1.1 The disadvantages of underdevelopment.

Bound within this concept lies the need for more general development of infrastructural facilities in rural areas, which hampers the quality of life for specialists working in rural areas. Specialists working at rural CHCs face significant challenges stemming from inadequate infrastructural development such as residential facilities, educational infrastructure and workplace location. The specialists believed the lack of proper residential facilities interfered with their privacy and lifestyle. The lack of maintenance and essential facilities like stable water and electricity supply at the allotted residential quarters added to their daily burden.

As shared by a PG medical resident (male, 31 years, Government medical college),

‘The quarters are never good for a specialist to live at the CHC level. Basic facilities are always compromised. There is no electricity facility, water supply or security. This is one of the big reasons for specialists not joining rural jobs!’

They felt unsafe and vulnerable when impatient villagers demanded services outside their working hours contributing to their struggle to live in these areas with their families. A specialist physician (male, 40 years, rural CHC) shared, ‘Some villagers never understand that we have a personal life. They come to seek treatment after we have reached home and our working hours have ended, thinking that being physicians, we are made for them and bound to become available all the time for them. We cannot deny them. Otherwise they create unnecessary trouble for us.’

Since it conflicted with the specialists’ goals for family life, the lack of educational infrastructure at rural CHCs was found to be a more significant concern among most of them for not joining the rural health centers. Although highly educated and skilled, they shared that they have had to compromise on their children’s educational needs, recreational activities and personality development. This shortcoming becomes a barrier to retaining specialists in rural health centers, as it contradicts their dignified lifestyle.

A specialist physician (male, 35 years, rural CHC) shared,

‘Being a specialist physician, you also want a living status for yourself and your family. This is not possible in a rural setting. There is always a lack of good schools and proper recreational facilities for children. There is a lack of other basic facilities that one cannot compromise.’

Additionally, far-away workplace locations from one’s hometowns, family concerns and inadequate transportation facilities in rural settings significantly hinder specialists from reaching the health centers in time. They felt that job postings were hardly assigned to them near their hometowns, which made them unwilling to join and continue their jobs in rural areas. A specialist physician (male, 38 years, Government DH) shared,

‘What happens is that a specialist is never given a posting in his hometown. He is always placed at locations far away from his hometown. How does continuing with jobs in such a scenario make sense? A person has a family life also.’

Such combined infrastructural deficiencies foster an environment where specialists struggle to reconcile personal and professional responsibilities, exacerbating systemic dissatisfaction with rural healthcare assignments and making rural healthcare postings an unappealing choice for themselves.

1.2 Local political climate.

The ‘local political climate’ category reflects the work environment of rural CHCs, which specialists perceive as being shrouded in power dynamics of non-technical people such as the village Sarpanch and members of the legislative assembly (MLAs). Such an environment is characterized by a lack of formal operational mechanisms and a socio-economic-political backdrop. A Sarpanch is an elected decision-maker inside the village-level constitutional entity known as the Gram Sabha in India [37]. An MLA is an individual elected by the constituents of an electoral district to serve in the state legislature under the Indian system of Government [38]. Panchayati Raj Institution (PRI) is a system of local self-governance for villages in rural India, which seeks to implement local democracy and promote development in rural regions [37]. As per the Panchayati Raj System, which was introduced nationally in the year 1993, the village head Sarpanch and other elected members at the district level have the right to monitor and demand quality health services as part of empowering the communities and improving accountability of the healthcare system [37]. However, the specialists were firmly against the excessive involvement and escalation of power to these people to constantly monitor and govern them despite being untrained in the functionality of the healthcare system. According to the specialists, as elucidated below, the involvement of such local governing authorities has disrupted their internal accountability, professional autonomy and identity.

A specialist physician (male, 36 years, rural CHC) shared,

‘Sarpanch thinks that everything is under their control and interferes in everything we do. They will even check our attendance register and inspect everything about who is coming, who is going, and day-to-day work-related activities, despite not knowing the medical health system.’

Likewise, specialists perceived their transfers as unjustified without a well-defined transfer policy. They found transfer policies strictly politically driven, which lacked procedural fairness and rationalization in their execution. Only those with firm political connections enjoyed the perks of getting their desired rural postings in the system, while the rest struggled to survive. Firm political grounding coupled with poor execution of HR policies contributed to their low morale, inadequate geographical distribution and migration.

A specialist physician (male, 37 years, Government DH) quipped, ‘There is no policy like a transfer policy. They can post anyone wherever they want to post them.’

Similarly, promotions in the healthcare system comprised elements of ‘political unfairness’ as they favored specific groups of people and offered specialists limited room to shape their career prospects and build their capacity. Specialists shared that promotions to senior authority positions, such as chief medical and health officer (CMHO) and block medical and health officer, were not rationalized and lacked appropriate evaluation channels, which lowered their work satisfaction.

