Opening more medical colleges is not the solution to India’s chronic shortage of doctors in the rural areas.
India is the largest supplier of foreign medical graduates to the United States and the United Kingdom. Yet, its own rural areas have remained chronically deprived of professional doctors. The historical antecedents of these shortages could be traced to a landmark health policy document, the Bhore Committee Report of 1946. That report constructed the concept of a ‘basic’ doctor as one trained through five-and-a-half years of university education. An alternative cadre of Licentiates who were trained over a shorter duration and who formed two-thirds of the country’s medical practitioners then, was abolished, in spite of strong dissent from several members of the committee. These dissenting comments must be revisited in the context of India’s persistently poor health indices and inadequate health services for the majority.
The report
In October 1943, the Government of British India appointed the committee to survey the state of public health in the country, and make recommendations for future development. The committee chaired by Sir Joseph Bhore, a senior civil servant, comprised eight British and 16 Indian members. The Bhore Committee Report, published in 1946, was meticulously drafted and reflected its members’ profound understanding of health matters. They presented statistics on the disease burden and attributed the poor state of health in the country not only to inadequacies in medical services and health personnel but also to the prevailing social ills — poverty, illiteracy, poor nutrition and unsanitary conditions.
The report is best known for providing the blueprint for a modern public health delivery system in India, along with the training of its personnel. Foremost among these was the ‘basic’ doctor of modern medicine who would be central to the delivery of primary healthcare. These were far- reaching recommendations and shaped the course of public health and medicine in independent India. But on closer examination, a number of flaws are revealed.
Two classes
There were two classes of medical practitioners of Western medicine at the time of the Bhore survey: graduates who underwent a five-and-a-half-year course in the medical colleges, and Licentiates (LMPs) who underwent a three-to-four-year course in medical schools. Of the 47,524 registered medical practitioners at that time, nearly two-thirds (29,870) were Licentiates and one- third (17,654) were graduates.
The report informs us that in the rural areas health care was delivered through sub-divisional hospitals and dispensaries that were managed mostly by Licentiates. Besides, there were large numbers of indigenous practitioners providing affordable and accessible healthcare to the masses.
The Bhore Committee proposed a three-tier district health scheme. A primary unit would be at its periphery, a secondary unit at the sub-divisional headquarters would provide more specialised services, and a district organisation would be in charge of the overall supervision of district-level health activities.
Though conceptually well-organised, the scheme was designed to cover only a fourth of the population in the first five years (78,080,000 out of a projected 315 million in the report) and less than half (156,200,000 out of a projected 337.5 million) over the next 10 years. The report was silent on how the needs of the rest of the country would be met.
Nonetheless, the committee recommended that the Licentiate qualification be abolished, all medical schools be upgraded to colleges, and all available resources be directed into the production of only one type of doctor. He or she would have the highest level of training — a five-and-a-half-year university training, similar to what the Goodenough Committee had proposed for Great Britain as the gold standard. The committee believed that there was no role in the modern medical scheme for indigenous systems of medicine and its practitioners: these systems were considered “static in conception and practice.”
Six members of the committee, five Indians and one Briton, put up a brave dissent. They repeatedly argued that in view of the manpower shortages, the country should use every possible means, including the shorter Licentiate course, to increase the number of trained medical personnel. They pointed out that England had abolished Licentiate teaching only after 100 years and Russia relied extensively on ‘feldshers’ (medical assistants) to run 48,000 dispensaries. They noted with anguish that since the new scheme would benefit only a section of the Indian population, “Public health over the remaining four fifth to one-half of the country… will atrophy. There will be no personnel like the licentiates even to help the regions and institutions which will come under neglect.”
Prophetic
The dissenters’ views proved prophetic. They said that the “basic doctor would not willingly fit into the rural scheme.” India’s six decades of chronic shortages of doctors in the rural areas are grim testimony to this fact. They argued that “while a majority on the committee can abolish the licentiate, they cannot prevent other practitioners, practising a variety of systems of medicine, taking his place.” Time has proved this also to be a prescient observation. Studies show that since Independence and even today, much of health care at first contact in rural India is delivered not by qualified doctors but by informally trained and unlicensed private practitioners.
What happened to the highly trained basic doctor of the future?
The Bhore Committee estimated that around 15,000 doctors would be needed in the scheme in the first five years, and around 30,000 over 10 years. As the number of medical colleges roughly doubled during this period (from 19 in 1946 to 42 in 1956) it can be estimated that the number of graduates also doubled.
It is difficult to obtain exact data on how many graduates entered the health system over 10 years, but almost all of India’s Five-Year Plans and national health policies since 1947 have lamented the shortage of doctors in the rural areas.
