sustainable solution to health system performance (Dussault & Diallo et al. 2003). The HR policy should be comprehensive and should be completed at the earliest to guide the whole process of HR system in the sector. The policy should include all the component of the HR system in an organization so that it will guide the system to implement in all level, particularly in a decentralized environment. Better distribution of personnel by categories and places is still a challenge for the health sector in Arunachal Pradesh; maximum number of health workforce is concentrated to urban and easily accessible areas counterpart to the rural and remote areas. Interpreting this issue, suggestion could be to formulate a human resource policy to the deployment and incentives for attracting the human resource in the needy and remote places.

5.6.2.4. ROBUST RECRUITMENT, SELECTION AND DEPLOYMENT PROCESS Investment in employee begins with recruiting process and selection process should be revived and extensive use of different sources of recruitment should be used. Recruitment and selection processes should be based on an objective system to eliminate bias and discrimination. The use of newspaper advertisement should be continued along with the use of other medium like internet, advertisement in regional papers or on national papers etc. to search a wide range of pool for the vacant posts. The selection process should not be bracketed to walk-in-interview only, it should comprises of written test, interviews and professional practical test along with a understanding of the candidates will to work in rural and remote areas. Side to it the decentralization of the recruitment should be strengthen in terms of ability to do so. The new recruiters or the existing physicians, nurses and mid-wives should be properly deployed based on the needs of each part of the state and the district and job descriptions. New graduates from training institutions should be promptly absorbed to
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avoid frustration and consequent brain drain, but the eligibility and recruitment norms should be followed. 5.6.2.5. FINANCIAL INCENTIVES INCLUDING THE SALARY COMPONENT Direct financial incentives to practice in rural areas may encourage rural practice, especially in developed countries, but reports from developing countries are not positive (Smith, 2010). In the study it is found that the workforce are more trends to financial incentives and salary differentiation than that of urban areas and salary hikes in the context of the contractual, while talking about the attraction and retention of the workforce. There is a need of development and implementation of financial incentives for rural and remote area posting, it should be plan and adequate budget provision should be there. Side by side, it is high time to make a differentiation in the salary structure of the urban posting and rural posting, featured by higher in rural and lower in urban areas. Along with these interventions, there is a need of enhancing the salary of contractual physicians, nurses and mid-wives, so that their salary could match the permanent workforce salary structure. The incentive system should be competitive that could be accepted by the Physicians, nurses and mid-wives. The incentive should be placed according to the category of the post and categorization of place of posting. 5.6.2.6. REWARD AND RECOGNITION PROGRAMS Irene (1997), advises not to force and manipulate staff to accept rural posting after their will. Financial incentives are generally ineffective when used alone (Smith, 2010). Many international studies point out that compulsory rural service programmes should be accompanied by support and incentives given to the health personnel (Liaw ST et al 2005, Omole O et al 2005). It is well known compulsion alone cannot work and a mechanism of differential rewards, appreciation and recognition programme should be developed within the system. It is also suggested to differentiate the

performers and non-performers, which is a missing component presently in the system. This will motivate the performers to perform more and the non-performer will kick start.

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5.6.2.7. FOCUS ON CAREER DEVELOPMENT OPPORTUNITIES AND JOB SECURITY Equitable distribution of health professionals and their retention is in turn related to the prospects of career progression and the incentive packages associated with the posts (Martinez & Martineau, 2002). Every individual whether working at the lower level or higher level needs growth in professional life. Thus, the career development opportunities can attract and retain workforce in job. In this study also it is found that the respondents are looking for the career develop path while attracting and retention is concern in rural and remote area. Therefore, the career path should be pre-defined and strict to rules and regulation, and the implementation should be fair and un-biased and strictly be based on merit and then seniority based. The policies on career development should be revived and make strong career path which can attract physicians, nurses and mid-wives in rural and remote areas. The career path

