|Year : 2015 | Volume
| Issue : 3 | Page : 189-195
Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work?
Suchitra Lisam1, Sulakshana Nandi2, Kanica Kanungo3, Prem Verma4, Jay Prakash Mishra5, Dilip Singh Mairembam1
1 Human Resources for Health (HRH), National Health Systems Resource Center, New Delhi, India
2 State Convenor, Public Health Resource Network, Chhattisgarh, India
3 Programme Coordinator, Chhattisgarh, India
4 Programme Associate, State Health Resource Center, Chhattisgarh, India
5 Executive Director, State Health Resource Center, Chhattisgarh, India
|Date of Web Publication||7-Sep-2015|
National Health Systems Resource Center, NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: To address the acute shortages of health workers in underserved, remote, and difficult-to-access areas, the Government of Chhattisgarh and the National Rural Health Mission (NRHM) launched the Chhattisgarh Rural Medical Corps (CRMC) in 2009. CRMC has enabled provisions such as financial incentives, residential accommodation, life insurance, and extra marks during admission at the postgraduate (PG) level to eligible doctors for the attraction and retention of health workers, i.e., doctors, staff nurses, auxiliary nurse midwives (ANMs), and rural medical assistants (RMAs) in underserved areas. Objectives: This study aims to understand the CRMC scheme in terms of implementation, challenges, gaps, and outcome in achieving the attraction and retention of health workers in the remote and difficult-to-access areas of Chhattisgarh. Materials and Methods: The study adopts a mix of both qualitative and quantitative research methods. The purposive sampling method was used for the selection of three districts having normal, difficult, and inaccessible areas. Data were collected through key informant (KI) interviews with beneficiaries and non-beneficiaries of CRMC or district and state government officials, and reviews of document were analyzed using a thematic analysis approach. Results: CRMC has made positive outcome as 1319 health workers, including doctors, have joined the service in 2010-11, reducing the vacancy of doctors from 90% to 45%. The scope of CRMC was primarily limited to payment of monthly financial incentives. The fund utilization rate of CRMC has increased (from 27% in 2009-10 to 98% in 2011-12), though there are delays in payment of incentives. The majority of staff lack awareness about CRMC during job applications. The payment of incentives based on facility performance has demotivated staff. Conclusions: Establishment of a performance management system, activating the CRMC cell to make it functional, and wide publicity of CRMC benefits are likely to improve attraction and retention of staff.
Keywords: Chhattisgarh Rural Medical Corps (CRMC), financial incentives, health workers, National Rural Health Mission (NRHM), retention strategies
|How to cite this article:|
Lisam S, Nandi S, Kanungo K, Verma P, Mishra JP, Mairembam DS. Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work?. Indian J Public Health 2015;59:189-95
|How to cite this URL:|
Lisam S, Nandi S, Kanungo K, Verma P, Mishra JP, Mairembam DS. Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work?. Indian J Public Health [serial online] 2015 [cited 2018 Sep 23];59:189-95. Available from: http://www.ijph.in/text.asp?2015/59/3/189/164656
| Introduction|| |
Lack of health workers is one of the main constraints in achieving population health goals in many countries. The Joint Learning Initiative for Human Resources for Health estimates that to achieve 80% coverage of the population with skilled attendants at birth, a minimum threshold of 2.5 workers per 1,000 population is required.  The World Health Report concluded that "the severity of the health workforce crisis is in some of the world's poorest countries, of which 6 are in South East Asia out of 57 countries having critical shortages of health workforce."  Internal migration has also been cited as a contributing factor for this crisis,  with some workers migrating to other countries in search of professional development and a better quality of life.  The consequent shortage of staff has increased the workloads which led to decreased motivation thereby causes hindrance in improving performance of health system. 
India has been facing the challenge of shortage of skilled and trained medical personnel, especially in rural areas. There are 100 skilled service providers (doctors, nurses, and midwives) per 100,000 population as against the international norm of 228 per 100,000 population.  The density of allopathic physicians in urban and rural areas was 11.3 and 1.9 respectively,  and the number of registered medical practitioners is 840130. 
In an earlier study,  it was concluded that interventions to alleviate shortages of health workers in medically underserved areas include recruitment of those individuals into healthcare education who are most likely to work in such areas, improvements in working or living conditions in underserved areas, and financial incentives. In addition, locally based "selection of candidates"  is generally believed to contribute toward promoting the retention of staff in rural areas, and it has also minimized geographical barriers to service provision. 
