Letter to the Editor
Service Bond and Rural
Mental Healthcare in India
in the 21st Century: Why
We Stand Here?
To the Editor,
T
he rural population, which con-
stitutes 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 resourc-
es, infrastructure, and supportive frame-
works 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 set-
tings, 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 com-
munication.
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 contrib-
uted to gross nonuniformity. This gives
rise to dissatisfaction among healthcare
providers and disparity in service provi-
sion. 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
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023
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) adminis-
trative 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 exer-
cise 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 ques-
tionable whether such a policy (service
bond for medical graduates and post-
graduates), 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 health-
care.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 stu-
dents, the bond amount is `5 lakhs in
Goa and `1 crore in Uttarakhand). There
is a need for strong political will, ade-
quate 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 com-
munity 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 health-
care. Recently, the Tele-Manas program
has been introduced to provide mental
healthcare to people in need. The Mental
Healthcare Act 2017 emphasizes the pro-
vision of essential mental healthcare for
all. Strengthening all these structural
changes is expected to enhance the avail-
ability and accessibility of rural mental
healthcare for all and would be sufficient
to replace the rural bond service of psy-
chiatrists. Meanwhile, the postgraduate
psychiatrists serving the bond, need to
be utilized optimally for effective imple-
mentation 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.
Declaration of Conflicting Interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
1
Letter to the Editor

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