Health is a state of mental, social and physical well-being and not merely an absence of disease or infirmity. To achieve this noble objective, India requires health care professionals who are trained in institutions with standardised infrastructure, and the availability of accessible and equitable health care for both the rural and urban populace. Recently, the health sector has been in the news — from the creation of a rural based graduate medical education programme, the introduction of a common medical entrance exam, the recommendation by the Indian Council of Medical Research (ICMR) to include cancer under notifiable diseases, and the death of infants and children from infectious diseases. These issues may appear very diverse from the outside but are interconnected.The growth of medical education has been exponential, from 88 colleges in 1965, to 335 in 2011. Several more are in the pipeline. But West Bengal has fewer colleges, completely disproportionate to the State's needs.
The non-availability of qualified faculty, sub-standard infrastructure and clustering of medical colleges contribute to poor training and limited exposure to clinical material. The net result is that the outgoing ‘basic doctor' is not fully equipped to face the challenges of ensuring ethical and safe medical practice.
Rural based medical graduates
Recently, the number of seats in private and public medical colleges has been doubled and efforts are on to conceptualise a rural doctor scheme with 3{+1}/{-2}years of training to improve the doctor-patient ratio in rural areas. Over the years, various committees — from the Bhore committee in 1946, the Bajaj committee, the National Knowledge Commission-2007 (NKC), headed by Sam Pitroda, to the present Medical Council of India (MCI) Vision Documents 2011 — have made recommendations to improve the medical and paramedical education systems. The NKC is for training existing health care professionals and workers as multipurpose workers who will have a thorough knowledge of the management of basic health care medical practices and imparting health education. The creation of multipurpose health workers, improving the role of specialist nurses and Accredited Social Health Activists (ASHA), will provide a solution to needs in rural and underprivileged urban pockets. A rural doctor programme signals a lot of confusion and challenges the fundamental essence of human rights — ‘Equality.' An individual in a village should have every right to access a well-qualified doctor just as his urban counterpart can.
There are various paramedical courses — nursing, physiotherapy and pharmacy with a training of four years and the MBBS course of 5{+1}/{-2}years. In a medical hierarchical system, a doctor leads the team, so where will a rural doctor with a training of 3{+1}/{-2}years be positioned?
Doctors selected for the regular MBBS, especially in public medical colleges, have maximum grades but it is uncertain whether students applying for the rural doctor programme will be of the same calibre. Doubling the doctor population and creating new courses alone will not improve the standard of health care. On the other hand, it is easy access to health care, availability of medicines, provision of clean water, sanitation facilities, a vaccination programme similar to what is there in developed nations, a uniform protocol-driven patient management system in certain areas such as obstetric emergencies and medical conditions such as heart attack, and strokes, and first aid to accident victims which will result in an improvement of health care.
To enhance the equitable distribution of doctors, the MCI needs to relook the methods of granting permission for new medical colleges. When there are clear guidelines for setting up of school, primary health centres, PDS shops and even anganwadi centres, the MCI should, in similar manner, formulate stringent regulations to avoid overcrowding in medical colleges. Special incentives should be provided to encourage colleges in rural areas, in the northeast and hilly regions. Avoiding overlapping of medical colleges, the creation of more paramedical courses with an effective public-private partnership model and, most importantly, the provision of urban amenities in rural areas will pave the way for uniform distribution of doctors and equitable health care. Irrespective of his/her geographical location, every person needs quality health care. Therefore, it is safer to be in the hands of a few well-qualified doctors and multipurpose workers. The NKC has provided feasible working solutions within the existing system to increase human health resource. Therefore one needs to question the validity of the rural doctor training programme.
The other contentious figure is the doctor-population ratio. In 2005, itwas 1:1,722. The present estimated ratio, logically, should be around 1:1,450. However the MCI vision document estimates it at 1:1,700 in 2010. The planning of health manpower varies from country to country, and, in a country like ours, from State to State. Therefore there is a need to create a methodology to accurately estimate the doctor-population in accordance with our disease distribution, density of population, etc .
Entrance test NEET
The objectives behind the National Eligibility-cum-Common Entrance Test (NEET) are to set up a uniform standard for basic medical education, by including nearly 15 per cent of the State's medical seats, both private and government, under a single umbrella, disallowing students from appearing for a number of entrance exams in order to save time, energy and money. Premier institutions like the All India Institute of Medical Sciences (AIIMS) and a management quota have not been included under the NEET. Maharashtra, Tamil Nadu and Andhra Pradesh have opposed the system because they have a well-established and acceptable selection process. As the medical education system is a State subject, most States feel it is an infringement on their federal rights. Certain political observers feel that the NEET is an indirect way of diluting the reservation system that has been implemented following the Mandal Commission's recommendations.