Rao and Ramani found that around 18 states in India compensate doctors for service in difficult areas, whereas five of these states give incentives to auxiliary nurse midwives (ANMs), nurses, and paramedics.  Strategies for engaging with rural communities and empowering them to demand quality essential services may, in the long term, be the key to creating a more equitable balance of human resources (HR) for health. 
Chhattisgarh faces a huge shortage of trained manpower, especially in the underserved areas. The vacancy rate is 92% for specialists in community health centers (CHCs), as only 46 specialists were recruited against the sanctioned posts of 572, while 40% of medical officer (MO) posts got filled up against 1432 sanctioned posts.  To address this critical lack of HR, the Department of Health and Family Welfare, Chhattisgarh and the National Rural Health Mission (NRHM) introduced the Chhattisgarh Rural Medical Corps (CRMC) in 2009. Under CRMC, health facilities are categorized into three zones according to difficulty levels and various incentives, including financial support and extra marks for postgraduate (PG) admission, are provided for each level. Since its inception, no formal assessment of CRMC has been done, which is required in the context of the deployment of HR in large numbers.
Our research will highlight the process of implementation of CRMC, assess its outcome in improving the availability of HR in underserved areas, and identify implementation loopholes. This study also holds lessons for other states and at the national level with respect to the possibility of implementation of similar schemes for increasing the availability of HR in difficult areas.
| Materials and Methods|| |
The study used a mix of both qualitative and quantitative research methods for exploring the scheme, objectives, extent of implementation, deployment of health personnel, and experiences of health workers and managers around these issues. We used semistructured and open-ended questionnaires for key informant (KI) interviews.
We undertook a desk review of government documents about the CRMC scheme, objectives, and implementation process; CRMC revisions; grading of facilities; recruitments and postings of personnel in CRMC areas; incentives provided against those proposed, etc. We adopted a purposive sampling method for the selection of districts, i.e., Gariyaband, Jashpur, and Kanker having three different areas of accessibility for the purpose of covering different perspectives of staff working in remote areas, areas adjacent to urban areas, and conflict-affected areas. A study of the changing status of HR in terms of number of applicants and those recruited under CRMC, and number of CRMC beneficiaries, i.e., those who had been paid financial incentives over the years had been undertaken.
Twelve health facilities including six CHCs, four primary health centers (PHCs), and two district hospitals were covered across three districts. Health facilities were chosen based on proximity to district headquarters office. A total of 57 respondents including specialists, MOs, staff nurses, rural medical assistants (RMAs), program managers, and government officials were interviewed. The respondents were CRMC beneficiaries and those who were eligible but not receiving any benefits.
The Ethics Committee of the National Health Systems Resource Center (NHSRC) approved the methods and materials, including the questionnaires and checklists used in this study. Informed consent was taken from each respondent after providing an explanation of the study purpose, study outputs, and the use of findings for midcourse corrections of CRMC and for research publications.
| Results|| |
The study explored the policy framework, implementation status, and outcome of CRMC through desk review on CRMC, analysis of HR and financial records, and responses from KIs including CRMC beneficiaries, non-CRMC beneficiaries, and government officials.
CRMC policy framework
Under CRMC, various health workers deployed in health facilities located in "difficult," "most difficult," and "inaccessible" areas of CRMC had to serve for a minimum period of 4 years. They were given monthly incentive apart from their monthly salary based on type of staff cadre and CRMC posting area. CRMC has provisions for insurance of staff under Group Medical Insurance against death or permanent disability due to accidents, along with a compensation of INR 10 lakhs in case of death of the staff due to Maoist attack while discharging his/her duty. Eligible MOs serving not less than 2 years are given extra marks during admission to the PG level against reserved seats of the State Government. From INR 7.35 crores in 2009-10, the budget had gradually increased to INR 1087.39 lakhs with a 20% increase in the proportion of staff members (MOs and RMAs) including ANMs joining CRMC areas. 
The trend in utilization of CRMC funding over the years (in percentages) is depicted in [Figure 1]. It showed an increase in terms of budget utilization over 4 years of CRMC implementation in the state.
CRMC lists were made in 2011-12 as per the scoring system developed by NHSRC for grading CRMC areas as accessible, difficult, most difficult, and inaccessible areas. The number of facilities categorized under CRMC when compared for both rounds shows that in 2009, 92.5% of facilities were classified as "most difficult," which had decreased to 30.6% in 2011. As per the revised lists of facilities 2011, 55.1% of facilities got recategorized as "difficult." In line with the revised grading system of 2011, 11.2% of facilities were categorized as "inaccessible," which was not included in the previous category of facilities in 2009 [Table 1].
