availability of doctors at primary health centres of andhra pradesh, india p. mahapatra, d. thota,...

7/28/2019 Availability of doctors at primary health centres of Andhra Pradesh, India P. MAHAPATRA, D. THOTA, C.K. GEORGE, N.S. REDDY

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Offprint fromThe NationalMedical Journalof IndiaVolume 25, Number 4(July/Aug 2012)


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Medicine and SocietyTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 25, NO.4, 2012

Availability of doctors at primary health centres of Andhra Pradesh, IndiaP. MAHAPATRA, D. THOTA, C.K. GEORGE, N.S. REDDY

ABSTRACTBackground. A vailability of doctors at prim ary healthcentres (PHCs) is a m a jo r c on ce rn. W e m e as ure d th e o pe ra ti on alavailab ility of doctors in PHCs and exam ined the effect ofresidential distance and private practice.Hetbods. Thirty-six health centres, consisting of sixran do mly selected P HC s fro m six p urp osiv ely ch osen d istrictsIn Andhra Pradesh were studied. C ross-sectional data onres id en tial dis ta n ce, p riv ate p ractice and attendance pattern of

38 operatio nal ly available m ed ical officers w ere analysed.Results. About 80% of doctors residing w ithin 20 kmat tended their PH C on all 6 days of a w eek, com pared w ithonly 33% for those staying >40 km away. A m ong thosestaying >20 km away from th eir P H C, th e o dd s o f a bs en te eis mby privately practising doctors w as 3-24 tim es m ore than forth ose not practising priv ately .Conclusion. Res idential distance seem s to affect theoperational availability of doctors. Priv ate p ra ctic e b y d oc to rsliving w ithin 20 km from the PH C does not seem to affect theiroperat ional av ailab ility. However, priv ate p ractice by doctorsstaying >20 km aw ay from th eir PHC m ay affect theiravai la bil ity .N atl M ed J India 2012;25:230-3INTRODUCTIONAn appropriate health workforce is essential for delivery ofoptimal healthcare services. 1 However, complete or partialabsenteeism of doctors is invariably a problem. Availability ofdoctors is seen to be a key indicator of patient satisfaction andreliability of a health service.P Non-availability of doctors inprimary health centres (PHCs) has been an important publicconcern.r" The Supreme Court ofIndia has observed that 'in ruralareas, there are no doctors' .7Availability has various meanings and is measured in differentways.8.9Availability of healthcare professionals can be viewedbroadly fromthe (i)supply side perspective orinherent availability,and (ii) user access perspective or operational availability.Geographical distribution and inherent availability of doctors inThe Institute of Health Systems, HACA Bhavan, Hyderabad 500004,

Andhra Pradesh, IndiaP. MAHAPATRAHealth Management Research Institute, Hyderabad, Andhra Pradesh, IndiaD.THOTAThe Global Fund to Fight AIDS, Tuberculosis and MalariaC.K.GEORGEEMRI, Hyderabad, Andhra Pradesh, IndiaN.S.REDDYCorrespondence to P. MAHAPATRA; [email protected],

[email protected] The National Medical Journal of India 2012

agiven area have been measured using indicators such asphysician-or doctor-population ratios. Population-based measures of inherentavailability of doctors do not tell us much about services athealthcare institutions (HCls) such as PHCs.Most studies on human resources in HCls report about

inherent availability. For example, reproductive and child healthfacility surveys measured professional staff availability basedon the number of staff, either sanctioned and/or filled-in postsusing static and cross-sectional indicators such as the number ofstaff posted and number of staff found at the time ofvisit. 10-13 The Planning Commission study regarding functioningof PHCs ascertained the number of doctors in position against thenumber of sanctioned posts. Although the indicator of percentagedoctors-in-position looked good, the field teams in this studyobserved that actual absenteeism of doctors was high.' A fewstudies measured absenteeism ofdoctors toexamine its associationwith contributory factors. For example, Chaudhury et al.1415report that residence inheadquarters, opportunity cost of providerstime (i.e. scope for private practice), road access and ruralelectrification correlated highly with the rate and pattern ofabsenteeism of medical officers. Some studies' report qualitativeinformation based on client perception and experience aboutoperational availability of doctors. We measured operationalavailability of doctors at PHCs in rural areas and examined itsrelation with selected systemic and personal factorsMETHODSSelection of PResThirty-six PHCs were randomly selected from within ageographically stratified sample of six districts. The 22 ruraldistricts inAndhra Pradesh were grouped in three political regions,namely Telengana, Andhra and Rayalaseema. From within eachof the three political regions, one district with low infant mortalityrate (lowest IMR) and another district with high mortality rate(highest IMR) were purposively selected. Low IMR is usuallyassociated with a higher development index and high IMR withbackwardness. Districts with extreme IMRs were included in thestudy to ensure that the sample represented the range of experiencefrom backward areas to more developed districts. Six PHCs werethen selected from within each of the six districts by simplerandom sampling. Twenty-one of the sample PHCs had a singlepost for a medical officer (MO), another 14 had two posts forMOs, and one PHC had four posts for MOs. Thus, 53 posts forMOs spread over 36 PHCs were available for observation.Data collectionA team oftwo field investigators visited each of the sample PHCs,for at least 3 days, between September to December 2006. Thesevisits were made, with a short advance notice, usually on theprevious day, or the same day morning. Follow-up visits wereneeded in many cases to complete the data collection sche~ules.