The NKC suggests that in the current selection process most graduates are unlikely to serve in the rural areas as they come from the privileged sections. The commission also indicates that “merit” is a reason conjured to maintain the privileges within the upper crust of society.
The larger canvas
Today, an India that is following the path of liberalisation has made remarkable progress in various fields of science and technology. Yet our human development indicators are among the worst in the world — at the 119th position among 169 countries. The spectrum of diseases is as diverse as our motherland — diabetes, hypertension, cancer, morbidity from road traffic accidents to infectious diseases such as HIV and encephalitis. The incidence of cancer is on the increase. Recently, the ICMR has made a strong plea to include cancer under notifiable diseases.
The main areas that require focus are:
The 12th Five-Year plan has proposed increasing expenditure from one per cent of the GDP to 2.5 per cent, and this should become a reality. It is the private sector, an inevitable permanent feature of our health-care system, that contributes to nearly 80 per cent of health care expenditure. Though private health care has partially alleviated health problems, most of it is urban-centric. Recent figures suggest that 70 per cent of hospital beds are in the top 20 cities, of which 15 per cent are in six major cities. To encourage health care investment in towns, rural, hilly and northeastern areas, special fiscal and non-fiscal incentives should be provided. Special tax benefits such as longer holiday periods and an exemption from minimum alternate tax will be an impetus to private players to move away from cities. Revisiting the Rangarajan report (criteria for infrastructure) 2001, is necessary and the Health Ministry should engage in a dialogue with stakeholders to consider their long-term demand for the provision of an infrastructure status to the health industry.
The implementation of universal health insurance schemes will be a boost to the private health sector but, once again, it is mandatory that there be just a single scheme in every State. At present, a few State governments have successfully implemented universal health insurance schemes. Therefore, the introduction of parallel health schemes by the Centre for political reasons should be avoided. Instead, it should integrate funds into the State insurance system. The universal health insurance will pave the way for opening more hospitals in towns and villages.
Education on preventive and early diagnostic health care should be the priority because even today hundreds of mothers and infants die from preventable causes. Over the last few decades, the medical field has seen newer innovations, prevented illnesses and death and increased the lifespan. This kind of phenomenal growth is possible because health-care professionals have moved away from their insular existence and adopted a multidisciplinary approach. In the same way, the Health Ministry should engage in interaction and dialogue, and formulate policies in close coordination with the relevant departments and ministries to improve the health care system. For example, working with the Integrated Child Development Schemes (ICDS) will help combat malnutrition and improve maternal health care that would result in a significant reduction in maternal and infant morbidity and mortality. Other key ministries that can contribute to positive health outcomes include food, rural development and environment. Poor enforcement of legislation in the food industry — excess sugar, salt, ghee, etc, — has resulted in lifestyle diseases such as obesity and diabetes, while increasing environmental pollution is causing a rise in instances of cancer.
Regulation of the pharma industry, increased funding for research and development and special incentives for medical equipment and technology industry are other areas that need to be addressed.
Within the realms of the Health Ministry, an area that has a system in place and working fairly effectively is medical education. The Centre should allow every State to have its own method of selection of candidates yet have a regulatory body to oversee the management of the medical education system. Various committees have requested a strong regulatory central body but its role should be limited. An MCI-like body should only oversee the State Medical Council and have the powers to punish it in the event of irregularities. At present, the medical education system serves two masters — the Centre and State, leading to the present state of affairs with nearly 54 per cent of the total number of 335 medical colleges in the southern States.
Every person should have access to a well-qualified basic doctor and to a health centre with adequate facilities. India has produced world-class, health care professionals and will continue to do so. International health tourism is in autopilot mode but we need to take off at the national level, and plan for our millions who have inadequate and sometimes zero access to health care. Therefore, a holistic health care policy plan alone will take India into the league of developed nations. India can boast of its IT revolution, has the capability to lay an FI race track and continue its space rocket launches but all these spectacular successes will be offset if news headlines scream of infant and maternal deaths from avoidable causes and the arrival of killer diseases like cancer.
In 1831, Alexis de Tocqueville, an authority on democracy, said the power of democracy lies in its tendency to centralise power. Let's hope that the Union Ministry will disprove the Tocqueville theory, will leave the selection of medical students to the State authority and create innovative policies to tackle the larger issues that have to be addressed on a war-footing.
( The author, a practising obstetrician and gynaecologist, is a former Tamil Nadu Minister. E-mail: poongothaibalaji@yahoo.com)