especially of contractual are to be given emphasized at present along with the job security issue of the contractual. There should be clear written policies for providing permanent positions to the contractual. It is also suggested that the minimum period of contractual service should be 3-5 years not 1 year of at present. It will improve the sustainability of contract positions. 5.6.2.8. IMPROVING LIVING CONDITION It is found in this study that the living conditions are likely to be important in determining health workers decisions to move to and remain in underserved areas. The importance of living condition is seems to be higher in ensuring the physicians, nurses and mid-wives in the rural and remote areas. The living condition including the housing, electricity, water supply and transport & communication does not directly relate to the HR activities. Though, the issues have a greater impact on HR attraction, deploying and retaining in the rural and remote areas. Most of the respondents emphasized on improve living condition for attracting and retention factors. Thus, the doable point is infrastructure development for proper accommodation facilities, provision of electricity (where electricity is not possible Solar could be the option) and provision of water supply should be ensured. However, the other components are not directly in the hand of the sector but it can be solved with the convergence with the other departments and local governance, thus improving the living conditions.

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5.6.2.9. IMPROVE WORKING CONDITIONS To attract and retain the workforce is rural areas, it is necessary to improve the working conditions in the health institutions. It start with it can be done with the provision of equipments, drugs and supplies and other working conditions like other basic amenities in the work place and overall the safety of the workforce should be the priority. The function of the health facilities should be improved by adequate provision of work related items. 5.6.2.10. INTENSIVE TRAINING AND SKILL DEVELOPMENT WITH POST EVALUATION Training should be designed to help employees not only their positions but is should be altogether have a benefit to the professional traits also that means they should take personal benefits also from the training. The training and skill development should include inductions and refreshing training as well. The post evaluation of training at the field level should be started and support the workplace to increase their performance. 5.6.2.11. EMPHASIZE ON SUPERVISION AND MENTORING We believe a great supervisor is actually an excellent coach, not just a boss Dr. Reddys Lab. (Chapelli,2011). It is suggested that to strengthen up the supervision and mentoring activities of the Physicians, Nurses and Mid-wives, especially the new comers. The mentoring and supervision should not be just fault taking out of their works but to mentor and guide them. This will create conducive environment between the employees and management and it will give a boost in the job satisfaction of the workforce and will contribute to motivation to continue in the rural and remote area service. 5.6.2.12. REGULATING WORKLOAD AND INCENTIVES Minimizing the workload in a flick is not possible in the inadequacy of workforce. However, it is suggested that the duty hours should be fixed for every groups and individual in a manner that it do not adversely affect the mental stability of an already frustrated groups of employees. The overtime facilities should be provisioned to boost their morale. The technical workforce should not be waste for management and clerical works. The posting of clerical and managerial cadres should be ensured.

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5.6.2.13. ROTATIONAL POSTING The option for rotational posting and follow up of minimum rural area posting may be ensured. The minimum tenure of the posting should be ensuring with the fairness and without any bias. The transfer and posting should not be influenced by the favoritism and political influences. The minimum tenure of 3 years for rural service may be extended to 5 years, but it should be strictly followed by rotational posting to urban areas. 5.6.2.14. STRENGTHEN PERFORMANCE APPRAISAL The system of performance appraisal should be further strengthen and make it meaningful. No performance appraisal should be done in merely to complete the formalities; rather it should be based on the reality and actual facts. It should be used regularly to enhance the performances of the workforce. The performance appraisal should be used for the reward and recognition program and the incentive programs. Much of the challenge in health reform involves shifting incentives to improve productivity, quality, and performance (Forgia,2005).Good performance should be linked to incentives and the system should be based on objective criteria to avoid favouritism. 5.6.2.15. CONSISTENCY OF DATA ON WORKFORCE To ensure that the right health worker is in the right place with the right skills, managers need accurate HRH data for HR planning from beginning to work together to develop a HRIS that tracks health professionals from training until they leave the workforce. HRH planning in the absence of reliable data is not optimally possible, therefore, there is a need of reliable database i.e., more comprehensive data on other categories of health workers, which is absence in the current position. The HR data should be maintain properly with the detail of the workforce and their service tenure in a place. It should be computerized and the consistency of data for every sections of the department should use the same HR data to plan and execute. By this the proper distribution of the physicians, nurses and mid-wives can be possible and the minimum tenures can be managed.

