Between 2015 and 2021, nearly two-thirds of the MBBS graduates from Grant Medical College (GMC) or J J Hospital in Mumbai, Maharashtra’s biggest government medical college, opted out of their compulsory one-year rural posting. During this time, the hospital received Rs 27 crore in penalties for opting out — with many students yet to pay the fine.
Now, authorities have tweaked the norms to ensure that MBBS graduates can no longer skip rural service by paying a fine.
The World Health Organisation recommends a ratio of one doctor for every 1,000 people. In Maharashtra, the ratio is 0.84 to 1,000. In the state’s rural areas, the gap is even wider — as the recent The Indian Express series on healthcare in tribal-dominated Nandurbar revealed.
To bridge this gap, years ago, the state had introduced a one-year mandatory rural posting, or “social responsibility service”, for all students after the completion of their MBBS course.
During this one year, they are supposed to treat patients in primary health centres (PHCs) or rural hospitals.
But doctors cite a number of reasons for opting out — among them are lack of medical facilities and infrastructure, educational delays and security issues.
According to data obtained by The Indian Express from JJ Hospital, 1,364 students got MBBS degrees between 2015 and 2021. Among them, only 467 or 34 per cent of the doctors served in rural Maharashtra; 897, or 66 per cent, opted out.
Data also showed that during the pandemic years of 2020 and 2021, the hospital reported the highest number of doctors opting out since 2015. Among the 390 who got MBBS degrees, only 94, or 24 per cent, served in rural areas.
Before the latest revision of norms, doctors failing to serve in rural areas had to pay a fine of Rs 10 lakh. The penalty was Rs 5 lakh from 2004-05 to 2007-08.
In 2015, the hospital collected Rs 2.75 crore in fines. The figure was Rs 1.44 crore in 2016 and Rs 3.37 crore in 2017. It surged to Rs 4.95 crore in 2018 and to Rs 6.98 crore in 2019.
The collected fines dropped to Rs 3.25 crore in 2020 and Rs 4.45 crore in 2021. The plunge, despite high opt-outs amid the pandemic, was because 202 of 390 defaulters did not pay the penalty by the end of 2021.
In all, at least 574 doctors haven’t paid the penalty to the hospital between 2015 and 2021. This number is effectively higher as several have agreed to pay the fine and not deposited it as of 2021 end.
Speaking to The Indian Express, Dr Dilip Govindrao Mhaisekar, director of the Directorate of Medical Education and Research (DMER), said: “We have canceled the option of paying a penalty to opt out of rural service. So, starting from the 2022-23 academic year, all MBBS students will have to serve in rural areas after obtaining their degree,” he added.
Asked if the state would take any step against the doctors who did not pay the penalty, Mhaisekar said: “When required, we will call them for their service in rural regions. If they refuse, we will take action.”
Dr Abhay Shukla, a health advocate from Pune, said that many doctors from influential families do not face action. “Private medical colleges charge up to Rs 1 crore for MBBS courses, one-tenth of what government-run colleges charge as fee. So, the families don’t mind spending Rs 10 lakh as penalty,” he said.
For serving their rural bond, doctors get over Rs 70,000, which is much higher than the salary paid by private hospitals. “Private hospitals pay around Rs 40,000 to Rs 50,000 after MBBS. So, it is not because of money that MBBS doctors opt out of rural bond,” said a doctor who served his rural bond in Gadchiroli, a Maoist-affected district.
When The Indian Express spoke with medical students, they expressed their apprehension about their security. “There are high incidences of medico-legal cases. Also, due to lack of security personnel, doctors often get assaulted which further deters them,” said another doctor.
“During our course and internship, we always serve patients from vulnerable communities. Then why send us again to the countryside? Students from other government institutes like IITs are not sent to such rural posting. They directly go abroad…,” said a doctor from the Maharashtra Association of Resident Doctors. He also blamed the DMER for delaying postings of doctors.
Pointing out that GMC is run by public money, health activist Bandu Sampatrao Sane from Amravati said: “After getting the MBBS degree, doctors want to either serve in urban areas or pursue post graduation. They avoid compulsory rural posting though they have pursued MBBS at nominal fees in the hospital.”
But doctors point to the daunting work conditions. “The infrastructure in rural PHCs and hospitals are so bad that it becomes impossible to work. The centres don’t even have bathrooms and women doctors have to walk for kilometers just to relieve themselves,” said a doctor who completed her MBBS course from Nair Hospital in 2021 and served her rural posting in a BMC-run peripheral hospital.