The Medical Council of India (MCI) has finally given the green signal to a three-and-a-half-year medical course — BSc in Community Health. This has the potential of changing the face and functioning of more than one lakh primary health centres (PHC) in the country, especially in remote rural and tribal areas and mountainous terrain.
The move reverses a historic decision taken by Sir J.W. Bhore, chairman of India’s first health survey and development committee in 1952, to abolish the Licentiate in Medical Practice (LMP) and establish a single medical qualification, a university degree MBBS, as the requirement to become a doctor.
Unfortunately, MBBS doctors taught in urban medical colleges have been unwilling to serve in far-flung and inaccessible areas. At present, 26 per cent of doctors live in rural areas, serving 72 per cent of India’s population. The density of doctors in urban areas is nearly four times that of rural areas. This anomaly has long needed to be corrected.
During his visit to China, Union Health Minister Ghulam Nabi Azad is said to have seen for himself the effectiveness of “bare foot doctors” in rural areas similar to our health sub centres, and wanted this model replicated in India. But the process began on February 6, 2010, when experts in medical education and public health who had gathered in Delhi for a two-day national consultation, gave their full backing to the ambitious project of the Union Health Ministry and the MCI to launch the Bachelor of Rural Medicine and Surgery (BRMS) course.
In September 2011, the Planning Commission and its expert group gave their approval to the three-and-a-half-year long BRMS degree. They even recommended that as a career progression incentive, a BRMS candidate may be promoted to the level of public health officer after 10 years of service.
Finally, a year after that, the MCI has endorsed BRMS under the new name BSc in Community Health. This should not be seen as something “substandard” dished out to “second grade citizens” of the country. At the level of the PHC, this medical qualification will suffice. The “ideal best” should not become the enemy of a “do-able good.”
Checks and balances
Many hypothetical catastrophic scenarios have been predicted. Will they not be tempted into private practice? Won’t they not migrate to urban areas and compete with MBBS doctors? Will they be required to take government jobs in rural areas as a condition of admission? Who will control/ensure the quality of their education?
But there are some precautionary measures in place. BRMS graduates cannot affix the prefix “Dr.” to their names. The candidates are locally recruited to serve government health institutions under a service bond. They will have a clear career progression path as “health officers” up to the district level. The course is designed to produce health workers who will be an effective link between basic health workers and the doctor at the PHC or community health centre (CHC). They will be taught to treat minor ailments, help in delivery and administer first aid; but most importantly, when and where to refer a pateint promptly, in case of complications. They will be used for implementation of national programmes also.
The decisions to accept and implement the course are now with State governments. Chhattisgarh, where this model was adopted in 2001, has shown that it can be successfully implemented with good results.
Aside from the shortage of doctors, it was the point-blank refusal of MBBS doctors to go to remote PHCs that compelled Chhattisgarh to launch a cadre of rural medical assistants (RMA) a decade ago. Opening new medical colleges was not a solution at that time: it would mean a waiting period of six years with no surety that those who graduated would join government service. Thus, six colleges began training RMAS from 2002 — about 150 of them every year. The MCI did not agree to the project, and the Indian Medical Association (IMA) even challenged it in court, but the course and certification survived with a change of name. The graduates got a diploma, not a degree, in modern and holistic medicine even though the course was similar in content to the MBBS programme.
In May 2006, the first batch passed out, and completed a year’s internship — a month in a sub health centre, three months in a PHC, four in a CHC, and four more in a district hospital.
By early January this year, in 18 districts of Chhattisgarh, 1,233 RMAs were posted in PHCs and health sub centres, out of whom 490 were women. The State had created 741 regular posts out of its own budget in addition to the National Rural Health Mission (NRHM) funded contractual posts. Though 361 PHCs (managed by Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy or AYUSH and paramedical staff) did not have an MBBS doctor in August 2008, they all now have RMAs.
Impact
In 2009, a study was undertaken to assess the performance of health-care providers at the PHC level based on the knowledge, attitude, behaviour and practice — including community perception. Titled “Which doctor is for Primary Health Care?” it was carried out by the Public Health Foundation of India and National Health Systems Resource Centre, New Delhi along with the State Health Resource Centre, Chhattisgarh. It found the prescription ability of RMAs to be on a par or better than that of medical graduates at the PHC level in relation to commonly prevalent diseases based on five clinical case management scenarios on pneumonia, malaria, preeclampsia, diabetes and diarrhoea and one referral case (TB). The study is available online at http://nhsrcindia.org/
Monitoring data shows better utilisation of PHC services after the posting of RMAs. Assam has already replicated this model.
Let the efforts of the Ministry of Health & Family Welfare and the MCI take root and show results in four years. The medically marginalised people of rural India should be the judge of its success or otherwise.
(Dr. K.R. Antony is president, Public Health Resource Network, India and former Director, State Health Resource Centre, Chhattisgarh. Email: krantony53@gmail.com )
