Health systems are increasingly being understood and described as complex adaptive systems. I attended an interesting discussion the other day at Health Systems Global on “Postings and Transfers” of healthcare staff, a cross-cutting issue in most countries, where a former bureaucrat from an Indian state was invited to share about measures that have been used to address these challenges. A good part of her narrative focused on how young medical doctors have been successfully encouraged to practice at remote hilly areas. This has been done by providing an incentive related to training opportunities in postgraduate medical education. A quota is reserved for those serving for a period of time at hilly and remote regions. She added that appointments at these remote centres are now in high demand, often receiving a far higher number of applications as compared to the number of such facilities. In effect, this was seen as an innovation/success.

Here I pause to provide context to the situation of young doctors in India, something the speaker was unable to do at the panel discussion mostly due to time constraints. A basic medical training is considered inadequate both by doctors and by the society in general (for various reasons), and so there is a great pressure on young medical graduates to enter a postgraduate training program. The process towards entry into a postgraduate training program in India may most accurately be described as a rat race. Some wise person has stated that in a rat race, even if you win you are still a rat. The reason it becomes a rat race is that the chunk of cheese is small and there are too many rats. There are relatively very few postgraduate training opportunities as compared to the number of young medical graduates. So much so that while preparing for these entrance tests (which can take on an average two years, while doing nothing else), most of my classmates lost enough weight to start resembling rats. I conveniently decided to exit the system early on by taking up a research career.

We have a situation where young doctors are desperate. So desperate that they would go to these to remote hilly areas to get an edge in the exams. This has led to another rat race for positions in those remote healthcare facilities. Therefore the life of a young medical graduate is basically a series of rat races, making “rat-triathlon” a more appropriate coinage. Due to this, it becomes a bit difficult for me to accept such incentives as innovations, though I completely agree about the need for doctors to work in those areas and other such areas of need. I guess most of the young doctors have very good experiences too from these remote areas effectively making them both good clinicians and also potentially community oriented.

Coming to the other side of the catch-22 situation, the health system also has another important priority, which is to increase the number of opportunities in postgraduate medical education. Now if these opportunities are increased, will it mean that the quota system progressively becomes an ineffective tool? As we can see, the two priorities here – postings in rural areas, and increasing postgraduate educational opportunities are in conflict with each other (by virtue of educational opportunities being used as incentive for postings to hilly regions). In such a situation, how else might we bring doctors to those areas? Maybe I’m just over-thinking it, and there will always be young doctors dependent on such systems for accessing better opportunities, educational or otherwise. Or there will be other incentives, which will appear with changing times, needs and situations.

These were just random musings that occurred to me while listening to the delegates the other day.