What gets docs to villages: Double pay, cheaper education, salary cut, fines

Maharashtra recently drafted a bill to create a special reservation quota up to 10% in undergraduate (MBBS) and 20% in post-graduate (MD) medical seats for those who give a commitment to work in tribal and rural areas. Candidates must serve for a period of seven years immediately after completion of MBBS and for five years after MD.

Across rural India, particularly in tribal and remote areas, the crisis in the healthcare sector has been compounded by a severe lack of doctors. States have been promoting various incentives to make new doctors opt for rural postings, but with mixed success.

“The healthcare situation in rural Maharashtra is dire. There is a huge network of 1,816 primary health centres, 400 rural hospitals, 76 sub-district hospitals and 26 civil hospitals. But this is rendered useless because of lack of manpower,” said healthcare activist Dr Amol Annadate.

The situation is perhaps worse in Odisha, which has a large population in remote areas. Now, though, it has introduced a system which is beginning to make a difference. Starting April 2015, a place of posting-based incentive policy for doctors was started by dividing the 1,750 government hospitals into five categories: from V0, the least vulnerable hospitals, to V4 the most difficult ones. These categories are based on backwardness of the area, Left-wing extremism, road/train communication, social infrastructure and distance from the capital.

Those posted in V4 category get 100% extra pay, while general medical officers in V4 hospitals get Rs 40,000 per month more and specialists Rs 80,000 additionally. There are 100 V4 and 137 V3 hospitals. Doctors working in V1 to V4 institutions get additional marks in postgraduate entrance examinations. “Young doctors are interested in joining remote and inaccessible areas to get additional marks for selection in PG courses,” health secretary Pramod Meherda said.

A doctor who has served in V4 institutions gets 10% extra marks in NEET for every year he has served, up to three years. Those who have served in V1 institutions will get 2.5% extra; V2 5% and V3 7.5%.

These measures have begun having some impact: as of December 2018, the KBK (Kalahandi-Balangir-Koraput) region had 1,072 doctors compared to 786 in March 2014.

Next door in Jharkhand, 65% of women are anemic. Vector-borne diseases like malaria, kala azar and Japanese encephalitis are endemic. Malnutrition is also above the national average. And the number of vacancies for doctors is more than half the total number of posts.

The government in 2017 began constructing three new medical colleges in Palamu, Dumka and Hazaribagh to increase the number of MBBS seats, which stands at 350 (combining the functional medical colleges in Ranchi, Jamshedpur and Dhanbad). Three more colleges were announced in Bokaro, Koderma and Chaibasa. However, with existing medical colleges reeling under shortage of faculty, the retirement age of serving faculty members was raised to 65 years.

“We have a sanctioned strength of nearly 11,000 doctors in state health service, of which approximately 6,000 are lying vacant,” a senior official in health department said. “Doctors do not want to work in district hospitals and CHCs because the pay is less, and these places are far-flung, remote and have law and order problems,” the official added. Of Jharkhand’s 24 districts, 19 are affected by Maoism. That in turn has hit healthcare, often leaving poor citizens helpless.

Private players were roped in to set up clinical and radiological test centres in district hospitals. In February this year, a Hyderabad based health-chain was given the nod to set up telemedicine centers in 110 CHCs. A pilot project was started in Ranchi in January whereby privately-employed doctors would be paid to visit rural health centres to set up camps and perform surgeries if required.

State health secretary Nitin Madan Kulkarni said, “We have rolled out a recruitment process for specialist doctors. In-principle approval has been given for additional allowances and incentives to medical officers in 2019-20.”

In the mountains of Uttarakhand the unavailability of medical facilities is so severe that it has become one of the causes of migration of villagers. The government has tried various carrot and stick methods to get trained physicians to give their services in remote areas. Since 2008, the government has been offering MBBS courses at subsidised rates in state-run medical colleges to students who sign a bond that mandates them to serve in the hills after completing their course. The subsidised fee ranges between Rs 15,000 and Rs 40,000 per year (a similar MBBS course in a private medical college would cost Rs 5 to Rs 7 lakh per year). However, most MBBS graduates after completing their course do not honour terms of the bond even though the state government raised the penalty amount for defaulters to Rs 1 crore in 2017.

Taking an unprecedented step, the medical education department recently issued legal notices for recovery of money to 383 doctors for not keeping their commitment to serve at least five years in the hills in exchange for subsidised education. In 2016, the health department published notices in leading dailies about those doctors who were shifted to the hills months ago but did not join duty. This was done in order to “name and shame” them.

Doctors, however, said lack of adequate infrastructure was the reasons for their reluctance to serve in remote areas. "Even if we go to hill postings, our hands are tied because equipment available to us is not adequate. Also, emergency and trauma facilities are missing,” said Dr NS Napchyal, former general secretary of Uttarakhand Provincial Medical Health Services.

“Apart from infrastructure, there is also some risk to life. We have seen how aggressive attendants from rural areas become in case of any mishap,” said Dr Sachchidanand Kumar, member of central working committee of IMA, Bihar chapter. “Housing is another problem.”

Back in the capital city of Delhi, poor patients lying on the pavement and along the boundary walls of All India Institute of Medical Sciences has been a common sight for decades. While one of the reasons for this is the quality of services provided at the premier medical institute, another important factor remains the lack of facilities at state-run community health centres and district hospitals.

According to rural health statistics 2017, there is a serious shortage of specialists in states, especially in tribal areas. Madhya Pradesh, for example, requires 416 specialists to run its CHCs but has only 25 specialists. Gujarat needs 368 specialists but only 38 as on March 31, 2017.

“A possible solution to address the shortage of doctors in rural areas could be mandatory posting of fresh MBBS graduates in rural areas before granting them their first promotion,” Vice-President M Venkaiah Naidu said last year. States would do well to heed that.