Should Specialist Rural Posting be made Mandatory in India?

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Bonding doctors to serve necessarily in the rural areas has been a debatable topic since long. A recent decision from the Supreme Court of India to formulate a policy for compulsory rural postings for specialist doctors is adding voices to the ongoing debates. Does this verdict consider all perspectives, or do we have the equipped infrastructure in the rural backward regions for specialists, or should specialist rural posting be made necessary in India, Bhanu Pratap Yadav explores these questions.

The Problem

Indian healthcare system faces a giant challenge to serve the rural, deprived section of the society. There is a severe scarcity of doctors. Many new medical colleges are coming up to equate the doctor-population ratio in India with the WHO standards of 1:1000. As per Ministry of Health, Government of India (information provided by the MCI), doctor population ratio of 0.77:1000 (after considering attrition) as per current population estimate of 1.33 billion. Per NITI Aayog, India is expected to meet the WHO norm doctor-patient ratio by 2024. But still, India has a whopping shortage of specialists. In some states and Union Territories, there is not even a single specialist practising in the public healthcare sector. Dr V K Paul, Member NITI Aayog, admitted that attaining the required number of specialist doctors is five times more difficult an agenda.

The pain of the shortage of doctors gets intensified with an unequal distribution with the majority working in urban areas. The government is looking for multiple ways to make healthcare delivery possible where it is needed most, which is rural India. In a pursuit to provide last-mile care, the Supreme Court, on August 2019, has directed the central government to frame a policy of compulsory rural tenure that will apply to postgraduate medical students pursuing their speciality level medical studies in government medical colleges. In case the students fail to fulfil the conditions outlined in the bond, they will be required to pay a set penalty for the same, as defined in the bond. “The objective of the policy is to ensure that specialist health care is extended to the have-nots also,” it added.

Citing the decision in the larger public interest, the court said that the government invests a lot in medical college infrastructure, and providing a quality education at a reasonable fee in comparison to the private medical institutions. Having said that, this is the right of the government to expect doctors to serve in rural areas to boost healthcare services and provide quality healthcare to the underserved people.

Dr Rishabh Joshi, MS at AIIMS, Bhopal, welcomes this decision. He believes the step will improve access to the specialist treatment at the grass-root level. But proper infrastructure, support system and competitive financial incentives should be provided to prevent the policy failure. An NHSRC study (2016) across 5 States suggests that inadequate infrastructure is the second most barrier (36%) for doctors to rural services. Specialists skills cannot be effectively used in a low-resource setting with poor infrastructure.

A specialist doctor passionate to tender his services at the primary level finds his hands tied because of the unavailability of required facilities. Imagine a nephrologist or neurologist posted in a rural part is doing nothing but prescribing medicines like general practitioners. Especially the fresh doctors should get exposed to the most cases helping to sharpen their skills. “Mere posting specialists doesn’t solve the problem, the facilities provided should be focused too. A surgeon without proper instruments or an operation theatre is nothing but a waste. Same applies to the other specialities,” (sic) says Dr Rishabh.

Social factors also cause the attrition of specialists from rural areas. Unavailability of quality educational institutions, poor transport links, threats from the miscreant community members are among the reasons, doctors are unwilling to serve in rural regions. To make the solution sustainable, a holistic approach for development is much needed.

As of yet, a few States have this compulsory bond policy. However, it is different everywhere ranging from service bond of 2-5 years or penalty goes up to crores. Health is a States’ affair and they should be independent to decide what’s best for their public. Having the advantage of decentralized policy making, probability of exploiting doctors by putting vague and unjustified conditions of serving period and penalty in the bond is high.

On the other hand, the formulation of a uniform policy for States varying drastically in terms of HR, geography and health status would not be a sweet task either. The acceptance and feasibility of uniform policy would still be in the dark. Justified reasonable bond conditions are a must for the policy. “It is good to have a uniform policy across the nation otherwise some states use this compulsory service as a torture tool. They put irrational terms and conditions in the bond-like serve 10 years or pay a crore in case you fail to do so,” opines Dr Rishabh.

The Sri Lankan Wisdom

Rural posting of doctors has been a success in a few Asian nations including Sri Lanka. Surprisingly, the retention rate is better without even a mandatory policy in place. Sri Lankan doctors, post-internship, are allowed to choose the place of posting but the decision lies with the government which follows a merit-based order. They have a 4-year rotation plan for doctors but one can apply for transfer after 2-year service at a station. However, if one had served for a year in a difficult region then they can apply for a transfer after one year. This has resulted in less attrition of the doctors. Also, doctors are allowed to do private practice which is a huge incentive for doctors to stay in difficult areas. And doctors serving at tough regions get preference for training, conferences and workshops, and some additional tax benefits too. Apart from this, the government allocates more funds to the primary level hospitals to improve the infrastructure, reorienting the curriculum and making it more community and public health oriented.

Sri Lanka never compromised on the medical services for its citizens. Even in the times of one of the greatest civil war against the LTTE, the government never let the medical services suffer. The commitment to the public service was commendable, and it still exists in their system. It is indeed a small nation but has a good infrastructure, road connectivity, and facilities for the doctors like provision of necessities (quarters, electricity, and drinking water). Rather than incentivizing the doctors monetarily, they acknowledge and value the public servants, and treat them as an asset to the nation. They even have a stringent law against the miscreants of society who misbehaves/mistreats doctor on duty.

The Road Ahead

It is the need of the hour to learn from such great models across and formulate one for India to make healthcare accessible for all. There must be a practical, considerate, justified, coherent, comprehensive policy in place. Doctors are rapidly moving towards the private sector, and a strong and lucrative policy is required to make them stay in the public healthcare sector. Undoubtedly a policy is needed in a place, but would that solve the core issue. What about the political will to foresee the bigger picture, the infrastructure at the primary health facilities, the facilities and social institutions doctors need, the commitment levels to serve the rural population, and the recognition which doctors must get. Nevertheless, it's a great move from the apex court to get started, although we still have a lot to figure out.

Vivek desai