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A critical review of the utilization of residential accommodations

in public sector health facilities in District Swabi

Mohammad Khalid, PHSA Peshawar.

ABSTRACT: Background: A major portion of the developmental budget is being spent
on the construction of residential accommodations for health staff in public sector health
facilities by the government but most of these accommodations are not utilized by the
designated health staff in rural areas. Unfortunately one can hardly find a study in
literature which has addressed this issue in detail. Methods: An effort was made to look
into the problem through a cross sectional study conducted in public sector health
facilities in district Swabi. The aim of the study was to review in detail various aspects of
the accommodation problem affecting both public and the health employees. All
available residential accommodations in public sector health facilities were included in
the study. Results: The study found that there is a low (20 to 30 %) utilization rate of
residential accommodations in rural areas both by doctors and paramedics as compared to
the urban areas where the rate was much higher (92-94%). The main causes of non
utilization of residential accommodations were posting near the family residence, strong
nuclear family system in the district and poor living conditions in rural areas. Poor
physical structure of the accommodation’s buildings, non functional electricity and water
supply and poor security in rural areas were additional findings. Deduction equal to 20-
25% of the basic pay from the designated staff for these accommodations was a major
disincentive to the health staff in rural areas. Almost 85 % of the accommodations were
never repaired since their construction by the government and most were not suitable for
living. Recommendations: The main recommendations were improvement of the living
conditions, offering incentives to staff for staying in the rural health facilities, provision
of free accommodations in hard areas and the appointment of separate accommodation
coordinators in EDO health and DGHS offices for managing accommodation-related
issues.
Keywords: Residential accommodations, Public sector health facilities, Reasons for non
occupancy of accommodations.
Introduction: Federal and provincial Governments are spending millions of rupees on
the construction of public sector health facilities and residential accommodations for staff
and doctors in these facilities.
While in the cities these accommodations are hardly being found vacant, most of these
are not used by the designated staff in rural areas. What are the reasons and impacts of
the non-utilization of these accommodations have never being investigated.
There are several aspects of this issue. The public health aspect is the most important one.
Most of the population in rural area is not getting community based, 24 hours health care
coverage from public sector health care facilities and in rural areas the provision of
accommodations to health care providers seems to be wastage of the taxpayer’s money.
Another aspect of the problem is the imposed cutting from the salaries of the designated
employees who have no choice but to pay for the residence whether they occupy the
accommodations or not. Even repair cost (also called house rent) equal to 5% of the basic
pay is deducted from the salaries of the doctors.
The government share of the problem is the lack of maintenance and repair of these
accommodations, resulting in almost total destruction of rural health infrastructure.
Another unfortunate aspect of the problem is that researchers hardly address rural health
problems. In primary care medicine this is commonly referred to as the “10/90 gap”
which means that only 10 % of the research in the world is directed at the 90 % of the
health problems that are present in the primary health care sector. (1)
So to address the problem in its entirety this study was designed to find the major aspects
of the problem.
Material and Methods:
This was a Cross sectional study, conducted during the months of March and April in the
year 2007.The study included all residential accommodations in public sector health
facilities in district Swabi, NWFP. There are a total of 48 health facilities, including
BHUs, RHCs, CH, DHQ and completed Shah Mansoor hospital complex in Swabi. The
total number of residential accommodations in these facilities was approximately 252.
The sampling method used was Census. District Swabi has a total of 60 health facilities.
The detail is as under:
1. District Head Quarter Hospital 1
2. Shah Mansoor Hospital Complex (Almost complete) 1
3. Civil Hospitals 3
4. Rural Health Centers 2
5. Civil Dispensaries 8
6. Mother Child Health Centers 3
7. Basic Health Units 42
Total: 60
The 3 Mother Child Health Centers and 8 Civil Dispensaries did not have residential
accommodations for the staff so they were excluded from the study. All the rest of 49
health facilities were included in the study. A questionnaire was made in consultation
with the supervisor and teachers of PHSA and was filled during visits to the concerned
facilities.
Prior permission was obtained from the EDO Health Swabi for the survey and interviews
of the staff as well as for looking into the records of the Accounts section in connection
with House rent and 5% maintenance and repair cuttings from the salaries of the
concerned staff. The field survey and facilities visits started from 15th March, 2007 and
were completed on 1st April, 2007. During field survey data regarding all aspects of the
residential accommodation like location, occupancy, serviceability and reasons for non-
occupancy was recorded, using the questionnaire. The researcher himself physically
verified the building condition, water supply, electricity and security status of each
residence.
Record of deductions from the salaries of the designated employees, both house
allowance and house rent (5% maintenance and repair) were collected from EDO (H) and
DAO Offices. Similarly data regarding the repair and maintenance of the
accommodations, since their construction, was also collected from the staff and from the
EDO health and / or Services and Works department Swabi. Cost estimates of
construction of a bungalow and a 2-room quarter was also obtained from the services and
works department. Epi Info version 3.2.2 was used to analyze the data.
Results: The total numbers of residential accommodations were 252 in all these 48
health facilities. Out of 252, 71 were bungalows and 181 were two rooms’ quarters.
According to Services and Works department 233 were serviceable and 19 were
unserviceable. Although the overall accommodation occupancy rate was 50 % for all
facilities, the BHU accommodation occupancy was 34 % which is much lower than the
92 % accommodation occupancy rate in the Hospital setup (DHQ, CH, and RHC).
Similarly there were only 5 unoccupied accommodations in hospital setup as compared to
101 unoccupied accommodations in the BHU.