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SECTION 7 CONCLUSION

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5.7.1. CONCLUSION
This study has attempted to document the gravity and complexity of the HR issues in Public Health Sector in ensuring attraction, deployment and retention of the Physicians, Nurses and Mid-wives along with the contribution of Health Sector Reform in this HR issues along with HR Practice in Reform Process in the health sector in Arunachal Pradesh. Adequate human resources for health (HRH) are a key requirement for reaching health goals, the study found that, the shortages of physicians, nurses and mid-wives are an ongoing problem in the public health sector in Arunachal Pradesh. One of the most enduring characteristics of the rural health landscape is the uneven distribution and relative shortage of health care professionals (Hart, 2002). To fuel on this part the urban-rural disparities in distribution of this workforce is there, with an intention of migrating is more and the trend is to migrate to urban areas. There is low job satisfaction in the workforce in the current job at rural and remote areas. It is contributed by many of the factors including financial and non-financial benefits. Attraction and retention of physicians, nurses and mid-wives in remote and rural areas are determined by many factors including financial incentive, career development opportunities, recognition etc. But, the factor of compulsion is the main factor of stock in rural and remote areas, and rest of the factors have less contribution, and the financial benefits along with non-financial benefits seems to be migrating factors. The attraction, deployment and retention of physicians, nurses and mid-wives in rural and remote areas are a real challenge and a difficult situation, and affected by several factors ranging from organisational factors to external environmental factors and to personal factors. However, the personal factors have less affect on the situation. The massive poor living conditions in the rural and remotes areas, poor working condition in health institutes, poor career development opportunities with lack of financial benefits are some of the factors that contribute to the reluctances of the physicians, nurses and mid-wives to serve the rural and remote areas in the state. The sector has nothing to offer presently, to attract and retain and to distribute rationally this workforce, which in result deteriorating the situation in the rural and remote areas. Moreover, the reform process is doing less for the HRM perspectives and the HR practices are not effective enough to solve the problems in the state.

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This study shows that a blend of interventions is needed to improvised the situation. Nevertheless, the implementation of financial as well as non-financial interventions are to be ensured for improving the situation of Physicians, nurses and mid-wives in rural and remote areas. Thus, it is clear that many factors affect the rational distribution, attraction and retention of Physicians, nurses and mid-wives in the rural and remote area ranging from environment issues, organisation issues as well as the personal issues, along with the production issues, the facilities and basic amenities along with financial incentives are determinant of manpower in rural areas of the state. It is also known that to solve these HR issues, no individual interventions are not adequate, it need a pyramid of interventions to ensure the minimization of the issues. Moreover, a blend of initiatives is needed to address the problems of distribution, attraction and retention of manpower in the state, there is a need of continue focus and commitment on the part of government and as well as the political will to solve the problem. In conclusion, efforts to strengthen health sector must address the HR issues and a good Human Resource Management and a far sight in HR requirements are needed.

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Appendix
Appendix 1: Manpower Recommended under IPHS

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Appendix: 2

QUESTIONNAIRE FOR PHYSICIANS NURSES AND MID-WIVES

A. DEMOGRAPHIC INFORMATION 1. Respondent ID :

2. Position: a) Physician (Medical Officer) b) Nurse (GNM/Staff Nurse) c) Mid-wife (ANM) 3. Age:

4. Sex: a) Male b) Female 5. Family Background: a) Rural b) Urban 6. Marital Status: a) Married b) Unmarried 7. Length of Service in rural area: 8. Working in: a) SC b) PHC c) CHC d) DH 9. Nature of Employment: a) Permanent b) Contract

