We examined the experiences of public sector doctors with recruitment in two Indian states. The paper highlights the discontent of AYUSH and allopathic doctors with the recruitment, but how this is consistently worse for AYUSH, especially in State 1, in several ways. One, there are significant discrepancies in salaries and allowances between AYUSH and allopathic doctors. Two, AYUSH doctors experience stagnated career progression and high job insecurity. Three, the system can sabotage AYUSH doctors’ expectations of progressing to regular recruitment. And finally, AYUSH doctors perceive the system to be highly inequitable and unresponsive towards their concerns, which has implications for health services. The findings are important from the perspectives of policy, implementation, and governance because, although the Indian government established the framework for AYUSH integration, our results show that the integration operates quite differently in practice in the two study states and that HRM practices, as perceived and experienced by the contractual AYUSH doctors, reveal significant inequity against AYUSH contractual doctors.
Our findings suggest that both AYUSH and allopathic doctors complain about failures in policy implementation in both states. For allopathic doctors, it is a result of bureaucratic inefficiencies due to failing to conduct regular PSC examinations. However, for AYUSH doctors, the failures in policy implementation are reported as worse, with significant inequities. The first form of inequity perceived by regular and contractual AYUSH doctors was the meagre salaries and the discrepancies in allowances, corroborated by other Indian studies [12, 14]. Another form of inequity reported in this paper was the lack of salary revisions and annual increments for contractual AYUSH doctors in State 1, unlike regular AYUSH doctors and allopathic doctors. Some Indian studies also support these findings with considerable disparities in salaries, lack of allowances for family, health, and housing, which further disadvantage AYUSH contractual doctors [12]. One of the key findings is the perceptions of unfairness among AYUSH doctors regarding the health administration’s reliance on and expectations of AYUSH doctors in meeting the health workforce requirements for rural postings and working nearly around the clock. Other than issues of working overtime, Indian studies have reported the poor facilities and infrastructure at rural health centres that AYUSH work within [12].
The most significant form of inequity experienced by AYUSH doctors is the lack of opportunities for regular recruitment in State 1. This is a key finding as it suggests that not only are contractual AYUSH doctors highly disadvantaged compared to allopathic doctors, but they are also worse off than AYUSH doctors from State 2 and other Indian states that offer regular recruitment for these doctors. From a policy and health workforce perspective, this is an important finding because although AYUSH has been integrated into health services through various initiatives such as the NHM, the reported disparities experienced by AYUSH doctors suggest a rather underwhelming implementation of the national policy to mainstream and integrate AYUSH into the system [12]. The lack of opportunities for regular recruitment in State 1 suggests the dynamics of the labour market, allowing the state to be in a much stronger position to negotiate and determine recruitment conditions, almost unilaterally in State 1. Studies in the area of health workforce from India have reported how the administration unilaterally determines doctors’ initial postings [16].
Many HRM issues identified in this research, such as poor salaries and incentives, lack of career progression, demotivation, and job insecurity, are linked to contractual recruitment, which was a central preoccupation for doctors. Unfortunately, the contractualization of labour in India is part of an increasing trend that has been ongoing since the inception of the NHM—India has seen an increase in the proportion of contract workers from nearly one in four in 2004/2005 to one in three in 2011/12. Researchers argue that contractualization has permitted the use of labour without according them workers’ rights [25]. Evidence from our research highlights this in the treatment of AYUSH doctors under the NHM, who are paid less than their counterparts, and other studies also report lower pay compared to other health workers like nurses [26].
Our paper also highlights that periodic assurances from the administration and the health system reforms in other Indian states have raised expectations among AYUSH practitioners regarding their regularization. However, these assurances are merely rhetorical, with the reality being that State 1 has failed to regularize the services of these doctors. The system’s failure to recruit AYUSH doctors can sabotage their hopes and expectations of progressing to civil service recruitment; thus, the doctors perceive these periodic assurances as manipulative—a tactic that allows the state to retain the existing doctors to meet its strategic needs.
The contractual appointment of AYUSH may be a strategic approach for the state to meet its temporary service demands, but from the doctors’ perspective, it is a tactical approach. This compounds many problems for doctors, including job insecurity and a lack of career progression, which are causes of demotivation among health workers in Sierra Leone [27], and public sector doctors and nurses in India [28,29,30,31]. Our findings suggest that State 1 continues to exploit the policy environment to determine recruitment legislation, policies, and structures, thereby enabling the state to maintain the contractual recruitment of AYUSH doctors without providing avenues for regular recruitment. Despite the high discontent and breach of expectations among AYUSH, the actions of these doctors are limited to requests, and the study participants did not report other forms of resistance. This is a striking finding considering the health system context in India, where recruitment-related issues have been challenged in courts [32] and other Indian studies have reported the use of strong resistance and power by the doctors to influence decisions related to their postings [17]. The researchers did not investigate the reasons for the lack of resistance from AYUSH doctors, but there are two likely explanations. One, the AYUSH doctors passively accept what the administration has to offer with the hope that situations would improve in the future—the periodic assurances from the administration partly support this. And two, the embedded medical hierarchies that have led to the marginalization of TCAM by the allopathic profession [33]. Thus, these doctors have little power to influence their recruitment, presenting a challenge to the effective integration of TCAM [34].
