by Dr M C Gupta
A critique of the Indian government's decision to start a short term rural medical course.
More than six decades after independence, India has not been able to provide proper health and medical care to about 70% of the billion plus population living in rural areas. On the whole, there is no shortage of doctors in India. The allopathic doctor-population ratio at present stands at 1:1,722, according to the Medical Council of India. It is 1:781 if those qualified in Indian medicine systems and homeopathy are also counted, as per the statement made in July 2005 by the minister of state for health and family welfare, Panabaka Lakshmi. [Ref-- http://www.financialexpress.com/news/doctorpopulation-ratio-stands-at-11-722/139...
However, the distribution of doctors is highly skewed, with the majority concentrated in urban areas.
WHY DON’T DOCTORS LIKE TO SET UP PRIVATE PRACTICE IN RURAL AREAS?—
The answer is simple. Remote and rural areas lack basic living and educational facilities, security and potential to earn a reasonable living, as also scope for career advancement for themselves and their family. These are legitimate expectations, rather essential requirements, for any citizen, not only doctors. Even otherwise, due to several reasons, there is a growing reluctance on the part of doctors to set up their own private practice. Two obvious reasons are lack of opportunity for professional advancement and the increasingly hanging sword of medical malpractice litigation. This trend has been obvious even in UK. In 1983, 46% of newly qualified doctors cited general practice as their first choice career. In 1993 only 25.8% did so, with a further drop to 20% in 1996 [Goldacre MJ, Davidson JM, Lambert TW. Career choices at the end of the pre-registration year of doctors who qualified in the United Kingdom in 1996. Med Educ. 1999;33:882–889].
AN IMMEDIATE APPROACH TO THE PROBLEM: TRANSFERRING DOCTORS FROM URBAN TO RURAL AREAS—
All doctors in government service are subject to transfer to any place as per government rules. If the government means business and if its tears for the rural population are genuine, there should not be any problem in filling up all vacant posts of doctors in rural areas by transferring doctors from urban areas. The vacancies thus caused in urban areas can be easily filled by fresh recruitments. Even if some vacancies remain in urban areas, it won’t cause any suffering to the people because there are enough private hospitals and nursing homes in urban areas.
OTHER POSSIBLE APPROACHES:
There could be other possible approaches for correcting the skewed rural-urban distribution of MBBS doctors:
ONE—(Waiver of fees): Government should grant waiver of fees or high concession in fees to those who join MBBS course under a bond and surety that they would serve in a rural area for ten years after graduation. The government will thus have no problem in getting enough doctors for all its rural health facilities. If the government is not able to offer a job due to any reason, it should be permissible for these doctors, under the conditions of the bond, to get a job in a non-government health facility in a rural area or to set up practice in a rural area.
In order to ensure compliance, the government should amend the Indian Medical Council Act, 1956, to incorporate a clause that such doctors who avail of free / highly concessional medical education in government medical colleges will, for a period of ten years, be given a temporary license to practice medicine, either in service or in their own private practice, in the defined rural, remote, hilly or tribal areas. Only at the expiry of this 10 year period will they be eligible for grant of permanent registration with the medical council. This will, in a simple deft stroke, solve the problem of lack of doctors in rural areas.
TWO—(Compulsory rural service for doctors): So far, the government has toyed with the idea of compulsory rural service for fresh medical graduates. This would be unfair to the rural population who deserve, like others, to be treated by experienced doctors. Additionally, it would amount to exploitation of fresh medical graduates. An alternative has been suggested by the Tamil Nadu Government Doctors Association. It has suggested that in states where there is an acute shortage of doctors in rural areas, the State Governments may direct the respective State Medical Councils to register all medical graduates for a period of 10 years in the first instance, which should include one year of compulsory rural service. Renewal of the registration should be subject to having rendered rural service at any time during the 10 year period.
THREE—(Incentives for establishing practicing in rural areas): Doctors should be encouraged to set up private practice in rural areas by providing financial and other support and incentives. Such support may be partly as free initial aid and partly in the form of soft loan from rural development bank.
FOUR —(Incentives for establishing hospitals in rural areas): The government should encourage establishment of private hospitals and nursing homes by giving financial and other incentives. If there are more hospitals in rural areas, this automatically means more doctors will be available there.
