Missing doctors

A patient suffering from enteric fever being treated at a makeshift shed outside the Kucheipadar Primary Health Centre in Rayagada district of Orissa, in August 2007.-LINGARAJ PANDA

UNDENIABLY, public health in the country is in a state of crisis. The indicators are, in fact, shocking: India carries 20 per cent of the global disease burden, which is less than its share of the world population at 17 per cent. Specifically, this includes a disproportionately high share of the global burden of pre-transition communicable diseases and other vaccine preventable diseases: 23 per cent of child deaths, 20 per cent of maternal deaths, 30 per cent of tuberculosis cases, 68 per cent of leprosy cases, 50 per cent of polio cases and 14 per cent of HIV infections. The same is true of other diseases such as malaria, acute respiratory illnesses and diarrhoeal diseases. Mortality as a result of communicable diseases amounts to 2.5 million child deaths and an equal number of adult deaths a year. If one adds the poor maternal and neonatal health status to the above statistics, communicable diseases account for nearly half of Indias disease burden.

Targeting these diseases, as the 2007 report of the task force set up in 2005 under the National Rural Health Mission (NRHM) pointed out, does not require high clinical expertise or expensive and high-tech diagnostic aids. The broad ambit of primary health care services is sufficient to address this issue. The chief problem, however, has been the lack of access to appropriate primary health care, particularly in rural India, which the NRHM is supposed to address. In fact, the most significant aspect of the Indian public health system is the pronounced disparity between urban and rural areas. For example, in Andhra Pradesh, the rural infant mortality rate (IMR) is 67 compared with 33 in the urban areas; in Karnataka, the rural IMR is 61 as against 24 in the urban areas. This is a clear consequence of the highly skewed nature of health care in favour of urban India. Although rural people account for nearly three-fourths of the countrys population, they are denied even the basic medical care required for treating common and preventable medical problems that constitute 80 per cent of all medical conditions.

The primary reason for this difference in the availability of primary health care services is the human resource crisis. There is an acute shortage of medical professionals on the one hand; and a highly iniquitous distribution of the numbers that exist on the other. Three-fourths of 0.7 million graduate doctors legally permitted to practise as qualified doctors operate in and around urban areas, thus catering to just 28 per cent of the countrys population and leaving the rural folk underserved or totally neglected in terms of basic health care. In large parts of the country there is no semblance of a subsisting primary health care system, remarked the 13-member NRHM task force set up to address the issue of medical education and the human resource problem.

The primary health care infrastructure in the country is a three-tier system with Sub-Centres (S.Cs), Primary Health Centres (PHCs) and Community Health Centres (CHCs). The S.Cs are the most peripheral and the first contact point between the health care system and the community. The PHC is the first contact point between the village community and the certified medical officer. A CHC, with specialised services in the form of surgeons, obstetricians and gynaecologists, physicians and paediatricians, is a referral unit for four PHCs. According to the 2008 Bulletin on Rural Health Statistics (BRHS) of the Ministry of Health and Family Welfare, there are (as of March 2008) 1,46,036 S.Cs, 23,458 PHCs and 4,276 CHCs. However, on the basis of the norms set by the Ministry and the 2001 Census, there is a shortfall of 20,486 S.Cs, 4,477 PHCs and 2,337 CHCs.

But the situation is actually worse because of the deficiency in the human workforce even in the established units. At present, a sub-centre is not designed to have a qualified doctor but is manned by at least one Auxiliary Nurse Midwife (ANM)/Female Health Worker (FHW) and one Male Health Worker (MHW). There are 24,375 doctors serving the PHCs, which, given the estimated rural population of about 830 million, implies a doctor population ratio of 1: 34,000. This is much below the global standard set by the World Health Organisation (WHO) of 1: 250. Compare this with the figure of 1:472 in Delhi, for example. In fact, the country (rural+urban) average of 1:1676 is itself much less than this and does not compare favourably with those in other parts of the world.

But, more significantly, according to the BRHS, there is a serious human resource shortfall in all the tiers (see bar charts): 12.4 per cent shortfall of the total requirement in FHWs/ANMs, 56.8 per cent in MHWs and 15.1 per cent in doctors at PHCs. The BRHS points out that a significant fraction of the sanctioned posts are vacant at all levels; 18.8 per cent specifically in respect of doctors at PHCs. Of the 23,458 PHCs, 12.4 per cent are without a doctor, 37.8 per cent without a lab technician and 16.3 per cent without a pharmacist. At the sub-centre level, 6 per cent are without an FHW/ANM, 41 per cent without an MHW and 5 per cent without either. As the task force pointed out, doctors in position does not necessarily mean that the doctors are physically present at their respective centres and performing their duties; in fact, absenteeism is very high.

