Why are medical graduates not joining the rural services in India

Dear Sir

There are significant differences in the health parameters between the urban and rural areas of India. While most parameters have reached levels comparable to the developed world in the metropolises, they remain significantly lower in the rural areas of the country. One of the major reasons for this difference is the insufficient deployment of human resources, especially doctors in the health institutions located in rural areas. Physicians are reluctant to take up jobs in rural locations. The government of India estimated in 2010 a short-fall of 10.3% for doctors at primary health centers (PHCs) and 62% for specialists at the secondary level.^[1] The doctor: population ratio is 13: 10000 in the urban areas but only 3: 10000 in the rural areas of the country.^[2]

Joining in and adhering to rural health services are often defined by the availability of benefits like financial incentives in the form of loan repayment and scholarships for students willing to serve in rural areas, as in the United States. Monetary incentives along with professional development opportunities are also used for recruiting and retaining physicians to rural areas in several other countries. The government of India provides incentives such as the rural or hardship allowance and reservation of post graduate seats for physicians serving in the rural areas. However, these are not considered enough motivation by the vast majority of medical graduates in India, who take up jobs in city based hospitals, sometimes for lesser remunerations. Professional isolation and lack of infrastructural facilities, less salary, low standard of living and limited exposure as a doctor continue to discourage physicians from joining rural service. This trend is not unique to India and reluctance of medical graduates to set up rural practice or join rural health services have been in seen in countries both from the developing as well as the developed worlds.

The most important determinant of taking up rural posting has been seen in various studies to be the rural background of the medical graduate.^[3,4] The second strongest predictor of rural service is undergraduate and post graduate clinical experience in a rural setting.Error! Bookmark not defined. Countries like the USA, Canada and Australia have increased the selection of students with a rural background for medical schools as one of the strategies to increase the number of physicians in rural areas.^[5] No such scope for preferential selection of candidates with rural background is currently possible in India as admissions to medical colleges are based on scores in entrance examinations. It is important, therefore, to make sure that the interns have a good rural experience which will kindle their interest in future rural jobs.

Although the current MCI (Medical Council of India) undergraduate curriculum focusses on community based approaches to healthcare, teaching at the medical colleges continue to stress upon curative hospital based treatment. The medical graduates tend to lack the skills of managing patients at the primary care level. The community and the healthcare industry are more appreciative of the work done by specialists. The generalists and especially the rural doctors are looked down upon by the specialists, who underrate the attributes of primary care. The low morale of physicians working in rural hospitals affect their involvement in the academic or training activities of the undergraduate medical students during their rotatory rural postings. Since the medical officers at the BPHC are not directly involved to the training and supervision of the interns during their posting at the BPHC, the interns fail to gain from the rural physician's first-hand experience of managing patients, nor acquire the skills necessary to work in a rural set up. Care must therefore be taken to design a clinical programme for the interns to highlight the important role that the rural physician plays in terms of the promotive, preventive, curative and rehabilitative aspects of health. He should be introduced to the services being delivered at the primary health care centres along with guidance in the implementation of the various national programmes. The senior medical officers posted at the rural institutions need to act as mentors to the interns in the rural area. Dolmans et al found that that high quality supervision, faculty development and initiatives focused on helping clinicians create a supportive environment for learning, providing constructive feedback and teaching to student's learning needs, are keys to an effective clinical rotation.^[6]

Rural training during internship provides the interns with an opportunity for hands on experience in primary health care. Developing a structured, mentored and thoroughly supervised training programme involving the preventive, promotive, curative and rehabilitative aspects of primary health care will make the interns more likely to accept the programme as a learning opportunity and spark interest in future rural postings.