EXCLUSIVE "Doctors on Duty". Where in the world and how students are required to work in the state system, based on the model proposed by Bolojan

The policy of conditioning the completion of studies on a mandatory work internship in the country where they were trained periodically returns to the agenda of governments, especially in areas with a chronic staff shortage, but remains extremely controversial.

In this logic of contestation, there is also the proposal of Prime Minister Ilie Bolojan that graduates of state medical faculties be required to remain and work in Romania for a period of at least two to five years after graduation.

Why do these policies arise

Governments justify "compulsory service" or "bonded scholarship" programs through three main reasons: the high cost of training, the lack of personnel in disadvantaged areas, and the emigration of graduates.

In healthcare, training a doctor or a nurse means years of publicly funded studies; when graduates leave immediately for the West or the private sector, the state loses both the investment and the workforce it needs in rural areas.

The proposed solution is a contract: the state pays (partially or fully) the cost of education, and the graduate agrees to work for a determined period in the country, often in underserved areas.

How it works: the logic of "bonded"

Comparative analyses identify three major models of compulsory service: programs linked to licensing (without an internship you do not receive the right to practice), scholarships (funding involves a bond), or mandatory placement in certain public positions.

In many states, compulsory service applies mainly in healthcare – doctors, nurses, midwives, other professionals – and lasts between one and five years, usually in rural or peripheral areas.

Coercive mechanisms range from the withdrawal of the right to practice freely to substantial fines or the obligation to fully repay the scholarship if the graduate refuses to fulfill the obligation.

A classic example is the "bonded scholarship" scheme in several Asian and African countries, where medical students from public colleges sign a contract stating that, upon graduation, they will work for two to five years in the public or rural system; if they leave, they pay a penalty or refund the cost of their studies.

The German case: Landarztquote – contracted obligation

In Europe, Germany is one of the few examples of an explicit "bonded" system in civil education, through the so-called Landarztquote.

Several states reserve a percentage of medical school places for candidates who sign, before admission, a contract: in exchange for access to studies, they commit to becoming family doctors in rural or deficit areas.

The contract is strict: after completing residency in specialties oriented towards family medicine (general medicine, internal medicine, pediatrics), the graduate must work for at least ten years as a family doctor in a "Bedarfsgebiet" in the state; interruptions for pregnancy or parental leave automatically extend the duration.

Failure to comply with the obligation can result in a penalty of up to 250,000 euros in certain states, an amount explicitly designed to deter "evasion" from the rural system after the state has provided the study place.

Landarztquote strongly contrasts with the dominant European model, where publicly funded medical school places are not linked to post-licensing work obligations, but only to academic conditions and duration of studies.

Non-coercive models: Norway, France, the United Kingdom

Other European states have generally chosen to avoid legal constraints on graduates and to work with institutional mechanisms and incentives.

In Norway, the distribution of doctors in rural areas has long relied on a decentralized internship and training system in the northern part of the country: graduates receive a number and choose positions in that order, which leads many young doctors to isolated communities for 1–3 years.

However, it is more of a mandatory training stage than a "bonded scholarship": after completing their internships, doctors can leave the area or even emigrate, without penalties of the reimbursement type.

France faces "medical deserts", but the response is mainly focused on bonuses, installation facilities, telemedicine, and "citizen medical service" projects proposed as voluntary instruments, not as a general obligation.

The National Academy of Medicine has suggested a year of civic medical service for young doctors in underserved areas, but in the form of a voluntary contract, precisely to avoid infringing on the freedom of doctors to settle – a strong principle in French medical culture.

In the United Kingdom, the NHS Bursary financially supports medical and dental students in their final years, covering tuition fees and part of living costs, but without explicitly imposing a minimum number of years of work in the NHS after graduation.

Most graduates enter foundation training and specialization within the NHS anyway, which creates a de facto retention, but there is no legal clause of the type "work X years or repay the scholarship".

Beyond healthcare: education and STEM

The logic of "study now, serve later" is also found in other fields, especially in education and science.

In the USA, the TEACH Grant and other federal programs for teacher training condition the transformation of the grant into a non-repayable aid on the graduate's commitment to teach for four years in schools with low-income students, in disciplines with shortages; otherwise, the grant automatically converts into a loan that must be repaid.

The Philippines have developed science and technology scholarships whereby students who receive funding must work in the country, in the field in which they were trained, for a period at least equal to the years of the scholarship, thus contributing to the research and innovation infrastructure.

These programs do not formally block emigration, but make it costly: the graduate can leave, but assumes the repayment of the funding or penalties.

Effectiveness and criticisms: what studies show

Systematic reviews of compulsory service programs show a mixed picture.

In the short term, these programs do succeed in sending personnel to areas where otherwise no one would go: rural hospitals, isolated regions, poor communities.

Some participants remain in these areas after completing their obligation, but the proportion varies greatly: some studies indicate about 20% retention, others higher figures, depending on local conditions.

However, criticisms are consistent:

The quality of services may suffer when staff come just to "do the internship and leave"; disadvantaged areas become "training grounds" for unprepared young people, with very high turnover; the obligation may be perceived as unfair and demotivating, especially when infrastructure, salaries, and professional support are weak.

Additionally, there is a principled problem: how legitimate is it for the state to condition the right to practice or access to education on a forced work internship in a certain area, especially in democracies that protect freedom of movement and choice of profession?

Differences in philosophy: coercion vs. incentives

Comparing these systems, two distinct philosophies emerge.

The first is the coercive/contractual approach, in which the student signs an explicit bond: they receive funding, and in exchange, they work X years in a certain area or institution; deviation attracts penalties (reimbursement, fines, blocking the license).

Germany, through Landarztquote, and numerous states in Asia and Africa illustrate this model, especially for general medicine; for some, it is an acceptable compromise between public interest and individual freedom, for others, a form of "coerced service" in disguise.

The second is the incentive-based approach and institutional design, in which the state uses scholarships, bonuses, mandatory internships, decentralized training, and better conditions to make disadvantaged areas attractive, without legally binding the graduate to a job.

Norway, France, and the United Kingdom predominantly fit into this model, relying more on the combination of professional ethos, training planning, and financial incentives than on punitive contracts.

In the background, especially in Europe, there is also the legal constraint of free movement and the right to work within the Union, which makes it much more difficult to establish national regimes that condition licensing or funding on post-study obligations that would limit emigration.

The fundamental question: a tool of public policy or a form of coercion?

At the level of public policy, post-licensing compulsory service appears as a relatively cheap tool for governments: it does not need to quickly remedy territorial inequalities, but only to direct graduates to where no one wants to go.

In the long term, however, effectiveness depends on something else: if after two, three, or ten years the infrastructure remains precarious, salaries low, and professional support absent, the obligation produces only a continuous flow of young people who come "to the internship" and leave as soon as the contract ends.

The differences between systems actually show differences in vision: some states treat publicly funded education as a contract with mutual obligations, including service, while others see it as a social right that cannot be conditioned by an imposed work internship.

Behind the technicalities, the debate remains one of principle: how far can the state go in "tying" the careers of graduates to recover a public investment and repair its own regional development failures.

Analysis conducted with the support of Perplexity