FIGURE: 1 OCCUPANCY IN BASIC HEALTH UNIT

Occupied
52, (34% )

Unoccupied
101, (66% )

FIGURE:2 OCCUPANCY IN HOSPITAL SETUP

Occupied
55, (92%)

Unoccupied
5, (8%)

There were a total of 72 Category III Bungalows in the district for doctors. 12 posts of
medical officers were vacant. 60 doctors were posted and among them only 30 (50 %)
were living in the remaining 60 bungalows. In BHU setup 42 bungalows were available
but 8 posts of doctors were vacant. In the rest of 34 bungalows only 7 (20.5 %) doctors
were living with families. In hospital setup (RHC, CH and DHQ) 29 bungalows were
available for doctors and 3 posts of doctors were vacant. Out of the rest of 26 bungalows
23 (88.5 %) were occupied.
There were a total of 180 Quarters for the paramedical and supporting staff .77 (50 %) of
the designated 153 Quarters were occupied while 27 were vacant due to the non-
availability of the designated person. In BHU 45 (38 %) out of 119 Quarters were
occupied. In hospital setup 32 (94 %) out of 34 Quarters were occupied.
Table No: 1 - OCCUPANCY OF ACCOMMODATIONS IN BHUs
LIVING IN NOT LIVING IN TOTAL DESIGNATED
CADRE
FACILITY FACILITY ACCOMMODATIONS
Medical 10 32 42
Technicians (24 %) (76 %) (100 %)
14 28 42
LHV
33 % 67 % 100.0 %
24 14 38
Chawkidar
63 % 37 % 100.0 %

Although there were a total of 232 serviceable accommodations in the district but only
213 were designated to staff. The rest were not allotted to anyone due to the designated
post being vacant.
The reasons given by the health care providers for non-occupancy of accommodations
were grouped in 13 categories. Most common reason was that own accommodation was
available near the place of duty. The rest are being given below in a graphical form.

FIGURE: 3 REASONS FOR NON OCCUPANCY OF
ACCOMMODATIONS I
60

50
(21) 12 % Building
(57) 37 % Own

(10) 6.5 % Personal
(15) 10 % No water
residence

(15) 10 % Security

(11) 7 % On duty

40
(9) 6 % Unmarried
(13) 9 % No

(4) 2.5 % Spouse
elsewhere

(8) 5 % Private
electricity

30
reasons

Postgraduation
(5) 3 % Kids
practice

elsewhere
education

(2) 1 % Poor

20
sociality
(3) 2 %

10

0
In this study 4 aspects of the accommodations were checked by the researcher. The
results are given below in tables 2-5.
Table No: 2 – Physical Condition (Buildings) of Residences
BUILDING Frequency Percent
REASONABLE 93 37%
POOR CONDITION 159 63%
Total 252 100.0%