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Informationabout availability, residence and private practice ofthecurrentlyposted doctors was gathered. Mas from other HCIs,put in-charge of the PHC under study, were included only if theyvisitedthe PHC regularly and contributed to patient care. Thosehandlingonly administrative functions such as drawal of salary,and not contributing to professional services were excluded, asthey visit the PHC occasionally, only in case of administrativeexigencies.Availability was assessed by the field investigators, based ontheirown observation over a 3-day stay at the PHC, and detaileddiscussionswith key informants such as paramedical staff at thePHC, patients, attendants, staff of local medicine shops andlocallyresident community leaders. During their visit to the PHC,fieldinvestigators asked key informants to recall the attendancepatternof Mas. We realized that key informants' recall of theattendancepattern of a doctor would be influenced by variousfactors, such as their relationship with the Mas, and theirexpectationofwhat should be revealed. For example, paramedicalworkers closely associated with an MO tend to recall a moreoptimisticpicture ofMas attendance. Some paramedical workerstendtoreport the prescribed working hours as actual availability.Tominimize the potential for reporting bias, field investigatorsinterviewed several key informants, including people who wereoutsidethe PHC establishment but had an opportunity to observetheattendancepattern of doctors. Each key informant was reassuredabout total confidentiality and anonymity of the interviews, andencouraged to accurately recall the actual attendance pattern oftheMas over a longer period, ignoring occasional deviations. Tofacilitateaccurate recall bykey informants, investigators proceededfromlonger and easily identifiable discrete time measures such asdays in a week, followed by morning and evening shifts, endingfinally with an estimate of the approximate hours of attendance ineach shift, on a typical day. Key informants were asked if theattendance pattern observed by the investigators during their visitto the PHC was typical of the concerned MO. Finally, the twoinvestigators triangulated the information gathered from keyinformants, their own observations and arrived at a consensusbetween them about the typical attendance pattern of each MO.Mas wereexpected to beavailable atthe PHC from 9 a.m. to 12p.m. and4-6 p.m., in addition to aweekly medical camp. However,

Mas who attended the PHCdid not necessarily work for the entireduration of the day. Investigators enquired about the typicalattendancepattern and usual hours of presence in the PHC of eachMO.Hoursof availability per week were computed by counting thenumberof typical attending days and usual presence, in hours, onthose days. Field investigators used their judgement to weigh theinformation provided by various key informants. Estimates by keyinformantsworking closely with the concerned doctors or known tobe critical of them were discounted. Feedback of key informantsassessed to be more credible were given more weightage. Hence,the estimation of the typical attendance pattern of each doctor wassubjective, by the field investigators based on their interactionswith various key informants and their own observation during the3-day stay.Field investigators enquired about the actual residence of all

Mas by asking each of them as well as key informants such asparamedical personnel working in the PHCs. Investigators thenpersonally visited the actual place of residence and estimated theroad distance to the PHC. Field investigators made extensiveenquiries to determine extramural affiliations (private practice) ofMas. First, key informants such as paramedical workers wereasked ifany of the Mas working in the PHC had a private practice

