Every senior medical doctor should earmark one month in a year to train doctors in rural areas

Dr Farhat Mantoo, Head of HR, MSF in South Asia, raises concerns about the shortage of doctors in the rural areas and provides strategies to attract the much need talent, in an interaction with Raelene Kambli

What are the reasons behind the shortage of doctors working in the rural areas of India and how to address it?

There are multiple reasons for this reluctance:

• Medical education in India is very expensive: According to the Medical Council of India (MCI), 52125 students graduate every year from 412 medical colleges. A significant number of these students graduate from private medical colleges, many of which charge illegal donations, or ‘capitation fees.’ Since medical education from such colleges comes at exorbitant prices, graduates naturally seek lucrative jobs over jobs in rural areas that pay less.
• Government hospitals are understaffed: The doctor-patient ratio results in a strain on tertiary healthcare services. We need to find a balance between centralisation and de-centralisation of services without compromising on quality. The medical system in India needs an evaluation to understand if this is the best model given the population size and geographical spread.
• Poor working and living conditions in rural areas: Lack of adequate funding is the biggest reason for poor health infrastructure development that prevents doctors from serving in rural areas.
• Syllabus: Medical colleges do not offer a community-oriented syllabus.
• Reluctance from medical students: Medical students are not ready to accept rural-serving projects for many reasons. These include:

1. The pressure to pursue a specialisation;
2. Repayment of hefty loans;
3. Dearth of quality faculty;
4. A higher degree (MD degree) requires a medical student to dedicate comparatively more time than students pursuing other professions;
5. Security issues in conflict areas;
6. Internship in rural areas does not give the student the chance to interact with senior professionals due to understaffing.

Are there any programmes conducted by the govt to talent toward public health? If yes, how effective or ineffective are these?

Several strategies have been employed by the Government of India and different states across the country in order to improve the situation of human resources in health systems. For instance, a popular scheme of reservation of post-graduate seats for those serving in the public sector was introduced in several states (Shroff et al., 2013). The National Rural Health Mission (NRHM) was established in 2005 with a focus on improving healthcare in the rural areas of India (Sundararaman and Gupta, 2011). NRHM has introduced special allowances for medics working in insecure areas including hardship allowance and performance incentives, among others. Further, NHRM realised that regular compensation is not enough and supplemented it with incentives. For instance, the Chhattisgarh Government in partnership with Public Health Foundation of India (PHFI) worked on an initiative to get doctors and medical staff to live and work in districts torn by left-wing extremism. More autonomy to district collectors and access to flexi-funds such as National Health Mission (NHM) and district mineral funds (DMF) have made it possible for them to offer specialists salaries that are two-and-a-half to three times what they’d get elsewhere.

The Ministry of Health and Family Welfare (MoH&FW) allows doctors to pursue a private practice alongside reporting to Primary Health Centres (PHCs) just twice a week. Further, doctors working with MoH for 5-6 years are also sponsored to pursue their Masters degree. Recently, MoH&FW announced that contractual doctors who complete three years will be become permanent.

Do you think that including public health as a part of medical education can be a good idea?

Service orientation is the core of medicine and the medical fraternity engages in various ways to contribute to the society. The fraternity’s work in rural parts is one of them.

The first step should start at an early stage i.e., during medical studies. This is where the faculty/ senior doctors should not only start talking about working in rural areas but also walk the talk. Every senior medical doctor should earmark one month in a year to coach and train doctors in rural settings. A doctor’s work in rural areas needs to be showcased and more success/ human stories need to be presented using different media. Improving the quality of personal and professional experience is equally important to motivate youngsters to work in remote locations. Proper briefings to manage expectations and sufficient support on the ground can in still in young doctors the knowhow and confidence that their actions can prove the difference between life and death.

Your recommendation to attract doctors to work in the rural areas?

Health and technical infrastructure in rural areas needs to be improved and the idea of service orientation needs to be re – invented. Some states have come up with innovative approaches. I think the key is to engage with initiatives such as the Association of Rural Surgeons of India to understand how to make work in rural India equally rewarding and professionally challenging. The below recommendations are based on MSF’s experience of sustaining an adequate pool of doctors:

• Yearly trainings, promotion, holiday and relocation policies should be employed to retain and attract quality staff. Here promotion policy can be viewed in two ways- a) performance and b) experience.
• Create a pool of professionals who can work on short interim positions throughout the year (contracts can offer short-term consultancy services) and offer mobility (the doctors can work in different projects in India and may also get an opportunity to work internationally).
• Invest in basic living conditions of medical doctors as there is not much recreation in rural areas.
• Involving medical professionals in training local staff, recruitment, and patient management can create a sense of belonging to the project.
• Facilitate family postings to attract experienced doctors and specialists.

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