It is noteworthy that health care-related subjects have been capturing media attention and holding it on for three months now. It started in February 2010 with the proposal for a short-term medical course to expedite the process of expanding the number of doctors serving in rural India. There has also been some focus on the inadequacy of funds to implement health care schemes and the need for increased spending on them. And then came the report that the Union Cabinet has given approval to a bill that would regulate private hospitals and pave the way for guaranteeing “the right to emergency care” for accident victims and the like.
As a prelude to ensuring ‘the right to emergency care,' the Union Cabinet recently approved the Clinical Establishments (Registration and Regulation) Bill, 2010; the hope is it will be placed before Parliament soon. The Bill makes it mandatory for all clinical establishments in the country to provide treatment to any person in an emergency condition. When the Bill becomes law, it will be the first piece of legislation to make it obligatory for the clinical establishments to provide emergency treatment to the needy.
Reluctance to treat accident victims
The Bill does not prescribe imprisonment for non-compliance, but it gives powers to the registering authority to impose a hefty fine (up to a maximum of Rs. 5 lakh). If not paid, the fine amount will be recovered under the Revenue Recovery Act. Clinical establishments are generally reluctant to treat accident victims, fearing legal problems, and so refer them to government-run hospitals. Several private hospitals and nursing homes refuse admission to women if they are not prepared to pay the treatment charges in advance.
The new enactment followed a Supreme Court direction, as far back as 1989, that emergency care should not be denied to anyone for any reason. In Parmanand Katara vs Union of India, the court accepted an application by an advocate. Referring to a news item titled “Law helps the injured to die” in the Hindustan Times , the lawyer brought to the court's notice the difficulties those injured in accidents faced in accessing to life-saving medical treatment. Many doctors and hospitals refused to treat them unless certain formalities were completed in these medico-legal cases. The Supreme Court directed the medical establishments to provide instant medical assistance to the affected people, notwithstanding the formalities to be followed under procedural criminal law. It has taken 21 years for the executive to come up with draft legislation on the subject.
The rigorous pursuit of neo-liberal reforms and the consequent withdrawal of the state from many areas in the social sector stood in the way of regulating private sector service-providers in respect of medical care. However, persistent efforts by social workers, political activists, and women's organisations have put some constructive pressure on governments at the Centre and in the States to think of some pro-poor healthcare reforms.
Welcoming an editorial titled ‘Empowering patients' in The Hindu (April 12, 2010) on the subject, a reader, S.V. Venugopalan of Chennai, stresses a patient's right to be kept informed of the nature of his or her ailment and the risks involved in the treatment. “Universal health care and an inclusive health agenda put in place by the Central Government alone will make hospitalisation an encouraging experience rather than a nightmare,” he writes. Well said.
Another aspect of health care that has been highlighted by Union Minister of Health Ghulam Nabi Azad is the poor status of public health and inadequate funding of medical care in rural India more than six decades after Independence. Mr. Azad's admission came as his Ministry was celebrating across the country the fifth anniversary of the National Rural Health Mission (NRHM). The Mission has achieved several targets but its major objective of putting a reliable rural health system in place needs a lot more attention, according to a study.
On the positive side, both maternal and infant mortality rates have come down to some extent — the former from 304 to 254 for 1,00,000 live births and the latter from 66 to 53 for every 1,000 live births. There is visible growth in the field of institutional delivery, which means more women go to hospital for childbirth under competent guidance. However, neo-natal deaths present a huge challenge in States like Uttar Pradesh and Bihar and chronic malnutrition and under-nourishment continue to take an appalling toll.
One of the major challenges in rural healthcare, according to Mr. Azad, is the inadequacy of funds for schemes in villages. “Rural health,” he points out, “needs a lot more attention and the government spending of just one per cent of the GDP on health is too low. We need to increase public spending.”
Shortage of qualified doctors
The third and other intractable problem is the well-known shortage of qualified doctors willing to serve in rural areas. The situation in 150,000 ‘Primary Health Centres' (PHC) in rural India is appalling. Since these PHCs have no doctors, many poor people have started going to the nearest town for treatment. Mr. Azad has highlighted the fact that 80 per cent of India's medical human resource is serving just 20 per cent of its people, most of whom are living in cities and towns.
The decades-old shortage of doctors has assumed emergency proportions in rural India, which accounts for a population of 740 million people. In the primary and community health centres, not more than 25,000 doctors are working, with a doctor-population ratio for the rural areas being 1:30,000 against the all India ratio of 1:1,722, which by itself is far too low.
This is in spite of the fact that every year, thousands of medical graduates are coming out of medical colleges, including many private colleges. A sizeable number of these doctors take up jobs in western countries. In the 1970s and 1980s, when there was an exodus of doctors, engineers, and technologists from India, there was some attempt to woo them back, on the moral ground that they had to return to Indian society some of the benefits they had received, for example through the state subsidising their education. Relatively few responded. Now, thanks to the withdrawal of the state from funding professional education, it is not realistic to expect the young men and women who study in private colleges spending several lakhs of rupees to be swayed by such arguments. It is also not surprising that the government's appeal to medical students and young doctors to serve in rural areas has met with no worthwhile response.
Course in rural medicine
Under the circumstances, the central government has turned to desperate alternatives, such as the proposal to start a three-and-a-half-year Bachelor of Rural Medicine and Surgery (BRMS) course for doctors to serve in rural areas. The proposal has apparently won the government's support, though it has attracted a lot of flak from the medical community and the media.
There are also moves to woo medical students with incentives. Mr. Azad has announced that new medical colleges would be opened across the county and the number of seats would be increased in the existing colleges. Interestingly, when this newspaper published an editorial, which highlighted the need to attract medical graduates in a big way to serve in rural areas but argued against the short cut of introducing a diluted medical course for rural India, as many as 40 readers responded with their comments and prescriptions. The newspaper also published some lively articles on the subject, one of which was by former Union Minister of Health and Family Welfare, Dr Anbumani Ramadoss, who expressed himself against the short-term course on the grounds that it was “discriminating” in nature and was “against the spirit of the Constitution and human rights.”
Mohammed Zainulabddin, writing from Gulbarga, expressed the view that rural folk would consider the proposed short-term course as discrimination and a violation of basic human rights. He suggested that pharmacy graduates, who have gone through a four-year course, be trained for the purpose. Their subjects of study are almost the same as those of medical students, with the notable exception of Clinical Practice. An additional one-and-a-half year course for pharmacy graduates on Clinical Practice would make them better qualified than perhaps a BRMS, the reader felt.
Professionally and intellectually as well as socially, there is no justification for making the kind of rigid distinction between urban and rural India that the proposed short cut implies. According to the World Health Report 2009, the world's population is shifting towards urban areas, with an estimated 49 per cent living in urban areas in 2007. Today's village is not what we knew 30 years ago. What justification can there be for segregating doctors, stipulating that this category with this diluted qualification can work only here and not there?
> readerseditor@thehindu.co.in
