Background Lack of adequate number of service providers in rural and hard to reach areas is a concern for policymakers and implementers in India. Development of robust promotion and tenure (P&T) policies is meant to provide an equitable and enabling working environment, and to reduce these deficits.

Methods We conducted our study on P&T policies in five Indian states, using a qualitative policy-mapping approach to allow for better understanding at macro level. We did a document review (policies and government orders, guidelines and other relevant literature) and conducted in-depth interviews with stakeholders comprising of 31 government officials, 21 service providers, and six representatives of staff associations. Matrices were drawn up to illustrate the content of documents and role of different actors in the implementation process. Data were manually organised by emerging themes and analysed.

Findings Common P&T measures that were seen across the five states were: (1) development of compulsory rural tenure, ranging from two to six years depending on the cadre and state context; (2) ceiling on the proportion of transfers (between 3% and 30% of the total cadre of workers); and (3) special privileges for social upliftment.

In India, states have developed P&T policies that are either in accordance with the needs of health department only or generic ones, catering to all government departments. Development of department-specific P&T policies aims to understand the service providers' needs and accordingly implement policies. Decisions related to postings and transfers of staff are taken at the state level. The need for authorities performing rational P&T is seen as essential. Currently the process is governed by authorities ranging from principal secretary (Health), who is responsible for transfer of medical officers, to Additional Directors (Health and paramedical services), responsible for transfers of other cadres.

Obviously, P&T procedures have to be transparent. Two of the five states have addressed this aspect through a web-enabled counselling process. Anticipated vacancies have also helped to bring transparency in P&T procedures. Providing special provisions for widows, women, and specially challenged – and listing them by priority – has helped in the retention of service providers in all five states. Initiatives like empowering committees to provide recommendations on transfer norms for medical and paramedical staff is undertaken in one state. The breach of minimum compulsory tenures for serving in rural areas is a common practice for doctors across all states. All the five states have introduced minimum tenure policy for general areas and rural areas, but the non-compliance has resulted in unfair postings and transfers.

Discussion P&T policies are meant to support health professionals. However, only a few of them truly reflect the professionals' needs and perspectives. Observations from the study indicate the need to augment policy changes including political commitment and increase transparency in P&T processes. These interventions will go a long way in building commitment for the policy implementers and enable service providers to work in such areas where they are needed most. Well-defined transfers and postings policies may be helpful to ensure rational rotation of staff across different areas. While implementing such policies, special relaxations for women should be made and the P&T procedures with the guiding rules may prove beneficial in this regard. To undo the urban-rural divide of the service providers, states should introduce and implement minimum tenure policy for normal areas and rural areas. Few states have already demonstrated this utility. The development of a Human Resource database, which is updated periodically, is essential for a transparent transfer process. Geographically defining areas based on the difficulty of the terrain and service weightage based on service in difficult areas will provide rational distribution of staff in rural areas.

No competing interest.