Who should be entering our medical schools? The answer is simple. It depends on the product you want. Who decides that product specification? Those who run the institution or those who enter it? Again, the answer is simple — those who run the institution.
Then why is it not done so? The authorities of government medical schools have neither the freedom nor any daring initiative to decide on the product design.
Barring a couple of exceptions, the managements of private chools have decided to cater only to the “market needs.” And the market wants only doctors who can run hospitals and nursing homes that generate profit. So the product they churn out — doctors — require knowledge and skills prescribed by the Medical Council of India and certified passed by various universities. Who cares to look into country’s health care deficit and peculiar needs?
This “business model” has its own dynamics. The private sector has invested huge capital in medical education. Those who enter these schools also incur a huge expenditure. So they both want their share of profits.
Who can blame them? They both know well the “business of making a doctor.” It is a unique process where the product is self-designed, and the machinery and the institution just enable the product’s self-evolution or metamorphosis.
Any good factory boasts its product and attributes its high quality to the selection of good raw materials and excellent manufacturing processes. Unfortunately, in a social product like doctors the raw material is selected only on the basis of the score in qualifying examinations, apart from reservation for certain population groups. But is that enough?
Should there not be more stringent criteria and conditionality in the selection of the “raw material”? Aptitude, motivation and soft skills of decorous behaviour and communication are also important. The current struggle is between fundamental social responsibilities and market-based ideologies.
Is it not time for a democratic, socialist welfare state to intervene to safeguard the best interest of the marginalised sections? Shouldn’t the state regulate the production of doctors quantity and quality-wise if it spends the taxpayer’s money? Under Universal Health Coverage (UHC) of the 12th Five-Year Plan, the government is the enabler and guarantor of equitable access for all citizens, resident in any part of the country. If equity is the buzzword in UHC, a mere increase in the total number of doctors produced will not achieve the goal. The ambitious plan is to set up 129 medical schools by 2017 in the currently underserved districts, especially in Bihar and Uttar Pradesh.
Will a mere increase in the production of doctors ensure their availability in remote areas? We may increase availability from the current level of six doctors to 20 per 10,000 population statistically, but equality in dispersion is not guaranteed. It will only aggravate the already skewed distribution density of doctors in urban areas. What else does 65 years of medical education since Independence tell us?
Shouldn’t we train doctor-aspirants who opt to serve in the underserved areas? Who are the doctors now serving in remote rural and tribal areas under challenging conditions? Why are they sticking on in spite of the difficulties?
We asked that question in Chhattisgarh. It was a joint research* by the State Health Resource Centre, Chhattisgarh, the Public Health Foundation India and the National Health Systems Resource Centre, Delhi.
An analysis of some of the findings showed that both extrinsic (environmental) and intrinsic (personal) factors played a part in determining doctors’ decisions to stay on, and they were interdependent. Some doctors wanted to maintain the close relationships they had developed with the local communities and their acclimatisation over time to rural life. Geographical and ethnic (tribal) affinities, rural upbringing and personal values of service to the poor and selflessness were the intrinsic factors cited as reasons for their liking a rural posting. Spiritual and religious leanings, disinclination for private practice, satisfaction and personal fulfilment and a feeling of self-worth made them opt for rural service.
Hence the selection process should involve, apart from academic merit, testing whether candidates have the above traits. Let there be psychometric assessments and unbiased professional evaluation of aptitude for serving the disadvantaged communities and willingness to accept minimum amenities. Why not give priority to such candidates who have a sentimental attachment to backward areas while allocating government-sponsored seats with a bond for serving in those areas for a minimum of 15 years like those joining the Armed Forces Medical College?
Select the right aspirant who will go to underserved areas rather than the wrong candidate who dodges rural service, even though he/she had high marks in the qualifying entrance examination. The country cannot wait any longer for such a policy shift in medical education if we really mean to achieve Universal Health Coverage with equity in access.
*[Kabir Sheikh, Babita Rajkumari, Kamlesh Jain, Krishna Rao, Pratibha Patanwar, Garima Gupta, K.R. Antony, T. Sundararaman. “Location and vocation: why some government doctors stay on in rural Chhattisgarh, India” International Health (2012)
>http://dx.doi.org/10.1016/j.inhe.2012.03.004]
(The writer is President, Public Health Resource Network, India, and was Health & Nutrition Specialist for UNICEF and Director, State Health Resource Centre, Chhattisgarh. Email: krantony53@gmail.com)