Table No: 3 – Electricity of Residences
ELECTRICITY STATUS Frequency Percent
PRESENT / FUNCTIONAL 179 71.0%
NOT PRESENT / POOR WIRING 73 29.0%
Total 252 100.0%

Table No: 4 – Water Supply of Residences
WATER SUPPLY STATUS Frequency Percent
FUNCTIONAL 162 64%
NON FUNCTIONAL 90 36%
Total 252 100.0%

Table No: 5 – Security of Residences
SECURITY Frequency Percent
GOOD 163 65%
POOR 89 35%
Total 252 100.0%

Almost 85 % of the accommodations have never been repaired in the last 10 years or
since their construction. Work for minor repair is in progress in about 8 %
accommodations and only 7 % of accommodations were repaired in the last 5 to 10 years.
Table No: 6 – MAINTENANCE AND REPAIR OF RESIDENCES

Maintenance And Repair Frequency Percent
Less Than 5 Years 14 5.6%
More Than 5 Years 4 1.6%
Never Done 214 84.9%
This Year 20 7.9%
Total 252 100.0%

According to the rules the person who is allotted a government accommodation is not
entitled to get House Allowance (HA). This allowance is deducted at source. A total of
Rs 245166 per month, house allowance is deducted from salaries of all 213 employees
who are being allotted the accommodations. The doctors who reside in bungalows also
pay 5 % of the running basic pay to government. This is called house rent (HR) and is
supposed to be spent on maintenance of the residences. The maintenance and repair
allowance, called house rent is not deducted from those who are allotted two-room
quarters. Monthly deductions of this allowance from all the designated doctors are Rs
33501 per month.
Discussion: Poor availability of doctors in rural areas is a common phenomenon in
Pakistan. Majority of those who are posted in rural areas do not live in the facility
accommodations. The causes are many and thus the problem is not a simple one.
Many studies in Pakistan by government departments and researchers have revealed that
doctors are reluctant to go to the rural areas commonly known as the periphery. (9, 14)
The important causes are poor working conditions, poor accommodation facilities and no
special incentives.
The study, which covered all the accommodations in all health facilities in the district,
revealed some interesting findings. There were a total of 252 residential accommodations
in the whole district. Of the 252, 181 were two rooms’ quarters for paramedical and
supporting staff and 71 were category III bungalows for doctors. Majority (67 %) of the
accommodations were located in purely rural areas and the rest 31 % were in urban areas.
The overall accommodation occupancy rate was 50 % by all health care providers. The
occupancy in urban areas was much higher (92 %) as compared to rural areas (34 %).
Only 20 % doctors were living in the rural areas (BHUs) as compared to urban areas
where 88 % doctors were using their official accommodations. A survey by ministry of
health in collaboration with WHO has reported the overall accommodation occupancy
rate of 41 % and an occupancy rate of 18.5 % among doctors working in BHUs (14).
These results are approximately similar and the difference may be due to the method of
sampling as all accommodations were included in this study.
Although the overall accommodation occupancy among paramedics and supporting staff
was the same as doctors (50 %) only 38 % of the paramedical staff was residing in the
BHUs. Among them 33 % Lady Health Visitors and 24 % Medical Technicians were
residing in the BHUs. Even 37 % Chawkidars who are supposed to take care of the
government property and assets were not living in the facilities. In urban areas 94 % of
the paramedical and other supporting staff was residing in their accommodations. 19 (8
%) of the accommodations were not used due to non-availability of the designated staff in
the district.
All those health care providers who were not living in the facilities (106, 50 %) were
asked the reasons for non-occupancy. For some the answer was simple but some give
multiple reasons for not living in the facilities.
Out of 106 respondents, majority (37 %) gave the reason that they were posted near to
their own family accommodations and that due to the joint family system they were not
allowed by their families to live in the facility. This group said that they will not shift to
their official residences, whatever incentives were offered to them .This may be due to
the strong rural socio-cultural values and strong nuclear family system in Swabi.
Although 159 (63 %) residences were in a bad shape only 12 % considered it a reason for
not living in the facilities. Similarly only 10 % each considered poor security
(accommodations near grave yards or away from main population) and non-availability
of water as the reasons for not staying in the facility. Non-availability of electricity was
the reason in 9 % of the cases.
Of the 106 non-occupants 7 % HCPs, mostly doctors were unfortunate because they were
allotted accommodations in one facility from where they were drawing their salaries and
were asked officially to work in another facility. The people served by these facilities are
also disadvantaged by the fact that the posts are filled and so no other doctor can be