FIVE —(Reservation of PG seats): 50% postgraduate seats in medical colleges should be reserved for those who have worked in rural areas for 5 years.
SIX—(Other incentives): Provision of free housing to doctors; Provision of free quality education, including free boarding and lodging, to children of doctors serving in rural areas; free internet and telephone; subsidized transport facilities etc.
SHORT RURAL MEDICAL COURSE
On 23 December 2009, The Tribune carried the following news item:
“To cope with the shortage of doctors in the rural areas, the Union Health Ministry announced, its decision to create another cadre of medicos who will be deputed exclusively in villages. Besides announcing various incentives to encourage private players in the health sector, the ministry has also amended Act of the Medical Council of India (MCI) to facilitate opening of medical colleges and institutes in the rural belt of the country.
Addressing a function after laying the foundation stone of a hospital here, Union Health Minister Ghulam Nabi Azad disclosed that his ministry had already finalised a four-year course for doctors to create another cadre of medicos. "This new cadre would be below the present MBBS doctors but their degrees would be recognised by the MCI". The new course would comprise a three-year academic course and a one-year house job, he said and added that the MCI had already prepared the syllabus and it had already been sent to different states for approval. "We have already completed all formalities and now state governments have to take the final decision", he said. "Ultimately, state universities have to recognise the course".
Expressing confidence that the new cadre of medicos would revolutionise the health sector, Azad said it was mandatory for all doctors, trained in the four-year course, to serve only in the rural areas. "They would not be allowed to serve in the urban areas", he said and added that apart from this new cadre, MBBS doctors would also be deployed in the rural areas.”
COMMENTS ON THE ABOVE GOVERNMENT DECISION--
This decision has evoked strong reactions. It is a tricky subject. Much can be said for or against the government’s decision. As a matter of fact, I have passed through both phases. At first, my own reaction was strongly in favour of the short term course. Then, after interacting with many doctors, I started veering towards the opposite view. Recently, I came across two excellent articles in The Hindu. One was against the course (by former health minister Dr. Ambumani Ramadoss) and the other in its support (by Professor K.S. Jacob of CMC, Vellore). I have given below the extracts from both these articles, followed by my own views.
A—EXTRACTS FROM THE ARTICLE BY DR. ANBUMANI RAMADOSS—
The full article, published in “The Hindu”, 27 February 2010, can be viewed at
“The proposal to introduce a shortened medical course is a folly: it will aggravate the rural-urban divide and give a raw deal to villages.
The proposal put forward by the Central government to introduce a shortened medical course at the graduate level to serve the rural areas will only widen the rural-urban divide and impede India's role as an emerging global power. In seeking to virtually revive the Licentiate Medical Practitioners (LMP) scheme that was available before Independence, the government has taken a regressive step. And in the process it is resorting to discrimination against rural folk, who are taken for second-grade citizens deserving medical care by a brigade of ‘qualified quacks'………………. The LMPs outnumbered the MBBS graduates and largely served in the rural areas. Following the Bhore Committee report of 1946, medical courses were unified into the standard five-and-a-half-year MBBS degree.
The issue is the impact of this scheme on the status of the rural Indian. In what way are rural Indians different from their urban counterparts? Do they deserve health care from medical personnel who are less qualified than those who attend to the health needs of their urban brothers? Are their well-being and lives less important than those in urban areas? This discrimination could sow the seeds of disunity and discrimination. The scheme is against the spirit of the Constitution and human rights.
The proposal is superfluous, too. Any State can introduce a short-term medical course. We do not need a centralised concept of rural service, governed by the likes of the Medical Council of India (MCI).
The need is to utilise existing personnel prudently. Today even medical colleges recognised by the MCI, numbering about 300, face faculty shortage. How is the government planning to equip the so-called rural-based institutions that will eventually churn out semi-qualified medical personnel, with faculty and infrastructure?
India has a wealth of alternative medical systems such as Ayurveda, Siddha, Unani, Homeopathy and so on, that brings in hundreds of thousands of qualified medical professionals into the health care industry. They qualify after more than four years of training. It would be easier to use this huge corps of medical manpower according to the needs of the local regions rather than create a new cadre.
Today a nurse undergoes four years of training during her or his course, whereas the proposed BRMS course is for three and a half years. The rural folk would be better off being catered to by nurse-practitioners who are more qualified than the ‘qualified quacks.'
