Understanding of individual rationality and institutional constraints: the case of deficiency of doctors in rural Bangladesh

Abstract

Background Bangladesh is suffering from lack of adequate doctors, especially in the rural areas. Most of the posts for the doctors of the rural health facilities are vacant. Moreover, the absence rate of doctors is very high in the peripheral health centres. On the other hand, urban centres are overcrowded with doctors in the hospitals and their own private clinics. Many previous studies tried to identify the factors behind the dichotomous reality of the placement of doctors in rural and urban areas, but few of them explain the puzzle theoretically in Bangladeshi context. Therefore, this paper offers a literature review on the shortage of doctors in rural areas from the theoretical point of view. This study focuses on how individual rationality and institutional constraints are reflected in the studied literature. Methods This paper is a literature review on placement of doctors in rural areas. Both the literature related to rural placement of doctors in Bangladesh and in other countries was reviewed. We conducted a systematic databases search to find the literature concerning the supply of doctors to non-urban areas. Then we searched for literature about the economic theories of rational behaviour and institutional constraints. We used Braun and Clarke’s thematic analysis approach to analyse the data. Sources included journal articles, government reports, the internet, books etc. Results It was found that weakness in institutional constraints and/or lack of institutional support leads to shortage of doctors and higher absenteeism in rural areas. Moreover, lack of monitoring of the authority creates opportunities for doctors to behave rationally for utility maximization, in this case by avoiding appointment to rural health facilities or, if appointed, by being absent. Conclusion Doctors in Bangladesh do not want to serve in rural areas and avoid appointment there, or remain absent often, mostly because of institutional weakness. For the doctors, non-appointment or absence is rational, utility-maximising behaviour, given their preference maps. Therefore, there is a clear relationship between the two concepts: institutional weakness and rational behaviour of doctors: that is, as the institutional constraints become more weak, individual rational conduct of the doctors, contrary to the interest of the institution, becomes more common.