Karnataka government attempts to ensure round-the-clock provision of healthcare services at government-run facilities through doctors paid on daily or per-case basis.
Published Jan 08, 2025 | 7:00 AM ⚊ Updated Jan 08, 2025 | 9:47 AM
File pic for representation. District Health and Family Welfare office issues memo asking private hospitals, clinics, doctors to provide wheelchair and ambulance for two days. (Wikimedia Common)
On 21 December 2024, when 25-year-old Vaishali Kotabagi arrived at the Hukkeri Taluk Hospital in labour, her family hoped for the safe birth of her child.
Instead, they left with unimaginable grief. A preventable tragedy unfolded as Vaishali was referred to the Belagavi Institute of Medical Sciences (BIMS) due to the absence of a doctor at the Taluk hospital.
Within hours of delivering her baby girl via cesarean section, Vaishali developed chest pain and died — a death her family attributes to negligence and a glaring healthcare failure.
Investigations into the incident revealed that critical care personnel, including obstetricians, were unavailable on-site, leading to a dire situation that could have been prevented with prompt attention.
This incident is not just an isolated case of negligence — it is a damning indictment of Karnataka’s inability to ensure that doctors reside in their designated district headquarters, a mandate often ignored despite its critical importance to rural healthcare.
To prevent such incidents from recurring, the Karnataka government recently issued two notifications: The first mandates that doctors stay at the accommodation/house/centre locations to ensure the timely provision of emergency services.
The second notification of the state government pertains to an alternative recruitment option.
With the intention of running services 24/7 and ensuring that health facilities at the taluk and district levels do not lack specialists, the Karnataka government has decided to hire specialists on a per-day basis at Ayushman Bharat Arogya Karnataka Scheme rates (ABArK) or on a per-case basis.
South First spoke to doctors and experts to understand if this was a good idea.
While a few were apprehensive about how the implementation of this scheme would pan out, some asserted without doubt that it would be problematic on several fronts.
Speaking in an exclusive interview with South First, state health minister Dinesh Gundu Rao discussed the matter of doctors not residing in the villages or taluks to which they are appointed.
Citing the example of the Ballari maternal death he said, “We want to ensure that the doctors and healthcare workers appointed for a particular taluk or PHC (primary health centre) remain stationed at the place where he or she is appointed. The problem occurs when they stay at districts and are not available in their designated hospitals.”
He said the state government would take to strictly monitoring whether doctors and other healthcare workers engaged by the government are present at their sites of work.
Gundu Rao also said the government wants to ensure that treatment is available at the PHC or taluk level facility around the clock, so people have no reason to mistrust government hospitals or fear that they would be too poorly staffed to deal with emergencies. He said the state would ensure that proper care is available for all women approaching a government facility during pregnancy.
“We want to create a triad. For instance, if there is going to be a gynaecologist in a Taluk hospital then we want to ensure there is also an anaesthesist and a paediatrcian as well. Similarly, we want to have two sets of these doctors stationed there so that medical help is available 24/7,” the minister said.
On condition of anonymity, a senior doctor in Chitradurga district hospital told South First, “The minister may have been advised that hiring doctors on a per-case or per-day basis would help ease the situation of lack of doctors and aid in providing medical care 24/7 to patients. However, this might only help specialists; it may not work out so well on the ground, in actual practice. Regular audits to ensure doctors reside in their designated locations, with strict penalties for absence from work can ensure they work as per law. However, the government also needs to offer a decent salary, options for career advancement, and an allowance for postings that involve some level of hardship to the families of doctors.”
In the circular issued by the Karnataka government on “Hiring of specialists against sanctioned vacant posts in health and family welfare department on modes other than fixed monthly remuneration,” the state government mentions that the decision to hire on a per-day or per-case basis was arrived at based on suggestions from district health and family welfare officers and district surgeons.
The rate to be paid to them per day would be arrived at by dividing the total monthly amount paid to a contract specialist by the number of working days in the month.