What is definitely known is that around 10 years later, in the early 1960s, nearly 18,000 graduate doctors from the Indian sub-continent migrated to the U.K. in response to Health Minister Enoch Powell’s call to save the U.K.’s rapidly expanding National Health Service (NHS) from a staffing crisis. In November 2003, a BBC documentary “From the Raj to the Rhondda: How Asian Doctors Saved the NHS,” acknowledged the contributions of doctors from the Indian sub-continent to Britain’s most deprived areas, where no British doctor was willing to go.
Even today, the second largest proportion of doctors registered with the U.K.’s General Medical Council, by country of qualification, is from India: they number 25,720, or 11 per cent of the total. India also provides the largest pool of international medical graduates to the U.S.
Turf protection
Medical historians point out that the Indian doctors who collaborated with colonial rule were the ones who stepped into positions of power after 1947. Their socialisation into the western model meant that the “development of medical practice in India did not follow the pattern that was being advocated for developing countries at the time. Indian degrees were quite suitable for working in England, but probably totally irrelevant for working to the benefit of the vast majority of the Indian population.” (Professor Aneez Esmail, 2007)
Ironically, even less-trained providers can efficiently deliver primary care. However, efforts to revive a Licentiate type of cadre, as recommended by the National Health Policy 2002 and outlined by a Task Force on Medical Education in 2007, have been non-starters. This is due to resistance from a section of the country’s medical fraternity which carries a turf protection mindset, supported by obstructive legislation contained in the Indian Medical Council Act of 1956.
An alternative
In view of the obvious deficiencies in India’s overall rural infrastructure, it is unlikely that the rural areas will have a sufficient number of doctors over the next several decades. Thus, the solution to India’s doctor shortages does not lie in building more medical colleges. A better alternative would be to draw from other countries’ experiences of developing mid-level practitioners: Clinical Officers and Medical Assistants in Africa, Physician Assistants in the U.S., Nurse Practitioners in Canada, and the rural doctors in China who number more than a million. These cadres are typically trained for three years and empowered to provide clinical services. Studies so far suggest that their performance and outcomes are in no way inferior to that of doctors trained for longer periods.
In the short term, India must also upgrade the skills of existing unlicensed rural practitioners and empower government nurses and pharmacists to take on additional tasks. An alternative to the IMC Act is the Drugs and Cosmetics Act that empowers States to recognise practitioners other than MBBS-holders to provide a limited range of medical care services. Chhattisgarh has invoked this power to create a three-year diploma course for Practitioners of Modern and Holistic Medicine.
(Meenakshi Gautham, PhD, is a public health specialist ( gautham.meenakshi@gmail.com);K. M. Shyamprasad, M.Ch., FRCS, is a former vice president of the National Board of Examinations, MoHFW, India ( shyamprasad@nlhmb.in). Legal inputs have been received from Indira Unninayar, Supreme Court Advocate.)
Keywords: India, rural areas, health, concern, Licentiates
In this essay I suggest that 'critical spirituality', an amalgamation of critical theory and African American prophetic spirituality can enhance the discourse of transformative educational leadership. I argue that this new theoretical interpretation can function to not only deconstruct asymmetrical relations of power that dominate the educational system but can also be instrumental in prescribing acts of reflective resistance purposed to bring about a radical reconstruction of schools
I would like to put forth the following suggestions-
1. Common entrance exam and allocation of seats based on "merit" and not based on "reservation". Medical education is very important for the welfare of the nation. So I feel that there should be no bias in the system. Whoever top the list should be given a chance to study (let the top 1000 students join the college irrespective of reservations!). This is the only way to produce real good Doctors.
2. The Doctors who take up rural service should be provided with incentives like good remuneration, good education facilities for kids, house, transportation etc like Dr.Balakrishnan had mentioned.
3. Political influence should be less.
4. Hospitals should have better facilities and funding should be increased.
Let's be practical.I have completed my MBBS and am now doing masters in medicine.I am willing to serve in any rural area for the benefit of the rural people but what will I get in return considering the enormous amount of hardwork I have done all these years first to get in a medical college,then to survive in it,then to get admission in a masters degree and then again such a schedule that you forget you are a living human being? All these years I have been far away from my family and every year I get 10 or 20 days to be with my near and dear ones.I have been reduced to a mere spectator of the joy and sorrow of my family. And what will I get in return when I start working in a government hospital in any urban area of any metropolitan city in India just forget about the rural areas?
The problem is not with doctors but with the civil service and the government. Rural hospitals have no facilities. Funding for health is very very little in India. Corrupt civil service and politicians prevent any sensible honest doctor doing their work properly. Naturally doctors leave for greener pastures. There is no use in doctor-bashing. How many of the persons who have commented above will see a less qualified health professional, if one of their close relative has a medical problem? Probably not many. But it is alright for rural Indians (poor Indians) to be treated by less qualified person!