231or clinical affiliation with a private healthcare provider. Next, theinvestigators enquired, in the neighbourhood of the doctor'sresidence, about private practice and location of his/her clinic.Finally, the investigators located the clinics or hospitals to verifyif the concerned doctor did actually practise there. Informationabout private practice was gathered from these clinics. The Mascovered by the study were assured that information gathered abouttheir actual residence and private practice will bekept confidential,anonymous and used for statistical purposes only. All Mas, in thesampled PHCs, consented to gathering of information about theirresidence and private practice.RESULTSNumber of posts of MOs and availability of doctors in PResIn 2006, of the 53 sanctioned MO posts in all 36 PHCs, 44 werefilled (17% vacancy), and only 38doctors (72%) were operationallyavailable. The remaining 6 Mas were either on long-term.deputation elsewhere or on study leave. From the user perspective,14% PHCs had no doctor and 28% of sanctioned doctors were notavailable (Table I). While at least 50% of available doctorsattended the PHC on all days, some attended only a few days ofthe week. Although doctors are expected to be available for bothshifts, most of them were working one shift. Only 21% of doctorsattended both shifts. On an average, doctors spent about 4.8 hourson the days they attended the PHC. Accounting for the attendingdays, the mean service time available per week was 25 hours,which is 83% of the full-time equivalent (5 hours per day for6 days in a week). Computing 3 hours for 100% of operationallyavailable doctors in the morning shift and 2 hours put in by 21%

TABLE. Availability of medical officers (Mas) at primary healthcentres (PHCs) in Andhra PradeshItem Single MO Multiple MO All

PHCs PHCs PHCsNumber of PHCs 21 15 36Sanctioned posts of MOs 21 32 53MOs posted 17 27 44Operational doctors 17 21 38PHCs with no doctors (%) 19.1 6.7 13.9Single operational doctors (%) 80.9 46.7 66.7Two operational doctors (%) 0 46.7 19.4Operational doctorsMean (median) days attended 5 (6) 4.9 (6) 4.95 (6)per weekSingle shift availability (%) 100 100 100Both shift availability (%) 35.3 9.5 21.1Mean (median) available 4.53 (5) 4.95 (5) 4.76 (5)hours/attending day

Mean service hours/week 24.6 25.4 25.0PHCs with one sanctioned post of MO were classified as 'single MO PHCs' whilethose with ~2 posts of MOs were classified as 'multiple MO PHCs'. The value ofmean service hours/week was calculated by aggregating the weekly service hourestimate of all doctors. This estimate was slightly higher than the estimate obtained bymultiplying the mean attending days with mean available hours/attending days. Forexample: 5x4.53=22.65 hours/week for single MO PHCs compared to 24.59 hours/week obtained by aggregating hours/week by each doctor. Similarly,4.95x4.9O=24.29 hours/week for multiple MO PHCs compared to 25.38 hours/weekobtained by aggregating hours/week by each doctor. This is because the latterestimate is based on the sum of hours/day weighted by days/week. Those who attendmore days in a week also tend to work longer hours on their attending days and thoseattending the PHC for a few days tended to be present for fewer hours even on thedays they attended. Hence, the aggretate estimate of hours/week is higher than thatderived from the mean hours/day and mean days/week.


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advance notice is likely to have improved doctor attendance tosome extent. The Bangladesh stu dy'? reported that 41 % -44 % ofUpazila(sub-district) Health Centres and Upgraded Family Welfare

s did not have any doctor at the time of the survey.Doctors do not usually attend their PHCs on all working days.

an attendance was about 5 days per week and the mediane was 6 days per week. However, doctors who attended

rPHC did not usually stay for the evening shift. Only 21% ofs were available for both shifts. This is consistent with thendings of the Bangladesh 14 study which reported thatofessionals are more likely to be at work during official morningoursthan in the afternoon. Most other findings of this study areotdirectly comparable to the results of other studies, as theeasures of availability are different. For example, the study byopakumar and others' showed that only 28% of respondents

ra Pradesh reported that a doctor was available in aovernment health facility.Operational availability does not suffer much in case of doctorsiding at distances up to 20 km from the PHC with 78% ofoctorsresiding within 20 km from the PHC attending the healthntreon all 6 days of a week. However, residence farther than 20

n appears to increase absenteeism with operational availabilityriously affected in case the MO is residing >40 km away fromPHC. The difference in proportion between various residentialstance groups is not statistically significant, as the sample sizes

ll. However, the direction of the estimated parameters isuitively appealing. About 70% of doctors residing close to theCG;20 km) were available for 5-8 hours in a day, whereas only%of those staying away from the PHC (2:21 km) were availabler the same duration. The difference in working hours of doctorsying >41 km away and those staying closer is statisticallynificant. Considering the trend of fewer attending days and theference in their working hours, it appears that a residentialnce of >40 km from the PHC may seriously affect a doctor's

erational availability at the PHC. Other studies too have reportedrse effect of residential distance on availability. The

ngladesh study 14 reported that among doctors in Upazila healthtres, 36% of doctors living in a different town did not show uptime during a day compared to 13% for those who lived in thee town.The combined effect of private practice and farther residentialnce was significant. Doctors living close by G;20 km from the) are able to attend regularly even if they do private practice.er, doing private practice by doctors staying >20 km away

m their PHC is affecting their operational availability. Amonge staying >20 km away from their PHC, the odds of absenteeismprivately practising doctors is about 3 to 24 times that of thosepractising. However, studies with larger sample sizes are

