The Supreme Court, in an order upholding compulsory rural service bonds imposed by states for admission to PG and specialty medical courses, has stressed on the need for a uniform policy on this. The Centre and the successor regulatory system to the Medical Council of India should take heed. The apex court has fixed the compulsory rural service period upon passing the courses at government medical colleges at two years, and the bond-release amount at Rs 20 lakh. Given how both compulsory service periods and bond amounts varied from state to state—from two to five years, and up to Rs 50 lakh, respectively—a uniform service period and bond-release amount across the country is a good idea. Those challenging the compulsory service norm had contended that the condition is illegal and arbitrary.
The SC pointed out that the government spends a large amount in training each medical graduate and post-graduate in government medical colleges—AIIMS calculates the cost of producing one MBBS at Rs 1.7 crore—but just a fraction of this is paid for by students. Besides, the public-sector allopathic doctor-population ratio stands at 1:11,082 against the WHO recommended ratio of 1:1,000—this translates into a shortage of 600,000 doctors—and the brunt of this is borne by rural areas. Some of the country’s least-developed states fare the worst; as per data from the directorates of state health services and the National Health Profile 2018, Bihar, Uttar Pradesh, Odisha, Chhattisgarh, Jharkhand, and Madhya Pradesh have worse government doctor penetration than the overall India figure.
Primary health centres that serve the rural populace are short of at least 3,000 doctors, with 1,974 PHCs operating without a single doctor. The community health centres, the first port of call for the rural population for specialist care, are short of nearly 5,000 surgeons. So, a compulsory rural service clause that ensures specialist healthcare is extended to rural areas is welcome.
But, while compulsory rural service is a good idea, there are other potential solutions to the chronic doctor/specialist shortage that the government should consider. It could work on converting district hospitals into medical colleges. This can be a cure for the high costs of medical education—on land, equipment, utilities, teaching staff, etc—that force the government to significantly subsidise this, by supplying ready infrastructure. Indeed, the UPA-II government had proposed an undergraduate degree in Rural Medicine and Surgery, for which students were to be trained at district and sub-divisional hospitals, but this never really took off. Nations with much better doctor-population ratios have got there, in part, because they were not hindered by the cumbersome norms that medical education in India has.
This is not to say that the norms are summarily undesirable, but there is space for reform. And, in case the government of a state is not able to spend the amount required to upgrade a district hospital into a medical college, there are around 330 private/trust-run hospitals with 300-800 beds already conducting postgraduate training that, as Dr Devi Shetty recommends, can be partnered for undergraduate training through problem-based learning, or learning through cases rather than lectures. It is also important that the government encourages enough quality private colleges to come up. The increased supply in trained doctors will cause some to shift to the rural market.