Opinion » Lead

Updated: November 23, 2009 23:21 IST

Eleventh Plan and health care

P. S. Appu
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Deputy Chairman of the Planning Commission Montek Singh Ahluwalia at a meeting to seek the approval for approach to the Eleventh Five Year Plan. File Photo: V.V. Krishnan
The Hindu
Deputy Chairman of the Planning Commission Montek Singh Ahluwalia at a meeting to seek the approval for approach to the Eleventh Five Year Plan. File Photo: V.V. Krishnan

The Eleventh Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome, bemoans the Plan document.

The role of health care in economic development has received increasing attention in recent years. There is a general agreement that economic growth is not merely a function of incremental capital-output ratio. Investment in man -- enhanced allocation for education, imparting skills and health care -- plays a significant role in fostering economic growth. It is, therefore, in the fitness of things that the Eleventh Five-Year Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The Plan document presents a well-conceived, comprehensive programme for the sector. According to the Prime Minister, the aim is to provide broad-based health care in rural areas through the National Rural Health Mission (NRHM).

Health care in a shambles

While the proposed structure for providing health care is adequate and commendable, what is in place at present is thoroughly disappointing. The Plan document itself bemoans: “The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome.” (The Eleventh Plan: Vol. II, page 61, para 3.1.16.) The Plan deplores the critical shortage of health personnel, particularly doctors and nurses, poor working conditions and inadequate incentives, and the low utilisation of the meagre facilities in government hospitals. Government hospitals at all levels present a picture of neglect and decline.

I shall deal with two major problems: shortage of doctors for rural service; and the desperate state of medical education.

Health care after independence

Before independence, medical facilities in rural India were rudimentary. The Community Development Block pattern of rural development launched in the 1950s was the harbinger of modern health care in rural areas. According to the approved model, every block was to have a Primary Health Centre (PHC) with 10 beds at the block headquarters and three sub-centres at carefully selected locations. The sanctioned staff for a PHC consisted of two doctors, one Lady Health Visitor and two Sanitary Inspectors. One post of Auxiliary Health Worker and two posts of Auxiliary Nurse-Midwives were sanctioned for each sub-centre. A doctor was required to visit each sub-centre twice a week. I was the Collector of Darbhanga in north Bihar from mid-1958 to the end of 1960. During my tenure, out of the 44 blocks sanctioned for the district, only 37 had become operational. Some 25 blocks had one doctor each and the rest none. Most posts of Lady Health Visitors and Auxiliary Nurse Midwives were vacant.

As chance would have it, I became Bihar’s Health Secretary in July 1962 and stayed on in the post for nearly five years. The total number of blocks in Bihar was about 600. In spite of my best efforts, very few blocks had the full complement of doctors and paramedical staff. During the severe drought of 1965-66, it was only by resorting to draconian measures that we could ensure that all blocks had at least one doctor. Most doctors had an urban background and were reluctant to go to rural areas lacking in modern amenities. There has been no significant improvement in the situation during the last four decades. According to the data given in the Eleventh Plan, there is a shortage of 5,801 doctors in PHCs and a shortfall of 4,681 specialists in Community Health Centres (CHCs).

The Eleventh Plan presents a well thought-out and comprehensive structure for health care in rural areas. The important features of the set-up are:

— 1.75 lakh sub-centres each with two Auxiliary Nurse Midwives at one sub-centre for each panchayat (five or six villages).

— 30,000 PHCs at one for a group of four or five sub-centres. Each PHC will have one Lady Health Visitor and three staff nurses. There will also be an AYUSH physician. (AYUSH is acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy).

— 6500 CHCs each with 30-50 beds. The staff will include seven specialists and nine staff nurses.

— 1800 taluk or sub-divisional hospitals and 600 district hospitals will be fully equipped to provide quality health service.

When this structure is in position, and if it functions reasonably well, we can expect a significant improvement in the quality of medical care in rural India. There will, of course, be an enormous increase in the number of medical graduates, postgraduates and nurses needed to operate the system. The baffling question is how to find the number of personnel needed to fill the vacancies and new posts.