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B. EXPLORING THE DIMENSIONS IN ATTRACTION ISSUES FOR RURAL AND REMOTE AREAS SERVICES

i) Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Please select the factors that attracted or placed you to current job in the rural and remote area? Attributes Select (Tick) Financial incentives / Rural allowances/ Performance incentives Improved working condition Availability of equipment, drugs and supplies Authority, independency and autonomy Career development opportunity Continuing education/higher education Opportunities Training and skill development Opportunities Compulsion (minimum rural service tenure or non-transferable or Management or political pressure) Flexible working hour with minimal workload Supportive supervision and mentoring Amenities like housing, conveyance provided Reward and recognition system Teamwork and Interpersonal staffs relationship Safety at workplace Availability of good schools for children nearby town Current health facility is closer to hometown or Closer to family and friends

ii)

Please select the factors that may attract you and new physicians, nurses and midwives towards rural and remote area? Attributes Higher Salary package in compare to urban posting Financial incentives / Rural allowances/ Performance incentives Conducive working condition Availability of equipment, drugs and supplies Opportunity for authority, independency and autonomy Career development opportunities Continuing education/higher education Opportunities Training and skill development Opportunities Rotational Posting after completing minimum rural service tenure Job security Flexible working hours with minimal workload Supportive supervision and mentoring Access to amenities like housing & conveyance Better teamwork and good interpersonal staffs relationship Safety at workplace Good reward and recognition system Availability of good schools for children Current health facility is closer to home-town or Closer to family and friends Select (Tick)

Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

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C. EXPLORING THE DIMENSIONS IN RETENTION ISSUES FOR RURAL AND REMOTE AREAS SERVICES

i) On a scale of 1 to 5, Please rate how satisfied are you with your present job in rural area? [1) Highly Dissatisfied 2)Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) Highly Satisfied] Attributes Overall Job satisfaction 1 2 3 4 5

ii) Please select the factors that contributed to your satisfaction level of your current job in rural and remote area service? Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Attributes Salary Better Job Prospects in future Job security Career development opportunities Opportunities of continuing education/higher education Training and skill development Opportunities Work environment Adequacy of equipment, drugs and supplies Financial incentives linked to rural posting Non-financial benefits/allowances linked to rural posting Appropriate Work load Matching of skills and tasks Support, supervision, management and mentoring Reward system and recognition Social recognition and opportunities of public services/ care to patients Teamwork and Interpersonal staffs relationship Safety at the workplace from external environment Access to free accommodation (Housing)with basic amenities Please tick

iii)

Please share your intention to migrate keeping the salary constant, what will be your choice to migrate?

Sl. No 1 2 3 4

Attributes To continue in your present rural area posting (if yes pl. go to no. iv) To shift to another rural health institute (if yes pl. go to no. v) To shift to another urban health institute (if yes pl. go to no. v) To shift to another job in some other State/sector (if yes pl. go to no. v)

Tick one

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iv)

Please select the factors that motivate you to continue in the current job for at least 3-5 years or more in rural and remote areas Serial Attributes Select no. (Tick) 1 Satisfied with salary 2 Getting adequate financial incentives/ Rural allowances/performance incentives 3 Improved working condition 4 Adequate drugs/equipment at the rural health centre 5 Career development opportunities 6 Scope for continuing education/higher education 7 Scope for training and skill development 8 Job Security 9 Flexible working hours with minimal workload 10 Improved support, supervision and mentoring 11 Strong Teamwork and interpersonal relationship 12 Anticipation of obtaining a regular position after contractual position 13 Adequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) 14 Achievement is recognized and rewarded 15 Geographical affinities(Hometown near)and familial associations 16 Good schools for children/ education prospects of children 17 Opportunity for both spouses to work and live in the same location 18 More Autonomy in current place of posting

v)

Please select the push factors for your intentions of leaving or seeking transfer from the current job in rural and remote areas for urban areas. Sl. no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Attributes Poor salaries Lack of adequate financial incentives/ Rural allowances/performance incentives Poor working condition Inadequate drugs/equipment Lack of Career development opportunities Lack of scope for continuing education/higher education Limited opportunity of training and skill development Lack of Job security Unusual working hours and excess work load Poor support, supervision and mentoring Lack of others cadres, teamwork and interpersonal relationship Inadequate living conditions (access to amenities like housing, water, electricity, conveyance and communication) Achievement not recognized Lack of safety at workplace Limited or no good schools for children/ education prospects of children Lack of Autonomy Select (Tick)

