Service bonds in rural health care in India - Challenges and the way forward

Rural healthcare service in India- challenges and the way forward

The healthcare system in India, like other Low-Middle Income Countries (LMICs) face the challenge of providing equitable and quality health services to its population. The figures from rural and tribal areas of the nation show considerable improvement in the infrastructure and manpower over past 15 years. However, there is still a huge shortage of doctors and other staff at primary health care centres (PHCs). The data from community health centres (CHCs) reveal even a bigger mismatch with a shortfall of 79.9% specialists as compared to the requirement. Also, 68% of the sanctioned posts of specialists at CHCs are vacant.¹

While many state governments have adopted several short-term and long-term measures to deal with this issue there is a huge non-uniformity among the states. Several states in India have implemented regulations seeking medical graduates, post-graduates and super-specialists enrolling in all the public and private (50% of total seats) institutions to serve state for duration ranging from 1 year to 10 years² after these courses, so as to ensure the availability of doctors in the resource-limited settings.³ Though the National Medical Commission recommends uniform rural service bond for the medical undergraduate, there is no uniformity in bond duration after completion of medical postgraduation.²

The regulations are not uniform and the doctors from the states serving under bond feel disadvantaged, as students prefer studying in states with no bonds. Besides, evidence from states like Gujarat show that introduction of rural bond hasn't made much of an improvement to the quality of healthcare services, with more than 90% of medical students paying the bonds and leaving them for higher education.⁴

Some states have even made the decision to completely halt the bailout of rural bonds in order to fully implement the plan. But it is critical to realise that pushing medical students and placing financial restrictions on them cannot guarantee high-quality, continuous rural service. Although the workforce issue is one that both the federal government and the state governments desperately try to draw attention to, little has been done to change how community centres are currently run. According to a preliminary study conducted in Odisha, sufficient housing, higher wages, and workplace amenities could boost student retention, the fulfilment of rural relationships, and their willingness to continue serving.⁵ The reservation of post-graduation seats for in-service rural doctors have also proved to be an efficient incentive to increase deployment. To improve the healthcare services in developing countries, WHO had laid down several recommendations in 2010⁶; however, the challenges have not changed over past decade. There is need to check the successful implementation of global policy recommendations. Making the bond duration uniform across the states, will make this policy more acceptable by the young doctors and may enhance their motivation to serve in rural areas. Similarly, the policy should also cover the medical graduates and post-graduates pursuing their medical course from central institutes as well as private medical institutions. Awareness about this rural service bond policy will help the medical aspirants and young doctors to keep a balance between their aspirations and societal expectations.

Table 1 summarizes the remedial strategies that can potentially help address the issue of shortage of graduate and specialist doctors at rural health centres.

Table 1.

Multidimensional strategies needed to improve rural healthcare.

	Sectors for improvement	Improvement strategies
1.	Infrastructure
	a. Better accessibility	The connectivity of PHCs and CHCs through all season road transport needs to be ensured.
	b. Improvement of medical infrastructure	Ensure adequate infrastructure at health centres, availability of medical equipment and supply of essential drugs (As per Rural Health Statistics [RHS] 2020, 4.3% PHCs are without electricity, 6.9% do not have water supply and 7.8% are without all-weather motorable road).
	c. Better housing and environment	Ensuring uninterrupted electrical power supply and backups continuously for emergency services and at least during outpatient working hours for outpatient services. Provision for clean water supply, proper biomedical waste management and drainage system.
	d. Safety and adequate support	Safety related concerns of healthcare staff serving at rural centres should be addressed in coordination with local law enforcement agencies so that they can work stress free.
2.	Uniform bond requirements	National Medical Commission (NMC) needs to mandate a uniform standardised bond structure as different structures and costs add on to the student's financial burden.
3.	Incentives	Provision of graded incentives based on the locality and terrains (more for difficult terrains and tribal localities) to attract doctors. It can be in the form of money and/or quotas in promotion, higher education and permanent jobs in the respective states/regions.
4.	Postgraduate training opportunities	The delayed postgraduate training hinders the growth of graduates as they can't compete with fresh graduates during post-graduation. There should be adequate support and study leave implementation early (rather than after five years) with legal binding for short-term service like in defence recruitment.
5.	Immediate and/ or permanent recruitment	Most of the recruitment in rural settings occurs for a shorter period. Immediate recruitment in government settings needs to be ensured along with permanent recruitment of people opting for it.
6.	Increased digital connectivity	All the centres in the country should move towards digitisation via a simple application. The digital connectivity of all primary health care centres and community health centres through a one stop mobile application would ensure greater transparency, efficient data storage and complaint redressal by responsible authorities. (65% of PHCs have a single computer as per RHS 2021).
7.	Long term curriculum changes
	a. Promotion of rural training	There can be sensitisation workshops organised by recent in-service graduates to motivate their juniors regarding the benefits of rural training.
	b. Institutional sensitisation	The public and private institutions need to have a system in place under which the undergraduates can observe and learn the functioning of rural health centres under direct or indirect supervision of their teachers/mentors/seniors. This can be in the form of rural health centre posting for a certain duration during community medicine postings to sensitise and motivate the graduates.
	c. Increase in number of reserved postgraduate clinical seats.	The number of allotted reserved clinical seats for in-service candidates (especially in medical specialities) needs to be increased to fulfil current lacunae. The number of postgraduate vacancies remaining unfilled in non-clinical branches needs to be balanced with the limited number of clinical seats.
	d. General practice or family medicine postgraduate training	Experts have suggested the inclusion of a two-year diploma or three-year degree course for family medicine or general practitioner training like in the USA and the UK. The need of family medicine in most CHC and UCHC is still considered desirable at present while they need to be turned to essential.
8.	Increasing awareness among villagers and tribals	In rural and tribal areas, word of mouth promotion, free health check-up camps could ensure that people visit centres regularly instead of opting for quacks.

Contributors

Conceptualization- SC, AS, SKK. Data acquisition and writing-original draft- SC, Writing-final review, Validation and Supervision- AS, SKK.

Declaration of interests

The study authors do not have any relevant financial disclosures.