How to improve the situation in rural india?
1) well trained doctors and nurses for both rural and urban area( rich and poor). 2)increase funding for health.
3)less interference from civil servants and politicians( like defence department)
4) real incentives for doctors and nurse to work in rural areas like good housing, education for children, security, transport etc( IAS officer will get the best facilities even in a remote part of country. however doctors, nurses and teachers are left to fend for themselves)
5) innovative private public partnership schemes like providing land to built hospitals in rural area at a cheap rate, low interest loans etc. this problem cannot be solved by government alone.
India have one of the best pool of doctors in the world, use and manage them properly. no use bashing doctors and nurses. you need them on your side to solve the problem.
From
an ordinary doctor
The current medical education system in India trains Doctors for tertiary care and there is no emphasis on training on primary or secondary care as result the modern medical graduate is forced to do postgraduation and super specilisation. This system must change. There must be more emphasis on primary and secondary care so that Doctors will go to rural areas and treat people and be good Doctors!!!
This is a good and thought provoking article. The higher the qualifications or the prestigious the institutions, the more far away the settlement of doctors from the rural places or even from India. They need more orientation towards the need of rural India. But it has failed so far in all these years due to the green pastures available somewhere. So, reconsidering LMP or starting a special course to cater to the needs of rural people may be the solution. Making the rural postings compulsory for the present generation medical students won't solve this problem. Instead, it will make negative impact of the move as it has already started. Government must take bold steps at the earliest to rectify the anomaly of inequity in health care distribution to some extent. The recent policy by the present government to have a Medical College per district is a good move. But the Public Private Partnership in this area needs scrutiny.
It seems the Medical Council of India isn't thinking in the lines of middle level practitioners. Its president Mr. Ketan Desai, in an interview to education supplement of The Hindu (dated 16 November,2009), suggests the idea of a MBBS-rural degree. These graduates would be duty-bound to serve the rural population as per a formal commitment, it seems. Also, only students from rural areas will be admitted to this programme. Another suggestion, by Mr Desai to address brain drain of medical graduates is to increase the number of post graduate seats available so that medical students do not leave the country seeking PG avenue.
This is a hope for those who dream of becoming doctors and whose family can't afford huge the fees.
The government should open more of ayurvedic, homeo and unani hospitals as they can easily handle common health problems of the poor.
I congratulate the authors who have made indepth study on the issue and have produced a remarkable document. Till Rural India gets urbanized with water and electrification facility made available there, besides roads etc, in next 50 years, (I hope if economy improves by then, it's possible), we have to look for alternative courses to be created as suggested aptly in this article for delivery of health care in Rural India. Central government must seriously consider taking over from states the responsibility of providing Health Education, its delivery of services and science education in Rural India. We need a big budget. Best wishes. Ramesh Deka , New Delhi.
I work in a rural area as a surgeon. This is an excellent article highlighting grass root realities. I have two comments:
1. Just being a basic doctor in a rural area is not enough to meet the needs. Often surgical and medical emergencies confront the doctor that demand immediate action, without which the patient will die. The recent Diploma in Rural Surgery conducted by the national board is an attempt to meet this need and equip a doctor to face the surgical emergencies and act in rural areas without having to refer long distances and sometimes lose the patient on the way. This program has not yet been recognised by the MCI despite its immense potential.
2. The philosophy and ethos of medicine is dwindling into a memory from the past, and not emphasised enough in medical training. It is only this philosophy that will hold a doctor in service of his fellow man in difficult circumstances. The role of community medicine should also receive more emphasis in training, as it is an oft glanced over subject, albeit less glamourous, but essential for Indias health. All this has to do with medical training, and of course, who holds the cards here? The MCI of course.
Hospitals must make use of technology for remote diagnosis of patients in need of basic health care in rural areas. That way doctors need not travel to far flung places and patients benefit from interacting with them via technology.
Very bold article. Pathetic plight. At one extreme our Prime Minister is proud about the drain of our professionals to the Western world...and at the other end he worries about the lack of technical and medical professionals in India ... we spend Rs 600 crore per year on AIIMS from our tax payers money ...and 56 % AIIMS trained doctors are in USA. We are actually training our citizens for medical labour in the western world. In Tamil Nadu the trained dhai system had successfully reduced maternal and infant mortality rates. If rural nursing midwives can deal with socially sensitive issues like child births and vaccination, why cant we do it in other specialities? The Indian Union should stop centralised approach to health care and empower states to develop their own mechanisms of health delivery and training programmes according to their felt needs.
Dear Madam,
Your write-up on the chronic shortage of medical practitioners and reasons behind it was very informative. And solution is also worth giving a try.
I have one question in this regard.