The doctors would be paid as per the number of days served by them, subject to the condition that they serve at least two days a week. The current per day rate, the circular said, was ₹3,930.
Meanwhile, under the new scheme of recruitment, a radiologist could be hired on a per radiograph/CT/MRI scan basis.
They can be given the liberty to either come in person and certify the scans or do the same through teleradiology, with the system to be provided by the radiologist. The rates for this can be fixed through a local tender, subject to an indication of some ceiling rates by the commissioner.
The funds for such recruitment would be drawn from the ABArK funds.
Speaking to South First, Dr Sylvia Karpagam, public health practitioner, said the decision by the department to hire specialists daily is problematic on several fronts.
This may be an attempt to plug gaps in the short run, she says. “In the long run, there needs to be investment by the system in more government medical colleges with specialised training, mandatory rural postings to different parts of the state, and permanent rather than contractual positions,” she says, explaining that healthcare is made possible through the web of interactions between practitioners, and the sharing of knowledge and experience from the more experienced to the fresh recruits.
Good support structures, networks of fellow doctors that one can rely on for advice in times of dealing with difficult medical conditions, proper support from paramedical staff, and good infrastructure are all vital to the provision of healthcare of good quality, she said, explaining that a public health cadre, like the one available in Tamil Nadu, is needed in Karnataka. The state needs to offer proper regulation and oversight.
Dr Karpagam explained that the private health sector lobby has grown tremendously, and its continued growth was dependent on the attenuation of the government system.
“The focus of the government should be on strengthening public health services rather than buying services piecemeal from the private sector, including daily services.”
Per-day, per-case hiring of doctors, she said, would lead to fragmentation and go against the vision of comprehensive and holistic health services. The accountability of the health system would become harder to establish, and patient care would suffer.
Interestingly, the literature available has shown that educational strategies were the most practiced retention approach for the healthcare workforce. They not only address the immediate need for skilled personnel but also ensure the alignment of healthcare practices with contemporary medical standards.
A study published in 2024 in BMC Health Services Research shows that a significant retention approach involves linking educational opportunities to long-term service agreements.
The study cites the success of programmes like Thailand’s CPIRD (Collaborative Project to Increase Production of Rural Doctors), which ties community-based medical training to mandatory rural service obligations.
Such initiatives can address immediate workforce shortages while aligning healthcare practices with contemporary medical standards. A senior doctor suggests a tailored version of this for Karnataka.
“The best approach would be for the government to sponsor medical students for postgraduate studies, with an agreement for a five-year service term post-training. A higher penalty for breaking this agreement could ensure a sustained supply of specialist workforce,” the doctor suggested, unwilling to be named in this report.
Financial incentives are another proven method for attracting and retaining healthcare professionals in underserved areas. The study cited earlier emphasises the importance of hardship allowances, regular salary raises, and performance-based bonuses in motivating healthcare providers.
Doctors from Karnataka stress the need for competitive pay structures to make rural postings attractive, especially for specialists.
“Financial incentives must be significant enough to outweigh the challenges of working in remote areas. Regular salary hikes and hardship bonuses can help retain talent,” Dr Karpagam said.
When a doctor decides to stay and work in a rural area, he or she would need requisite professional and personal support. The Karnataka government states that under the law, doctors need to be housed in the headquarters or taluk to which he or she is posted.
Public health professionals assert that doctors should ideally have conducive living conditions, flexible working hours, and decently equipped hospitals to be able to function well.
“These measures ensure doctors feel valued and supported, fostering long-term commitment to rural service,” a senior doctor from Davangere district hospital told South First.
Non-financial strategies like public recognition and proper integration of doctors into local communities also prove effective in retaining healthcare professionals. These could be cost-effective and foster a sense of purpose among healthcare providers. Public acknowledgment of their contributions can significantly boost the morale of doctors, explained the study.
(Edited by Rosamma Thomas).
