by Dr M C Gupta
Reasons why many doctors in India prefer to work in government hospitals.
|PUBLIC / PRIVATE JOBS FOR DOCTORS
When I completed my MBBS in 1964, there were hardly any jobs for doctors in the private sector. The scene has now changed. According to government figures, only 19 % doctors are in the government sector . As a matter of fact, the private sector provides 58 percent of hospitals, 29 percent of the beds and 81 percent of doctors.
We frequently hear complaints that good doctors holding senior positions in public or government hospitals, including teaching hospitals, are leaving government jobs and joining the corporate sector. On the other hand, there are many highly qualified and respected senior doctors in government jobs who could get ten times the salary in the corporate sector but continue to work in the public sector. What are the factors that motivate them? Sonal Shukla, in an article titled “Lucre or Love”, has recently discussed why, despite the rapid emergence of corporate healthcare, there are still large numbers of dedicated doctors who have turned their backs on enormous pay packets just to keep working in a Government hospital .
This article compares how far the two sectors fulfill the needs and aspirations of doctors. I will not indulge here in the subjective discussion of whether it is good or bad on the part of senior specialists in government service to opt to join the private sector. I will, instead, discuss the situation with respect to an objective yardstick, developed by Maslow, and would examine which of the two sectors provides more sense of satisfaction to doctors by fulfilling their needs.
Abraham Maslow developed a theory of personality that has influenced a number of different fields, including education and management. This wide influence is due in part to the high level of practicality of Maslow's theory . Human resource managers now realize that men do not work for money alone. There are needs other than money and everybody prefers a work situation where multiple needs, besides money, can be fulfilled. Maslow stated that human needs can be classified into five levels in a hierarchical manner, represented by Maslow’s pyramid, whereby the most basic needs are at the base of the pyramid and once these are fulfilled, man tends to seek jobs that provide fulfillment of higher needs. A review of Maslow’s work can be found at . Starting from base upwards, he has listed human needs are listed as follows:
Level 1--Physiological Needs—Such as air, water, food, clothing, housing etc. They come first in the person's search for satisfaction.
Level 2--Safety Needs—General safety and security
Level 3--Needs of Love, Affection and Belongingness—Everybody seeks to overcome feelings of loneliness and alienation. This involves both giving and receiving love, affection and the sense of belonging.
Level 4--Needs for Esteem--When the first three classes of needs are satisfied, the needs for esteem can become dominant. These involve needs for both self-esteem and for the esteem a person gets from others. When these needs are satisfied, the person feels self-confident and valuable as a person in the world. When these needs are frustrated, the person feels inferior, weak, helpless and worthless.
Level 5--Needs for Self-Actualization-- Maslow describes self-actualization as a person's need to be and do that which the person was "born to do." For example, "A musician must make music, an artist must paint, and a poet must write."
The first four of the above needs are called deficiency needs. Without them, a person’s life is deficient. The last one adds an extra element to a life that is otherwise full.
Let us now list the reasons why doctors prefer or don’t prefer to quit a government job in favour of a highly paying corporate sector job. I have listed these factors in relation to the different levels of Maslow’s hierarchy of needs.
1—Pay scale: Corporate sector often pays more than the government sector. However, this is mainly at higher levels of employment, such as consultants. The pay level of residents in corporate hospitals is often less than that in government hospitals. Pay level relates to level one (physiological needs) of Maslow.
2—Job security and welfare: Corporate jobs carry no job security. Government jobs are quite secure because the government has to act as a model employer. It can’t act to the detriment of the interests of the employees. Even after retirement or death during service, there are benefits like pension, family pension etc. If a person develops serious disease or meets serious accident, he would be out of corporate employment but would not ordinarily be shunted out of government service. This aspect relates to level two (Safety needs) of Maslow.