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vi)

Please select the factors that may motivate you to retain the current job in rural and remote area other than that of factors that what you are satisfied with current time. Attributes Select Sl.no. (Tick) 1 Increase salary by half 2 Increase salary by double 3 Financial incentives for rural posting/ Rural allowances/performance incentives 4 Improved working condition 5 Job Security 6 Adequacy of equipment, drugs and supplies at Health centre 7 Career development opportunities 8 Opportunities of continuing education/higher education (support for further education) 9 Training and skill development Opportunities 10 Rotational posting 11 Opportunity of autonomy 12 Flexible working hours with minimal work load 13 Adequate patients/clients at current facility 14 Supportive supervision, management and mentoring 15 Good reward and achievement recognition system 16 Good teamwork and good interpersonal staffs relationship 17 Security & Safety at workplace 18 Availability of good schools for children 19 Improve living conditions (Access to amenities like housing, water, electricity, conveyance and communication)

vii)

Please Share any other point related regards your current job in rural area in the context of HRM.

........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... viii) Please share your perspective on contractual employment (only for contractual)

........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................

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D. EXPLORING THE VIEWS IN HEALTH SECTOR REFORM

i) On a scale of 1 to 5 please rate the following statement regarding ongoing health sector reform process in your organisation? [1) Strongly Disagree 2) Disagree 3) Undecided 4) Agree 5) Strongly agree] Serial Attributes 1 2 3 4 5 No. 1 The Reform has made the Human Resource Policies clear and understandable at your level 2 The reform has made the placement, transfer and promotion transparent, fairer and unbiased 3 The reform has made your job description clear 4 The reform has increased your chances of being promoted 5 The reform has made the Salary structure Competitive for rural area posting 6 The reform has made regular and adequate financial incentives and allowances for rural area posting 7 The reform has increased the activities for your performance appraisal and positive action on them 8 The reform has made an improvement in working condition in your work place 9 The reform have increased the training and skill development Opportunities 10 The reform have improved the availability of equipment, drugs and supplies essential to perform your assigned tasks 11 The reform have improved mix of other cadres in your workplace 12 The reform has made your workload more manageable 13 The reform has made improvement in supportive supervision, management and mentoring form higher authority 14 The reform has made work independent and more autonomy 15 The reform has made improvement in housing and other amenities at your workplace 16 The reform has made rural health care services an attraction for the potential physicians, nurses and mid-wives to work in rural and remote area 17 The reform has made overall HR practice effective and conducive in the organization

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E. EXPLORING THE DIMENSIONS IN HR POLICIES AND PRACTICE IN ACQUIRING (ATTRACTION), DISTRIBUTION AND RETENTION IN RURAL AND REMOTE AREAS

i) On a scale of 1 to 5 how do you feel about the following practices in your organisation regarding rural and remote area services?
[1) Highly Dissatisfied 2) Dissatisfied 3) Satisfied nor dissatisfied 4) Satisfied 5) Highly Satisfied] Serial Attributes 1 2 3 4 5 No. 1 Recruitment and selection process 2 Policies for placement, transfer and promotion 3 Fairness of HR Practice for placement, transfer and promotion 4 5 6 7 8 9 Magnitude of management favoritism and political interference in transfer and posting Response of administration/management on your placement, transfer and promotional grievances Participation and involvement in the decision making of your placement and transfer HR Practice for retentions Financial Interventions HR Practice for retentions Non Financial Interventions Training and Development

:::::::::Thank You:::::::::

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Appendix :3 INTERVIEW SCHEDULE FOR STATE AND DISTRICT MANAGEMENT REPRESENTATIVES Part I DEMOGRAPHIC INFORMATION 1. Your current post/position? . 2. Gender? 3. Age? Male Female

..

