BW Hayes, K Butterworth, B Neupane
Nick Simons Institute, Nepal

 

ABSTRACT BACKGROUND: The MD in General Practice is the one postgraduate programme specifically seeking to address the rural doctor shortage by training doctors for district hospitals. OBJECTIVE: To explore the key issues of practice location of all MDGP graduates to enhance recruitment of doctors in rural practice. METHODOLOGY: Study of demographic factors of 98 living graduates enhanced by qualitative study using triangulation of data from one postal questionnaire, one hand delivered questionnaire with semi-structured interview and focus group discussion. RESULTS: The spouse growing up outside Kathmandu and whether the doctor had ever been a Health Assistant were the statistically significant factors in whether currently working outside Kathmandu. The main themes arising with regard to improving recruitment of doctors to GP were: Selection of rural candidates Raising awareness of General practice both in the community and in undergraduate medical training Having GP input to training of undergraduate doctors Providing early positive rural experience during training Selective admission to postgraduate GP training programmes with provision of scholarships CONCLUSIONS: Factors affecting GP recruitment in Nepal are complex and interacting. Addressing these issues requires a holistic and integrated response to encourage, place and appropriately use the skills of GPs. Key words: Practice Location, General Practice Training, Recruitment.

The Medical Doctorate in General Practice (MDGP) began in 1982 as an initiative of the Tribhuvan University and the University of Calgary, Canada. Phases 1and 2 had overseas components but Phase 3 from 1991 has been conducted entirely within Nepal. Subsequently BP Koirala Institute of Health Sciences (BPKIHS) started a MD in Family Medicine in 2001 and National Academy of Medical Sciences (NAMS) started an MDGP programme in 2005. This has been the one postgraduate programme specifically seeking to address the rural doctor shortage by training doctors for district hospitals. In the light of Nepal's shortage of rural doctors to address the health needs of this country (2005 Ministry of Health figures suggest urban doctor ratio of 1:1,057 and rural of about 1:41,000), a study of factors affecting a doctor's decision concerning practice location is helpful.

Studies from developed countries notably USA, Canada and Australia suggest a number of significant factors. The doctor's background especially growing up in rural area has generally been found to be the most important independent predictor of rural practice(1-3). Other factors suggested and studied have been exposure to rural practice during medical training both in medical school (4,5) and residency(6,7), personal intention and motivation - commitment to rural family medicine appeared to be a powerful factor (1,8,9) and various financial, professional and lifestyle issues(10). Fryar et al(3) concluded that personal characteristics and background may be useful considerations in selecting applicants for family practice residency programmes committed to reducing shortages of health care service in rural areas. Felix et al(11) also concluded addressing community factors in recruitment efforts through community development activities may increase their success. There appear to be different factors in retention⁽¹⁾.

In a 2001 study of thirty-nine MDGPs⁽¹²⁾, rural upbringing appeared the most significant in determining location of work. Because numbers were small, it was felt a repeat of the study in a developing country like Nepal with larger numbers may add more useful and robust information to what is already available from developed countries.

This study was done by hand delivering or mailing a questionnaire to the MDGP graduates resident in Nepal between June and September 2006. It was the same questionnaire used in the 2001 study.

Information was collected about personal demography and current and previous places of work and work habits. Places of work were classified as whether within or outside the Kathmandu Valley since this is the major urban area of Nepal. The data results were compiled and analysed in SPSS and SAS programmes looking at what background factors influenced the current place of work.

There was also a qualitative study using triangulation of data from one postal questionnaire, one hand delivered questionnaire with semi-structured interview and focus group discussions during a national symposium on General Practice.

Two authors independently read and transcribed each of the questionnaire responses, identifying main themes emerging and performing initial coding. A high level of agreement was found between raters on the main issues. There were no significant outlying data. The summary of focus group discussions and plenary notes were also independently read and transcribed by two authors. A full description of this symposium's findings is found in a separate paper (Building up General Practice for Nepal, 2006). The final analysis was developed in discussion with all authors.

Some contact was made with 75 of the 87 graduates living in Nepal and responses were received from 62 doctors, 39 from outside of Kathmandu valley and 23 from within Kathmandu, an overall response rate of 71%.

One graduate had died and eleven are overseas. At least three of these twelve had worked at some time in rural areas.

Where are Nepal's General Practitioners?

• Fifty-three (62.1% of those in Nepal) were out of Kathmandu Valley.
  - Thirty in government service, eight in Medical Colleges and fifteen in Private Institutions including mission hospitals/ Private Practice.
  Note - there are no females (out of 9 graduates) currently working outside Kathmandu.
  
• Thirty - four (37.9% of those in Nepal) were in the Kathmandu Valley.
  - Eleven in government hospitals, twelve in Medical Colleges and eleven in Private Institutions/Practice. (Of these, at least five had at some time worked in rural areas.)
  
• Eleven were overseas.
  - Of these at least 2 had done some work previously outside Kathmandu.

The location of practice by region is illustrated in Graph 1.

GRAPH 1. LOCATION OF MDGP'S by DEVELOPMENT REGION

RESULTS and DISCUSSION of Factors in Location of Work

The univariate analysis using chi-square of the independent variables and the 2 dependent variables of place of first practice and of current practice is shown below.

