Whither mandatory 'rural bonds'? With few doctors in rural Maharashtra, public rural health is at risk

By Gajanan Khergamker*
Sixty-year-old Jamunabai Vasawe was bitten by a snake at six pm. Belonging to Manibeli village on the banks of Narmada river in Nandurbar district, Maharashtra, bordering Gujarat, her family rushed her to the closest sub-centre, only to find it was shut. As for the primary health centre, it was simply out of reach.
A boat ambulance placed for emergency medical care for villagers in the remote tribal area was delayed by two hours. And, by the time the tribal woman was administered anti-snake venom (ASV), her condition had worsened beyond repair. She was declared dead in a government hospital in Garudeshwar, Gujarat, at around 11 pm.
It was the second snake-bite death that Nandurbar registered within a week on June 28 this year. Fourteen-year-old Ravish Vasawe had earlier died in Gaman Ashramshala, where he studied in Class VII. Reason: The nearest primary health centre in Gaman had no nurse or paramedic staff. Although Ashramshala teachers took Ravish in a private vehicle to Molgi a good 22-km away, the boy died on the way.
Maharashtra proposes to convert 1,270 sub-centres to health and wellness centres under the Ayushman Bharat programme, yet Nandurbar’s 20 sub-centres do not even have permanent structures. Although the tribal district has 290 sub-centres, tribals claim that even basic services are lacking. With no road access, the district makes use of three boat ambulances to provide health services to 33 villages!

Incidentally, Maharashtra recorded the highest number of snake-bite cases in India with 38,917 cases in 2017-18, of which the most were in rural regions, at 29,912. Doctors are few and far beyond in rural Maharashtra placing public rural health at direct risk. Little wonder that the mandatory ‘rural bond’ signed by medical students across the state while pursuing education in government colleges and now, across private colleges too, must be fulfilled in letter and spirit.
That, however, appears to be a tall order with the fraternity and its members in question ready to put in their might behind the stream of defaulter students, now professionals. Inordinate legalese and administrative delays besmirch the well-meant intention behind the ‘bond’ whose nomenclature itself reveals the apathy towards practice in rural India.

Doctors in Maharashtra have, of late, been a frazzled lot. They’re being issued notices to pay up long-pending bond amounts, they had signed up for, ranging from Rs 15 lakh up to Rs 2.5 crore depending on their specialization. As the law mandates, if the doctors do not serve the bond, they must pay a penalty.
The Directorate of Medical Education and Research (DMER) has written to Maharashtra Medical Council (MMC) asking to take stringent action if the doctors fail to respond to a second notice to serve their bonds or pay up. With more than 3,000 doctors having failed to honour medical bonds in rural areas, the DMER has decided to take stringent action against them. Doctors across Maharashtra are set to lose their licences as the DMER has now written to the MMC.
The DMER had earlier sent notices to 4,500 doctors, who had not served their mandatory one-year bond service in the state since 2009. Of these, 1,500 doctors had replied to the state’s notice. Following this, the DMER had served an ultimatum to the pending defaulters asking to either respond or face action. The state government had also written to the MMC asking to suspend the registration of those doctors who failed to serve the bond.
If doctors do not serve the bond, they are asked to pay penalty -- Rs 15 lakh to Rs 2.5 crore depending on the course. A government resolution to this effect was passed in May 2010. will get compounded with a cumulative interest for the period left unpaid.
Apparently, of the 3,000 doctors who have not responded, as many as 1,000 are not in the state and owing to the unavailability of doctors in rural areas, patients suffer without medical treatment. The doctors, who have served their one-year mandatory bonds will be allowed to sit for their PG exam.

Dr Shivkumar Utture

Meanwhile, the Maharashtra Medical Council President Dr Shivkumar Utture says, “There are about 3,000 to 3,500 medical students graduating every year. And they are not provided jobs. Students claim there is an acute deficit of jobs. Also, legally, it is difficult to bind them to the bond.” And, that is the reason that not a single registration of a doctor has actually been ‘cancelled’ according to him.
“There is the need to bring all these issues under the Medical Council Act. The Council cannot enforce anything until it is included in the Act. “You see, the government is supposed to give letters to the medical student who has to fulfil the rural bond. If the government itself does not give the letters to the student, how will he fulfil it?” says Dr Utture.
The aim of Maharashtra Medical Council is not to take money and fine students, he adds. “MMC is not a fining authority. The Council rules say that every five years doctors need to renew their licences and show 30-hours credit of Continuing Medical Education (CME) before renewal. The Council’s suggestion to introduce Continuing Professional Development (CPD) as part of the CME has been accepted. Rural Medical Camps organized by the government or with some recognized NGO like Indian Medical Association (IMA) have now been passed as CPD and they will be considered Credit Points now,” he says.
Replacing the ‘one-year rural bond’ with a ‘CPD’, particularly so rural medical camps, organized by NGOs may be the way around a legally-binding bond between the student and the government, suggests Dr Utture.
He says that this will also ensure that rural Maharashtra will obtain ‘experienced’ doctors as opposed to ‘inexperienced’ medical students otherwise provided through the rural bond.
There are a host of discrepancies between state acts with regard to the issue triggering a growing need for a central act in situations such as these, points out Dr Utture. “Doctors get harassed due to the lack of uniformity across India. State bodies are given power to give qualifications that are only recognised across the state in question. For instance, a diploma in Maharashtra is not recognized by Karnataka or MCI,” he says.
“As for the letter issued by DMER to MMC to take action, I have yet to go through it. The licences cannot be suspended as we have to look into the legal aspects. A final decision will be taken after meetings with the respective officials and investigating the issue,” he says.
Even while the ‘notices’ and ‘suspensions’ of licenses of ‘errant’ doctors continue unabated, three enterprising individuals are set to use drones to deliver blood, vaccines, emergency medicines, anti-snake venom serum and life-saving equipment like defibrillators to patients across India. And, Bloodstream – run by Air Aid Private Limited is set to be integrated with Maharashtra’s health supply chain by mid-2019.
In times like these, for a Jamunabai to die for want to medical aid is almost criminal. The State government, the medical fraternity and private players should jointly work towards ensuring the letter and spirit of a rural bond are upheld.
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*Founding editor of "The Draft". A version of this article was originally published in www.thedraftworld.com