What we find is that in private hospitals there is unacceptably high rate of Caesarian operations. Which is high is proved by the fact that in rural areas and in government run hospitals that rate is near normal.
Mahesh V. Chopade
The authors should be congratulated for putting forward a succinctly written article on alternate credible approaches to address the issue in India. Public health care has been neglected area by the government with inadequate human and capital resources. The total health care Expenditure is around 4.9 % of the GDP indicating the political will and commitment of the country to issue.
Indiscriminate transfers into rural areas especially within the health, education and education departments have meant several round pegs sitting in square holes including so called punishment postings. Political will and good governance will remain a myth without total transparency and accountability. As long as nepotism and corruption exist many of the rural posts will remain vacant in reality.
I have two suggestions
1.Starting premedical courses of 1 year duration with a key incentive of making it a preparatory route to the regular medical course (MBBS) for the candidates in the future (with the added incentive of credits with a progression directly into the second year of the medical degree course). The programme should be an on-campus programme and not of the distance education variety and should include extensive practical work. The students should be duly registered after successfully completion of the course.
2.Sandwiching the internship between the 5 ½ year programme for medical graduates and not at the end
The revival of licentiates appears to be an easy and convenient solution to a seemingly intractable problem. But it has serious disadvantages. The proposal might have been apt at the time of Bhore committee but is inappropriate now after so much advances in medical science and so much expansion of medical education. Today, even a five year MBBS course is considered insufficient to train a doctor. Moreover after 60 years of Independence, the people's expectations are also much higher. Even the greatest protagonist of these upgraded paramedics-- China-- has abolished the 'barefoot' doctors. Further, these licentiates have no chance of career development and promotion. They would stagnate at the same position with no incentive to perform well. In other words, the proposal would condemn the poor in the rural areas perpetually to poor medical care.
The current shortage of rural doctors is artificial, created by an imbalance between demand and supply and aggravated by poor compensation and very unsatisfactory working conditions. India at the present juncture, can well afford to both enhance suitably the emoluments and give them good working conditions. Besides, there needs to be a non-discriminatory and transparent system of postings and transfers in the rural areas. If everyone knows that he or she has to serve a prescribed period by turns in the rural areas and would be subsequently be rewarded by urban postings, everyone will readily comply. Today some people perpetually rot away in difficult areas while others that are well connected enjoy the plum postings. In short, with political will, financial support and good governance the problem of shortage of doctors in rural areas can be resolved in about a year. There is indeed no need to compromise on quality.
This debate is going on from time immemorial, only out of the box and drastic measures will solve the problem
We need to pay attention to infrastructure development, rather than harping on physicians moving to rural areas, if development is there, people will automatically stay in rural areas or reverse migration will be there.
Incentives in keeping the population healthy is a good idea. But that will take others besides health workers to do the job.There is clear evidence that when a country provided basic aminities, like good nutrition , clean drinking water and inculcated good civic sense into its populace, health of the people improved. In some countries, health workers are involved in extensive preventive aspects, such as health education in nutrition, disease prevention and life style changes.
This article has given new direction and momentum to my thoughts on public healthcare in India. My general perception has been, to complete 5 ½ years of medical education and to work in a rural setup is so contradictory that one would call it extreme service. And most of my schoolmates who have now graduated as doctors feel the same way. The idea of mid level practitioners is brilliant! If I were oriented in college to fit into rural clinics, I would not feel bad at all. I’ll actually pat myself if I find myself a good village to work in.
Interesting article
This is a brilliant article. Here are my suggestions:
1. If polytechnics offering three year diploma engineering courses, why can’t there be diploma medical doctors?
2. There are foreign educated doctors who are harassed by MCI. Why not they be permitted to practice for three years in the Government hospital and get their registration without sitting for screening test (which is not relevant).
3. Why not more medical colleges be started. India should have 600 medical colleges – one for each district. Now they may have only 250. Like IIT that has been started, AIIMS should be started in another ten cities immediately.
J.N. Manokaran
First of all I want to thank the authors to bring to light the issues pertaining to the trained manpower in the medical sector of India. It is all together very informative and also has some really thought provoking propositions( especially for our policy makers).
Considering the current population trend it may soon become very difficult for a ordinary person to consult a doctor, considering ones fees and and availability.
This can be primarily attributed to the privatization of the medical of the medical sector which has adversely affected the poor. Moreover the failure of government health services has only aggravated it.
I hope that bodies like National Knowledge Commission will suggest some measures in this regard.
It is not fault in the system but fault in the mind set of the people working in these centers. How much infrastructure is created for centers? Do you think that barefoot doctors would stay and serve people? Simple statistics - nearly 90 per cent of deliveries take place in PHCs/ Hospitals in TamilNadu. Do you want to reverse it?