As per the Programme Implementation Plan (PIP) of 2012-13, differential incentives and facility-based monitoring was launched, which revised CRMC policy in terms of incentives and geographical areas. The scope was created to provide performance-based incentives for 2011-12, of which 5076 facilities were identified.
Attraction and retention of health workers
CRMC had played a role in the attraction and retention of staff in difficult-to-work areas. The majority of staff members considered the provision of financial incentive as an important reason for continuing working in such areas. Since the introduction of CRMC, 1319 health workers had joined CRMC areas in 2010-11, bringing down the vacancy rate of 90% to 45% across facilities. It had increased to 1658 in 2011-12, and the majority of the workers were deployed in difficult areas [Table 2]. 
|Table 2: Resources (manpower and financial) allocation over the years under CRMC15|
Click here to view
The provision of extra marks for PG admissions has helped in retention of MOs in these areas. However, certain gaps in the implementation and management of CRMC were observed. An MO said:
"I can get same salary in any private hospital in Raipur but CRMC makes the difference. Here I am getting CRMC benefit but in the city I would have to do private practice to get this amount."
The main reasons for MOs wanting to continue working in CRMC areas were getting CRMC benefits and to obtain grace marks during PG admission.
Payment of incentives
Delayed and irregular payment of incentives was observed as the biggest problem faced by the beneficiaries. Across the sample districts, eligible staff nurses who had joined CRMC were not receiving any CRMC benefits in the form of financial incentives [Table 3]. All four specialists who joined CRMC received CRMC incentives [Table 3].
|Table 3: Beneficiaries of CRMC incentives versus non-CRMC benefi ciaries among KI respondents|
Click here to view
The majority of beneficiaries were unaware of the incentives received as it was given as lump sum amounts on irregular basis. Moreover, the reasons for delays or difference in amount were not explained to the workers, which demotivated them. The removal of staff nurses from the CRMC list and the revisions of incentives for staff working in the "most difficult" and "inaccessible" areas created confusion and affect their morale. The payment of incentives has been delayed in all three districts. The delays were as high as 16 months both in Gariyaband and Jashpur districts, and up to 20 months in Kanker district. An MO posted at Kander CHC said:
" Non-CRMC area people are not getting (incentives) and we are also not getting so what is the advantage for us?"
In many instances, the problem of irregular incentives was much more serious. An RMA said:
" (I am) not getting CRMC even after filling bond. (I) went to meet State Nodal Officer who said come after one week. It (Raipur) is too far so I cannot go again whether I get it (incentive) or not."
Facility performance and CRMC financial incentives
The currently used performance indicators for provision of CRMC benefits do not adequately capture the performance of health workers, as the performance indicators relate to the functionality of the health facility. Performance indicators primarily evaluate the individual without considering the workload. Moreover, it also did not take into account the support system available, including inadequate staff and an irregular supply of drugs and logistics. Moreover, the majority of staff members in PHCs and health sub-centers (HSCs) did not receive the incentives, due to the low delivery load at these facilities. The parameters developed were not based on the availability of service providers, including support staff, who are critical for delivering services. An M.O said:
" If the number of deliveries is considered for provision of performance based incentives and the target is not achieved, then it is a programmatic fault not doctors. So why should we not be given the incentive? If target for number of deliveries is not achieved but at least some deliveries are conducted at the HSC (Health Sub-center), then is this to be considered good or bad?"
Extent of CRMC implementation
CRMC was designed in a comprehensive manner for the attraction and retention of health staff in underserved areas with provisions of financial incentives, insurance, educational benefits for children, housing, leave, etc. However, in practice it was limited to providing financial incentives and certain advantage for entry into PG admission. Housing, educational facilities, transport, and security are basic essentials demanded by staff working in any area. Though the financial incentives have led to retention of staff, the nonprovision of facilities such as housing, educational facilities for the workers' children, transport, and insurance has affected the morale of the staff in the CRMC areas, resulting in a lack of interest in joining CRMC areas. The non-provision of residential accommodation, educational facilities, transportation allowances, and life insurance could be the reasons for eligible health workers not finding CRMC attractive enough to join for working in remote and difficult areas. Many provisions are not adhered to on part of the Government despite the agreement signed between the parties.
Grading of facilities
Facility grading, developed in 2009, has been revised in 2011 [Table 1] based on standardized checklists that took into account different sets of criteria, such as physical accessibility criteria based on distance from urban centers, district headquarters, and motorable road; environment criteria such as social and natural factors; criteria for housing and family amenities; and also the vacancy status for MOs. The increase in number of facilities under "difficult" and "inaccessible" categories as per the revised grading system had helped in more rigorous targeting of facilities. However, anomalies in grading, when identified, did not actually translate into modification on the ground in some cases. The current facilities initially graded as "very difficult" have been changed to "difficult," and the reasons for the change were not known among the beneficiaries, resulting in confusion among affected staff members who were not receiving the graded financial incentives due to the revision of the grading system.
