Elite resistance

A woman at Gobarpada village in Visakhapatnam district, Andhra Pradesh, is virtually left to die after one of her hands, injured while working in the field, turned gangrenous. The nearest primary health centre is situated about 20km from the village, beyond hill ranges. The photograph was taken on June 6.-SUMIT BHATTACHARJEE

The government and the MCI dither on a proposed course to provide better primary health care in villages.

On February 27, the Delhi High Court slapped contempt notices on the Union Health Secretary and the Chairperson of the Medical Council of India (MCI) for their non-compliance with its order of November 10, 2010, to initiate measures to introduce a Bachelor of Rural Health Care (BRHC) course of three and a half years by March 2011 to meet the primary health care needs in rural areas. The measures included finalising a curriculum and syllabus for the course. The order was issued following several hearings on Writ Petition (Civil) No. 13208 of 2009 by Meenakshi Gautham, a public health specialist, and the Garhwal Community and Development Society (GCDS).

On the basis of submissions by the MCI and the government (namely, the Union Health Secretary), the court had said in its November 2010 order that the MCI should finalise the curriculum and syllabus within two months (that is, by January 2011) and that the Ministry of Health and Family Welfare should start the course within another two months (March 2011). Since the order was not complied with for nearly a year, Meenakshi Gautham filed a plea to initiate contempt of court proceedings against the respondents. The court gave four weeks for the respondents to respond to the contempt notice. The respondents made their submissions in March/April.

To recall, the BRHC was envisaged as a course aimed at creating a special cadre of health care professionals to render basic primary health care to the medically unserved and underserved rural population. This was proposed following the recommendations of the Task Force of the National Rural Health Mission (NRHM) in its report of 2007 and the November 2007 resolution of the 9th Conference of the Central Council of the Ministry of Health and Family Welfare ( Frontline, February 26 & April 9, 2010). The idea of such a cadre, distinct from graduate MBBS doctors, was mooted to address the acute shortage of skilled and trained health care workers in rural India. It was meant to impart the basics of primary health care through a short-term degree course in medicine to students who had passed 10+2. They would be recruited locally and trained at a district-level college or institution. After graduation, they would be required to serve in their home regions for a given period.

Three-fourths of the countrys 0.5 million medical graduates function in and around urban areas, serving less than one-third of the countrys population, while the rural population is deprived of even primary health care. There is also a geographical imbalance in the training of what is called Human Resource in Health (HRH). Only 193 of the 640 districts have a medical college, while the remaining 447 districts do not have any training facilities, according to the Steering Committee on Health of the Planning Commission for the Twelfth Plan. The World Health Organisation (WHO) recommends 25 health care workers for 10,000 people, but India has only 19, of whom only six are certified doctors. The urban density of doctors is roughly four times the rural density (13.3 in cities against 3.9 in villages, for 10,000 people). If this estimate is adjusted for the qualification of the health care worker, the ratio becomes even more skewed 11.3:1.9.

The primary health care infrastructure comprises sub-health centres (SHCs), primary health centres (PHCs) and community health centres (CHCs). The SHCs are the most peripheral and constitute the rural communitys first contact point with the health care system. It is at the PHC level that the village community has its first contact with a certified medical officer (MO), a qualified doctor with an MBBS degree. At present the SHCs are not designed to have medical officers and have only auxillary nurse-midwives (ANMs) and male health workers (MHWs). A CHC is a referral unit for four PHCs and has specialised services rendered by surgeons, obstetricians, gynaecologists, physicians and paediatricians.

The table shows the current gaps in HRH in the rural public health care system. The 24 per cent shortfall of qualified doctors at the PHC level is fairly significant. In fact, the shortfall has been increasing steadily in the past few years. Given the HRH requirement in 2020, this gap is likely to rise steeply, particularly if the goal of universal health coverage (UHC) is to be achieved in the next couple of decades. It is to address this critical gap that the BRHC course was proposed. The High Level Expert Group (HLEG) constituted recently by the Planning Commission has also supported the proposal. The Groups report of November 2011 on universal health coverage says: We recommend the introduction of a new three-year BRHC degree programme that will produce a cadre of rural health care practitioners for recruitment and placement at SHCs. The Planning Commissions Steering Committee on Health for the Twelfth Plan has also endorsed it.

