The concentration of health workers in urban areas is not a problem that is unique to India. Indeed, both industrialized and developing countries around the world face disparities in the distribution of health personnel (Dussault and Franceschini 2006). There are many reasons why health workers typically choose not to work in rural areas. Salary emerges as an important component of a job and strongly affects the willingness to work in rural areas (Chomitz 1997; Serneels, Lindelow et al. 2007). However factors other than salary also play an important role in the preference of urban positions. For example access to training, health care and education for children, promotion opportunities, the availability of electricity, water and housing are all reasons that urban jobs are usually favored(Dussault and Franceschini 2006; Lindelow and Serneels 2006; Serneels, Lindelow et al. 2007).In Pakistan, the absence of equipment and supplies was a major deterrent for accepting a rural post (Zaidi 1986). A study on rural health worker motivation in Vietnam highlighted the importance of appreciation and support from managers and colleagues as well as from the community (Dieleman, Cuong et al. 2003).

Individual characteristics can also affect the decision to serve in rural areas. It is generally accepted that a person from a rural background is more likely to pursue a career in rural areas (Laven and Wilkinson 2003; Matsumoto, Okayama et al. 2005; Dussault and Franceschini 2006; Lehmann, Dieleman et al. 2008). Schooling in rural areas also appears to have a similar effect although rural medical training alone is unlikely to have a major impact on increasing the rural workforce (Eley and Baker 2006). In addition, women are less likely to accept a post in a rural area than are men, though the presence of family members in rural areas may mitigate this effect (Doescher, Ellsbury et al. 2000; Dussault and Franceschini 2006).

Several financial and non-financial incentives have been proposed to deal with the shortage of rural health workers. Financial incentives alone are unlikely to be successful in attracting health workers to rural areas (Anderson and Rosenberg 1990; Sempowski 2004). Thus incentive packages tend to be a combination of financial and other incentives. These range from improved working and living conditions to increased training opportunities (Lehmann, Dieleman et al. 2008). In Indonesia, for example, doctors working in rural areas gain a salary bonus as well as preferential entry into a prestigious civil service post and subsidized specialist training (Chomitz 1997). In Thailand, financial incentives for hardship posts were combined with investment in rural health infrastructure in order to improve living conditions (Wibulpolprasert and Pengpaibon 2003). Both countries also had forms of compulsory rural service though, in general, these were not well-received. Indeed, Sempowski (2004) finds that physicians who voluntarily choose to work in rural areas are more likely to stay there for longer periods of time. The multi-dimensional nature of the problem suggests that incentive packages that address several aspects of employment choice are likely to be most successful in recruiting health workers to rural areas.

Uttar Pradesh Health System

The state of Uttar Pradesh (UP) is India’s most populous state and has some of the poorest health and economic indicators. In India and UP, health workers tend to be highly concentrated in urban areas of the country with doctor and nurse densities in urban areas 3-4 times higher than that of rural areas (cite Health Workforce paper). Though UP has a much lower overall density of nurses than the national average, the distribution of nurses between urban and rural areas also corresponds well with what is seen nationally. Thus, the distribution of health workers in UP is generally representative of the country as a whole.