Perspective on rural posting after postgraduation in India

Sir, According to Rural Health Statistics of India, in 2017, a large number of posts of doctors (8286 against 33,968 sanctioned) at primary health centers and specialist doctors in community health centers (8105 against 11,910 sanctioned) remained vacant.[1] Unwillingness of doctors to serve in the rural area is a fact behind this shortfall.[2] The choice of urban posting was favored by undergraduate students due to the facility of higher education, carrier growth, higher income, and better lifestyle.[3] The psychology behind the choice of urban posting is invariably similar for postgraduate (PG) students also. To combat this situation of shortage of doctors in rural area, most of the state governments of India have decided to introduce “indemnity bond” for students seeking admission for PG courses (degree and diploma).[4] Compulsory rural posting after medical graduation and postgraduation is not only trending in India but also a global strategy to provide comprehensive health service to population.[5] However, the current situation of “indemnity bond” signed by students has a serious limitation. A simple illustration is presented in Figure 1. It demonstrates three situations. In situation (a), the student secured a rank in entrance examination and had money for admission in a private medical college. The student got admitted in a private medical college and eventually passed and was free to practice. In this case, there is a freedom to practice in suitable settings according to the doctor's choice.Figure 1: Illustration showing cases of three different students from their admission in postgraduate course to be free to practiceIn situation (b), the student secured a rank in entrance examination and got a seat in a government-run medical college. According to the states' policy, an “indemnity bond” was signed for rural service during the admission. After passing the final examination, the student was bound to join rural service. After completion of the tenure of “indemnity bond,” the doctor was free to practice. In situation (c), a similar student like (b) got admitted in a government-run medical college after furnishing the “indemnity bond” and passed the final examination. At that moment, the bond money was paid to the state government, and the doctor got freedom to practice in preferred settings. Hence, what actually making some students to serve in rural area is solely dependent on the financial condition of those students. If every student was able to pay money, all of them could escape serving the rural area. What does India need to strengthen rural health service – doctor or money? Illustration as shown in Figure 1 answers this question. We felt that the current system of rural posting is based on the discrimination on the basis of financial condition of students. Stakeholders should rethink the current situation and polish the “indemnity bond” for rural service. Policy should be made equal for all students pursuing PG degree or diploma from government-run medical colleges. Some points which can be considered by policymakers during rethinking about the “indemnity bond:” Uniform rules across states for rural posting No bond during admission in PG courses Compulsory 1-year internship after postgraduation in concerned subject Uniform attractive stipend during internship, additional incentives for posts in remote areas Provision for inclusion of students in internship program who passes from private medical colleges Make the internship mandatory for candidates applying for government job. Financial support and sponsorship Nil. Conflicts of interest The first author passed PG degree from an institute where there was no indemnity bond for any service. The second author passed PG degree from an institute where he signed an indemnity bond and currently serving the state government as per the signed bond.