Unfortunately, a realisation of the importance of such a cadre seems to be lacking both within the government and the MCI, the statutory body concerned with medical education, which was asked by the Ministry to design the curriculum for the proposed course.

One of the main reasons for the governments soft-pedalling on the issue is the opposition to BRHC from the largely urban-centric fraternity of medical professionals, which seems to influence the MCI as well. The Indian Medical Association (IMA) has attacked this course and has resorted to placard-carrying processions and dharnas in different parts of the country. Now it has called for a nationwide strike on June 25 to protest against many of the governments policies relating to health. The BRHC is among the policy decisions the IMA opposes, and it calls it sub-standard. It is not clear how the IMA has come to this conclusion when the curriculum and syllabus are yet to be finalised, unless it is privy to the deliberations of the Board of Governors (BOG) of the MCI. The High Court issued the contempt notice because the BOG failed to come out with a course and notify it as it was required to do.

Life of a person living in the rural areas, the IMA has argued in its statement, is as important as the life of a person living in urban areas. As such there are no diseases confined exclusively to the rural or the urban areas. By introducing separate set of medical professionals exclusively for rural India, the government is in fact resorting to discrimination against rural citizens by treating them as second class citizens. This is violating Article 14 of the Constitution of India [Right to Equality]. It has also put forth other non-workable and infeasible propositions to address the shortage of medical professionals in rural areas.

Its elitist and urban-centric perspective is revealed when it argues thus: Doctors not going to rural areas is the problem of governance. Adequate allowances and facilities like rural service allowances, proper free accommodation, and education allowances for children, vehicle or vehicle allowances, appropriate reservation for education and employment for their children, sabbatical leave for academic enhancement of doctors, allowances for attending academic conferences for updating their knowledge, facility for interest-free personal loans should be provided to doctors serving in rural areas. This will attract doctors to rural areas. Clearly, the IMA is completely missing the rationale of it all.

If evidence was required to prove why the IMA and other opponents of this course are wrong, a study carried out by Krishna D. Rao, associated with the Public Health Foundation of India (PHFI), in 2009 in a region of Chhattisgarh provided it. The study made a comparative assessment of the performance of different types of clinical care providers working at the primary health care level. The region chosen for the study was one where the public sector could not provide adequate medical officers at PHCs. Interestingly, Chhattisgarh was one of the first States (besides Assam) to create a cadre of rural health care providers called rural medical assistants (RMAs), who were trained for three and a half years and interned for a year. RMAs are currently serving several PHCs where there are no medical officers. However, the IMA opposed this course and forced the Chhattisgarh government to shut it down after it had run for a few years.

The study compared medical officers, RMAs, AYUSH doctors and paramedical staff (nurses and pharmacists) in their capacity as the main providers of clinical services at PHCs. It found that medical officers and RMAs are equally competent to manage conditions commonly seen in primary health care settings. AYUSH doctors are less competent, while paramedics are the least competent. This was true for infections and chronic and maternal health conditions and for a range of patient types, from infants to adult men and women.

Overall, the study found that in primary health care settings, clinical care providers with shorter-duration training were a competent alternative to physicians. The findings of the study thus endorse the introduction of rural cadre such as the RMAs of Chhattisgarh or those with the proposed BRHC degree. Indeed, said the study, limiting BRHC graduates to serve only at sub-centres, as is currently proposed, is under-utilising their potential in a rural environment of physician shortages. The study noted that many States were posting AYUSH doctors to fill the vacancies of medical officers at PHCs, but it expressed doubts about the appropriateness of this practice.

The study made a related, and important, point that successful primary health care is built on the trust and rapport between the health care worker and the community. Emphasising the importance of the health care workers continued engagement with the community, the study countered advocates (like the IMA and the MCI) of human resource policies that involve placing medical professionals in PHCs for a short duration (for instance, compulsory rural service for a few years). In some ways, the study said, the debate over whether non-physician clinicians are a reasonable substitute for physicians misses the point because the correct comparator is not the physician but the situation where no physician is present. Non-physician clinicians offer a substantial improvement over the latter.