BIHAR,MP,RAJASTHAN, UP,CHATTISGARH, MUST LEARN FROM SOUTHERN STATES.
Dr.S.Ponnuraj
Gandhigram
PS
If you need please come and see Gandhigram/Tamil Nadu my plea is do not generalise your views comparing western countries, Please talk to Arvind eye hospital/Hirudalaya ,Bangalore!!!
A real marvel in terms of information this article has carried with itself.Amazing to see it covered most of the value based ingredients of BORE,S committee as well. one most important fact that biasing of the courses offered earlier in medical colleges has,t been a successful attempt ,and further problem of shortage of doctors aggravated by unusual migration of them.Again the question of technical up-gradation of institution raises,and looking at present rate of growth of population ;we possibly face a chronic shortage of doctors in quality terms as well.What if our government successfully turns up outflow of brains of youth to an rewardable inflow from abroad, it will definitely boon our pharmaceutical industry,and eventually will affect our economy.
The Indian Medical Council should take lessons from their engineering couterparts. As in case of technical education ,on one hand we have world renowed IITians in India ,but we don't approach an enginnering graduates from IITs for our repair or maintenance works for that we have a pool of skilled manpower from ITI institutes. On the same lines we could create a benchstrength of medical professionals with basic knowledge of medicines. Their requirement is also highlighted by the fact that the common diseses like diarrehoea, malaria cause more dent on health standards of Indians and these disease are like that they don't merit high standards of medical attention, professionals equipped with 3-4 years of basic medical knowledge are well equipped to tackle these diseases.
Basic Doctor is a practical and timely suggestion.China has barefoot Doctors.Turning a few MBBSes a year will never solve the problems of 110 Cr people.For every 200 people, we need a basic doctor. In other words every village should have a trained basic doctor. As the saying goes a village should be abondened if it does not have a lender,a physicion,a streem which never goes dry,and an elder who is well-educated and see what is good and what is bad dispassionately. We have a large number of unemployed youth who can become a basic doctor with one year intensive training. Rural,tribal areas lack basic medical services. Even in cities and towns adequate medical services are not available. Today an MBBS feels it below his/her dignity to call at house if it belongs to a middleclass and below.
Excellent article tracing the origins of the pathetic state of current Indian healthcare. The Bhore committee did well in setting goals but failed in identifying the means. Those goals are not acheived even after 65 years.
What we are producing is 'export quality' doctors only, and then try to place restrictions on what they should do. It never worked and it is not going to work. Politicians clamour when doctors leave the country but do not seem to have the vision to retain them in the country.
Abolishing the MCI is as good as trying to prevent corruption. It is a dysfunctional institution like many others (for example environmental ministry). We have learnt to live with it.
Thridly quacks are the people providing healthcare in remote corners of India. It is better to utilise them rather than engaging in witch-hunting, which needless to say does not acheive anything but enrich few corrupt officials.
In my opinion what may be a better idea would be to start a parellel health practitioner training system using the district headquarters. Perhaps it could be a diploma. The main areas of training should be basics of medical sciences, emergency life saving procedures, and treatment of common conditions. There should be restrictions on more complex procedures (for example cesaerean delivery). They are not doctors, hence should not call themselves so. However in due course with sufficient experience and perhaps with some exit examinations, they may be provided equivalance to doctorship.
What it could achieve?
Those health practitioners, if trained in a district headquarters hospital, are likely to come from the same district or same society. They are likely to be retained there which is not the case in medical college.
The health practitioner training system will provide some training to those quacks and might encourage safe practice or at-least avoid dangerous practice.
It releives several madness that afflict our young generation. First the madness of +2 exams, and entrance exams or paying a ludicrous amount of Rs. 50 lakhs to get an MBBS seat. Such people who get imbibed in such so-called 'acheivements' will try for more such 'acheivements' like getting into post-graduate degree or emigrating abroad. I myself was there in both phases of madness, emigrated abroad and then starting to think is it really what I should have done.
There may be nothing new in these suggestions, except that there was nothing to think about for me.
Basic Doctor is a practical and timely suggestion.China has barefoot Doctors.Turning a few MBBSes a year will never solve the problems of 110 Cr people.For every 200 people, we need a basic doctor .We have a large number of unemployed youth who can become a basic doctor with one year intensive training.Rural,tribal areas lack basic medical services .Even in cities and towns adequate medical services are not available.To day an MBBS Feels it below his/her dignity to call at house if it belongs to a middleclass and below.
Dear Sir
I am a doctor from Kerala who have been in North India worked in some rural setups for long time and now working in an influential position with an organisation in Delhi. Beofre I tell you more, I would like know what help you can offer from you side to do about this lack of doctors in rural areas? Can the Govt join with rural hospitals in terms of taking care of their pay. One can talk a lot but let's bring it to practice.
