The Dravidian model of public health

The practices followed by Tamil Nadu can be replicated to facilitate social advancement throughout India

January 27, 2022 12:15 am | Updated 12:15 am IST

MADURAI, TAMIL NADU, 15/12/2015: A doctor examining a child at the Urban Primary Health Centre in Tirunagar ward 98 of Madurai Corporation. Photo: R. Ashok

MADURAI, TAMIL NADU, 15/12/2015: A doctor examining a child at the Urban Primary Health Centre in Tirunagar ward 98 of Madurai Corporation. Photo: R. Ashok

The recent Supreme Court judgement upholding the constitutionality of reservation for Other Backward Classes (OBC) in National Eligibility cum Entrance Test (NEET)‘s All-India Quota (AIQ) seats for undergraduate and postgraduate medical and dental courses is a landmark in the history of social justice in the country. “The propriety of actions and dedication to public service should also be seen as markers of merit, which cannot be assessed in a competitive examination,” observed the bench comprising Justice D.Y. Chandrachud and Justice A.S. Bopanna. In the light of these crucial observations, it is high time that we demystify the narrow definitions of merit. “Merit should be socially contextualised and reconceptualised as an instrument that advances social goods like equality that we as a society value,” the apex court said. In this regard, the practices followed by Tamil Nadu, where the notion of merit has taken into account the role of historical privileges instead of an illusory inborn ability, can be replicated to facilitate social advancement throughout India.

A tectonic shift

Successive Dravidian governments in Tamil Nadu have had a broad and an inclusive understanding of ‘merit’ and its social implications. Hence, affirmative action to provide reservation for in-service doctors has stood the test of time for well over four decades. The introduction of the scheme reserving 50% of the postgraduate and super-specialty medical seats for government doctors ushered in a tectonic shift in providing tertiary health care in government hospitals. It resulted in the expansion of public health infrastructure in the State. This progressive reform paved the way for ensuring the availability of specialists in multiple disciplines such as gynaecology, anaesthesia, general medicine, paediatrics, general surgery and orthopedics, which were scarce in almost every district headquarters hospital across the State 40 years ago. This was complemented by super-specialty departments like Urology, Nephrology, Cardiology and Neurology in the Madras Medical College (MMC) in the 1960s and 1970s. The provision of reservation for government doctors in super-specialty courses contributed to a steady rise in the availability of multi-specialty experts not only in metropolitan cities like Chennai, Coimbatore and Madurai, but also Tier-2 cities as early as the 1990s. Today, the public health sector in Tamil Nadu has 900 super-specialists in different disciplines, a number comparable only to a few European countries.

The unique scheme had a dual effect. It encouraged young MBBS graduates to serve in rural areas, as serving for three years in Primary Health Centres (PHCs) in rural areas is an eligibility criterion for graduates to avail themselves of the reservation policy. As a consequence, State PHCs and government hospitals never witnessed a shortage of doctors and people got better healthcare facilities at their doorsteps.

The healthcare managers in the Tamil Nadu government were not short-sighted while formulating the policy. They unveiled a unique superannuation bond for these government doctors to ensure that those who secure postgraduate or super-specialty seats by availing themselves of in-service reservation will serve the government till their retirement. This legal binding has ensured that a vast majority of the specialists continues their service in the government sector throughout their career. The main aim of this superannuation bond was to prevent the brain drain either to the private sector or to places abroad. It has proved to be a win-win situation for doctors and the government. This unique scheme is present nowhere in the country.

If one attempts an objective analysis of the contribution of two prestigious institutions — MMC and IIT-Madras —where ‘bright’ and ‘meritorious’ students land, in societal advancement and regional development, MMC would shine largely due to its adoption of reformatory policies that are consistent with the societal needs of Tamil Nadu.

A myopic view

However, with the introduction of NEET and Regulation 9 by the Medical Council of India (MCI), the admission policy has undergone a sea change. The weightage for government doctors who serve in rural areas has reduced. The MCI has framed a policy of giving only 50% of postgraduate diploma seats to service doctors, exempting postgraduate degrees. Besides lack of consultation with stakeholders, the policymakers in Delhi are yet to put forth their rationale for this myopic view in the public domain.

Shockingly, the Union government went to the extent of filing affidavits opposing in-service reservation before the Madras High Court and Supreme Court when the new rule was challenged by the Tamil Nadu Medical Officers Association. While the State government rightly says that dismantling incentives to serving doctors would jeopardise healthcare delivery system in the State, the Union government is opposing the very idea by hiding behind the nebulous regulations of MCI, a regulatory watchdog without any legal teeth to formulate policy. With this move, the Union government has put the rural healthcare delivery system in peril and pushed young doctors, who find it difficult to compete with their urban counterparts who have access to niche coaching institutes, out of the system to prepare for competitive exams instead of serving the poor in rural areas.

It is unfortunate that the affidavits filed by the Centre on both the OBC reservation and the government in-service doctors reservation cases in the court are based on a narrow reading of what constitutes merit rather than an inclusive prism called public health. Instead of trying to widen the scope of a time-tested practice, which would ensure robust supply of specialist and super-specialist doctors to strengthen public health care, the Union government is hell bent on unleashing misery. Its lament about the unwillingness of doctors to work in rural areas and its attempt to push them to take up compulsory rural service after MBBS or to introduce a bridge course for AYUSH doctors to incarnate them as rural physicians is purely rhetorical.

In continuation of the maladies of NEET, from 2017, it became compulsory for individual States to surrender all the seats of super-specialty courses to the central pool for common counselling, forgoing the domiciliary needs (15% of MBBS seats, 50% of postgraduate seats but 100% of super-specialty seats are surrendered to Centre, which is known as AIQ) and also abolishing government doctors’ reservation. Disposing of a case filed in the Madras High Court by members of the Service Doctors and Postgraduates Association for the reintroduction of 50% service doctors’ reservation in super-speciality courses, the court has directed the Centre to provide reservation for service doctors in super-specialty courses. Will the Union government act in accordance with the recent judgement of the Supreme Court, which has advocated a broader definition of the concept of merit by facilitating a smooth reintroduction of in-service doctors and domiciliary reservation for respective States in super-specialty courses from the current academic admission year?

Sundaresan Chellamuthu is Associate Professor of Radiation oncology, Tamil Nadu Government Multi Super Specialty Hospital and State president, Government All Doctors Association, and Sakthirajan Ramanathan is Assistant Professor of Nephrology, MMC

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