posted in these facilities to serve them, an example of poor management.
Out of 106 respondents 7 % doctors stated that they had some personal reasons for not
living in the facilities while 6 %, mostly females were not living in the facilities because
they were unmarried and were not allowed by their families to live alone in the facilities.
This also reflects a strong influence of the family on the female health workers. The
families of female health workers often try to post them near to their family
accommodations, using the maximum possible political and other pressures on the
administration.
Five percent were of the opinion that private practice was not good in their places of duty
and 3 % each mentioned their spouse jobs or kids education as their reasons for not living
in the facilities. Only one percent of the 106 considered poor sociality as the reason for
not residing in the facilities. The reason for this was that most belonged to the same
district and same social background.
Several studies have been done in Pakistan and abroad to find reasons for unwillingness
to work in the rural areas. Most of them however were done to study the unwillingness or
incentives packages for working in rural areas and most of the respondents were doctors.
Studies focusing mainly on accommodations in public health facilities are hard to find
and the current study is probably the first of its kind in this respect.
A study titled “Doctors perception about staying in or Leaving Rural Health Facilities in
Abbotabad“done in 2000 has given different reasons for unwillingness to serve in rural
areas. In this study the doctors considered lack of clinical growth, no clinical experience
and delay in post graduation as the reasons for not working in the rural areas. Poor living
conditions, kids’ education, private practice and spouse jobs were less frequent reasons.
(14)
In the performance evaluation of the RYK project in Punjab it was revealed that doctors
are not only living in the facilities but are satisfied and happy with working conditions in
the project area. The reason is simply the fact that they were given good
accommodations, higher salaries and other financial incentives and this made the model a
success story despite the fact that they were not allowed to practice privately. (18)
Another study in South Africa has shown that doctors considered better accommodation
and financial incentives as the top reasons for staying in the rural areas. (50) Similar
studied in other countries have also considered poor accommodations, lack of incentives
and non payment of house allowance as the main reasons for not working in the rural
areas. (45, 49)
In this study 4 aspects of the official residences were also checked from a non-technical,
common man’s perspective.
The physical examination of the buildings revealed that most were in a very bad shape.
About 159 accommodations were not worth living still the government services and
works department had declared only 19 residences as unfit for living. The rest were
allotted and the designated persons were being charged. This is a disincentive rather than
an incentive for the rural doctors. Buildings in some BHUs like Shiva, Bahader Abad and
Mian Kali were worth seeing as they were totally irreparable and nothing more than just
walls but the doctors and paramedics in these hard rural areas were still being charged as
these accommodations were serviceable in government papers.
The second aspect of the accommodations, which was checked, was electricity. Almost
73 (29%) either had no electricity connections or the wiring was dangerous and not
functional. In the ministry of health and WHO study 55 % BHUs had electricity while the
study in Abbotabad showed that 33.3 % rural health facilities had electricity. (14) The
former was done some 14 years ago and the later in 2000 and this study is being done in
2007. This might be the reason for the difference as electrification of the villages has
increased significantly in the last few years.
The water supply in health facilities is mostly linked with electricity as no electricity
means no water pump and no piped water supply. A total of 90 (36 %) accommodations
did not have either a piped water supply or the pipes were not functional in the
accommodations. The 1993 government of Pakistan study had shown that 39 % RHCs
and 78 % BHUs did not have water supply. The reason may still be the same as discussed
above. In the study in 2000 in Abbotabad the word “safe water supply” was used with a
percentage availability of 20.6 %.
The security of the accommodations not only includes the location but also a boundary
wall and the presence of a Chawkidar. In total 35 % (89 out of 213) of accommodations
were lacking any one or a combination of the above criteria. Out of the 43 BHUs the post
of Chawkidar was vacant in 5 of the facilities and 16 of the Chawkidars were not living
inside the facilities. More than 5 facilities were situated near the graveyards and 2 were in
the middle of graveyards. One can well imagine the dangers of living with families in