I am willing to do something about it. What help can you offer? THEN we will talk more.
Dr. John Thomas
Why not appoint rural doctors to a radius of village populations, paying each a monthly stipend when villagers are well? If some fall ill, let the stipend be reduced till they are well again! This will give the doctors an incentive to prevent and cure illnesses! Getting paid when people are healthy and nothing when they're ill!
The bio medical model followed by the Indian health care delivery system is a colonial legacy.
It has many negatives aspects:
1.It caters only to the physical aspects, specializing in parts of the body, over looking the other dimensions of the person.
2. It gives undue and total authority to doctors ignoring the patient, and other health workers’ contributions
A better model would be the Standardized Nursing language (SNL), which includes nursing diagnosis, patient outcomes and nursing interventions, for the following reasons:
1. It diagnoses and treats the human response of people to health care problems and life processes
2. It is inclusive and collaborative to other holistic concepts that are evidenced based.
3. It has been researched, classified, with the levels of the health professionals who can practice each intervention and the time needed for the interventions being worked out.
4. A large number of nurses are being trained in this model in India as it is mandated by the Indian Nursing Council syllabus. They have the basic know how but need support by health center authorities so that the structure of the health centers is not hostile to the changes being brought about.
5. It is amenable to conversion into computer data and therefore soft wares can be developed to suit Indian conditions, by the large pool of computer language experts, in India.
6. This model is gaining acceptance and being implemented in the EU, Australia, Japan, and Brazil.
First the government has totally failed to read and foresee the long term consequences of the shortage of doctors commensurate to the growth of population while implementing the Bhore Committee recommendation and unilaterally abolished the both the Licentiate doctors education and also their practive in lock stock and barrel at one stroke of the pen. Secondly it failed to pay higher renumeration to the doctors so as to retain them in this country. Because of poor salary many doctors are in the habit of going to US and UK to serve there for lucrative salary. The government failed to restrict thier going abroad. This is a cause for our fall out in provding health care to the poor. Thirdly government threw the health and medical care sector to the private sector. Health care became dearer and scarce for the poor rural folk in India.
We do have diploma course of study to any main brach like engineering etc,. So there is no harm is reopening the diploma courses of study in medicine too. Opening of more and more medical colleges so as to add more doctors to the doctors fraternity will do no harm. They will be marginally affected monetarily. After all doctors professsion is a noble profession and they are the key players in providing health care to the public.
Congrats! Dr. Shyam and Dr. Meenakshi and all the other team members who work for the great move... I am happy for the comments on this article.It strengthens hope for success of the idea.... Keep going team!! Good luck..
Geetha G
This article analyzes the shortage of doctors in India since British Raj . As large number of doctors are immigrated to UK or USA , India had faced and is facing server shortage of doctors especially in Rural areas.However this article fail to notice current trends in Medical education for last ten year .
Introduction of diploma could increase health care staff but we can not compromise on quality of medical service .As we can not trade off quality for quantity government should encourage people to take Medical degrees by building more prestigious colleges with affordable fees and at the same time government should provide benefits for doctors who are practicing in rural areas so that their income will be on par with doctors in cities .
Government should restrict immigration of highly skilled doctors to western countries which will help to build medical talent in the country .
The options are well presented. But the real issue and challenge is to convince the decision makers sitting on top of the professional bodies.
Yes I fully agrees to the views of the authors;If we are to improve the health services offered to the poorer sections of the society we must think of such kinds of trained personnel instead of producing a large number of MBBSs. Also the Indian systems of medicine can play fruitful roles in some cases.
Certainly a very insightful article. Working in the U.K., you don't mind being posted in the remotest corner as long as you make enough money and have job satisfaction. To attract doctors for rural medicine there should be more incentives as we are living in a very materialistic world.
THe concept of LMP should be back as even in U.K. you have nurse-led clinics/nurse consultant and Advanced Nurse practitioners working in place of doctors.
It is indeed a great article. However, the solution presented in the article may not meet its objective for the following reasons:
- Indian population is driven by property prospects and prestige
- While mid-level doctors are needed in many cases. There is also a possibility of them looking for an urban opportunities for better prospects.
- Some of these practioners may also later try to become a full doctor(MBBS) and move to other nations, again for prospects.
- In an urban settlement, there is more opportunities for private consulations which is the main source of income for the doctors in India. But that is not the case in Rural areas. Chronic poverty usually makes the rural resident look for cost effective approaches.
This may prove to be a deterrent to even mid-level practioners.
They may either resort to corruption or would try to leave the rural areas.
