It was around 10 am when Jyoti, a young labourer, walked into my outpatient department (OPD) in the primary health centre (PHC) of a small village in Maharashtra. She had walked six kilometres and travelled for over an hour to reach the PHC. She was writhing in pain while her mother-in-law was in a hurry to leave. Sonography is, generally, advisable in her condition.
I counselled them to go to a higher centre and offered to provide them with a vehicle. The nearest government centre was about an hour away, but with no sonography facilities, so they would have to travel to the city. There was a private centre nearby but they wouldn’t be able to afford it. I gave her pain medication while arranging for transportation. When I returned, they had gone. For them, the mild relief in the pain was more than they could have asked for. Sadly, Jyoti was one of the lucky few who could at least reach a primary care doctor, albeit with difficulty. In India, there are still millions who can’t.
Doctors are at the crux of any health system. For decades, India has been struggling with a shortage with the latest estimates suggesting that only 0.9 doctors are available per 1000 population, which is less than the WHO recommended minimum of 1/1000. The situation is worse in rural areas which is home to 72% of India’s population but are served by only 40% of India’s doctors.
Bonded government-medical service (the bond) is one of the state-level policies intended to address this maldistribution. Under it, graduates of government-run medical institutes are required to serve the public healthcare system for a stipulated period of time after completing their MBBS degree. This service is packaged as a ‘payback’ to the public for subsidising the students’ education through taxes. One can opt-out of it with heavy monetary payments. At face value, it seems to be a simple design, but has time and again, failed to smoothly fulfil its function. Here, we explore the reasons for the limited success of the bond policy in the second most populous state in India, Maharashtra.
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Flawed policy design
The first available government resolution (GR) on the bond dates back to 1996. Since then, the policy has been amended, relaxed, cancelled, and re-implemented at least ten times. The most recent series of amendments commenced in January 2017, when a GR called for the cancellation of medical licenses of about 4500 doctors in Maharashtra on the grounds that they had failed to adhere to the bond conditions. Anecdotally, notices were also received by doctors who had graduated years before the bond was implemented. This was followed, in October 2017, by a seemingly novel bond policy, which upon closer observation was exactly along the lines of the 1996 and 2006 GRs and had ignored their shortcomings.
Two important peculiarities are noticed across the GRs. First, all crucial GRs (e.g. 1996, 2006, and 2017) have been implemented with retrospective effect, meaning, if an MBBS student signed a bond (as a notarized affidavit) at the time of admission in 2011 which allowed them two attempts at their PG exam, the 2017 GR at the time of their graduation will either void or update the terms of the previously signed document. Such retrospective implementation of the bond was challenged in the court each time on the following grounds: “Authorities cannot change and apply rules retrospectively to detriment of students who have proceeded to take up their career on the basis of rules existing on the date of admission”. The government had to concede in all such instances.
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Second, all bond-related GRs seem to be using negative reinforcement to ensure widespread implementation, the only instance of positive reinforcement being the 2010 GR (incentivising bonded service with additional marks in the PG entrance exam). The repeated implementations, cancellations, and revisions in GRs related to bonded service indicate a lack of situational analysis and foresight on part of the government.
Lack of evidence
The policy of bonded service is neither novel nor limited to India. A literature review in 2009 showed that some form of mandatory medical service has been implemented in more than 70 countries. However, most evidence presented on its efficacy is seen to be anecdotal or descriptive. No controlled study rigorously assesses the impact of the intervention on healthcare availability, or health worker retention in underserved areas. The bond has been intermittently in place for about two decades in Maharashtra, but no formal analysis is available on its efficacy in rectifying the maldistribution of doctors.
We used the publicly available Rural Health Statistics (RHS) state-level annual data to gauge the impact of this policy on doctor availability in underserved (rural) areas. Medical Officers (MOs) under bonded service can be posted at rural (primary, secondary) or urban (tertiary) centres in the government health service. RHS provides data on the rural government sector, i.e., PHCs and Community Health Centres (CHCs).
Using RHS, trends in the numbers of MBBS doctors who are posted as Medical Officers (MOs) were compared with the timeline on the implementation of the bond. No specific data on bonded MOs was available, but any change in their numbers should reflect in the number of total MOs in the rural government sector, within a reasonable margin of error. In the figure below, a counterintuitive drop in MO numbers is seen in 2006-07, corresponding to the 2006 GR. A substantial increase in MOs is seen between 2010-11, corresponding to the 2010 GR and another dip is observed between 2011-13, corresponding with the 2011 GR. No changes in the MO numbers are seen corresponding to the other bond-related GRs.
Poor implementation and execution
These numbers are critical, yet they facilitate only a bird’s eye view of the problem. At the ground level, myriad hurdles obstruct the path of fresh MBBS graduates willing to serve in regions of need. The application process involves hours of waiting at government offices, a trip to the public health department in Mumbai, and a wait-time of about a month, if not longer. The choice of placement is conducted on a first-come-first-served basis with a lack of transparency.
In smaller districts, lobbying plays a vital role in getting a choice placement. At PHCs, a fresh MBBS graduate is expected to function as the head of the unit. They are hardly confident about being good clinicians but are expected to have administrative skills, and an above-average knowledge of the local language (which may not be native to them). The disparate vacancies in supporting cadres, limited facilities, and poor living conditions make it further difficult for a MO to optimally serve their function. Added to this is a fear of taking risks in unchartered or new territories.
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The bond is a well-intended policy. But, in a country where we have the right to education, one can argue over the ethics of mandating students to serve in undesirable conditions in return for educational subsidies. If such service is justified to be for the greater societal good by bringing doctors to rural areas, how does the option of getting out of such a service through heavy monetary payments on part of the defaulters help achieve that goal?
The bond as a policy is widely implemented but not evidence-based. It might be well-intended but comes with undeniable ethical qualms. Overlooking these drawbacks, if we still choose to support it, certain nuances must be worked out. Situational analysis of the available data, and a root cause analysis of previous failures of the bond by the government is crucial. After arriving at an optimised policy version, greater effort needs to be directed towards sound implementation.
If feasible, the entire responsibility of implementation should be re-allocated to a single authority to minimise inefficiencies resulting from interdepartmental politics. Digitising the application process with clear criteria for allocation, presented publicly will ensure centralisation, transparency, impartiality and ease of the process at both ends. Once placed, a bonded MO needs to be trained in the required skill set to function optimally in the new environment.
For a MO to excel at the clinical duties, a separate cadre (BBA/MBA) could be appointed for administrative responsibilities. Mechanisms need to be in place to ensure the availability of adequate infrastructure and support staff. More importantly, doctors at primary centres need to feel safe. This is a complex issue with intricate ties to village politics, but to ensure good healthcare delivery, it must not be ignored.
As of now, to a medical student, the bond may seem like an inconvenient obligation, while to the government it is a promising solution. However, for the solution to truly work, it needs to be redesigned as an incentivised opportunity that is demanded by the students. In the absence of a balance of demand-supply forces, we end up with a system of overworked, incompetent, disgruntled young MOs filling up vacancies, without being able to be good doctors to patients like Jyoti.
Dr Sweta Dubey is a bonded medical house officer at Nagpur Government Medical College and Hospital. Dr Surabhi Dharmadhikari has served part of her bonded service at a primary health centre in Pune. Siddhesh Zadey is a graduate student at Duke Global Health Institute, US. The authors have co-founded a nonprofit research group called ASAR.