This study shows that other than the financial incentives, the working environment remains very challenging in most of the CRMC areas. The study observed that certain factors, i.e., lack of proper housing and transport for staff, inadequate staff (including support staff), has led to increased work pressure on existing staff. There are huge gaps with respect to the supply of medicines, equipment, and other essentials.
Publicity about CRMC
The interviews with CRMC beneficiaries revealed that most of them, when they joined the health department, had been unaware of CRMC, as it had not been advertised widely. The review of advertisements showed that prior to 2011, no information about CRMC had been included in the advertisements for staff recruitment. The newly recruited staff were not informed about CRMC at the time of their job counselling nor given any choice with regard to working in CRMC areas. This has resulted in limiting the impact of CRMC in increasing HR in difficult areas. A staff nurse said:
" I did not know about CRMC and got to know only after others started getting money."
An MO who joined 2 months prior at the time of interview said:
" I am not much aware about CRMC and have not talked to any senior also about it. I came to know through word of mouth. I came to know about the scheme from friends after joining. We were not given any information at the time of counselling."
A BPM (Block Program Manager) said
" People are not aware of CRMC. There are no advertisements and staff have no knowledge about it."
Grievance redressal mechanism
Redressal of grievances with regard to CRMC did not at the time of the study follow a system. There was no cell with adequate resources, no assignment of clear responsibilities, and no authority for tracking the progress of CRMC. Unaddressed grievances have led to frustration among staff members, which is not conducive to a healthy work environment.
| Discussion|| |
There has been some positive outcome of retention measures such as the provision of financial incentives and giving extra marks during admission to PG in terms of the attraction and retention of medical doctors in rural and remote areas, seen in the literature in India and elsewhere. Most states in India offer a higher salary for public sector MOs serving in rural or remote areas than for those serving in urban areas, though the amount of the incentive varies among states. Our study shows that the CRMC retention strategy, though focused solely on the provision of financial incentives, has helped in the attraction and retention of health workers, particularly in remote and difficult areas. Our finding is similar to that of a previous study about the selection of candidates from among candidates who apply for a place in a financial-incentive program,  which can contribute to achieving the main objective of the program, i.e., to increase the supply of health workers to medically underserved areas.
Findings from the KI interviews indicated that the health workers who have availed of CRMC benefits, i.e., financial incentives, expressed deep concern over the irregular payment of incentives, with delays ranging from 16 months to even 20 months in some blocks. They also expressed discontent about the recent revision of CRMC guidelines regarding the provision of financial incentives to any staff based on overall performance of facilities. The revised guidelines have overlooked the functionality of facilities in terms of the availability of support services, drugs and logistical supply, and manpower and workload of individual staff. This undoubtedly affects the morale and motivation of these cadres of health workers. Our study found that certain factors, i.e., lack of proper housing and transport for staff, inadequate staff leading to increased work pressures on existing staff, and huge gaps in the supply of medicines and other essentials are areas of major concerns that need to be addressed for optimizing the benefits of CRMC. We also found that for retention of health workers, financial incentives alone are inadequate: Adequate supplies and infrastructure are factors that can significantly improve morale.  Studies in sub-Saharan Africa have shown that motivation is influenced by both financial and nonfinancial incentives. Poor salary and working conditions, limited access to training, and lack of adequate performance management systems were the key demotivating factors for health workers. Inadequate supervision and poor monitoring have undoubtedly affected the morale of health workers. This has resulted in those health workers undertaking tasks beyond their capabilities, compromising the quality of care provided, which resonates with the findings of our study. 
Lack of an integrated performance management has affected the morale of many health workers.  Regular supervision is likely to influence performance because these activities provide opportunities for interactions, clarifications, and receiving feedback, which can act as social glue for holding staff members together. 
Appropriate packages of monetary and nonmonetary incentives such as reservation for PG seats in return for rural service and improved housing are crucial to encourage qualified health workers to serve in rural, remote, and underserved areas. ,, Nonfinancial issues such as personal attributes, setting clear responsibilities, improving grievance procedures, appropriate job aids, resources/supplies, and mentorship systems at the local level could improve worker motivation.  It was also found that improving nonmonetary incentives, such as providing health workers with essentials, frequent refresher training, and supportive supervision could motivate them,  which also resonates with our study findings.