233required to better understand the relationship between residentialdistance and private practice on doctor absenteeism.ACKNOWLEDGEMENTSThis study was supported by a grant from the Planning Department,Government of Andhra Pradesh. We aregratefulto Shri A.K. Goel who wasSpecial Chief Secretary Planning at the time of the study. We also thank ourfield investigators: Y. Srinivasa Rao, P. Vijayakumar, M. Thriloknath,G. Gabriel, M. Buden Vali and Y. Eswaraiah.REFERENCES

World Health Organization. The WorldHealth Report 2006: Working together forhealth. Geneva:WHO; 2006.

2 PEO. Evaluation study on functioning of primary health centres (PHCs) assistedunder Social Safety Net Programme (SSNP). New Delhi:Programme EvaluationOrganisation, Planning Commission, Government ofIndia, August 200 I.3 Gopakumar K, Sekhar S, Balakrishnan S. The state of India's public services:Benchmarksfor the new millennium. Bangalore:PublicAffairsCentre, April 2002.Available at httpr//www. worldbank.org/publicsector/pe/milleniumreport.pdf(accessed on 14May 2012).

4 Doctors reluctant to work for government. The Hindu Hyderabad, 2006 Aug 23:6.5 Times News Network. Poor infrastructure hits tribal area PHCs. TheTimes of IndiaHyderabad, 2003 May 20:6. .6 Gungubele M. Statement on unavailability of medical doctors atTamboMemorial,Gauteng Legislature Health Portfolio Committee, South Africa. 1997 Jun 20.Communication Department of the Gauteng Provincial Legislature, SouthAfricanGovernmentInformation.7 Mahapatra D. 'Rural health care system abysmal' .Apex Court approvesfreshAIDScontrol programme, but raises concern. The Times of India Hyderabad, 200SOct 2.

S Katukoori Vamshi K. Standardizing availability definition. Como, WestAustralia:Plant Maintenance Resource Centre, West Australia. Available at http://www.plant-maintenallce.comiartic/esiAvailability_Definition.pdf(accessed on 14May 2012).9 Barringer HP. Availability, reliability, maintainability, and capability. Texas,USA:Barringer & Associates, 1997 Feb IS. Available at http://www.barringerl.comlpdflARMandC.pdf(accessed on 14May 2012).10 RamF,Paswan B,Ladu Singh L. India facility survey (under Reproductive andChildHealthProject) Phase II,2003.Mumbai:International Institute for Population Sciences(lIPS); 2005. Available at lzttp://www.rchiips.org/pdf/rch2/NationaCFacility_ReporCRCH-ll.pdf(accessed on 5 JuI2012).II Ram F, Ladusingh L. Paswan B, Unisa S, Prasad R, SekhcrTV, et al. District levelhousehold and facility survey 2007--{)S(DLHS-3). Mumbai:Intemational Institutefor Population Sciences (lIPS); 2010. Available at hllp:l/www.rchiips.org/pdf/. INDIA_REPORT_DLHS-3.pdf(accessed on 5 Jul 2012).

12 Advent HeaIthcare Group. Facility survey of public health institutions in Assam2007.NewDelhi:The Mission Director, National Rural HealthMission, GovernmentofAssam.Available athttp://www.nrhmassam. inlpdfl2_5_3.pdJ,2007Apr(accessedon 14May 2012).13 Lindelow M, Wagstaff A. Health facility surveys: All introduction. World BankPolicy Research Working Paper No. 2953. Washington DC:World Bank; 2003.Avail able at httpr//pape rs.ssrn. comlsoI3/papers.cfm? abstract_id=636315#(accessed on 14May 2012).14 Chaudhury N,HammerJS. Ghost doctors: Doctor absenteeism in Bangladeshi healthfacilities. World Bank Economic Rev 2004;18:423-41.15 Chaudhury N,Hammer J, KremerM,Muralidharan K,Rogers FH.Missing inaction:Teacher and health worker absence in developing countries. J Econ Perspect2006;20:91-116.16 Banerjee A, Deaton A, Duflo E. Wealth, health, and health services in ruralRajasthan. Am Economic Rev 2004;94:326-30.

availability of doctors at primary health centres of andhra pradesh, india p. mahapatra, d. thota,...

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