It should be possible to recruit adequate number of doctors and persuade them to stay in the field if the three suggestions given below are adopted and strictly enforced.

— After internship, every medical graduate should be required to work for a minimum of two years in rural areas before he is granted the MBBS degree.

— Only those who have completed three years of rural service should be admitted to any postgraduate course, including the Diplomate of the National Board.

— Every postgraduate student should serve for one year as a specialist in a CHC or sub-divisional hospital before he is awarded the degree or a diploma.

These proposals are not entirely new. Assam has already made rural service compulsory for medical graduates. Some medical colleges have been encouraging fresh graduates to opt for rural service for short periods. The implementation of the proposals, of course, calls for resolute political will. The rationale for making these seemingly harsh suggestions is this. Despite the recent increase in fee, medical education is heavily subsidised by the state. It is manifestly just and fair to stipulate that those who receive medical education should serve the rural society for a short period. Incidentally, the young graduates will benefit a great deal by getting an opportunity to improve their clinical skill. There should, of course, be substantial improvement in the salary of doctors and the amenities available to them.

Shameful state

The proliferation of sub-standard, under-staffed and ill-equipped private medical colleges in recent years is an unmitigated menace. A few institutions like the CMC, Vellore; St. John’s, Bangalore; and the Kasturba Medical College, Manipal, are among the country’s best. But many private colleges lack basic facilities and are run as profit centres for garnering huge amounts as capitation fee. I hear that the present capitation fee for an MBBS seat is Rs. 35 lakh-50 lakh and for a postgraduate seat above Rs.60 lakh. For a discipline like Radiology, the amount could exceed Rs. 1 crore!

Some 15 years ago, a relative of mine had to pay only Rs. 2 lakh through a bank draft and Rs. 2 lakh in cash to get his son admitted to a postgraduate course. The Indian Medical Council has laid down arduous norms in respect of faculty, hospital beds, equipment and so on. Apparently, there is some laxity in the enforcement of the norms. I have heard that while a well-equipped college may run into difficulties, substandard institutions manage to pass muster. I have also heard of cases in which retired teachers and other doctors with postgraduate qualification are shown as visiting faculty for short periods during an inspection by Medical Council teams. No civilised country, not even a soft state like India, can allow such a scandalous state of affairs to continue. It is time the government took resolute action to stem the rot.

Some reservations

The Prime Minister in the Foreword and the Deputy Chairman of the Planning Commission in the Preface have highlighted the positive role the Rashtriya Swasthya Bima Yojana will play in providing health care to the population below the poverty line. I have serious doubts about the benefits that will actually accrue to the rural poor from health insurance and the option to go to private hospitals. As I have not personally observed the working of the scheme, I would leave it to experts familiar with field conditions to evaluate the Yojana.

Another controversial matter is Public Private Partnership (PPP) in providing health care. I do not share the optimism expressed in the Plan document about the role of private institutions in providing health care in rural India. Nor do I agree with the Commission’s enthusiasm about the role of corporate health care and the benefits flowing from the expansion of medical tourism. These issues deserve to be dealt with by more knowledgeable persons.

I shall conclude reiterating that health care in rural India and school education throughout the country should squarely be the concern of the government. Private initiative can certainly supplement the government’s efforts in these fields, but that will benefit only the affluent.

(P.S. Appu is a former Chief Secretary of Bihar and former Director of the Lal Bahadur Shastri National Academy of Administration, Mussoorie. He can be reached at:

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Making doctors work compulsorily in rural areas is only going to suffocate the already hectic and costly health care facilities in urban areas. A prolific and affordable medical education system and an efficient tackling of brain drain[of not only doctors, but also nurses and paramedics] would help achieve some effect. Equally important is to have a monitoring agency to oversee the functioning of the health care providers and to check if the states give due respect to the objectives of the plan. The plan, as I see it, is seriously deficient in practicality and quite ambitious in theory.