At present there seems to be some sort of a stand-off between the government and the MCI on the issue. This is clear from the statements made by Health Ministry officials and the Minister on different occasions. According to a report in The Hindu on April 5, 2011, Keshav Desiraju, an Additional Secretary in the Ministry, stated that the MCI did not want to notify the course because in its opinion the course was not medical training and was not meant to produce doctors. But we certainly are not scrapping the course, he said.

In October 2011, a news report said that the Union Health Minister Ghulam Nabi Azad had given a three-week deadline to the MCI to endorse the new course, failing which the Ministry would issue a directive to it to introduce the course. According to him, the course had the backing of all the State governments.

We want an MCI stamp on the degree so that it is universally recognised, the Minister said. The syllabus is ready, and it is need-based. If the MCI endorses it, students will get the confidence that the degree has a standing, he added.

In fact, in its response to the contempt notice, the Ministry has stated that it had prepared the BRHC syllabus and curriculum in October 2010, which was sent to the MCI for its comments on October 28 that year. In response, the MCI sent its detailed comments, based apparently on the report of its Chairman of the Undergraduate Working Group, to the Ministry on December 28. These comments suggest that the MCI and the Ministry are not on the same plane on the nature of the course.

The MCI wanted the course to be redesignated as BSc in Rural Health Sciences. It added that the holder of this degree would not be qualified to practise independently as a fully competent medical practitioner. It also opined that the subject content included in the syllabus was too vast and might not be feasible. It suggested that the course should be redesigned to meet the generalist approach to the basic concepts of preventive medicine, symptomatology of disease, early management of common diseases (mainly acute conditions) and early recognition of complicated and complex problems.

In response, the Ministry said on January 25, 2011, that the MCI should stick to its previous stand as the issue (of the course name and syllabus) had already been discussed comprehensively.

Specifically, the Ministry clarified to the MCI that a person trained in BRHC should be allowed to treat independently all those conditions for which he/she has been trained within the overall set-up of an SHC and outside at the PHC/CHC level. On February 2, the Ministry asked the MCI to finalise the curriculum expeditiously and notify the course. In response, on February 7, the MCI again insisted that the course be called BSc (Rural Health Care) and added that it could be modified according to the local needs of each State.

It is pertinent to reiterate the recommendation of the NRHMs Task Force. The course, it said, was not aimed at producing short-course health practitioners with an open licence to practise across the entire allopathic domain but towards establishing a short-course training wherein non-clinical principles would be meshed with clinical training. The graduates of this course would be licensed to provide medical services within a notified package of primary health care. So it is somewhat puzzling how this entire debate arose about the vast contents of the course or the degree holder becoming a fully independent medical practitioner.

Interestingly, neither respondent has submitted to the court a copy of the proposed syllabus for the course. Further, the so-called report on the course that the MCI has submitted to the court is nothing but an e-mail exchanged on December 23, 2010. The MCI, which has been opposed to the idea right from the beginning, appears to be confusing the issue deliberately to delay the introduction of the course.

Between February 2011 and December 2011, despite the urgency demanded by the Ministry, the MCI did not take any steps towards finalising the course. Even in the MCI/BOG meeting of December 5, 2011, the topic was only discussed peripherally and there was no focus on finalising the syllabus or notifying the course.

From the responses of both the Ministry and the MCI to the contempt notice, it appears that since the Parliamentary Standing Committee also started independent deliberations on the BRHC course in January 2011, both thought it prudent to put the issue on the back burner. In his response, the Chairman of the MCI/BOG has stated that he appeared before the Standing Committee on December 27, 2011, and assured the panel that the MCI would finalise the course by April 2012.

Accordingly, the MCI /BOG deliberated on the BRHC on January 6-7, 2012. Action plans and a road map for introduction of the course have apparently been drawn up. The MCI is now calling it BSc (Community Health Care). On the basis of the experience of Assam, it has also called upon the Ministry to draft a piece of legislation for the introduction of a short-duration medical course. The Parliamentary Standing Committee is yet to submit its report, and it is not clear if the MCI will make public the course before that. It is not even clear if the Ministry has accepted the new nomenclature for the course and whether it is involved in these deliberations of the MCI.

The hearing on the contempt case is slated for early July. Things may become somewhat clearer then, nearly five years after the Task Force made its recommendation to ensure better rural health care.