Service Bond and Rural Mental Healthcare in India in the 21st Century: Why We Stand Here?

To the Editor,

The rural population, which constitutes more than two-thirds of the population of India, has high mental healthcare needs. As per the National Mental Health Survey (2015–2016), the treatment gap for psychiatric disorders is close to 85%. ¹ It also assessed the availability of mental health resources, infrastructure, and supportive frameworks and found gross deficits in all the domains involved in the provision of mental healthcare. ² With the vision to improve the quality of healthcare, including mental healthcare, in several Indian states, service bonds are made mandatory for getting medical degrees (undergraduate, post-graduate and super- specialty). This measure is expected to increase the mental health of human resources in public health and rural settings, as the psychiatrists are also bound to serve for the specified bond duration in different states. However, recent years witnessed significant challenges in effec- tively implementing this initiative, which we would like to highlight in this communication.

The foremost is the nonuniformity in the provision of service bonds and their implementation across the states. The states have the power to make public health-related rules. Their discretions regarding the bond duration, the amount one has to pay so as to not serve the bond, and the location of postings have contributed to gross nonuniformity. This gives rise to dissatisfaction among healthcare providers and disparity in service provision. Secondly, the service bond hampers the students’ pursuit of higher studies, especially the short-term post-doctoral fellowship courses. Thirdly, the frequent change in bond-related policies makes it difficult for students to plan their future. Fourth, psychiatrists are often posted at places where their skills are not adequately utilized because of the lack of infrastructural support.

Thus, regarding the efforts targeted at recruiting and retaining workforce in rural areas, the following issues need to be addressed: (a) the nonuniformity of the service bonds across states (despite students appearing and securing ranks in a common national level examination), (b) administrative delays in the recruitment or hiring process, (c) lack of role-clarity (at times specialists are posted at places where the infrastructure is lacking for them to exercise their skills), (d) uncertainty about career prospects, (e) lack of infrastructure, and (f) lack of incentives. ³

Service bonds are intended to improve rural healthcare. Meanwhile, the issues mentioned above are not adequately addressed. Thus, it becomes highly questionable whether such a policy (service bond for medical graduates and postgraduates), in its current form,^4–6 can improve the retention of doctors in rural areas. Rural recruitment under service bonds, for a mandatory period of a few years, does not ensure the provision of long-term good quality mental healthcare. ⁷ Instead, giving consideration to young doctors’ future career choices and providing them with the option of permanent recruitment on serving in rural areas will act as an immediate incentive and help them plan their long-term career goals. Also, there should be a certain level of uniformity across the states concerning this policy, to reduce any dissatisfaction creeping in among doctors (e.g., currently, for MBBS students, the bond amount is ₹5 lakhs in Goa and ₹1 crore in Uttarakhand). There is a need for strong political will, adequate funding, and better solutions to cater to the needs of graduates and postgraduates and not just rigorous implementation of service bonds.

To enhance mental healthcare at the community level, particularly in deprived areas, the government of India has been running the “National Mental Health Program (NMHP)” over the past several decades and periodically making amendments by addressing the loopholes. ⁸ The District Mental Health Program (DMHP) is being expanded to encompass rural mental healthcare. Recently, the Tele-Manas program has been introduced to provide mental healthcare to people in need. The Mental Healthcare Act 2017 emphasizes the provision of essential mental healthcare for all. Strengthening all these structural changes is expected to enhance the availability and accessibility of rural mental healthcare for all and would be sufficient to replace the rural bond service of psychiatrists. Meanwhile, the postgraduate psychiatrists serving the bond, need to be utilized optimally for effective implementation of DMHP (by appointing them at the DMHP districts), where they can get ancillary support from the mental health team (counselors, psychologists, trained nurses and social workers). This may help in enhancing rural mental healthcare.