Where the doctor predominantly grew up was used as the independent variable since there is significant correlation/co linearity with birthplace (just 2 born outside Kathmandu grew up predominantly in Kathmandu) and schooling (just 1 who schooled outside Kathmandu grew up predominantly in Kathmandu and 1 who schooled in Kathmandu grew up predominantly outside Kathmandu).

All tests were Chi-square with use of Fisher's exact 2 tail test where 2x2.
* p = 0.05-0.15 ** 0.001 -0.05 *** < 0.001 ns - > 0.15 (not significant)
Those factors with p<0.15 were then subjected to Multiple Logistic Regression to identify the main statistically significant factors determining practice location.

• The strong association between age (>= 45 and < 45), Years of GP practice (<= 6 and > 6), and the phase of the programme (Phases 1 and 2 vs Phase 3) is understandable as they are essentially conveying the same information (i.e. co linearity).
  
• Phase 3 doctors were more likely to have a Health Assistant background and had undergraduate rural exposure. In fact all Phase 1 and 2 doctors had a science background. This probably reflects the availability of training.
  
• Doctors with >6 years MDGP practice are more likely to have grown up outside Kathmandu.
  
• There is an association between spouses growing up in large urban centres and being more educated (a professional/graduate/health worker) probably reflecting opportunity.
  
• There is a strong association between the doctor's and spouse's place of growing up (rural and rural) which may also reflect opportunity for meeting/arranging marriage.
  
• There is a strong association between the 2 dependent variables indicating little movement of doctors.

For place of first practice whether in or out of the Kathmandu Valley, the factors which reached statistical significance (p<0.05) on multiple logistic regression are:

• the phase of the programme in which the graduate trained. Those trained in phase 3 were more likely to work outside the Kathmandu Valley (45/70) than those in Phases 1 and 2 (3/11).
  
• the age of the doctor. Those> =45 (26/37) were more likely to work outside the valley than those <45 (13/28).
  
• where the spouse grew up. Where the spouse grew up outside Kathmandu (34/48) the doctor is more likely to have first practised outside Kathmandu than when the spouse grew up in Kathmandu (5/18).

For current place of practice whether in or out of Kathmandu Valley, the factors which reached statistical significance (p<0.05) on multiple logistic regression are -

• Spouse place of growing up. The doctor is more likely to be out of Kathmandu if the spouse grew up out of Kathmandu (35/48) compared to the spouse growing up in Kathmandu (4/18).
  
• Previous type of work. If ever been a Health Assistant (26/36) then more likely to be practising outside Kathmandu than if done Intermediate in Science (13/30).

Unlike much of the international literature, the doctor's rural background did not reach statistical significance on multiple logistic regression analysis in this study but there may be some relationship with the spouse rural background which was the most consistent significant factor in this study.

Regarding the phase there is only a small number in Phases 1 and 2 and the high predominance of them in Kathmandu (8/11) may reflect their age and seniority and their need to be in teaching positions in Kathmandu. Specifically these early graduates became the department faculty. The age relation is at variance with the phase and may reflect that the more recent younger graduates are less likely to be outside Kathmandu because of recent security issues and the greater number of females.

Unlike some^{(6, 7)} but not all overseas literature⁽²⁾, undergraduate rural exposure did not appear significant as a determinant of location.

From the qualitative arm of the study, the main themes arising with regard to improving recruitment of doctors to GP and rural practice were:

• Selection of rural candidates with involvement of rural/peripheral communities in the process of selecting people they want as their doctor. This could be particularly applied to the already available 10 government seats in private medical schools.
  
• Raising awareness of General practice both in the community and in undergraduate medical training.
  
• · Having GP input to training of undergraduate doctors. A number of MDGPs cited good role models as significant in their choice - "One of my senior doctors encouraged me."
  
• Providing early positive rural experience during training. Several doctors' rural experience contributed to their choice. "While working in periphery (Okhaldhunga), I realized that MDGP would be the best speciality to provide optimum service."
  
• Selective admission to postgraduate GP training programmes with provision of scholarships. Doctors can be encouraged and selected who have already shown a commitment to serve in rural areas.
  

Limitations

One of the researchers and an assistant visited as many of the rural MDGP doctors as they could contact leading to a very high response rate of 75% (39/52). However, the focus group discussions were held in Kathmandu and many of the rural doctors were unable to attend due to the previously discussed problems associated with isolated practice in rural areas. This may have lead to an over- representation of more urban-based physicians.

In addition, the focus of this study was how to improve recruitment of General Practitioners in rural Nepal. Many doctors expressed the opinion that General Practitioners should not be seen purely as rural physicians.

• The spouse rural background and a HA background should be considered (along with doctor's rural background and interest in rural practice) in any selection of candidates for training.
  
• A need exists to establish an integrated career pathway of education and training for rural practice, beginning at the pre-undergraduate level and continuing through undergraduate medical education to specific rural practice vocational training followed by appropriate continuing and university graduate education, practice structures and family supports.

FUNDING
This study was fully funded by the Nick Simons Institute which is an organization with a mission to train and support skilled, compassionate health care workers for rural Nepal.

We would like to acknowledge Dr. Mark Zimmerman for his valuable advice and encouragement and Nick Simons Institute for sponsoring the national symposium on "Building up General Practice in Nepal."

We would like to thank Dr. Shiva Gautam for his valuable advice and assistance with the statistical analysis.

We thank all the MDGP graduates who gave up their valuable time to make this study possible.

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