|MEDICINE AND SOCIETY
|Year : 2022 | Volume
| Issue : 2 | Page : 167-169
Rural indemnity bond – Audacity in austerity or bonded labour?
Dayanand Medical College and Hospital, Ludhiana, Punjab; Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||19-May-2022|
|Date of Decision||21-May-2022|
|Date of Acceptance||23-May-2022|
|Date of Web Publication||29-Aug-2022|
Dr. Vasu Bansal
303 - G, BRS Nagar, Ludhiana - 411 040, Punjab
Source of Support: None, Conflict of Interest: None
The recommendation of a Rural Indemnity Bond after MBBS aims to address the rural-urban disparity in the Indian healthcare system. It is a radical reform in medical education curriculum and generates searching questions: How to affect the attitudes of medical graduates? Are there other successful models we can learn from? Do the healthcare challenges need a more integrated action? A policy enforcing the shunting of doctors needs to take the apprehensions of all the stakeholders into consideration. The broader issue of Rural Health Iniquity, that plagues the country requires interventions at multiple levels with a properly financed healthcare system at its foundation.
Keywords: MBBS, medical education, rural service
|How to cite this article:|
Bansal V. Rural indemnity bond – Audacity in austerity or bonded labour?. J Med Evid 2022;3:167-9
Public healthcare equity can be described as the 'readiness of all classes of society to access public health services'. India's non-performance, in this context, is well acknowledged. With over 75% of doctors catering to the urban population, the healthcare infrastructure of our country is fundamentally distorted and the idea of health equity in rural areas remains a distant dream. A discussion on the current policy framework to correct this imbalance sheds light on insufficient solutions prescribed in incorrect dosage.
In an attempt to reduce 'The Rural Mortality Penalty', many states in India now require compulsory rural service after MBBS. The Parliamentary Standing Committee on Health and Family Welfare, recommended, 'the compulsory posting of doctors passing MBBS in the rural areas for 3 years and practitioners violating the rule may be deregistered and prohibited from undergoing medical practices for the deregistered period' in its 126th report.
According to the latest data from the Medical Council of India, the country has about 605 medical colleges with a total annual intake of over 65,000 students. On the surface, a bond ensuring the funnelling of these numbers in areas lacking doctors seems like an ideal solution. A freshly minted doctor does not have a home or children to provide for. He is enthusiastic, restless to be of any significance and appears to be the most suitable cog to embrace the challenges that come along. In addition, an army of white coats can guard the naive population against the quackery rampant in these areas. However, despite the perceived benefits, careful consideration of the policy reveals significant issues in the machinery.
A fresh medical graduate, even if trained from a premier institute, does not yet have the skill set to manage a medical centre independently. Sending an inexperienced doctor will be inadequate at best and irresponsible in the majority of cases. Wide-eyed enthusiasm can seldom replace the blinkered competence in actual fieldwork. The greenhorn still feels like a student and is reluctant to take up the responsibility, and instead prefers to prepare for his post-graduation entrance examination. Besides, in a fraternity which anticipates soaring ambition as the default condition and prizes academic excellence, we cannot expect the denizens to hit 'hibernate' on their aspirations. At a time when it is more common to find multiple fellowships attached to a doctor's title than a middle name, it is easy to deduce why asking a medical student to take a detour to a rural posting, (for 3 years!) might seem more than a little unwelcome to him. These factors reduce the rural service to essentially unwilling bonded labour with those financially capable, readily 'paying out' of the service.
As an alternative, a programme where an experienced doctor is posted along with the fresh graduates is more suited harness their untapped enthusiasm. The experienced mentor can be present on a rotating basis; on an incentivised break from the urban grind. He can more effectively assist in a resource-limiting setting and can provide indispensable mentoring to students and make them feel confident and welcome in their new rural roles.
Specialists (even those in permanent government services) absconding from their remote posting is not a new story. This was also the situation in the government hospitals in Lakshadweep where the central health employees would often find themselves without their necessary counterparts (e.g. a surgeon without an anaesthetist). Even more commonly, the Central Health Services (CHS) specialists would be at headquarters or elsewhere moving papers and offices to ensure a posting back to the mainland! Hence, two strategies were successfully tried in Lakshadweep itself! First, a policy was made to post all available specialists in CHS serially for a few months each, and only once in their service at the main hospital in Kavaratti, the capital. At a stroke, they made the hospital functional and the doctors actually looked on it as a welcome break cum working holiday in a tropical paradise, rather than a Kalapani type penal sentence! The second strategy to supplement this was to have a partnership with private hospitals as a sort of a wet lease starting with the Amrita Institute of Medical Sciences, Kochi, signed a memorandum of understanding with the state administration. It led to a tremendous decrease in costs, especially transportation costs, for patients who otherwise would have been airlifted. Moreover, by posting all available specialists at once, the efficiency increased exponentially. The doctors too took the posting as a welcome break and felt relaxed and recharged after a stint on the island. Although challenging, highlighting the mutual beneficence of such initiatives can go a long way in overcoming the reluctance of specialists to travel into distant areas. Preferential home district posting can also boost recruitment and retention by allowing medical officers to stay with their extended families.