7. Years of management experience? .

1. EXPLORING DIMENSION OF HR ISSUES IN DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES FOR RURAL AND REMOTE AREAS 1. In your opinion, what are the key human resource issues on distribution of physicians and nurses in rural and remote areas in your state/district? 2. In your opinion, what are the key human resource issues on attraction and retention of physicians and nurses in rural and remote areas in your state/district? 3. What you think could be the main reasons for physicians and nurses turnover from the rural and remote areas of area of operation? 4. Could you please summaries the main HR issues and challenges regarding physicians and nurses that you are facing in order to implement Health Sector Reform effectively? 5. Do you have any further plans as reform initiatives for addressing the above mentioned issues regarding distribution, attraction and retention of physicians and nurses in rural and remote areas of your area? If yes what are they, would you like to share? 6. Are there any comments you would like to provide regarding the subjects not covered in this interview regarding HR issues of Physicians and nurses? 2. EXPLORING DIMENSION OF HRM PRACTICE IN REFORM PROCESS IN DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES FOR RURAL AND REMOTE AREAS 1. What is the name of the Department/Section which looks after Human Resource Management function in the organization at your level? 2. What is the staffing pattern of this section? 3. What HR functions are performed by the Department? 4. How do you assess the requirement of Physicians and nurses for the organization, particularly for rural and remote areas?

381

5. What are the HR practices used for attraction of physicians and nurses in rural areas? 6. What are the sources are utilized for the recruitment for recruiting physicians and nurses? 7. Did you find any problem in filling up vacancies of physicians and nurses for rural and remote areas? If yes. Please share the issue and the problems? 8. What are the criteria for placing and transfer physicians and nurses in rural and remote areas at your level? 9. What are the HR practices and core HR area used for retention of physicians and nurses in rural areas? 10. Does the organization have any financial incentives for rural and remote areas placement of physicians and nurses for attracting and retaining them in rural area services? If yes, would you like to share what are the types of incentives are given? 11. Does the organization have any non- financial incentives for rural and remote areas placement of physicians and nurses for attracting and retaining them in rural area services? If yes, would you like to share what are the types of incentives are given? 12. Does the training and promotional system have linked as a kind of incentives for rural area placement? 13. If Yes, How do you select these employees for training? 14. What are the initiatives at your level to maintain the minimum posting tenure in rural areas of physicians and nurses? 15. Are there any comments you would like to provide regarding the subjects not covered in this interview regarding HR practice regarding Physicians and nurses? 16. Would you like to through a light on the following issues under reform initiatives in the state? (TO BE ASKED ONLY FOR STATE LEVEL MANAGEMENT REPRESENTATIVE) a. Development of HRM & HRD policy especially related to contractual physicians and nurses under NRHM b. Availability of essential equipments, drugs and supplies for functionalizing a health centers in rural areas c. Capacity building d. Supervision of supporting nature e. Nursing and Paramedical education and Schools f. Medical Education and Colleges g. Accommodation facilities (New Residential Qtrs) in the rural areas health institutions 3. INFORMATION ON HUMAN RESOURCE IN THE DISTRICTS 1. Would you like to share the details on Health Institution in the district/state? a. Number of Total Health institutes in the District/State Sl.No. No of Health institutes in the District 1 District hospitals/ General Hospitals 2 CHCs 3 PHCs 4 SCs

Numbers

382

b. Number of Health institutes in Rural and remote areas in the District/State Sl.No. No. of Health facilities Total 1 Total no. of sanctioned sub centres 2 Total no. of functional sub centres 3 Total no. of sanctioned PHCs 4 Total no. of functional PHCs 5 Total no. of 24x7 PHC 6 Total no. of non 24x7 PHCs 7 Total no. of CHC 8 Total no. of CHC (FRUs) 9 Total no. of CHC which are non-FRUs 2. Would you like to share the details on the numbers of physicians, nurses and midwives in the district/state? c. Numbers of MO, GNM & ANM according to the Health institutions in the District Total Number of Sl. No. Health institute in the District Gynaecologist Paediatricians Anaesthetics Nurses Staff nurse/GNM (in nos.) Mid-wives ANM (in nos.) Physicians (Medical Officers ) (in nos.)
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1 2 3 4

