Objective="Increase presence of specialist doctors in tribal and backward districts."
Details for Reform Option "Incentive to Tackle Absenteeism among Doctors in Tribal Areas, Orissa"
One of the challenges faced by the public health system in India is the acute shortage of doctors, especially in rural and tribal areas. Most doctors, posted in rural areas, do not take up residence at their place of work and therefore they are not available for duty at the health institutions. In Orissa, absenteeism was found to be chronic in 11 tribal districts: Koraput, Malkanagiri, Nawarangpur, Rayagada, Bolangir, Sonepur, Kalahandi, Nuapara, Boudh, Kandhamal and Gajapati.
In February 2006, a resolution was passed by Government of Orissa (GoO) to curb absenteeism among doctors by giving them additional financial incentive. The resolution was passed only after the state finance department gave its clearance on January 17, 2006.
The scheme is being piloted for a period of two years to see how effective it is in curbing absenteeism among doctors placed in tribal districts. In December 2007, the scheme will be reviewed for extension.
The initiative gives additional financial incentive of INR.2000 per month to those Assistant Surgeons and specialists (class-II) at district level hospitals who attend to their duties. Those working in peripheral hospitals or dispensaries get a financial incentive of INR 5000 (€ 85.48) per month. If a doctor goes on leave for more than three days or is in transit on account of transfer, he or she does not qualify for incentive.
In order to get the incentive the Medical officers (MOs) in charge of Community Health Centres (CHCs), Primary Health Centres (PHCs) and Area Hospitals have to furnish a certificate every month to Chief District Medical Officers (CDMOs) certifying whether the concerned doctors in their administrative area have stayed and provided services in the respective institutions throughout the month.
Surprise visits are made by CDMOs to verify whether the MOs have been physically present in the health institutions. In case a doctor is found to have made incorrect statement regarding his or her attendance, the incentive amount is to be recovered from the countersigning officer.
The district collector, who is responsible for administration of the district, is supposed to regularly monitor the attendance of doctors. The CDMOs, in their fortnightly confidential report to the collector, incorporates information regarding absenteeism.
The initiative has been in operation only for a few months. The initial response is good. In Malkangiri, which is a tribal district, the rate of absenteeism has gone down considerably. However, a more definitive impact can be gauged after evaluation at the end of 2007.
The district makes the outlay from other allowances. The cost depends on the number of posts filled up.
Tribal districts of Orissa: Koraput, Malkanagiri, Nawarangpur, Rayagada, Bolangir, Sonepur, Kalahandi, Nuapara, Boudh, Kandhamal and Gajapati.
Access: The underserved population has greater access to services because MOs and specialists are present at their respective institutions in remote areas.
Monitoring: Need to oversee that the scheme is not misused.
Resentment: Ensure that there is no resentment among non-medical staff such as pharmacists, auxiliary nurse midwives, lady health visitors.
Vacant Post: In remote tribal districts, many posts of doctors are lying vacant. Unless these posts are filled-up, this initiative will not have much impact.
Opposition: The doctors are refusing to go for capacity building programmes for more than three days as they will loose their incentive.
Vacant posts of MOs are filled up.
Para-medical staff has to be in place.
Who needs to be consulted
Chief District Health Officers.
In-charge of respective public health institutions.
The government of Orissa has adopted the scheme for a period of two years. The success of this first phase will determine whether it will be extended or not.
Chances of Replication
Not too high, because most of the posts are vacant. This initiative, which at present is only for allopathic doctors, may show greater results if the government extends the same incentive to Ayurvedic doctors as well.
It is a challenge to have a suitable monitoring mechanism to ensure availability of doctors in remote areas. The mode of monitoring still remains random field visits by district officials. Involvement of Panchayati Raj Institutions may be a good strategy to monitor attendance of staff, but doctors have to be willing.
Dr. Nandini Roy, Research Consultant, National Institute of Medical Statistics, May, 2006.