Compulsory service programmes have existed since the early 20th century. Different names have been given to such programmes, including "obligatory", "mandatory", "requisite" and "coercive" programmes. In this paper, we will use the term "compulsory service" to describe such programmes. Literature shows evidence of programmes in the Soviet Union in 1920, (1-3) in Mexico in 1936, (1) and in Norway in 1954. In the 1970s, there was an acceleration of new programmes worldwide. No one reason is evident for this rapid growth, though this decade witnessed an overall increase in attention paid to inequities in health provision (as evidenced by the 1978 adoption of the Declaration of Alma-Ata), as well as increased worldwide interest in socialist ideologies, especially the belief in national service and pride. Over the years different countries created and implemented compulsory service programmes, one of the most recent ones was started in Ghana in 2009. Fig. 1 shows more than 70 countries with current and past compulsory service programmes. The map shows countries where this study found corroborative evidence of compulsory service programmes as well as countries where it found some indications, but no corroborative evidence.
Robust information on the specifics of compulsory service programmes is not readily available. We did a country-by-country inventory of all Member States of the World Health Organization (WHO). We did a literature search, formal interviews, as well as informal questioning of relevant informants to identify countries with compulsory service programmes and their details in each of the WHO regions.
A literature review was conducted of internet databases (Box 1) using the following terms: bond doctor, bond scheme, bonding, bonding medical, compulsory medical, compulsory medical service, conditional medical, conditional scholarship, mandate doctor, mandate medical, mandate nurse, mandate rural, medicatura rural, obligatory medical, obligatory service, coercive service, rural health service, rurales, social doctor, social medical, social nurse, [COUNTRY NAME] health human resources, [COUNTRY NAME] health human resources rural. A "snowballing" technique was employed, whereby references were culled from each document for review. All searches were conducted in English, though laws published in French, Portuguese or Spanish were reviewed after translation using Google Translator. Documents found included peer-reviewed articles and grey literature, historical and journalistic accounts, policies and laws. Documents were excluded from review if they did not specifically mention one or more compulsory service scheme.
To better determine the different requirements, interviews with key government officials from nine countries were conducted. A questionnaire was developed after a preliminary review of literature on compulsory service. This questionnaire was pretested in consultations with health workforce experts from five countries that provided feedback. The questionnaire was modified accordingly. Officials completing the instrument either via e-mail of telephone represented Australia, Ghana, Haiti, India (Tamil Nadu, Meghalaya), Mozambique, Nigeria, Norway, Peru and South Africa. Interview topics included: (i) history, (ii) description, (iii) administration and finance, (iv) outcomes, (v) problems/challenges, and (vi) advice to others regarding compulsory service programme implementation.
Classification of programmes
Based on the literature review and key informant interviews, a tripartite classification system for compulsory service programmes was developed (Fig. 2). The types are: (i) condition of service/state employment programme, (ii) compulsory service with incentives, and (iii) compulsory service without incentives.
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Condition of service
These programmes require health professionals to work for the government. …