Rural health: to tinker or transform?

The recent proposal to introduce a new medical course, Bachelor of Rural Health Care, has been met with resistance from many sections of the medical fraternity. Its opponents argue that it will result in second-class health care for rural India and increase the rural-urban divide. They suggest other solutions, including using the services of trained nurses and paramedics and medical practitioners from Indian systems of medicine. The compulsory posting of fresh medical graduates to rural health centres with weightage for rural service in selections to post-graduate courses is also cited as an answer to improve health care in rural parts of the country. Setting up of new medical colleges in north India, an increase in the permissible number of seats in existing institutions and private-public partnerships to improve rural health infrastructure are also suggested as remedies. Most of these recommendations are not new — have been around for decades — and do not directly address the reality of health and health care in rural India. Cynics would argue that these are suggested to tinker with the existing system, with the aim of actually maintaining the status quo.

Specialist factories and fetish: Currently, the training of doctors occurs in tertiary-care institutions, with specialist perspectives dominating the curriculum. Referral systems to tertiary care and prevalent narrow expert perceptions result in rare and exotic medical conditions forming the basic case load for teaching. Communication of theoretical knowledge without the transmission of the necessary skill to manage common diseases churns out doctors who are poorly equipped to work in primary care and small hospitals. Lack of clinical skill and absolute reliance on technology make fresh graduates uncomfortable outside a large hospital setting. Their obvious lack of confidence in managing simple diseases forces them to specialise. The long periods of training and the investment of time, effort and money, in addition, to the dependence on tertiary-care support and technology, make specialised physicians averse to working in small hospitals in rural India. Their narrow perspectives and circumscribed fields make them incompetent to manage common problems in primary and secondary care.

Compulsory rural service and commitment: Students from very few medical colleges in India have a compulsory obligation to serve in areas of need and in not-for-profit rural hospitals. Such service is enforced through the carrot of additional points for selection to post-graduate courses and the stick, which includes the refusal of certification for failure to serve. While this works well at a superficial level, most fresh graduates are uncomfortable in the alien environments of small hospitals and small towns where they are located. The vast majority complete their time limited obligations and leave; very few choose careers in primary and secondary care, opting instead to specialise and work in urban tertiary care. Such lack of long-term commitment among doctors to work in small hospitals weakens these institutions, resulting in their deterioration and eventual closure. The idea of a brief but compulsory obligation to serve in small hospitals in rural India is, thus, at best, a temporary solution and, at worst, a way to put fresh graduates completely off such service, thereby maintaining the status quo.

Health infrastructure sans work ethic: The National Rural Health Mission has had a major impact on the health and hospital infrastructure of rural India. It has brought in budgetary flexibility in the system with specific funding for local needs. It also funds human resource in situations of shortage. And yet, in many places, nothing has changed. While the renovated and clean primary health centres and district hospitals have made a big difference, the prevalent work ethic leaves much to be desired. Years of neglect have resulted in a work ethic which is less than optimal. While many doctors and nurses serve diligently, many are apathetic to the needs of patients. The infusion of money alone will not change the morale or the circumstances of service. Frequent transfers, political interference in postings and the lure of private practice need to be tackled for optimal health care delivery. The audit of the programme, thus far, has been about process. We await the assessment of its impact on health outcomes.

Specific intervention or generic personnel: The reality of primary care and rural India demand locally relevant solutions. Training generic personnel with long periods of exposure to tertiary care and then transplanting them to smaller settings is a sure recipe for disaster. The lack of skill and confidence in managing common diseases, the excessive dependence on technology and the different demands of the context make young doctors opt out of such service. They would rather go back to their tertiary care institutions for more training to become specialists. Poor monetary rewards and limited facilities in small towns also add to their woes.

The situation described begs the question: Are inappropriately trained generic personnel the solution to the current crisis of health care in rural India or should those who intend to serve in such capacity be given specific training to match their skills to the reality of primary and secondary health care? The generic health personnel currently trained lack the necessary skill to deliver the specific interventions required in small hospitals. Should we tinker with the existing system, which has failed to deliver adequate and appropriate health care to rural India or should we aim at transforming the structure in order to provide good quality health services?

Status quo or radical solutions: The fall of socialism and the rise of capitalistic thought resulted in the weakening of the trade union movement. However, the medical profession, the world over, under the guise of being part of scientific organisations, has consolidated its power. Doctors form a powerful trade union, successfully lobbying to maintain their special status, vested interests and their financial clout. Their success is attributed to their ability to disguise their actual intention of maintaining their monopoly on the supply of expertise by using scientific, ideological and moral arguments. The majority refuse to acknowledge the suffering of millions of Indians who do not have easy, affordable and equitable access to health care.

The debate on health care for rural India often sheds more heat than light. The majority of doctors will neither work in rural India nor will they allow systems to develop to meet its essential health needs. Yet, they talk of equal status for their rural brethren at every opportunity; they argue for equality of health services for all. Cynics would argue that these attempts are aimed at maintaining the status quo which suits doctors' vested interests. The strategies of centralisation of power and regulation and limitation of the supply of expertise result in their stranglehold on health care delivery. The larger vision of health for all and the need to empower other health workers have always been subservient to their collective self-interest.

The way forward

The disparity in health indices, infrastructure and personnel between rural and urban India demands urgent action and radical solutions. Such disparities are due to a toxic combination of poor social and health policies and programmes, unfair economic arrangements and bad politics. China has shown that “barefoot” doctors with specific training in the prevention of diseases and in the treatment of common health problems can improve indices of health. Equitable and accessible health care in Cuba has also demonstrated marked improvement in the health of its people.

The bold idea of the new course needs our support. Much needs to be done. Many issues related to the course, its curriculum, examinations, skill sets required, training, trainers, eligibility, practice, regulation and oversight need to be sorted. The course should concentrate on prevention of diseases and on public health. It should train for the provision of basic curative services for priority health conditions. It should transfer skill and confidence. It should set out and teach the criteria for referral.

The focus of the current debate should be on the health of the rural population of India. Achieving health standards similar to those living in urban India in the foreseeable future should be the goal. Pragmatism, rather than ideological arguments, is called for. Support for better essential health services, rather than the current status quo of neglect, is a fight for social justice and for the human rights of all peoples.

(Professor Jacob is on the faculty of the Christian Medical College, Vellore.)