A senior specialist physician (male, 68 years, retired) claimed,

‘Now, the entire setup is political. If a specialist is politically powerful, he easily becomes CMHO.’

Meanwhile, due to the lack of capacity-building workshops at rural CHCs, specialists also felt the challenge of their professional upskilling. They further expressed that due to systemic pitfalls, they could not use their professional clinical competence, making them feel like program managers rather than specialist clinicians with specific medical skills. They started feeling a never-ending juxtaposition between their clinical roles (which they were trained for) and their managerial roles (which they were expected to perform) to survive and serve the authorities’ ulterior motives. Specialists were also uncomfortable knowing that the system worked in a way that made them feel used and taken advantage of. A specialist physician (female, 34 years, rural CHC) added,

‘Training is never related to getting acquainted with new methods or for our capacity building, but it is always related to launching new programs, which is useless to us as specialists.’

Rather than systematic and transparent evaluation procedures, practices focusing on managing health program implementation (number of immunizations administered, diagnostic tests conducted, sterilizations performed and other related follow-up activities) instead of the health-related clinical outcomes were used to assess the performance of specialists. Such performance evaluation procedures created a sense of discontent among the specialists.

A PG medical resident (male, 34 years, Private medical college) shared, ‘There is a monthly system for providing performance feedback to us, but unfortunately, the feedback is not about the clinical treatments we do; rather, it is based on our clerical activities.’

At the same time, specialists perceived certain healthcare system practices, such as medico-legal cases as morally corrupt and unethical. Medico-legal issues refer to medical and clinical cases with legal implications [39]. They found this strictly unethical due to a lack of autonomy to exercise their professional rights. Ethical issues in medico-legal cases and diminished autonomy in decision-making intensified feelings of moral conflict among the specialists, which was evident in the narrative given by one of the specialist physicians (male, 37 years, rural CHC), wherein he was asked to fabricate a patient’s clinical report to help the patient’s family claim financial benefits from targeted government health insurance schemes. Concerned about his job security, he felt powerless when one of the local political figures asked for an unwarranted favor because his refusal could have adversely affected his future professional prospects. According to him,

‘If someone from a rich family expires in the village, then a specialist is pressurized to make false postmortem reports for his death. Maybe that person died due to a heart attack, but we are forced to make a false document for that person, stating that he died due to falling from a height.’

The same participant added, ‘A specialist is supposed to sign fake documents for a patient’s family, and if he denies it, he gets a call from some minister. Moreover, he must sign; otherwise, he gets his transfer the next day.’

Such a local political climate involving systemic deficiencies at multiple ladders at rural health centers undermined specialists’ ability to uphold their professional identities and self-esteem, leaving them undervalued, underutilized and disconnected from their intrinsic roles as specialist healthcare providers.

1.3 Healthcare system factors.

The ‘healthcare system factors’ category refers to the working conditions and hierarchical organization structure and processes at rural CHCs. The specialists perceived the workplace infrastructure of rural CHCs as limiting their ability to utilize their specialized skills, as there was often a scarcity of proper medical equipments, functional operation theatres, blood banks and essential facilities like water and electricity. The rigid allocation of resources did not cater to patients’ needs limiting specialists’ ability to provide care; for instance- specialists were compelled to prescribe drugs that were in supply rather than those needed by patients.

A specialist physician (male, 39 years, rural CHC) shared, ‘There are no medicines available that we want to give to the patients, no facilities, no investigations, and no instruments we want. There is no proper availability of water and electricity in rural CHCs. Even blood banks are far away, making patient care difficult. Unfortunately, we are forced to prescribe specific drugs that are in current supply, even if they are not adequate for the patients.’

Despite being competent enough to perform advanced investigations or surgeries, the specialists felt like birds without wings as they only had the facilities to perform simple surgeries and refrained from taking complicated medical cases.

A PG medical resident (female, 34 years, Private medical college) added, ‘Machines need to be better in terms of their functioning ability; they always have some technical errors. Moreover, if they will not function, how will we function? So, we refer patients to higher health facilities despite knowing we can treat them.’

Specialists further stated that the burden of participating in multiple meetings at the block and district levels shifted the focus of those in charge of the system from patient care to implementing public health management programs. Such non-clinical administrative tasks used to pile up their workload beyond their sanctioned working hours. Staying at the rural CHCs after working hours due to the constant influx of patients made them feel overburdened in the absence of other specialists and subordinate staff.

According to a specialist physician (male, 35 years, rural CHC),

‘We have to perform all the tasks except treating the patients. We are never asked about how many patients we treat and how many we refer to the next level. Instead, we must update the system about implementing different health programs. Because of such things, we are always busy making and sending the reports.’

