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.)
