Retention of Physicians in Primary Health Care Facilities of Khyber Pakhtunkhwa Open Access

Abstract

Despite extensive primary health care infrastructure, Khyber Pakhtunkhwa (KP) has failed to improve utilization of its primary health care facilities (PHCFs). A shortage of key cadres in the health workforce is one of the main reasons behind this problem. This case study aimed to identify factors behind poor retention of physicians in PHCFs across KP. A descriptive review was performed in this study using general Cochrane systematic review methods. This review examined the problems of physician retention in rural areas and PHCFs in different parts of the world and also assessed successful interventions implemented by different countries to resolve this issue. Policy documents and reports from Department of Health (DoH) KP were also explored to understand the current situation in KP and strategies implemented in this regard. It was observed that challenges related to physician retention in PHCFs of KP include lack of incentives, lack of career development opportunities, geographical inaccessibility, poor health facilities infrastructure and quality of life in rural areas. The study observed that these problems are remarkably similar to problems faced by other countries around the world. The strategies adopted by government of KP in the recent years have failed to achieve desired outcomes. This failure is widely attributed to lack of evidence-based policies and interventions implemented in the recent past. Based on effective strategies, successfully implemented in different countries to tackle this problem, this study recommended policy guidelines for DoH KP to improve physician retention in PHCFs. These comprise facility and services based financial incentives, restrictive measures and sanctions for physicians, personal and professional development opportunities, introduction of postgraduate family medicine residency programmes; and encouraging female physicians to enter practice. This study advocates that incorporating these recommendations into human resources for health (HRH) policies, DoH KP can improve physician retention in its PHCFs, particularly in rural areas.

Table of Contents

Table of Contents

Chapter 1: Introduction ..................................................................................................................1

1.1. Khyber Pakhtunkhwa: Geography and Demography.................................................4

1.2.    Khyber Pakhtunkhwa Health System and Service Delivery Structure......................6

1.2.1.    Khyber Pakhtunkhwa Health Organizational Structure..............................7

1.2.2.    Primary Health Care in Khyber Pakhtunkhwa............................................9

1.3.    Retention of Physicians in Primary Health Care Centers in Pakistan......................11

1.3.1.    Retention of Physicians in Primary Health Care Centers of Khyber Pakhtunkhwa..............................................................................................13

Chapter 2: Literature Review.........................................................................................................14

2.1. Physician Retention in Primary and Rural Health Care Centers of

     High-Income Countries................................................................................................15

2.2. Physician Retention in Primary and Rural Health Care Centers of

    Upper Middle Income Countries..................................................................................16

2.3. Physician Retention in Primary and Rural Health Care Centers of the Low and

     Middle-Income Countries............................................................................................18

2.3.1.  West Africa................................................................................................18

                       a. Senegal.......................................................................................18

b. Ghana.........................................................................................19

c. Sub-Saharan African Countries..................................................19

                       2.3.2.  South Asia..................................................................................................20

                                               a. Bangldesh...................................................................................20

                                               b. India...........................................................................................21

                                               c. Pakistan......................................................................................21

           2.4. Physicians Retention in Primary Health Care Centers:

     Case of Khyber Pakhtunkhwa......................................................................................23

2.5. Statement of Purpose..................................................................................................24

2.6. Research Questions.....................................................................................................24

Chapter 3: Methodology................................................................................................................26

Chapter 4: Results..........................................................................................................................30

            4.1. Situation Analysis......................................................................................................30

            4.2. Contracting of Primary Health Care Facilities..........................................................32

                       4.2.1. People’s Primary Healthcare Initiative in Khyber Pakhtunkhwa................33

                       4.2.2. PPHI Strategies for Recruitment and Retention of Physicians in KP.........34

                       4.2.3. Situation of Physician Retention in PPHI Districts (2011-2015)................35

                       4.2.4. Reasons for Termination of PPHI Contract.................................................37

                                   a. Governance Issues.................................................................................37

                                   b. Funding and Accountability Issues........................................................38

                                   c. Health Care Management Competency of PPHI Administration..........38

                                   d. Monitoring and Supervision..................................................................39

                                   e. Devolution of Health Sector..................................................................39

            4.3. DoH Strategies for Recruitment and Retention of Physicians in KP.......................40

                       4.3.1. The Khyber Pakhtunkhwa Health Roadmap...............................................40

                       4.3.2. DoH Strategies for Recruitment and Retention of Physicians in KP..........40

                       4.3.3. Extraordinary Leave and its Effects on Physicians Retention.....................42

            4.4. A Brief Comparison of Preventive Services under PPHI and DoH

        Administration..........................................................................................................43

                       a. Immunization.........................................................................................43

                       b. Mother, New Born and Child Care (MNCH) Services.........................44

            4.5. Summary of results...................................................................................................45

Chapter 5: Discussion, Recommendations and Conclusion..........................................................46

            5.1. Discussion.................................................................................................................46

            5.2. Recommendations.....................................................................................................49

                       5.2.1. Financial Incentives.....................................................................................49

                       5.2.2. Restrictive Measures and Sanctions.............................................................50

                       5.2.3. Personal and Professional Development Opportunities...............................51

                       5.2.4. Family Medicine Programmes.....................................................................52

                       5.2.5. Policies to Encourage Female Physicians to Enter Practice........................52

5.2.6. Policies to Encourage Female Physicians to Enter Practice........................53

            5.3. Conclusion................................................................................................................56

References......................................................................................................................................57

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Physician Retention
Committee Chair / Thesis Advisor	Deborah McFarland, Emory University

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