As mentioned in the report by the National Commission on Macroeconomics and Health, the Ministry of Health and Family Welfare, and the government of India, 78% of the total out-patient department consultations in the country are done in the private sector and only 22% are in the public sector.
This is just a glimpse of the poor coverage of government healthcare. As a result, the report states, every year around four crore people slip below the poverty line in trying to and struggling to afford health care.
In Maharashtra, the public health system consists of nearly 1,200 primary health centres (PHCs), 387 rural and 81 sub-district hospitals (RH and SDH) and 23 district civil hospitals. All of these have a large number of vacancies, especially those in the rural and tribal areas of Maharashtra.
It is imperative to fill up these vacancies with the available trained medical manpower as that will make life saving medical services available to needy people and help reduce the burden of diseases. This is especially critical in the present time.
For all the 2,960 MBBS, 1787 MD/MS/Diploma and 136 super-specialty doctors graduating every year from the government and municipal medical colleges in Maharashtra, it is mandatory to render one year’s service to the government.
At the time of admission to colleges, students have to sign an indemnity bond towards the discharge of mandatory service, failing which they must pay a penalty amount to the government. The size of this bond economy at Rs 14 billion a year is huge!
What the figures say
As per the performance audit report of 2009-2010 for the Maharashtra state by the Comptroller and Auditor General (CAG) of India, “…90% students who graduated from GMCs did not render service to the government.”
The report has referred to statistics in the period from 2005-2010. We recently filed RTI queries to four of the most eminent medical colleges in the state and have unfortunately found a similar sad picture.
This speaks to the widespread trend among medical graduates to skip the mandatory one-year stint with the government while not reimbursing the bond amount either.
We thus see a strange picture in the state of Maharashtra where there are lots of vacancies in spite of having a large number of young medical graduates legally available for service every year.
On the other hand, the recovery of bond amount from these medical graduates who refrain from doing this compulsory service is also not done. Since the record of completing the bond services (by actually working or submitting the penalty) if the medical students are left to themselves is abysmal, there is a need to further strengthen this system.
What the state could do
The usual excuse that students give is that their first preference is to prepare for PG examinations and join a PG course. While one should appreciate and encourage the desire of medical doctors to learn further, they can’t be left free to pursue that without completing the legal obligations of a prior arrangement that they have made with the state and the public.
To give an example, this should be akin to a bank not giving further loans to a customer till the time she or he honours the agreement and completes the repayment of the earlier loan instalments. Similarly, the state cannot go on providing subsidised education without ensuring that the student is fulfilling the requirements in the agreement, before becoming eligible for the next round of subsidy i.e. post graduate education in a government medical college.
If some MBBS doctors start saying, “We will serve our MBBS as well as our PG bond together in a two-year stint after our PG,” then even that is not healthy for the public as there are no seats for PG doctors at the Primary Health Centre level.
So in a sense the most basic and widespread unit of the health care system (a PHC) will not get a doctor. PG doctors would flock to bigger hospitals to do their UG and PG bonds together. The postponement of UG bond will not give young doctors a chance to see the larger reality of health challenges either.
Today, budding doctors refuse to get education from service, the rural poor don’t get the required services and the state is deprived of the income it can get from the recovery of the bond amount. Thus, fixing this tripartite problem is crucially important.
What the court has said
As per the judgment given by the Bombay high court on October 20, 2011 (in response to writ petition no. 1440 of 2011), the state government is to create a central agency where bonded doctors will register their choice of posting of medical officership (online) as soon as their final year examination is over.
In a May 3, 2017 order (in response to PIL no. 133 of 2007), the court directed the state government to make an in-depth analysis and study the reports submitted by Dr. Abhay Bang (who was invited to share his experiences). The reports also included a study note prepared by the author, regarding the implementation of bonded services.
Necessary regulations to ensure the accountability and smooth execution of bond services should begin with the 2,500 MBBS doctors who have finished their internship in March being immediately appointed in the public health system.
To speed this up, quick steps that can be taken. These include mandating the completion of bonded service by doctors, stipulating that without this they should not be eligible for further subsidised training, ranking of various districts in Maharashtra as per the number of vacant posts in the public health system, rolling out an online system for the allocation of bonded medical doctors to these vacant posts, and a proactive disclosure every year by the Public Health Department stating how many vacancies they filled using bonded medical candidates.
The Medical Education Department could also publish an index of government and municipal medical colleges in Maharashtra describing their institution-wise performance regarding how many graduates have not completed their bond and what is the bond amount to be recovered from them. The state should also make public the amount of the bond money recovered each year and the name of the defaulters who have not complied, as there is too much at stake here.
If this is not done, we will have a perpetual shortage of doctors in the public sector.
Amrut Bang is the programme lead of NIRMAN, a youth leadership development initiative that nurtures young adults as active contributors of social change. He holds an MS in Nonprofit Leadership from University of Pennsylvania.