This paper also highlights the tensions between doctors’ expectations regarding the regularization of the very small number of AYUSH doctors in State 1 and the state’s reasoning for its inability to do so. The core of these tensions was the absence of the AYUSH cadre and department in the state, leading to expectation gaps. The absence of legislation/policies, a separate cadre, sanctioned posts, and the department of AYUSH in State 1 is suggestive that the national policy articulations on the integration of AYUSH are not effectively translated into the state context [9]. While our study was not designed to explore the reasons for the absence of the AYUSH department in the state, literature suggests that a single department may govern all the prevalent systems of medicine, creating problems of hierarchy, inequitable representation, and marginalization of specific systems of medicine [9]. Thus, our research highlights the need for an institutional environment that effectively integrates different systems of medicine, enabling inter-system coherence in addressing the tensions and expectation gaps between AYUSH doctors and the state.
The sense of severe inequity experienced by AYUSH can negatively affect their motivation and trust, with critical implications such as poor retention and potential conflicts between doctors and the system. Thus, the issues highlighted in the paper have implications for health services that must be addressed before tensions between doctors and the administration escalate to levels where doctors resort to strong resistance and protests. Protests are reported when governments fail to address issues between health workers and the administration until the health workers resort to demonstrations [23]. A recent newspaper article from India reported that 800 AYUSH doctors protested in the state of Karnataka against discrimination in salary and allowance paid to them compared to the doctors working in the allopathy department [35]. Similarly, in LMICs like Nigeria, other health workers have alleged that the Nigerian health system is designed to favour the doctors [15]. The dominance of doctors over the years has encouraged other health workers to form a new group called the Joint Health Sector Unions in Nigeria [15].
The inequalities related to HRM, especially concerning the recruitment and employment of AYUSH doctors, highlight the complexities and realities faced by gig workers. This creates an institutional environment where the state can unilaterally set recruitment conditions, which may have serious implications for attracting and retaining health workers. Additionally, existing insurance schemes like Ayushman Bharat exclude AYUSH treatments, potentially hindering the development of AYUSH facilities. All these factors worsen the issues related to the exclusion and marginalization of AYUSH doctors and systems.
Our paper highlights how the contractual AYUSH doctors perceive themselves as highly disadvantaged. Despite these findings, the case study design and findings from State 2 offer some positive insights into how the regular recruitment of AYUSH practitioners can effectively address the primary concerns of doctors. State 2 manages to adopt a more inclusive approach towards AYUSH doctors, with initiatives to address state-level variations in the regularization of positions, and is one of the first few states in India to have initiated permanent recruitment of AYUSH doctors. Thus, the practice from State 2 suggests less systemic bias and non-inclusiveness of AYUSH, effectively bridging some of the expectations gaps identified in the study.
In summary, the study highlights a range of known factors, including some critical ones, that facilitate the effective integration, recruitment, and retention of AYUSH doctors within the health system. Since recruitment into the regular service is key to retaining doctors and is closely linked to other HRM issues discussed in the paper, we provide several key policy and implementation recommendations drawn from this research. However, given the contextual nature of health and HR issues in India, these recommendations remain broad and tentative. The conflicting tensions, expectation gaps, and lack of trust experienced by doctors in their interactions with the HRM system, along with the ad hoc solutions, worsen the HRM issues. Negative experiences and perceptions of the system perpetuate inequity, uncertainty, and the exploitation of doctors by the system. Therefore, from an employee perspective, predictable and timely opportunities for regular recruitment are essential. This can lead to more positive perceptions among AYUSH doctors regarding their fair and equitable treatment, particularly concerning issues of pay parity. This can also be crucial in addressing career progression and professional equity issues. Addressing perceptions is at the core of HRM, as the perceptions employees have about HR practices can significantly influence their behaviour and ultimately impact HR outcomes [36]. However, ensuring professional equity, fair treatment, and opportunities for AYUSH doctors may not be easy to achieve. It requires significant policy and legislative changes—specifically, the creation of the AYUSH department and a separate cadre of AYUSH doctors to ensure there are enough sanctioned positions for recruitment. Lessons can also be learned from State 2, which has been quite successful in providing professional equity and predictable career pathways for AYUSH doctors. Implementing these changes necessitates a shift from the health system’s current ad hoc, short-term, and tactical approach. This requires various institutions, including the PSC, Health, Finance, AYUSH, and administrative departments, to unite and adopt a more holistic perspective on HRM. Another recommendation is to delegate recruitment roles and powers within the established structures and institutions, away from the PSC, to other bodies, as done in State 2. Such changes can occur without necessitating significant reforms or legislative amendments. This can address expectation gaps and likely contribute to improved trust and retention.
This study has several limitations. Challenges encountered in the field, including limited access to key policy actors, policy documents, and HR data from the states, as well as time and resource constraints, prevented us from conducting a comprehensive institutional and system analysis. The constraints in the sample, with a limited number of doctors interviewed from the two states, limit the generalizability of the study findings. Considering the diverse nature of states in India, and the significant differences in the two states and the employment conditions of the doctors compared in the study, we acknowledge that generalizability becomes a challenge. Nonetheless, the study findings resonate with and reflect similar issues in other Indian states, supported by the literature. Furthermore, our sample did not reveal contractual doctors from State 2. This, however, does not exclude the possibility of their presence in the service; it is an artefact of the sample. Finally, the doctors may have a recall bias in specifying the exact dates for job-related events related to recruitment.
In conclusion, this paper locates the positioning of AYUSH doctors within the HRM space. It provides insights into perceptible inequities and breaches of AYUSH doctors’ expectations and how the case of contractual AYUSH doctors represents an extreme form of inequity. The policy and institutional environment around AYUSH integration is weak, and there is a critical failure of institutions in responding to the expectations of the doctors. There are also inadequate translations between policy and practice, which leave unresolved larger questions around holistic integration and inclusion of AYUSH that ideally should place them equally with their allopathic counterparts. Most crucially, the policy and institutional environment has a strong bias towards allopathic doctors, leading to further exclusion of AYUSH [37].
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