Abstract
Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural
retention policies: career development programs, compulsory services, and schools outside major cities – in terms of
context, contents, actors, and processes.
Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas,
which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013),
key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping.
Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were
often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary
expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries,
as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to
stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring
for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in
exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found
an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established
based on political consideration (public sector) or profit motives (private sector).
Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption,
undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend,
in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent;
career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and
respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the
spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political
interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish
rural medical colleges. Political commitment is a key to rural retention of doctors.