Improving doctor retention in rural areas

RECENTLY, Maharashtra stipulated that MBBS students taking admission in government medical colleges or on government reservation seats in private colleges can no longer skip their one-year compulsory rural service bond. Hitherto, MBBS passouts could choose to pay Rs 10 lakh in return for being exempted from rural service. The measure is clearly intended to enforce this longstanding but hitherto poorly evaluated regulatory instrument, whose spirit is nonetheless commendable.

But what is intriguing is that it follows on the heels of the Rural Health Statistics 2020-21, which show that there is a surplus of doctors in rural Primary Health Centres (PHC) in Maharashtra. Such contradictions open a Pandora’s box of contemporary issues that merit examination, particularly in view of the long-established nature of India’s rural-urban healthcare workforce dichotomy which till date has received only a knee-jerk reaction.

Firstly, it is important to draw a distinction between rural recruitment and retention. Despite an apparent surplus of doctors in rural PHCs in many states, widespread absenteeism from duty and high attrition are well-known issues afflicting rural healthcare. While the current regulatory instruments like compulsory service are targeted at increasing rural recruitment, they offer no hedge against high staff attrition. Staff retention has a cascading and reinforcing effect on organisational learning that helps bolster organisational performance and the many fallouts of high staff attrition easily cost a bomb to the healthcare system every year.

Secondly, rural workforce requirements and shortages must be examined from a holistic, sector-wide perspective which embraces both private and public sectors and is benchmarked against global population-level norms rather than just those presented by the existing rural infrastructure.

Significantly improving rural retention, however, will entail a departure from our current ‘reactive and coercive’ approach and embracing the multi-factorial nature of the rural retention challenge. Much work has been done in this area in the past couple of decades, including the World Health Organisation’s 2010 evidence-based framework which lays down four broad categories of intervention: educational, regulatory, financial, personal and professional support.

Lessons can be drawn from Chhattisgarh and the creation of the Chhattisgarh Rural Medical Corps (CRMC) in 2009. Under the CRMC, the state instituted a set of multi-faceted, sequential and complementary measures to improve rural doctor recruitment and retention. They include a 10-20 per cent higher pay, bonus marks for post-graduation, increasing the bond breakage penalty, providing better residential and transportation facilities and improving rural health infrastructure and organisational policies. This helped to significantly bring down vacancies from 90 per cent to 45 per cent, according to a 2014 evaluation.

Focusing merely on coercive regulatory instruments without attending to other ‘attractors’ of rural service, such as financial incentives and better practice conditions, are not only destined to be inefficient but can also backfire. An example is the frequent delay in the payment of salaries to rural compulsory recruits in states such as Karnataka in the recent past.

Another area of stark inadequacy is the under-emphasis on formative educational interventions to aid rural doctor retention. Two Asian nations, Myanmar and Thailand, can provide useful insights here. Myanmar embarked on a drive to expand and decentralise its nursing training infrastructure outside of its two major urban centres — Mandalay and Yangon. It also focused on preferential local recruitment of nursing students to facilitate local posting subsequent to the completion of studies.

In 1994, Thailand rolled out the Collaborative Project to Increase Production of Rural Doctors (CPIRD) as an alternative and parallel route to locally recruit, train and professionally place doctors in rural areas. Under the CPIRD, students recruited locally undergo clinical training in rural-located medical education centres and serve in rural hospitals for three years. Apart from addressing rural doctor shortages, CPIRD graduates have also been found to be on a par with regular trained doctors in academic performance, as per a WHO report. In addition, a number of other incentives, such as hardship allowances, helped reduce the physician density disparity between Bangkok and rural North-East regions from 21-fold to five-fold between 1975 and 2009.

While directly transposing such policies to the Indian context is not recommended, it is important to understand the significance of rural recruitment and training of medical students. Global experience suggests that while the effectiveness of inducement payments alone is largely equivocal, selecting students with rural backgrounds and training them locally can have a salutary effect on rural workforce retention.

Recent years in India have seen a lively discourse on medical curricular reforms. However, policies to enhance rural emphasis of medical training remain ritualistic. Addressing this will take an array of interventions, such as establishing more rural medical colleges, dedicating a greater portion of clinical training to grassroots-level health centres, curricular and entrance-criteria modifications, and reserving seats for students from rural backgrounds.

The time is ripe to recognise that falling back on compulsory rural service stints alone would be like blundering around in the darkness of ignorance. And the multifaceted nature of the challenge entails that multiple sectors and departments have to come together to tackle it effectively.

Also, the pervasive character of the rural-urban disparity across Indian states, notwithstanding significant regional differences in physician density, merits that a coherent and overarching national policy on rural retention be conceived.

While health is predominantly a state subject, medical education and the medical profession come under the Concurrent List of the Constitution (Items 25, 26), allowing room for Central intervention. Framing appropriate retention policies would require a sound situational analysis of the country’s contextual peculiarities, backed by bottom-up data. Much work is pending in this area, and the recent emphasis on collating a nationwide registry of health professionals is welcome.

The overarching national document should define the priorities and lay down the policy, planning and evaluation framework, allowing states and the local administration enough autonomy to design and adopt locally appropriate interventions.