The health of many living in our rural areas rests precariously in the hands of doctors who do not exist.
If the dearth of health human resources is a major issue in the country, its severest impact is probably in rural areas. The facts tell their own story of neglect: Over 17 States have an excess of 10 per cent vacancy in doctor posts in Primary Health Centres.
Rural areas in the country are served through primary health centres. One PHC is provided for every 30,000 population, and in hilly areas, for every 20,000 population. Going by the figures sourced from the National Rural Health Mission by PRS Legislative Research, the human resources crunch is probably hampering the implementation of the progressive National Rural Health Mission programme in States, and thereby, the access to health care in rural areas.
In the list of vacancies of doctor posts in Primary Health Centres, Chhattisgarh is at the top, with 71 per cent vacancy. As many as 1,058 posts of doctors out of 1,482 sanctioned posts are vacant. PHCs are required to have one medical officer and 14 other staff. West Bengal (44 per cent), Maharashtra (37 per cent), Uttar Pradesh (36 per cent) and Mizoram (35 per cent) are also on top of the list with high vacancies.
According to the document, only nine States, including Bihar, Jharkhand, Jammu and Kashmir and Punjab have no doctor vacancies at the PHC level. Among the better performers are Rajasthan (0.4 per cent vacancies), Andhra Pradesh (3 per cent), Kerala (7 per cent), and Karnataka (10 per cent).
Human resources availability in rural areas is a major issue across the country, says A.Padmanabhan, Advisor, Public Health Administration, National Health, National Health Systems Resource Centre (NHSRC), under the NRHM. “This is not for doctors alone, but nurses and other paramedical staff too,” Dr. Padmanabhan says. A number of State governments want to fill these vacancies, they call for applications, even propose some incentives for these posts, he adds. “However, the vacancies remain. Professionals are not willing to work in rural areas, clearly.”
Dr. T. Sundararaman, executive director, NHSRC, says, “Where you have a vacancy it definitely affects the programme in a major way. A whole lot of work is done by the team to provide public health. Some of the key tasks are in prevention and there is not a very big barrier between that and curative work. Say, for instance in tuberculosis prevention. If you do not have the staff, none of your programmes get off the ground.”
Part of the problem is also the skewed distribution of medical colleges. “Tamil Nadu has 40 colleges, and Puducherry, nine. About 60 per cent of all medical colleges are located within the southern States,” Dr. Padmanabhan explains.
This is true to an extent, but it is not the entire problem, Dr. Sundaraman adds. “It is not just about expansion of medical colleges, setting up more colleges. Maharashtra, for instance, has a lot of medical colleges, but it still is on top of the list of vacancies. Tamil Nadu too has 27 per cent vacancy in doctor posts. What do you do to get doctors, nurses and technicians? What do you do to get them to stay and work in remote areas and villages?”
Are incentives the solution, then? “At some point incentives help, but only if they are large enough. For example in Thailand, if doctors in Bangkok are paid 20,000 baat, the remuneration for those who work in rural areas is two to three times more,” says Dr. Sundaraman. Efforts to introduce compulsory bonds to hold people in rural areas do not work basically, and are also difficult to enforce. It is also politically difficult to raise penalties for violations.
In the West, separate courses are being conducted for the practice of family medicine, or general medicine. “Christian Medical College, Vellore, is running a two-year distance education programme. Students who pass out under this can handle small issues in rural areas efficiently,” says Dr. Padmanabhan.
Short-term training can be provided under the NRHM for specialisations.
“It is interesting to see how the different vacancies are estimated (by States). It is not inherent or fundamental. How far is the problem remediable, here and now. We know that it can, and has been solved in certain places,” explains Dr. Sundararaman.
What really makes a big difference is to get people from that locality, train them there, and situate them.