I think the following alternative will serve better:
- In France, the charge for a general practioner is fixed (within France, in some cases fixed for the region). To prevent the practioners from involving in malpractices, the French Government has issued a card for all residents of France, "Card Vitale". A patient approaching a doctor has to present this card to the doctor and the doctor will be paid by the Government, not by the patient.
When a new resident is sick and has not obtained a card, he will pay the doctor but the doctor should provide him a reimbursement form, signed by him. To fund the health scheme, a part of the salary or income is deducted towards this. An equal contribution is also provided by the employer. Ofcourse there are reservations for old and disabled people.
- The above point may reduce to medical burden on a person and to some extent deter prospect seekers seek urban settlements as the price is fixed and paid by the Government and not by the patient.
Hence, it also encourages the rural residents to seek better medical care than a cost effective one.
- However, this may not be a strong deterrent since the other amenities available in an urban settlement still holds its glamour and this has to be countered. One solution is to make it mandatory for the students to serve a period of 6 months in rural settlements. That is, every Medical student does his course for 5 years and does a house surgeon for another 6 months. This period can be increased to 1 year, 6 months in rural and 6 months urban settlements. Every student is to bring out a thesis on their practices, possibilities for improvement, etc from their experiences in rural and urban settlements.
- All private hospitals and medical centers are to rotate their doctors to rural settlements on a cycle basis.
- A mandate may also be brought on the number of years a doctor should serve in rural and urban settlements before he or she migrates to other nations for better prospects.
It should be understood that it is not that India doesn't have doctors, but that it has doctors who do not want to go to rural regions. It is also egregious on the side of the Government to not have improved the opportunities and amenities in rural region.
I am not a doctor and hence cannot really comment on whether LMPs would be enough for the health care system in rural areas.
But I have friends, who literally struggled, due to less number of seats available in medical colleges, to get a MBBS degree. As I understand MBBS degree is not easy to get and the graduates mostly know what diseases are and what cures are.
Unfortunate part is that after MBBS though my friends wanted to practice clinically, they could not get through the tougher criteria for admission to a higher degree (M.D.). They had to give up their dreams of clinical practice which is unfortunate as well as ironic considering the expertise that we need in rural India.
I request the Govt of India to look into all options. Getting LMPs (if they can do job well), giving ANMs positions (if they can help) in Govt dispensaries, making it a lucrative option for B.Sc Nurses to go to rural areas or allowing MBBS doctors to practice for a few years in rural areas and then allow them to go to separate schools straight or have another criteria to filter some out and let them be doctors. I believe that students' dreams should not be allowed to shatter because of the system.
It is not all about the skills. The passion to learn/practice also makes difference.
Wonderful ideas.They will really make a world of difference to our village life.
Medical Cadre trained for 3 years appears a practical solution both in Urban & Rural Areas. Few serious cases can be screened and sent to 5+ year trained physians and than to Specialists.
Need of the hour is to promptly accept and implement this proposal to mitigate the suffering of millions of our citizens.
Our effort should be to quickly build the cadre of first stage physicians, develop their expertise with regular refreshers to restore their respect in society.
We must thank the authors of this brilliant article, which highlights the need for making available affordable and credible primary health facilities for the teeming millions residing in our villages. If such a facility is made available, the rural-folk need not sell their family silver for making trips to cities far away, with their ailing wards, in search of good hospitals and doctors and meet the abnormally high medical expenses, lodging expenses& travel expenses to& fro. Short-term educated medical diploma holders,'Bare-foot' doctors as they are called, are required in thousands to be available for this service, in every taluka, if not in every village, and with assisting staff, and with enough medicines to redress this difficulty.We need a system that will ensure this.
fantastic report. I live in britain and my family has greatly benefited from overseas doctors contribution in terms of my family's health. But was extremely saddened to read that india is short of doctors, particularly in rural india. Most of the recommended ideas are great and should be implemented so that india becomes a leading country in providing health care to its masses
Very clear and practical article. I am thankful to The Hindu for giving voice to it. It is really a paradox that whatever Indian system generates at best is lured into other countries, here is no denying of the fact that everybody has the right to live the life the way they want but the responsiblities that come with subsidised education are never brought up when this argument is given.
In the rush towards profesionalisation our medical schools produce specialists and super-specialists who cater to needs of a few people, while the vast majority lives in utter disregard of their humanity.A country whose 70% population still lives in rural and semi-urban areas it is a shame that despite having the world's best minds there is a deficiency of this type.
India is different to any other country in terms of many factors, thus,the need is to find our own path and not to blindly follow foreign healthcare models to dot. Good things from them can be used to introduce efficiency in current medical practice.
One factor is booming of numerous flashy private medical schools, graduates from these colleges pay a hefty fee to study and it is obvious they must turn to cities to earn it back.