Despite their desire to concentrate on providing patient care, HR limitations reduced their ability to meet these expectations. Another specialist physician (male, 38 years, rural CHC) shared,

‘The whole subordinate staff is untrained. They do not even know the basic procedures to perform. We have to tell them everything. We do not have a team of other specialist physicians, like anesthesia, without whom we cannot perform surgeries effectively.’

Monetary incentivization was the major motivation for the specialists to accept rural postings. However, they soon desired salary increments after realizing the working conditions were inconsistent with their work parameters and career standards.

One specialist physician (female, 35 years, rural CHC) expressed, ‘Salary is the only and one of the major things that motivates us to join rural jobs. But still, we feel unsatisfied because nothing, like work conditions, infrastructure and living conditions, aligns with what we need to work at the rural CHCs.’

Complex interplay of civil society and healthcare system factors: In the rural healthcare system context, the complex interplay of civil society and healthcare system depicts the intricate accountability mechanisms of relationships among local governing bodies, senior administrative officials, rural communities and specialists in rural CHCs. The extent to which specialists can effectively exercise their professional autonomy to provide health services in the rural sector depends mainly on the interplay between civil society and the healthcare system. Such an interplay highlights how the current healthcare system, rural communities, combined ownership of local governing bodies and senior administrative officials have interfered with specialists’ professional autonomy and competence in the health system over time. This interplay is driven by resource scarcity, skewed power relations and a lack of sovereignty to exercise accountability. These factors impact their overt and covert experiences influencing their self-esteem, self-perceptions and professional identity. It leads to two intermediate consequences: extrinsic, including power struggles with senior administrative officials and local governing bodies, uneasy patient relations; intrinsic, which includes compromising with deskilling and self-role distance.

2.1 Extrinsic consequences.

The persistent struggle for power by the Sarpanch, local political leaders and senior administrative officials limited the work freedom of specialists as reputed health professionals. Despite learning the necessary skills and undertaking advanced training, the specialists reported having no right or say in the system. According to them, the constant burden of maintaining accountability without authority and an authoritative leadership style by non-technical people and senior authorities added to their invisibility in their professional roles. Such power struggles created a sense of entrapment and exasperation among the specialists making them feel caged and powerless.

A specialist physician (male, 37 years, rural CHC) shared, ‘The medical exam is one of the toughest exams in the country. Even after learning and practicing so much in the medical field, we still cannot perform our role as we lack work autonomy due to interference of Sarpanch and other people, which makes us feel powerless.’

According to the specialists, a general mistrust of clinical treatment procedures existed among the rural community members which hindered the establishment of compassionate relationships with the patients. Specialists revealed that they always bore the brunt of the health facilities’ inadequacies while being constantly judged for their actions and poor patient clinical outcomes (which, in reality, result from the lacunae in the system). With this lack of mutual understanding critical to their relationship with patients, they reported that they were never at ease in the community. A specialist physician (male, 35 years, rural CHC) stated,

‘In today’s times, the most important thing to a specialist is saving his life because if something unfortunate happens due to a systemic fault, 15 to 20 people will gather at that place (CHC). So, in that case, I will refer the patient to the next level. Because, unfortunately, if he dies, then I have to face serious consequences.’

Strong solidarity between the villagers and the local leaders often made the villagers vicious in strategically seeking the community’s attention for political benefits through unnecessary protests. The use of threats and violence during political negotiations indicated the relentless nature of the local communities in demonstrating their control of the health centers. Such malevolence often made specialists vulnerable, with neither their physical nor psychological safety considered a priority. A specialist physician (male, 36 years, Government DH) shared,

‘The more nuisance villagers create, the more attention they will get from the rural public and through such activities, they want to gain fame for their political leaders by highlighting them. I have seen it; physical violence is a huge issue.’

2.2 Intrinsic consequences.

Specialists working at rural CHCs faced internal psychological struggles that profoundly intensified their struggle in terms of ‘Compromising with deskilling’ and ‘Self-role distance.’

Compromising with deskilling refers to adjusting to the diminished skill level necessary for accomplishing specific tasks [40]. Specialists had complex reminiscences of their professional experiences. They were tacit in their feelings of being deskilled, pertinently rationalizing it by acknowledging the resource-poor restricted settings of their professional work environment. Although they aspired to provide complete patient care, the absence of workplace infrastructure, work autonomy, essential tools and assistance compelled them to diminish their standards, resulting in feelings of compromising with their deskilling and inadequacy. The identified deskilling outcomes encompassed diminished clinical knowledge, reduced patient trust and lowered confidence in clinical decision-making.

A PG medical resident (female, 33 years, Government medical college) shared, ‘We work so hard to enter our professional medical journey. However, soon after being in the system for 3-4 years and facing the realities of our work environment, we realize we have only one option except to accept this scenario, and gradually, we lose touch with our learned skills.’