This study has found that CRMC has been able to fulfill some of its purpose. It has positively impacted the retention and addition of HR in difficult areas. However, the study also found certain gaps in implementation conditions that could reduce the gains due to this scheme. In order to make the scheme more effective, the gaps in management of the program, monitoring, and grievance redressal need to be addressed by the Government urgently.
Financial support and sponsorship
The original study was supported by the National Health Systems Resource Center, the National Rural Health Mission, and the Ministry of Health and Family Welfare, Government of India.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Joint Learning Initiative. Human Resources for Health. Overcoming the Crisis. Boston: Global Equity Initiative, Harvard University Press; 2004. p. 33.
World Health Organization. Working Together For Health. The World Health Report. Geneva: World Health Organization (WHO); 2006. p. 3.
Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: A systematic review. BioMed Central. Available from: http://www.biomedcentral.com/1472-6963/8/247
. [Last accessed on 2013 Jun 20].
Kingma M. Nursing migration: Global treasure hunt or disaster-in-the-making. Nurs Inq 2001;8:205-12.
Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J. Loss of health professionals from sub-Saharan Africa: The pivotal role of the UK. Lancet 2005;365:1893-900.
Sundararaman T, Gupta G. Human Resource for Health: The Crisis, the NRHM Response and the Policy Options. Policy Brief: Institute of Applied Manpower Research; 2011. Available from: http://www.iamrindia.gov.in/Policy_Brief_Health.pdf
[Last accessed on 2013 Jun 15].
Deo MG. Doctor population ratio for India - the reality. Indian J Med Res 2013;137:632-5.
Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Serv Res 2008;8:19.
Lisam S, Mairembam DS, Hazarika A, Goel P, Srivastava R, Sundararaman T. Fixed human resources norms in indian sub centers - does the changing times necessitate innovations? Bonfring International Journal of Industrial Engineering and Management Sciences 2013;3:81-7.
Ruano Al, Hernández A, Dahlblom A, Hurtig AK, Sebastián MS. ′It′s the sense of responsibility that keeps you going′: Stories and experiences of participation from rural community health workers in Gautemala. Arch Public Health 2012;70:18.
Rao DK, Ramani S. What Works, Where And How Well? Lessons from a Comparative Assessment of Current Rural Retention Strategies for Doctors in India. Human Resource Background Paper 2. Public Health Foundation of India; undated. Available from:
Sheikh K, Rajkumari B, Jain K, Rao K, Patanwar P, Gupta G, et al
. Location and vocation: Why some government doctors stay on in rural Chhattisgarh, India. Int Health 2012;4:192-9.
Bärnighausen T, Bloom DE. Designing financial-incentive programmes for return of medical service in underserved areas: Seven management functions. Hum Resour Health 2009;7:52.
Manafa O, McAuliffe E, Maseko F, Bowie C, MacLachlan M, Normand C. Retention of healh workers in Malawi: Perspectives of health workers and district management. Hum Resour Health 2009;7:65.
Dielman M, Toonen J, Touré H, Martineau T. The match between motivation and performance management of health sector workers in Mali. Hum Resour Health 2006;4:2.
Wade GH, Osgood B, Avino K, Bucher G, Bucher L, Foraker T, et al.
Influence of organizational characteristics and caring attributes of managers on nurses′ job enjoyment. J Adv Nurs 2008;64:344-53.
Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98.
Kane SS, Gerretsen B, Scherpbier R, Dal Poz M, Dieleman M. A realist synthesis of randomised control trails involving use of community health workers for delivering child health interventions in low and middle income countries. BMC Health Serv Res 2010;10:286.
Bhattacharyya K, Winch P, LeBan K, Tien M. Community Health Worker Incentives and Disincentives: How They Affect Motivation, Retention, and Sustainability. Basic Support for Institutionalizing Child Survival Project (BASICS II). Arlington, Virginia: United States Agency for International Development; 2001. p. 36.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Challenges faced in rural hospitals: the experiences of nurse managers in Uganda
| ||T.A. Kakyo,L.D. Xiao |
| ||International Nursing Review. 2018; |
|[Pubmed] | [DOI]|
||Implementation research: towards universal health coverage with more doctors in Brazil
| ||Leonor Maria Pacheco Santos,Aimê Oliveira,Josélia Souza Trindade,Ivana CHC Barreto,Poliana Araújo Palmeira,Yamila Comes,Felipe OS Santos,Wallace Santos,João Paulo Alves Oliveira,Vanira Matos Pessoa,Helena Eri Shimizu |
| ||Bulletin of the World Health Organization. 2017; 95(2): 103 |
|[Pubmed] | [DOI]|