Policy makers must look into this aspect of our medical education that completely ignores rural health just because of its inability to pay for the 'doctor's education'. This same thing could happen to licentiate system if it is implemented without careful planning.Anwers to it must be explored.
Special regards to the authors.Thanks
I congratulate Meenakshi Gautham and Shyam Prasad for an excellent article. I hope the Government will act on the following suggestions:
1. Start Diploma courses in Medicine, like the Diploma Courses in Engineering and other subjects;
2. No instituion should be allowed to run a degree (MBBS)course unless it runs a Diploma (LMP)Course as well.
3.. Diploma holders as well as Nursing Graduates bemade eligible to join the third or fourth year of Medicine Course after completing their rural pssting. Likewise MBBS doctors be made eligible to apply for MD Course only after he/she completes the rural posting.
4. Freshers (both degree and diploma holders) should be posted to rural areas for at least three years before they can ask for a change of posting.
Dr.K.E.Vaidyanathan, President, IASSH
There is a desperate need for practical solutions to address the health-worker shortage in rural India. It is a given, that the qualified mainstream doctors will not relocate and sustain in that terrain. So what does it take to involve these informal practitioners and strengthen them to provide comprehensive healthcare, these practitioners have established themselves and won the trust of the villagers already.
I have personally seen that the poor people in villages have no access to good quality primary care. They rely extensively on uncertified private practitioners who must be strengthened to provide comprehensive care - as an immediate solution. They are the backbone of rural healthcare.
I would also like to suggest that IMC Act must be repealed or amended for people to have better access to well trained providers.
The major shift that we need in our country is in regard to approval of medical colleges. We hardly find one in rural areas. Many of the basic doctors looking for greener pastures does not necessarily imply the lack of willingness of doctors to work in rural areas. There are doctors who work in rural areas, with utmost dedication to their profession. We need to have medical colleges in the rural areas with the help of those doctors. This would attract aspirants towards the rural areas to pursue the course and would in turn benefit the rural mass.
Allopathy medical graduates seek greener pastures and will not serve in rural areas. The medical facilities are woefully lacking in rural areas. Hence Licentiate practitioners with three year license course in basic medicine are very much needed. Physiology and bio-chemistry can be taught in plus two classes in junior colleges. These licentiates can provide primary care and refer serious cases to referral hospitals. We need such an arrangement urgently.
There is a shortage of medical colleges in the country. Madhya Pradesh which is one of the largest States has only four or five medical colleges (western medicine). On the contrary there are hundreds of engineering colleges. I have seen students appearing for the pre-medical test for three or four consecutive years since the shortage of seats and extremely fierce competition.
Private medical hospitals should be allowed to open affiliated medical colleges. Seats in medical colleges should be reserved for each district. A small district sending ten students to a medical college can hope to get at least two or three back in the district after completion of the education.
Some suggesstions to provide better medical facilities: 1.As a part of course Medical staff having 5 year degree should must spend 6 – 1 year tenure in rural areas to acquaint him/her with the rural medical culture.
2.As Govt is spending crores on medical facilities in rural areas, proper invilagtion should be done by the Central body to investigate the loopholes why the facilities are not reaching to needy.
Well written article.
As I am a Pharmacist and already have done project on shortage of doctors in rural areas, I found that these recommendations are the best to follow. Our government should recognize the need of the time and act now.
A thought provoking article for those (including our policy makers), who are genuinely concerned about the serious deficiencies in rural healthcare. I fully agree with the alternative solution of building skills of rural health providers and empowering them through policy to deliver preventive and primary health services in the rural areas.
Special compliments to Dr Meenakshi Gautham, Dr K.M. Shyamprasad and Ms Indira Unninayar for providing some interesting inputs from the archives.
Excellent article with sufficient highlight on the shortage of medical staff in rural areas. It is shocking to know India supplies medicos to the U.S. and the U.K., whereas, we ourselves are suffering from shortage here in our country.
Some steps to save healthcare in India
1) Abolish MCI
2) Allow more medical, para-medical colleges and schools, including licensiate as suggested in the article above
3) All-India entrance only for all medical colleges - conducted by an autonomous body - for all UG and PG courses
4) Check the nexus between hospitals - pharma companies - doctors - scan centres etc. This nexus ends up hiking the end user cost for patients.
5) Those who study in subsidised govt colleges must serve 3 - 5 years somewhere in a Govt hospital in India. They would be paid market salaries during this service period.
It is regrettable that health care, despite being a critical issue, is nowhere to be seen in political campaigns. The most prevalent political rhetoric in rural areas is 'economic development', rather than improvement in standard of living. And if masses are not provided even a basic healthcare, it fails the purpose of any kind of economic reform.
Very good article. useful points.I agree with the views of the authors.
We need physician assistants to work in rural areas. A policy decision soon in this direction will benefit rural India.
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