Besides this, the experience of self-role distance created an inner battle among the specialists as they felt conflicted between their professional ambitions and the rigid limitations of their work environment. Self-role distance is the psychological disparity between an individual’s professional aspirations and job experiences [41]. The specialists experienced a tangled web of behavioral complexities due to contradictions between their ideal and designated professional roles. Such role ambiguity impeded specialists’ job performance and goal attainment in providing specialized treatment services.

A specialist physician (male, 36 years, rural CHC), who is a surgeon by training but could not perform procedures at a rural CHC, shared, ‘There comes the point when we forget who we are! I had never felt so low and helpless in my entire life; despite being a surgeon, I was practicing as a general physician.’

These extrinsic and intrinsic consequences collectively depict the challenges of specialists in navigating low job satisfaction and increasing emotional disconnection from their professional roles in the rural healthcare system.

Deep-seated discomfort: The blend of intrinsic and extrinsic self-consequences contributed to the ‘deep-seated discomfort’ – a state of persistent unease with oneself, experienced by the specialists leading to several work-related psychological insecurities. This deep-seated discomfort created a strong enduring sense of distress resulting from underlying unresolved emotions and profoundly impacting their emotional and mental well-being. Ultimately, it became a critical determinant in their decision to remain within or exit the system.

3.1 Action-interaction strategy for those who exit the system.

The decision to quit the healthcare system depicts the ‘risk-taking perspective’ of the specialists who wished to guard their professional identity. This approach indicates the action-interaction strategy of those specialists who left the rural health system and joined private health facilities to protect their professional identity. For many specialists, compromised work autonomy and lack of workplace infrastructure limited their scope of practice to function efficiently. They could not identify themselves with their professional roles which made them feel hopeless about their current aspirations and future career avenues. They felt a strong compulsion to preserve their professional skills, attain higher fiscal benefits and attract favorable professional growth opportunities. Basing their decisions on their personal and family’s economic and psychosocial well-being and leaving the health system to regain their collective sense of self, some specialists found it challenging yet felt compelled to exit the rural healthcare system.

According to a specialist physician (female, 38 years, rural CHC),

‘The biggest issue is that we are educated and learn the medical sciences but do not have the environment to execute our learning there. What is the point of staying there when we have invested ten to twelve years in learning the skills, and despite that, we are not sure about our place in the system!’

Specialists leaving the system faced conflicts related to professional identity, diminished work autonomy, lowered self-esteem, emotional distress, economic and psychosocial difficulties, risks associated with career transition and challenges sustaining professional competencies, all of which obstructed their professional growth and aspirations.

3.2 Action-interaction strategy for those who remain in the system.

‘Acceptance and Adaptation’ constituted the action-interaction strategies adopted by the specialists to help them remain continuously committed to their jobs and stay in the system. These strategies reflected the specialists’ adaptive choices to sustain themselves in the challenging environment. Such strategies involved accepting one’s circumstances and accordingly adapting to the existing healthcare system’s functionality while compromising one’s expectations and self-needs. Specialists who remained in the system accepted and adapted to their surroundings drawing strength from their strong spiritual beliefs and philanthropic inclinations toward life and other human beings. They perceived rural people as denied essential healthcare treatment services. They were also compelled by an innate desire to help them to the best possible extent, prioritizing rural service over commercial ambition.

A specialist physician (male, 32 years, rural CHC) shared,

‘See, I have been a spiritual person since the very beginning of my life. So, seeing people’s problems, pains and agonies always used to melt my heart and push me to help them to the best of my capabilities.’

Another specialist (male, 38 years, rural CHC) said, ‘I wanted to serve the community from where I belong, and my motive has never been to make it a commercial job. So, despite all my disadvantages and limitations, I have accepted the circumstances and compromised with my expectations of being competitive.’

Other specialists felt the loss associated with quitting was too high considering the limited comparable job alternatives and the struggle to find one that aligned their professional dignity and economic well-being. They continued working there despite their knowledge, skills and expectations being compromised because of the decent salary packages, incentives for procuring admission to PG courses and the security of a government job. The advantages of government employment outweighed the sacrifices for autonomy, skill enhancement and career advancement.

According to a PG medical resident (male, 31 years, Government medical college), ‘I never wanted to work in the rural area, but I needed incentives to get admission to PG as it is a very tough exam. Also, sometimes, a government job provides job security and stability.’

The personal impact of sustained engagement in the rural healthcare system involved sacrifices to one’s professional autonomy and self-esteem, reduced clinical knowledge and the lack of skill development needed for professional growth among specialists.

Both strategies emphasized specialists’ resilience while highlighting the structural adjustments necessary to empower them in their professional roles. Their decision to stay or withdraw from the rural healthcare system has had various repercussions as outlined below.