The doctor-patient ratio in India is 1:1,700. Add to this the doctors under the traditional medical systems and the ratio comes down to about 1:700. The World Health Organisation's recommended criterion is 1:300. To reach that target, we cannot go for short-sighted and short-term measures to create a cadre of semi-qualified professionals.
A committee under Dr. Sambasiva Rao (recommended) that anybody who aspired for a post-graduate degree should undergo a one-year compulsory rural posting. Unfortunately this recommendation came at the fag- end of my tenure. Had this been implemented, every year we would get nearly 30,000 fully qualified doctors working in Rural Health Centres.
The need is to start more medical colleges in areas such as the northeast, Bihar, Uttar Pradesh, Madhya Pradesh and Jharkhand. The country has nearly 300 colleges, of which 190 are in Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and Gujarat. Uttar Pradesh, with a population of 19 crores, has only about 16 colleges. Bihar, with a population of nine crores, has eight. Rajasthan with an eight-crore population has eight and Madhya Pradesh, with a population of eight crores, has 12. If the State governments open medical colleges in all the districts, we can have nearly 600 medical colleges, rolling out nearly 75,000 MBBS graduates a year.
We have another huge health resource pool to tap from: doctors trained in Russia and China. Their services can be utilised in the rural areas. Many doctors settle abroad. The government should take steps to prevent this drain by offering them attractive remuneration, avenues to train and upgrade knowledge and due recognition.
One school of thought favours admitting two batches of medical students in each institution every year – in the morning and in the afternoon. Clinical sessions could be alternated. By resorting to the double shift, we can double the number of medical graduates using the same infrastructure and faculty.
My suggestions in a nutshell are here. Make one-year rural posting compulsory for all MBBS doctors after internship. State governments should start medical colleges in every district to create more medical graduates. Increase the number of medical graduates and post-graduates using the existing infrastructure and faculty. Focus more on the northern and northeastern States. Expand and invest more in the National Rural Health Mission. Start government-run nursing colleges in all districts. Public-Private partnership ventures can be initiated, using the district and sub-district government hospitals for the purpose. Preference should be given to students from rural areas for admission to the MBBS courses, and it should be stipulated that the graduates work for five to 10 years in rural areas. The harmonisation and utilisation of doctors who have been trained in Russia and China, who have undergone seven-year MBBS courses, to fit into the rural programmes could help. The utilisation of doctors from traditional systems for specific needs and programmes could be planned. Anyone who wants to join a post-graduate course in a government college should have done a minimum of three years in a rural posting.”
B—EXTRACTS FROM THE ARTICLE BY DR. K.S. JACOB
Currently, the training of doctors occurs in tertiary-care institutions, with specialist perspectives dominating the curriculum…………. The long periods of training and the investment of time, effort and money, in addition, to the dependence on tertiary-care support and technology, make specialised physicians averse to working in small hospitals in rural India. Their narrow perspectives and circumscribed fields make them incompetent to manage common problems in primary and secondary care.
Most fresh graduates are uncomfortable in the alien environments of small hospitals and small towns where they are located. The vast majority complete their time limited obligations and leave; very few choose careers in primary and secondary care, opting instead to specialise and work in urban tertiary care. Such lack of long-term commitment among doctors to work in small hospitals weakens these institutions, resulting in their deterioration and eventual closure. The idea of a brief but compulsory obligation to serve in small hospitals in rural India is, thus, at best, a temporary solution and, at worst, a way to put fresh graduates completely off such service, thereby maintaining the status quo.
The reality of primary care and rural India demand locally relevant solutions. Training generic personnel with long periods of exposure to tertiary care and then transplanting them to smaller settings is a sure recipe for disaster. The lack of skill and confidence in managing common diseases, the excessive dependence on technology and the different demands of the context make young doctors opt out of such service. They would rather go back to their tertiary care institutions for more training to become specialists. Poor monetary rewards and limited facilities in small towns also add to their woes.
The medical profession, the world over, under the guise of being part of scientific organisations, has consolidated its power. Doctors form a powerful trade union, successfully lobbying to maintain their special status, vested interests and their financial clout. Their success is attributed to their ability to disguise their actual intention of maintaining their monopoly on the supply of expertise by using scientific, ideological and moral arguments. The majority refuse to acknowledge the suffering of millions of Indians who do not have easy, affordable and equitable access to health care.