District Hospital CHCs PHCs SCs Total

d. Numbers of MO, GNM & ANM according to the Rural and remote areas Health institutions in the District/state Sl. No. No. of facilities Total 1 Total no. of SCs existing / having infrastructure 2 No. of SCs having one ANM 3 Total no. of SCs having two ANMs 4 No. of PHCs not having any MO (MBBS) 5 Total no. of PHCs not having 3 staff nurses/ 3 ANMs 6 No. of CHCs not having full complement of specialists i.e. Gynaecologist, Anaesthetist, Paediatrician :::::::::Thank You:::::::::

CONFERENCE ATTENDED 1. NATIONAL CONFERENCE ON INFORMATION AND KNOWLEDGE MANGEMENT, 12TH MARCH 2011 AT FAKIR MOHAN UNIVERSITY, VYASA VIHAR, BALASORE, ORISSA (Presented a paper entitled: Knowledge management improve effectiveness in Human Resource Management) 2. INTERNATIONAL SEMINAR ON RESOURCE, TRIBES AND STATE, 13TH TO 15TH FEBRUARY 2012 AT RAJIV GANDHI UNIVERSITY, RONO HILLS, DOIMUKH, ITANAGAR, ARUNACHAL PRADESH (Presented a paper entitled: A study on distribution, attraction and retention of physicians and nurses to combat maternal and child mortality in four predominately tribal state of North-Eastern India) 3. INTERNATIONAL 5TH DOCTORAL THESES CONFERENCE, 2ND TO 3RD APRIL 2012 AT IBS, ICFAI FOUNDATION FOR HIGHER EDUCATION, HYDERABAD, ANDHRA PRADESH (Presented a paper entitled: An exploratory study on distribution, attraction and retention of physicians and nurses in rural areas in Arunachal Pradesh) 4. NATIONAL CONFERENCE ON HUMAN RESOURCE ND TH MANAGEMENT (2 ), 8 APRIL 2012 AT MANAGEMENT DEVELOPMENT RESEARCH FOUNDATION, NEW DELHI (Presented a paper entitled: Human Resource for Health in rural communities-A Study on distribution, attraction and retention in Indian public health system with special reference to Arunachal Pradesh) 5. INTERNATIONAL CONFERENCE ON CONTEMPORARY INNOVATIVE PRACTICES IN MANAGEMENT, 13TH TO 14TH APRIL 2012 AT PACIFIC UNIVERSITY, UDAIPUR, RAJASTHAN (Presented a paper entitled: The 21st century employment contract for solving numerical inadequacy of health workforce in Indian rural public health system 2005-12)

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PAPER PUBLISHED

1. PAPER ENTITLED: A STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION OF PHYSICIANS AND NURSES TO COMBATMATERNAL AND CHILD MORTALITY IN FOUR PREDOMINANTLY TRIBAL STATES OF NORTH-EASTERN INDIA. PUBLISHED IN RESEARCHERS WORLD, INTERNATIONAL REFERRED RESEARCH JOURNAL OF ARTS, SCIENCE AND COMMERCE, VOLUME-III, ISSUE-1, JANUARY 2012. PAGE -175 TO 185. ONLINE ISSN: 2229-4686; PRINT ISSN:2231-4172 (www.researchersworld.com) 2. PAPER ENTITLED : HUMAN RESOURCE IN THE PUBLIC HEALTH SECTOR: ISSUES AND CONCERNS IN THE STATE OF ARUNACHAL PRADESH. PUBLISHED IN PRABANDHAN : INDIAN JOURNAL OF MANAGEMENT, VOLUME-5, ISSUE- 4, APRIL 2012. PAGE 45-52. ISSN 0975-2854 3. PAPER ENTITLED: HUMAN RESOURCE FOR HEALTH IN RURAL COMMUNITIES-A STUDY ON DISTRIBUTION, ATTRACTION AND RETENTION IN INDIAN PUBLIC HEALTH SYSTEM WITH SPECIAL REFERENCE TO ARUNACHAL PRADESH. PUBLISHED IN REVIEW OF HRM, VOLUME-1, ISSUE-4, APRILJUNE 2012. PAGE- 121-135. ISSN-2249-4650

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