Indian states sweeten offers to cure rural doctor shortage
Dr Kapil Annaldewar walked away from his government job last October, 18 months before the end of his mandatory five-year term.
A laparoscopic and general surgeon in Garhchiroli, 800 kilometres east of Mumbai, he was supposed to spend five years working in government hospitals in Maharashtra state, including three years in rural locales, under the in-service quota of the medical college he attended. But he says he simply couldn’t take any more.
For a start, his salary was less than one quarter of the 330,000 rupees (US$4,810) per month that he now earns at a missionary hospital. As well, the rigid hierarchical system did not allow him to use or add to his expertise.
The accommodations provided in the rural communities were “pathetic”, discouraging him from bringing his dentist wife Shruti and son to stay with him. And the work ethic in government practice left much to be desired, the 38-year-old specialist says.
“Those who have higher ambitions will not benefit from a government job,” Dr Annaldewar told Asia Focus. “I was only allowed to do one or two general surgeries and no special operations. I am a bit ambitious and got frustrated.
“In October last year, I left the job without informing anybody. I have been absconding since then.”
Dr Annaldewar is not alone. In the 15 years to January 2017, 581 doctors in Maharashtra left government service without completing their terms. Thousands more across the country have walked away without fulfilling their agreements to serve in rural, tribal or other difficult areas.
Under the in-service quota, candidates for post-graduate medical programmes in Maharashtra receive favourable admission treatment and are paid a salary during their threeyear course. In return, they must post a 6-million-rupee ($87,500) bond under which they promise to serve in rural, tribal and difficult areas for five years.
Dr Annaldewar concedes he may have to return the bond if the state government takes him court and if he refuses to serve out the remainder of his government commitment. But that could take several years and by then he would have earned much more money, he says.
Despite the inducements of easy admission and subsidised tuition, the in-service quota programme has failed to lure doctors to rural, tribal and difficult areas. The result is a severe shortage of medical professionals and a thriving business for unqualified practitioners and outright quacks, often at the expense of patients’ health and lives.
This is why Maharashtra and other states have now decided to substantially increase the benefits promised to doctors for working in difficult locales.
The number of reserved places in Bachelor of Medicine, Bachelor of Surgery and postgraduate courses in government medical colleges will be increased by at least 10% for students who agree to serve in difficult areas, under a proposal drafted by the Maharashtra government.
The state is also hiring specialists at salaries on par with what the private sector is paying. Since December 2017, it has recruited 143 anaesthetists, 71 paediatricians and 142 gynaecologists. It has also fixed charges for Caesarean surgery, ante-natal checkups, assisted deliveries and paediatric treatment. As well, it plans to reopen salary negotiations with all specialists including dermatology, ear, nose and throat, and general surgery.
The government of Jharkhand, an eastern state with large tribal populations, is also wooing doctors to work in tribal areas and locales affected by regular flare-ups of Maoist violence.
Kripa Nand Jha, director of the National Rural Health Mission (NRHM), told Asia Focus that the government divides areas of need into three categories and fixes incentives accordingly. The state government asks doctors to propose salaries during the screening process and selects those who quote the lowest figure.
Doctors accepting such positions can expect to have their skills tested to the limit as the medical needs of long-neglected communities are quite acute. For example, 65% of women in Jharkhand are anaemic while vector-borne diseases such as Japanese encephalitis, malaria and kala azar (a parasitic disease marked by fever, anaemia and enlargement of the spleen and liver) are endemic.
Malnutrition is above the national average in the state, where some children kill squirrels to escape starvation. Half of the doctors’ posts are vacant in Jharkhand, which has only three medical colleges.
Odisha, another poor eastern state, has divided its territory into five categories based on backwardness, left-wing extremism, transport and communication, social infrastructure and distance from the state capital Bhubaneswar. Doctors receive extra pay and preferential admission according to these categories.
For instance, doctors recruited in the lowest category, V4, are paid double the normal starting rate. A doctor agreeing to serve in a V4 healthcare facility receives a 10% bump in his or her score on the National Eligibility Entrance Test (NEET).
In Uttarakhand, a state in northern India, medical students agreeing to serve in rural and hill areas receive tuition subsidies. For a student who posts a bond to serve in hilly areas, tuition is between 15,000 and 40,000 rupees per year, compared with up to 700,000 rupees in a private college. Defaulters can be fined up to 10 million rupees but the penalty is rarely invoked and the number of students serving in hilly areas remains minuscule.
Dr Amol Annadate, a paediatrician who runs a hospital in Vaijapur, in Aurangabad district of Maharashtra, believes government incentives will not work unless the infrastructure in the targeted communities is upgraded to an urban level and salaries are on par with the private sector.
“Don’t expect the doctors to make sacrifices. Why should they be idealistic and work at one-third or one-fourth of salaries i n private sector?” he asks rhetorically.
“Moreover, they don’t get potable water and proper sanitation. There is no security for female doctors. To top it all of, no technology is available to help them showcase their expertise.”
Doctors in government hospitals, he added, rarely get to participate in conferences to update their knowledge. “The government does not take care of its doctors. They start rotting in government service,” he told Asia Focus.
Dr Shiv Kumar Uttare, president of the Medical Council of India (MCI) in Maharashtra, attributed the low interest by doctors in rural areas to a lack of proper accommodation and facilities for the education of children.
Dr KK Agrawal, national president of the MCI, justified the violation of bonds by young medical practitioners. “The government also gives free education in schools. Does it expect school students to work only in government jobs?” he asked.
“Why do you want young doctors to serve in villages? They should serve there in the last five years of their service. Who will drive a bus after learning how to fly a plane?”
Dr Agrawal has proposed that health care be placed on the concurrent list of the Indian Constitution, which specifies the powers of the Union and state governments, so that doctors are paid uniform salaries in government jobs nationwide.
A doctor in government service earns a salary of between 40,000 and 70,000 rupees per month, plus accommodation. His or her private-sector peer can expect to earn a starting salary of 200,000 rupees, plus a car and accommodation with servants.
“Those who have higher ambitions will not benefit from a government job” DR KAPIL ANNALDEWAR Surgeon in Garhchiroli, Maharashtra