de 1993 «Por la cual se reglamenta el uso e industrialización de la flora medi cinal».

In India the problems faced by the health sector has been out in the open and it is relatively easy to comprehend the complexities due to the numerous levels of its shortcomings. The government is not oblivious to this fact and is searching for solutions to sort out these problems.

1. Persistent gaps in manpower and infrastructure especially at the primary health care level.

2. Sub optimal functioning of the infrastructure; poor referral services. 3. Plethora of hospitals not having appropriate manpower, diagnostic and

therapeutic services and drugs, in Govt., voluntary and private sector;

4. Massive interstate/ inter-district differences in performance as assessed by health and demographic indices; availability and utilisation of services are poorest in the neediest states/districts.

5. Sub optimal inter-sectoral coordination.

6. Increasing dual disease burden of communicable and non-communicable diseases because of ongoing demographic, lifestyle and environmental transitions,

7. Technological advances which widen the spectrum of possible interventions. 8. Increasing awareness and expectations of the population regarding health care

services.

9. Escalating costs of health care, ever widening gaps between what is possible and what the individual or the country can afford.

Source: Dr. Prema Ramachandran, health adviser, (Planning CommissionIndia) p.1. The list shows some of the persistent problems acknowledged by the government. Interestingly shortage of manpower has been given a high priority but it should be noted that these problems are not universally applicable throughout India, except in poorly performing states. It is quite obvious that there is not a single strategy that can be either envisaged or implemented to resolve all the problems. The logical option would be to pursue specifically targeted programmes that attempt to resolve a problem or a few at a time. However this is easier said than done, as there are problems solely to be dealt by the central government, the respective state governments and even different districts with

in the state. There are even cases where problems need to be resolved at all levels by a joint effort of all the major players, especially during outbreaks of epidemics and natural disasters. This list is not solely depicting the problems faced in delivering healthcare in rural areas but it highlights issues facing all of India. In table 5 a clearer picture of the persisting problems in rural areas is presented.

Table 6 Major constraints in rural health services and their probable causes. Major Constraints Probable Causes

1 Non-availability of staff. Rural postings not attractive. Lack of women doctors. Diverse tasks and absenteeism. Lack of posts.

Systemic inefficiencies.

2 Weak referral system. Lack of organizational support. Poor transport and communication. Lack of awareness in the community. Systemic inefficiencies.

3 Recurrent funding shortfalls.

Financial constraints. Lack of autonomy.

Negligible income from patient care. Bureaucratic delays.

4 Lack of accountability for quality care.

Obsession with targets for family planning. No system of clinical audit or quality control. Inadequate understanding of rural health services. Lack of interest.

Source Mavalankar et al 2003 p.7.

Table 6 encapsulates quite a wide range of problems and their probable causes, which constrain and are usually blamed for the dysfunctional nature of the rural health network. I do not intend to explore every aspect in detail but will try and present those relevant to the thesis. Some of the problems mentioned in table 6 I explore and elaborate in detail in chapter (4) where I write about the perceived problems faced by the people in accessing healthcare and the reasons they give for the suboptimal or poor service provided by the government. Certain aspects that have not been mentioned in table will include the effect of corruption in public healthcare provision and the vulnerability of entire population groups because of their economic status, gender, social group, age and location. Other the problems mentioned in table 6 is highlighted in chapter (5) where I analyse the outcome

of the interviews conducted with the doctors serving in rural areas of Bidar district. This is primarily because doctors have an overbearing influence and responsibility in the management of Primary Health Centres (PHCs). Therefore the functioning or non- functioning of the PHCs would overwhelmingly reflect on how well the doctor actually manages to deliver healthcare from the PHC he or she is entrusted with.

The problem of recruiting doctors to work in rural areas.

Although the government has been able to build PHCs and other centres, there have always been problems recruiting highly qualified staff, especially doctors, to work in these centres. The severity of the above problem can be observed in The Government of India health report (1999 GOI). Aggregated for India that has approximately 22000 PHCs, more than 4000 positions for PHC doctors lay vacant, above 1300 PHC run without any doctors, about 5000-laboratory technicians post for PHC are still to be filled and nearly 24000 positions for health workers are vacant. Several initiatives and incentives were adopted in order to find a solution to this problem; however as mentioned above there seem to be a lot of problems that need to be tackled in order to get the right people with knowledge and competence to run PHC smoothly. Services provided by doctors were meant to improve on the previous quality of service and also to provide a broader range of healthcare to the population. Prior to the interventions of doctors, poorly qualified staff, mainly Auxiliary Nurse Midwives (ANMs) and Male Health workers were often left to manage PHCs. There are different ongoing policies adopted in India and its states that aim to bring a balance in the availability of doctors between urban and rural areas.

The problem of recruiting highly skilled personnel to work in rural areas has been ongoing ever since health policy planners envisaged the concept of primary health care delivery in rural areas of India. This meant that although there was in many instances the infrastructure for a PHC there was not the manpower available to manage the facilities. It appeared especially that doctors resisted or were not interested in working in rural areas of the country. Historically similar problems are faced by many developing nations and there does not appear to be a cohesive policy that works for every nation. Some nations

depended on giving out financial incentives to doctors to work in rural areas. In Turkey doctors were given four times the normal salary to work in rural areas (Cheyne and Lloyd1975). This Turkish scheme however lucrative it may have seemed was not as productive as intended, because the doctors involved weighed other factors against it such as their own safety, the education of their children, lack of amenities and development of basic infrastructure. Providing financial incentives appeared to be the norm followed by many of the Indian states but the professionals mostly disregard them, as these initiatives were deemed inadequate (Indrayan 2000). It might be suggested that the financial incentives offered by the government in the Indian context never appeared to satisfy the levels expected by the doctors. The financial incentives at present only tend to meet about 10% of what is expected by doctors hence it does not appear to be appealing enough to attract them to work in rural areas.

In order to attract doctors to work in rural areas it was envisaged in the 9th plan (1997- 2002) of the country, to allow states to offer postgraduate seats (places) to doctors who completed working for a period of time in rural areas (PCI). Karnataka readily adopted this policy and made certain alterations to suit the situation within the state. The GOK has a policy to attract junior doctors to work in rural areas for six years with the incentive that after completing this duration they will be eligible to get postgraduate seats (KGMOA 2001). It must be noted that placement in postgraduate positions is in itself a financial incentive, because one can bypass the normal procedure of either having to pay vast sums financially or enter into highly competitive exams to get such placements.

My thesis will examine the effects of this policy on the delivery of healthcare to rural areas from the perspective of both the provider and consumer of healthcare. I intend to concentrate on one district of Karnataka state, which is known to be an area that is deprived and lags behind in development. The effects of the GOK policy will be closely studied in the Bidar district of Karnataka.