Abstract
BACKGROUND: Civil service and contractual recruitment are common recruitment pathways with significant differences in terms of security and benefits for rural doctors and their career trajectories. However, there are tensions between doctors' expectations of the systems and the systems' imaginings of what it offers in terms of recruitment. In this paper, we explore these tensions from the perspective of frontline public sector doctors. METHODS: This qualitative multiple-case study research was carried out in two Indian states. We used semi-structured interviews with 33 doctors and 28 key informants from the two states. Thematic analysis, using the framework approach, was used to arrange and synthesize qualitative data. In addition, job histories were constructed from the doctors' interviews to examine their experiences with recruitment and analyzed using simple numbers. RESULTS: The findings suggest that in one study State, the doctors and the administration perceive civil service and contractual recruitment differently with tensions between personal and systemic perspectives. Findings from this State suggest that contractual doctors conceive the progression from contractual to civil service recruitment as sequential. Contrary to doctors, health administration regards these two forms of recruitment as distinct-potentially complementary, but certainly strategic, but not necessarily sequential. However, there are several obstacles faced by doctors that negatively affect their expectations of progressing to civil service recruitment and their career trajectories. The critical obstacles are: prolonged contractual employment, irregular PSC evaluations, and decreasing opportunities to become civil servants. All these factors lead to discontent among contractual employees, with critical consequences for their career trajectories and job satisfaction. However, findings from the other State indicate the use of alternative approaches in recruitment, leading to frequent civil service recruitment and positive perceptions among doctors. CONCLUSIONS: The idea that civil service recruitment forms a continuum with contractual recruitment is a misconception held by rural doctors, while the administration sees important distinctions between them. This disjunction in perspectives is problematic, leading to negative perceptions and breach of doctors' assumptions, with broader implications. From a health systems and workforce perspective, the need for the administration to acknowledge and address disjunctions through effective human resource approaches is critical.