these kinds of situations at the mercy of empty-handed Chawkidars.
The survey showed that 84.9 % accommodations were never repaired, 5.6 % had some
repair in the last 5 years, 1.6 % residences were repaired some 5 to 10 years ago and in
7.9 % work was in progress during the survey period.
This reflects a very poor commitment of the government to the rural health service in the
district. The result is rapid loss of precious public property, poor rural health services and
demoralized health staff working in rural areas.
The financial aspects of these residential accommodations are important both to the tax
payers and the health staff as the current practice of building new accommodations is still
going on and a number of new BHUs are under construction in public sector where the
above practices will be repeated again. The construction of a single new category III
residence cost approximately 1.5 and a single quarter approximately 0.9 Million rupees to
the taxpayers (S&W Department). This is a big junk from the health budget and needs
proper attention.
In this study all deductions from the salaries of staff for the residential accommodations
were obtained from the accounts section of EDO health office. The total deduction of
house allowance was about 245166 rupees per month or 2941992 rupees per year. The
deduction for maintenance and repair was done from the salaries of doctors only and the
other staff was exempted. Total deductions for maintenance and repair were 33501
rupees per moth or 402012 rupees per year.
The major aspect of the deduction was that every person designated an accommodation
was charged whether he lived in the accommodation or not and whether it was worth
living or not.
These are major disincentives and the push factors compelling doctors to go to cities and
foreign countries. Whereas other countries are giving incentives to attract doctors to their
countries (39, 43, 45, 47, 48), we are pushing them out of the rural areas and the country.
Recommendations:
1. The accommodation issues in the districts may be given a special consideration by the
government and the matter may be discussed with all the stack holders and solved in
the best interest of the community, taxpayers, employees and the government.
2. The government should allocate enough budget for the repair and maintenance of the
residences to stop their further disintegration and thus loss of the precious public
assets.
3. To solve the problem of low utilization of residences in public sector health facilities
special salary packages, free accommodation facilities, tax credits, reservation of
seats for post graduation in government institutions (PGMI and PHSA), special seats
for the children of rural doctors in educational institutions and job opportunities and
scholarships in foreign countries should be introduced.
4. Electricity, piped water supply and telephone facilities should be provided in all
residences to lessen the problems of the health employees and their families, working
in rural areas.
5. The practice of essential 2 years periphery service in rural areas should be made an
essential part of medical education to acquaint doctors with the rural health problems
and prepare them for working in rural health facilities.
6. The government should give better grades, service structure and incentives (like the
one given to nurses) to female doctors and female health care providers to attract
them to the rural areas.
7. Deductions from the salaries of all the health staff in rural areas for the use of
accommodations should be stopped and free electricity and telephone facilities should
be given to doctors in the remote and unattractive areas of the province.
8. Doctors who are officially working in places other than their places of duty should be
exempted from deductions of house allowance and house rent.
9. Construction of new facilities should not be on the basis of political pressure and
availability of donated lands but new facilities should be constructed near to
populations and if possible near to the access roads for their maximum utilization by
the community and health staff.
10. A special post of accommodation coordinator should be created under the control of
EDO health to keep a proper record of the residential accommodations, their
occupancy, maintenance and repair, utilization, electricity, water supply,
serviceability etc.
11. The provincial health department should have an accommodation section with a
provincial coordinator, which should have the accommodation database and should
deal all the accommodations problems in the province.
12. More research studies are needed to study incentive packages for doctors, female
health workers and other staff for attracting and keeping them in rural health
facilities.
13. Research is also needed to study the possibility of renting out the unoccupied
accommodations in public health facilities to other government departments like
education for generation of revenue and decreasing financial burden on the health
employees.
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