from:  Senthil Rajan
Posted on: Nov 25, 2009 at 18:58 IST

If the Government cannot meet the health-care requirements of the average citizens, there must be some way of involving the NGOs who must be encouraged to manage the existing Govt/municipal hospitals and must be funded to manage the system. The private public partnership is a drain on the system. There are many genuine NGOs in India who can run many of the existing government hospitals at half the cost the government incurs and run much more efficiently. We must have a dialogue with these NGOs.

from:  P N V Krishnan
Posted on: Nov 25, 2009 at 18:21 IST

Another interesting article from The Hindu. While the author's diagnosis is correct, the treatment he advocates, implicitly and explicitly, leaves us wondering whether these solutions will resolve the health problems of India.

from:  barani
Posted on: Nov 25, 2009 at 17:11 IST

With MBBS seat being Rs. 35 lakh-50 lakh and for a postgraduate seat above Rs.60 lakh it is natural for any private operated health care to get back the money from the patient.

from:  Bobby raj
Posted on: Nov 25, 2009 at 13:37 IST

Kudos to the obervations of Mr P S Appu and the concerns raised him. In fact the RSBY scheme at some level neglects the appaling conditions of the existing public health infrastruture and will contribute to the increase in revenue of private medical hospitals at the expense of government. We already have a living example where health insurance has led to a systemic inequality in access to health care in US.

from:  Anupama James
Posted on: Nov 25, 2009 at 12:25 IST

The article highlights the high capitation fee accrued by the medical colleges. We need around 30,000 doctors where the supply is only 3000, since, only so many can afford post grad. medical education. How can you expect students to do social/rural service while paying the debt on educational loan? In matters of finance, it is important to understand where the money is flowing. People, corporates and industries are, anyway, paying for medical and health insurance. Can these insurance companies fund the medical educational institutions and attached hospitals from the insurance money that they receive from the people? In my opinion, this will close the economic loop. The students will have to pay less for their medical education. In return, they would be willing to serve in the rural heath-care system. The cost of doctor's fees will be lower, since, people have already paid-it-forward (through insurance cover). It will ultimately benefit the poor who have no insurance cover whatsoever.

from:  Sandesh Gandhi
Posted on: Nov 25, 2009 at 12:18 IST

The main asset of a country is its human resource and growth will become more consistent if this asset is taken care of. The role of the government is significant in this case as not all are fortunate enough to have education and health facilities. Also the negligence towards rural sector among educated youth can certainly be addressed by making it mandatory for the medical students to serve the rural areas during their graduation/post graduation.

from:  HARMEET
Posted on: Nov 24, 2009 at 18:49 IST

It is quite correct that health care in rural India and school education throughout the country should squarely be the concern of the government. But the government does not seem to lay stress on this vital issue. Health care has become costly and professional education has become the property of the few. This scene should change. Health care should be made cheaper by engaging more and more doctors. For this the government can consider of giving diploma courses in medical colleges as is done in the engineering colleges. This will supplemnt the work of graduate doctors besides provding relief to the rural folk.

from:  N. R. Ramachandran
Posted on: Nov 24, 2009 at 17:49 IST

It is true that "The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome". The health care has become a costly affair for the poor. It has becomne dearer. Some two decades ago my father underwent operation for enlarged prostrate. Now a friend of mine is to under go the same type of enlargeed prostrate operation. He is asked to manage around Rs 50000/- for this simple operation. So the government must come forward to make the heath care of the poor cheaper.

Posted on: Nov 24, 2009 at 14:21 IST

Sir, I do not agree with the view that internship of 3 years must be compulsory before granting MBBS degree. If that were done, to complete the postgraduate degree, a student will be of 30 years of age. Most of his youth will be spent in learning rather than actual practice. I think this should also be considered while deciding the tenure of internship.

from:  prasad chaphekar
Posted on: Nov 24, 2009 at 09:23 IST

As a surgeon working in rural Himachal Pradesh, I agree with the author. Insititutions like MGIMS WARDHA and CMC Vellore already have this system in place, where a candidate is allowed a post graduate seat only after complettion of the stint in a rural area.

from:  Philip Alexander
Posted on: Nov 24, 2009 at 07:29 IST
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