The debate on health care for rural India often sheds more heat than light. The majority of doctors will neither work in rural India nor will they allow systems to develop to meet its essential health needs. Yet, they talk of equal status for their rural brethren at every opportunity; they argue for equality of health services for all. Cynics would argue that these attempts are aimed at maintaining the status quo which suits doctors' vested interests.
The disparity in health indices, infrastructure and personnel between rural and urban India demands urgent action and radical solutions........... The course should concentrate on prevention of diseases and on public health. It should train for the provision of basic curative services for priority health conditions. It should transfer skill and confidence. It should set out and teach the criteria for referral.
The focus of the current debate should be on the health of the rural population of India. Achieving health standards similar to those living in urban India in the foreseeable future should be the goal. Pragmatism, rather than ideological arguments, is called for. Support for better essential health services, rather than the current status quo of neglect, is a fight for social justice and for the human rights of all peoples.
C—MY OWN VIEWS—
Let us try to be objective and look at hard facts, which may be listed as follows:
1—India’s population is 1100 million. At the WHO recommendation of 1 per 300 population, as mentioned by the previous health minister, India needs 3.7 million doctors.
2—Discounting ISM (Indigenous systems of medicine) doctors for the time being, India has about 0.6 million doctors, the shortfall being about 3.1 million.
3—Current rate of production of MBBS doctors by the 300 medical colleges at present @ 125 per college would be 37,500 per year, at which rate it would take about 80 years to produce 3.1 million.
4—If the ex-health minister’s suggestion of having additional 600 state medical colleges, one in each district, is implemented, this will provide 75,000 more doctors per year. 75,000+37,500= 1,12,500 per year. At this rate, it would take about 27 years to produce 3.1 million.
5—The 600 state medical colleges at district level can be established at no cost to the government in the following manner:
a—Land can be donated free by a village willing to have the college situated there. The district medical college need not be necessarily opened at the district head-quarters.
b—Initial cost can come from willing corporate houses who can establish the college in their own name. They can be given appropriate incentives for the purpose.
c—Running cost can come from fees charged from the students. Those who cannot pay can be given soft loans. Others can be given free education on the condition that they agree to practice in the rural areas of the particular district for 10 years and in other rural areas of the state for next 10 years. These conditions can be made legally binding and enforceable by appropriate legislation, including necessary amendments to the state medical council act and the MCI act.
6—The situation can be reviewed after 10 years. If necessary and feasible, an additional medical college can be established in those districts which still have paucity of doctors in rural areas.
7—In order to ensure proper standards of medical education in the district medical colleges, a scheme should be evolved whereby all faculty in the existing medical colleges will have to work in the district medical colleges on transfer basis for a period of 5 years during their teaching career.
NOTE—The above proposal has the following advantages:
a—It is cost effective. No cost is borne by the state.
b—It does not involve experimenting with creation of a new cadre of doctors, which is potentially fraught with problems. It was because of serious problems that the government decided to discontinue the erstwhile LSMF course.
c—It will address automatically the basic reason why doctors are unwilling to work in rural areas, the basic reason being utter lack of basic facilities to live and work and treat and refer patients. Establishment of district medical colleges and actual availability of gradually increasing number of MBBS doctors in rural areas will lead to development of such areas. For example, it will lead to infrastructural development in rural areas. Medical colleges and hospitals in rural areas would mean better housing, roads, electricity, water supply, communications, schools etc. in rural areas.
This will help decrease poverty in rural areas.
d—It will not meet resistance from any quarter, in contrast to the scheme for a short term medical course, which is meeting stiff opposition. Even the national Human Rights Commission has objected to it, saying that those who live in villages cannot be treated as second class citizens.
e—It will decrease migration from rural to urban areas because earning potential and job creation in rural areas will be enhanced.
f—It will improve administration in general. Rural postings will be less likely to be avoided by employees in general if rural areas become better developed.
e—It will minimize the menace of quackery to a significant extent, where quackery is defined as practice of allopathic medicine by those not qualified in this system.
f—Through improvement of rural infrastructure in general and medical, academic and professional infrastructure in particular, including expected decrease in quackery, it will encourage MBBS doctors to settle / work in rural areas and not to get concentrated in urban areas, as at present.
-- M C Gupta
MD (Medicine), LL.M.
24 December 2009 (Revised 13 March 2010)