# Voices From the Field: Stakeholder Perceptions Regarding the District Residency Program Implementation in the State of Kerala, India

## TL;DR

This study explores stakeholder views on a medical residency program in Kerala, India, highlighting its benefits and challenges.

## Contribution

It provides insights from Kerala's unique implementation of the District Residency Program, offering lessons for national policy refinement.

## Key findings

- Residents gained diverse clinical exposure but faced infrastructure and supervision issues.
- DME and DHS officials noted program benefits but emphasized the need for standardized evaluation and coordination.
- The DRP improved training and healthcare delivery but requires infrastructure and monitoring improvements.

## Abstract

Background and rationale

The National Medical Council (NMC) introduced the District Residency Program (DRP) in 2020, mandating a three-month rotational residential work in district hospitals for postgraduate medical students with the aim of revamping the traditional postgraduate medical education system. Despite its potential benefits, the DRP has sparked debate among stakeholders. This study thus aims to evaluate the stakeholder perceptions and challenges in the implementation of the DRP in Kerala using a mixed-method approach. Unlike earlier evaluations from other Indian states, Kerala presents a unique context due to its early and comprehensive implementation of the DRP, strong public health infrastructure, and high stakeholder engagement, making it an ideal setting to generate transferable lessons for national-level policy refinement.

Materials and methods

The study was conducted at Government Medical College, Thrissur, Kerala, with participation from stakeholders across the state. A cross-sectional design was used for the quantitative part of the study, and the Delphi technique was used as a qualitative approach to identify perceptions of implementing officials and their proposed solutions to the issues identified. Informed consent was obtained from all participants before collecting information for the study. A total of 586 stakeholders participated in the study (residents n = 282; Directorate of Medical Education (DME) officials n = 180; Directorate of Health Services (DHS) officials n = 124). Quantitative data were analysed descriptively using IBM SPSS Statistics for Windows version 26, and qualitative insights were collected using a three-round Delphi process with 25 invited senior stakeholders (retention 88%).

Results

A total of 586 stakeholders participated (residents n = 282; DME officials n = 180; DHS officials n = 124). Most residents described district postings as providing diverse clinical exposure but identified gaps in infrastructure and supervision continuity. DME officials acknowledged the program’s positive impact on service delivery and training but noted the need for standardized evaluation systems. DHS officials reported improved patient care and staffing at peripheral hospitals, while emphasizing the importance of better accommodation and coordination mechanisms. The District Residency Programme (DRP) was perceived to have a positive impact on postgraduate training by enhancing residents’ clinical exposure, independent decision-making, and familiarity with peripheral health systems. However, gaps remained in infrastructure, supervision uniformity, and academic linkage between district hospitals and medical colleges.

Conclusion

The study highlights that while the DRP in Kerala has enhanced postgraduate training and strengthened district-level healthcare delivery, further progress requires investment in infrastructure, specialty-specific postings, and structured monitoring mechanisms to ensure uniform academic and service outcomes across sites.