PRIMARY HEALTH CARE DELIVERY IN RURAL INDIA : EXAMINING THE EFFICACY OF A POLICY FOR RECRUITING JUNIOR DOCTORS IN KARNATAKA Swarthick E. Salins A Thesis Submitted for the Degree of PhD at the University of St. Andrews 2008 Full metadata for this item is available in the St Andrews Digital Research Repository at: https://research-repository.st-andrews.ac.uk/ Please use this identifier to cite or link to this item: http://hdl.handle.net/10023/630 This item is protected by original copyright Primary health care delivery in rural India: examining the efficacy of a policy for recruiting junior doctors in Karnataka. By Swarthick E. Salins Ph.D. Thesis July 2008. School of Geography and Geosciences University of St Andrews St Andrews Fife, KY169AL Scotland. Primary health care delivery in rural India: examining the efficacy of a policy for recruiting junior doctors in Karnataka By Swarthick E Salins Abstract. This thesis examines the role of primary health care delivery in rural India but specifically focuses on aspects from Karnataka state. It broadly reflects on the differences that exist between urban and rural populations’ access to healthcare. The concept of primary health care appears to have lost its lustre at present, it was once enthusiastically promoted in the late 1970s and 1980s but as chronic problems appeared to affect the smooth delivery of healthcare and nowadays major global bodies like the WHO and IMF have relegated primary health concept to a lower level. However in countries like India, which adopted this concept although its implementation has been riddled with complex ongoing problems, there are not sufficient grounds to abandon it completely. These problems are mainly due to the slow implementation, which has left a vast rural population with little or no access to healthcare. Primary health care strongly promotes equity of access hence is vital in many developing nations. Recruiting highly skilled personnel to work in rural health centres has been an ongoing problem, which hinders the effective delivery of healthcare. A policy followed by Karnataka state tries to rectify this problem by offering postgraduate positions to junior doctors who are willing to work in rural areas. The efficacy of this policy is closely examined from two perspectives. Those who consume healthcare in rural areas are given an opportunity to voice their concerns and also the doctors who work there represent the views of the providers of healthcare. This study was conducted in Bidar district, which lies in the north of Karnataka. Bidar is identified comparatively as a less developed district that has many problems associated with poverty and poor health status. In the process of conducting research a variety of interesting aspects have been highlighted. My hope is that relevant authorities identify with the problems and take measures that could benefit many people’s lives. i Interestingly it transpires from the views expressed by the rural respondents that they have a good grasp of what they think they will need to access a better form of healthcare from the existing system. However it appears that there is almost a universal fatalistic acceptance of them being helpless and voiceless about making any to change by their suggestions nor did most of them have a hope of influencing future prospects. The studies also indicated that where there is a better level of provision there the people tend to access healthcare from authentic sources as opposed to unregistered and unqualified personnel. The doctors suggested that the policy is very useful provided certain intrinsic changes are made. On the one hand they did accept that their cost benefit and academic value of this policy is great. On the other hand they suggested the hurdles put in the course of achieving the postgraduate position are arduous and often vague sets of guidelines are imposed, making it very hard to make a straightforward transition from working in rural areas to getting a postgraduate position of choice. The doctors working on temporary contracts appeared to suffer genuine discrimination especially due to number of years they spent trying to get permanent position, years which were not counted towards their ambition of further education. Where it appears there is very little difference in the roles and responsibility between permanent and temporary contract doctors the question of why it does not occur to the authorities to redress this issue is discussed. ii Declaration 1. I, Swarthick Ebenezer Salins, hereby certify that this thesis, which is approximately 94,000 words in length, has been written by me, that it is the record of work carried out by me and that it has not been submitted in any previous application for a higher degree. Date: ……………… Signature of Candidate:………………………………… 2. I was admitted as a research student in 200 and as a candidate for the degree of Ph.D. in September 2002; the higher study for which this is a record was carried out in the University of St Andrews between 2001 and 2008. Date:………………Signature of Candidate:…………………………………... 3. I hereby certify that the candidate has fulfilled the condition of the Resolution and Regulations appropriate for the degree of Ph.D. in the University of St Andrews and that the candidate is qualified to submit this thesis in application for that degree. Date:………………………Signature of Supervisor………………………… A. Unrestricted In submitting this thesis to the University of St Andrews I understand that I am giving permission for it to be made available for use in accordance with the regulations of the University Library for the time-being in force, subject to any copyright vested in the work not being affected thereby. I also understand that the title and abstract will be published, and that a copy of the work may be made and supplied to any bona fide library or research worker. Date: …………………… Signature of Candidate: ……………………… iii Acknowledgements. My stay in Scotland has been so eventful over the past 8 years that I have to thank so many people without their support I would not be in the position of writing this thesis and rewriting it again. This list does not represent the order of importance but I would like to show sincere gratitude for receiving all the help. Thank you, Balcraig Foundation and Ann H Gloag for personally taking an interest and sponsoring my studies at St Andrews. I would also like to thank ‘Capability Scotland’ for employing me and the continuous support sustained my stay in the UK but also for giving me a better insight for the needs of people with disabilities. The department of Management especially the role of late professor Mo Malek who encouraged me to enrol for a PhD and I am sure he would have appreciated me completing my studies. My parents who have passed away during my studies have actually inspired me to carry on. My mother always wanted me to get into further education whilst my father instilled that we all have the potential of doing good especially in the light of a his Christian influence. My hope is that I fulfil their desires. I want to thank the department of Geography for taking me onboard and in addition my supervisors Prof Robin Flowerdew and Dr Mike Kesby. Robin played a vital role in identifying my potential of writing this thesis but it must be noted it was like a geologist seeing a glint of kimberlite on the surface. However getting to the gemstone would make the scale of mining at Ekati appear like having a scoop of ice cream. I say this because before I arrived in Scotland I never knew how to switch a computer on let alone writing a thesis. I would like to thank those who participated in this research and allowed me access to vital information. My thanks to numerous supporters in India and Scotland who encouraged me to study and not give up this of course, this includes my family, friends and many associates. A special thank you to the Peterkin family for their vital support during bleak times. The NHS has also played a vital part of my life here and I would like to thank the UK government for having such a system. My three children were born here and without the NHS I would have had to struggle. iv Finally what would I do without my wife? Through all the struggles she has put up with me and endured right up to the end. Especially in the light of last year’s disappointment of me unsuccessfully defending my PhD it gives me great strength to see my family still stand by. Thank you all for your support and consideration. v Contents Chapter 1. The relevance of primary health care in India: in the light of health sector reform and the epidemiological transition. Page number • Introduction 1 Basic health services 4 • Defining the concept of primary healthcare. 6 Primary healthcare as a rural alternative. 7 Primary health care after the Alma Ata declaration. 11 • Health Sector Reform 15 The impact of User Fees. 20 The introduction of health insurance. 24 Growth of private sector 25 Contracting out of services; and reviewing the public-private mix. 26 • Epidemiological Transition. 28 Synopsis of the prevalence of diseases, epidemics and illnesses faced. 30 Non-communicable diseases. 32 • Primary health care model in India 36 • The problem 39 The problem of recruiting doctors to work in rural areas. 41 • Conclusion 42 Chapter 2. Methodology and strategies adapted for collecting the relevant data. • Introduction 45 Establishing the framework of primary data. 46 • Criteria needed to sample the rural population. 49 Pilot Studies 51 Selecting study area and the interviewees 55 vi Page number Methods used for gaining access to doctors to conduct interviews.