3--. Professional recognition—Recognition for professional excellence in India, whether in teaching, research or patient care, as measured by the yardstick of research publications and national and international awards, mostly comes to doctors in the government sector. This is a significant factor why doctors often choose not to opt for the corporate sector. This aspect relates to level four (Needs for Esteem) of Maslow.
4. Public esteem—Public perception of doctors in corporate sector is that they are more commercial in their approach, catering to the rich, while those in government sector are viewed as more interested in giving services to the poor and ordinary people. From a very different perspective, even the courts place more reliance on the opinion of a government doctor / institution than that of a corporate sector doctor. As per the Supreme Court and the Medical Council of India guidelines, the opinion of a government doctor / institution is essential before the police converts a criminal complaint against a doctor for medical negligence into an FIR [first information report]. Similarly, the consumer ‘courts’ often refer a complaint of alleged medical negligence to a government hospitals or the medical council for opinion rather than to a private or corporate hospital. The esteem attached to the reliability and impartiality of a government hospital naturally attaches to the doctors of these institutions also. This public esteem obviously pertains level four (Needs for Esteem) of Maslow.
5-- Independence: Doctors, in general, feel professionally more independent in a government set up. They can advise treatment to patients as they deem fit as per scientific practice of medicine. Doctors in private sector have to be guided by corporate / commercial considerations. A very senior cardiologist in a big corporate hospital once told me that the corporate management forces consultants to advise and carry out unnecessary angiographies and cardiac bye-pass surgeries so as to add to hospital income. The fate of those consultants who do not comply can be well imagined. Professional independence relates partly to level two (Safety needs) and partly to level five (Needs for Self-Actualization) of Maslow.
6-- Serving the poor: Doctors have, by and large, a desire to help the suffering. Doctors working in crowded general hospitals may have to work overtime for low salaries compared to doctors in corporate hospitals, but they derive an inner satisfaction when they are able to save poor patients and earn their gratitude. This certainly fulfills a bit of level five (Needs for Self-Actualization) of Maslow.
7—Adding to scientific knowledge—Only those working in the government sector in India, such as the well known medical institutes / colleges and the ICMR research centres, have an opportunity to work in the cutting edge areas of medical science and thereby add to the scientific base of knowledge for the whole mankind. This aspect relates to level five (Needs for Self-Actualization) of Maslow.
8—Fulfillment derived from teaching—Medical teachers derive a definite sense of fulfillment from teaching medical students. It gives them a sense of achievement when they feel that they are a source of guidance for new generations of medical professionals and often act as role models for them. In addition, the constant touch with the young generation helps them, too, to feel young. The fulfillment from teaching is available largely to only those doctors working in the government sector. It is true that there are quite a few private medical colleges in India now, but the fact remains that their standards are often lower than those of the government medical colleges. The fulfillment from teaching is relatable to level five (Needs for Self-Actualization) of Maslow.
The above analysis clearly shows that the fact that many doctors prefer to continue in government jobs in India is not inexplicable but can be rather easily explained in terms of fulfillment of their needs and aspirations in terms of Maslow’s hierarchy of needs. It is a fact that the basic or level one needs of most doctors are by and large met in case of doctors in government service. They are mostly class one government officers with salary comparable to non-medical officers and often get non-practicing allowance in addition to their salary. The higher needs at all the remaining levels have higher possibility of fulfillment in the government sector rather than in the corporate sector. Even regarding level three [Need for belonging], such need is better fulfilled in case of government sector doctors through the various doctors’ associations, such as Railway Doctor’s Association, CHS Doctots’ Association, SC/ST CHS Doctots’ Association etc., while there is hardly any similar counterpart in the corporate sector. It is significant to note in the above analysis that of the above mentioned 8 factors, all the four factors associated with the highest level of needs, namely, the needs for Self-Actualization, are the ones that are associated with the government or public sector alone and are missing in the private or corporate sector.
3----A.H. Maslow (1943). A Theory of Human Motivation, Psychological Review 50:370-96.
M C Gupta
8 January 2009