For more than love or money: Attitudes of student and in-service health workers towards rural service in India

Sudha Ramani* (Corresponding Author), Krishna D. Rao, Mandy Ryan, Marko Vujicic, Peter Berman

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

17 Citations (Scopus)
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While international literature on rural retention is expanding, there is a lack of research on relevant strategies from pluralistic healthcare environments such as India, where alternate medicine is an integral component of primary care. In such contexts, there is a constant tug of war in national policy on “Which health worker is needed in rural areas?” and “Who can, realistically, be got there?” In this article, we try to inform this debate by juxtaposing perspectives of three cadres involved in primary care in India—allopathic, ayurvedic and nursing—on rural service. We also identify key incentives for improved rural retention of these cadres.


We present qualitative evidence from two states, Uttarakhand and Andhra Pradesh. Eighty-eight in-depth interviews with students and in-service personnel were conducted between January and July 2010. Generic thematic analysis techniques were employed, and the data were organized in a framework that clustered factors linked to rural service as organizational (salary, infrastructure, career) and contextual (housing, children’s development, safety).


Similar to other studies, we found that both pecuniary and non-pecuniary factors (salary, working conditions, children’s education, living conditions and safety) affect career preferences of health workers. For the allopathic cadre, rural primary care jobs commanded little respect; respondents from this cadre aimed to specialize and preferred private sector jobs. Offering preferential admission to specialist courses in exchange for a rural stint appears to be a powerful incentive for this cadre. In contrast, respondents from the Ayurvedic and nursing cadres favored public sector jobs even if this meant rural postings. For these two cadres, better salary, working and rural living conditions can increase recruitment.


Rural retention strategies in India have predominantly concentrated on the allopathic cadre. Our study suggests incentivizing rural service for the nursing and Ayurvedic cadres is less challenging in comparison to the allopathic cadre. Hence, there is merit in strengthening rural incentive strategies for these two cadres also. In our study, we have developed a detailed framework of rural retention factors and used this for delineating India-specific recommendations. This framework can be adapted to other similar contexts to facilitate international cross-cadre comparisons.

Original languageEnglish
Article number58
Number of pages12
JournalHuman Resources for Health
Issue number1
Publication statusPublished - 21 Nov 2013

Bibliographical note

We would like to acknowledge colleagues at the Public Health Foundation of India and the Indian Institute of Public Health, Dr. Seema Murthy, Ms. Neha Khandpur, Dr. Saujanya Khanna, Dr. Maulik Chokshi and Dr. Indrajit Hazarika, for their valuable inputs. This study was done as a part of a larger study funded by the World Bank.


  • Human resources
  • Incentives
  • India
  • Primary healthcare
  • Rural recruitment
  • Rural retention


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