Those of us, lounging under the shade of tall tertiary care centres in metropolises, must realise that a functional rural health system will dramatically reduce the outpatient department (OPD) and surgery wait times and free up the emergency rooms, relieving them of significantly damaging pressure.
Lack of rural health services has always been viewed through the lens of human resource shortage, but actually is only a part of a bigger resource problem including drugs and other medicines and facilities. Poor, basic living conditions, social isolation and lack of security frighten the freshly baked doctors making them unwilling and apprehensive. 'There is no fan or electricity and even if it is there and if it goes off, nobody is there to repair it and if you need it very much you can call your own electrician and pay your own money and get it repaired'. (A Medical officer in Uttar Pradesh). Lack of safe transportation services and solitary living make remote villages unsuitable for living, especially for females. Will any parent consider it safe to send their sons and daughters to practice alone in a remote village? In addition, in stark contrast to the 'higher' social status of doctors in a community, there would be a tendency to see the young doctors as 'trainees' and actually looked down upon!
It is unreasonable to expect any interest in rural health services without providing adequate living arrangements and security provisions. 'Health' is constitutionally a 'state' subject and in many cases, a policy framework is spread across at least four different state-level directorates (medical education, medical health, family welfare and traditional medicine). The sizable heterogeneity in implementation leads to a lack of accountability. Developing a separate national, regional or state medical service, similar to central government cadre and armed forces (without total control by politicians and bureaucracy!) can help address several of these issues and lead to better utilisation of resources. Health services should be integrated with specialised management in resource mapping, planning and monitoring to address the deficit. Financial management should also receive priority, and financial specialists should be entrusted with budgets, accounting and auditing of performance. The impetus for telemedicine, after the lockdowns, can become the face of Digital India. Doctors should be seen as important stakeholders in policy planning and provisions of facilities and not just as expendable resources.
Public–private partnerships are considered the first-line therapy for the low productivity of public sector undertakings. However, the enterprise should be viewed with greater caution in the healthcare sector.
Inadequate monitoring can encourage 'Over privatisation'. Unnecessary procedures and excessive prescriptions, issues inherent to the private sector, can be detrimental and detract from the deal of universal health coverage. Instead of handing over the hospitals entirely to private players, the government can aim a 50-50 role in the management of hospitals. Expanding the PPP model in a step-wise manner, in the right spirit of corporate Social responsibility, can prove to be a potent catalyst in providing effective care.
Partnerships with non-governmental organizations (NGOs) can be evolved to include healthcare care delivery and quality monitoring. NGOs can operate on the provision of government budgets and grants in liaison with state health officials, especially in neglected areas. Jan Swasthya Sahyog, a non-profit organisation, established in 1999 by ex-AIIMS graduates operates in the Bilaspur district of Chhattisgarh. With an OPD of 300 people per day, it is estimated to cover over a million people that were effectively off the healthcare map. The average wait time for an appointment in the OPD is more than a week, highlighting the success of the institution and the urgent need for rapid replication. Promoting such high-performing organisations to serve as templates and inspire students to consider rural healthcare as a viable rather than forced career option.
The policymakers need to be reminded that a nation's capacity to deliver basic healthcare is perhaps one of the best markers of its concern and responsibility for its citizens. Any significant achievements in health indicators in our country are still comparable only to the poorest nations of sub-Saharan Africa. In a landscape where a failure of any social achievement is heavily politicised, healthcare infrastructure seemed to have for long missed the roll-call. The 2022 budget allocation for the health sector, even after the pandemic, is only 0.2% higher than the revised budget estimate for health in the previous year. The 15th Financial Commission (Report for 2021-26) recognised the need to increase the allocation on health by the Union Government. It has recommended that the public health expenditure of the Union and States together should be increased in a progressive manner to reach 2.5% GDP by 2025.
Season Two of the Amazon Prime web series 'Laakhon Mein Ek' is the tale of the challenges faced by a junior doctor while setting up a cataract camp in a remote village. It is a politically pragmatic tale of how the plight of a young doctor is linked to the inevitability of a broken system. Last year the COVID-19 pandemic, replaced the fictional montages with sordid images of migrants walking hundreds of kilometres in search of a doctor. Introspection and a strong political will are imminently required. The stakes are too disturbing for us to wait for another sequel.
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Conflicts of interest
There are no conflicts of interest.