A splendid response from readers to last week's column (‘Universal health care: media push needed,' December 27, 2010) denotes not only their deep concern for one of the major issues that confront them, but also their eagerness to share with others their understanding of the problem. The long letters from some readers testify to this. They register their displeasure over the failure of successive governments to evolve comprehensive, effective, and practicable healthcare policies — particularly during the last about three decades, which saw a gradual withdrawal of the state from health-related commitments.
Some noted that relevant issues such as the shortage of medical and paramedical personnel, the status of medical education, and health insurance schemes in many States could have been discussed in greater detail. Following up, this column addresses issues relating to medical education and also health insurance, which have seen some developments recently.
The content, quality, and status of medical education have a direct bearing on the quality of health care delivered in society. In contrast to engineering colleges, which have mushroomed everywhere, the number of medical colleges has grown very slowly. There are 273 medical colleges recognised by the Medical Council of India; they have a capacity to educate and train fewer than 32,000 students. The acute shortage of medical seats leads to an acute shortage of doctors, which continues to be felt especially in rural India. This hamstrings the functioning of rural public health centres and hospitals. Equally important is the question of quality. With talented doctors leaving government hospitals in large numbers to join corporate hospitals, government hospitals in urban India have also started feeling the pinch. The prohibitive cost of medical education, the capitation fee system that has managed to stay in many places defying adverse court verdicts, frequent changes in admission procedures, and hidebound professional opposition to major increases in the number of medical seats work against quantitative expansion as well as qualitative upgrading.
Dr. G.R. Ravindranath (Chennai) contends, in his e-mail response to last week's column, that privatisation of medical education has fuelled commercialisation of medical care. Rural hospitals suffer an acute shortage of doctors. His view is that if the efforts of the Medical Council of India (MCI) to hold a common entrance test succeed, it would do more harm than good for the less-privileged students. It might also affect certain special features of the reservation system in operation in Tamil Nadu. Further, students from non-Hindi States might find themselves disadvantaged, because they might have to write tests only in either English or Hindi.
The kind of situation Dr. Ravindranath discusses is not new. It is not difficult to understand the problems of aspiring young men and women seeking higher education in a multi-lingual, multi-cultured country. They will have to write the qualifying general academic examination in the next two months and sit for the entrance test (which was abolished in certain States, including Tamil Nadu some years ago). If a candidate is kept in the dark about the details of the admission procedure and the nature of the test, the mental stress can be imagined. Leaving such vital matters unaddressed, in uncertainty, is indefensible.
Misreading and confusion
The Medical Council of India (MCI) is yet to come with the needed notification and regulations for the common entrance test. To add to this, incorrect reporting of a brief Supreme Court order by a section of the news media, print as well as broadcast, caused some confusion in Tamil Nadu. Political leaders were critical of the entrance examination on the premise it would affect the implementation of the reservation system.
A report in The Hindu (December 14, 2010) said: “The Supreme Court on Monday [December 13, 2010] made it clear to the Medical Council of India that it could not grant approval for the proposal to introduce a common nationwide eligibility-cum-entrance test for MBBS and postgraduate medical courses from 2011-2012 even before the regulations were notified.” The Bench comprising Justices R.V. Raveendran and A.K. Patnaik said in a brief order: “We make it clear that the pendency of the application shall not come in the way of MCI notifying any regulations framed by it, in accordance with law, if it had been approved by the Centre. Nor would the pendency stand in the way of anyone challenging the validity of the regulation after it was notified.” For all this, the uncertainty over the entrance test continues for students.
One of the strategies adopted in various parts of the world to shield vulnerable sections of society from ill health is health insurance, the other one being government-run hospitals. Insurance schemes work well, particularly in respect of groups of people working in the organised sector. In such cases, either governments or employers pay the premia. But what is badly needed in India is a universal health insurance scheme to ensure decent medical coverage for all sections of the people. The Rashtriya Swasthya Bima Yojana (RSBY), the health care scheme meant for the Below Poverty Line (BPL) people, excludes a substantial number of middle income group people who do not have any insurance coverage. Those classified as BPL and covered by the insurance scheme are entitled to a maximum of Rs. 30,000 per family to cover hospitalisation charges. Several States, including Tamil Nadu, Kerala, Andhra Pradesh, Karnataka, and Rajasthan, have evolved their own distinctive health insurance schemes.
A reader from Nalkonda, Dr. J.P. Reddy, in his e-mail praises the successful working in Andhra Pradesh of the government-run insurance scheme, “Arogyasri.” Introduced boldly and imaginatively by the government of Y.S. Rajasekhara Reddy, the scheme treats the poor and the needy suffering from even major and complicated diseases absolutely free of charge.
S.V. Venugopalan (Chennai) has a quite different perspective on health insurance. Citing Michael Moore's “Sicko” (2007), he says the movie powerfully exposes the collapse of the health care system in the United States and the disastrous failure of insurance companies to honour their commitments to the insured. Dr. Lord W. Reza, in his communication, makes another point. Insurance charges, he contends, invariably inflate health care cost beyond reach. Governments have long been focusing on tertiary hospital care, deviating from the earlier emphasis on primary health care. “Encouraging the private sector in health care,” Dr. Reza asserts, “is not and will never be a solution.”
The debate on the most appropriate healthcare model for India will and must continue and newspapers must play a more active role in informing the reading public on the choices available to the country under challenging circumstances.