As a result, primary health care for the rural poor is served largely by untrained, unlicensed and unregulated rural medical practitioners (RMPs) and what they practise is often nothing but quackery. In a study conducted in rural Uttar Pradesh in 1995, only 3 per cent of medical practitioners were MBBS graduates or allopathic practitioners, while 68 per cent had no training in any form of medicine. But, more pertinently, as a paper in the Indian Journal of Community Medicine by C.S. Pandav and associates from the All India Institute of Medical Sciences (AIIMS) points out, this shortfall in rural areas is only going to increase, more so with corporatisation and privatisation of health systems. We have to be realistic and accept that trained doctors who have put in 10 years or so in training and are predominantly from urban areas are unlikely to want to go to villages.

After 4 years of the main course and one-year of internship, says the task force report, the finished graduate has very little hands-on experience. Most graduates are not confident enough at that stage to even provide primary health care services independently. The MBBS curriculum is closely linked to a tertiary care hospital. And, therefore, the graduates cannot function in a setting where there is no multidisciplinary support, or advanced diagnostic hardware (emphasis original). Indeed, recently the Chhattisgarh government advertised for nearly 1,200 posts of MBBS graduates to fill positions in PHCs. It received only 400 applications.

The report further says: The shortcomings perceived by the fresh medical graduates are principally the outcome of their urban orientation and the skewed pattern of their aspirations. The few with a rural background acquire an urban mindset in the course of their training that is focussed around a tertiary care hospital. Most graduates aspire to spend their career in the same urban ambience that they are familiar with [It] is because of this fixed mindset that the young graduates fail to position themselves comfortably in the social ambience of the country, and also fail to recognise health services as a fundamental requirement of the community.

It has been argued by experts that the solution for rendering primary health care to the underserved rural and urban poor population lies in a short-term, affordable medical course to create a cadre of health professionals with emphasis on clinical training and a problem-solving approach, with non-clinical principles meshed with clinical training. Chinas barefoot doctors during the Cultural Revolution period, which later got integrated into the national health policy as Rural Cooperative Medical System (RCMS), is perhaps the earliest example in the independent developing world to address rural primary health care. In the 1960s, the RCMS covered nearly 90 per cent of Chinas villages. The WHO has regarded the RCMS as a successful example of solving shortages or medical services in rural areas.

Indeed, such mid-level health workers or non-physician clinician (NPC) programmes have evolved more recently in Nepal, Thailand and Vietnam and the countries of Africa and the Pacific to cater to the specific requirements of individual countries in their rural settings where regular physician-doctors are in short supply, and have been generally successful.

In a December 2006 editorial, the medical journal Lancet commented: Employment of [mid-level] non-physicians would ease human resource constraints, such as shortages of trained professionals, because of international migrationor reluctance to be deployed to rural areas. Costs would also be reduced because mid-level providers are less expensive to train and easier to train and generally need less complex diagnostic tests and equipment in their practice. In some circumstances, mid-level providers might even provide better quality of care, because they are focussed on specific tasks, relate better with local communities, and could have a more holistic approach to the problems at hand.

A 2008 WHO report acknowledged the success and increasing spread of the use of mid-level practitioners but argued for their integration into the national health policy framework, standardisation of their categories and training and, most importantly, data gathering of the impact and experiences of such systems across the developing world.

But such an intervention has not been forthcoming from Indian policymakers despite repeated recommendations to that effect by expert groups. The National Council on Macroeconomics and Health (NCM&H), also constituted in 2005, noted: Training the existing RMPs, who enjoy a measure of social consent, over three years could have the twin benefits of addressing over 80 per cent of health care needs within the village habitation itself and also at the same time relieve the pressure on the production of trained medical doctors who, by virtue of their training and professional aspirations are reluctant to serve rural villages.

Indeed, one of the important terms of reference of the NRHM task force was to examine the feasibility of such a short-term course. We have for far too long, said the task force, clung to the belief that only graduate doctors can render competent health care, and that all other attempts to deliver health services are ill conceived and against patient interest. The task force is of the view that this bland assertion needs to be critically examined.

Accordingly, it recommended a three-level health care system: the first level would be limited to a restrictive service package of primary health care, provided by practitioners with appropriate training; the second level would be that of graduate doctors; and the third, that of specialists.

The appropriate medical education, it said, for service providers of the first level would be less elaborate than that required for a graduate MBBS degree, but is considered entirely feasible to ensure that the skills available to a short-course service provider would be fully adequate for the common conditions included in that level of health care.

It further clarified that the variant considered was not a short-course health practitioner with an open licence to practise across the entire allopathic domain but a short-course training after which the practitioner would be licensed to provide medical services within a notified package of primary health care.

It may be mentioned in passing that pre-Independence India did have a short-duration course for Licentiate Medical Practitioners (LMPs); it was a three-year course in medical schools. It was the LMPs who delivered health care in rural areas. The Bhore Committee report of 1946, however, recommended that the licentiate qualification be abolished and all available resources be directed to produce one type of doctor after a five-and-a-half-year training. There were dissenting views in the committee on the grounds of manpower shortages, particularly for the rural areas where the basic doctor would not willingly fit. Indias six decades of chronic shortages of doctors in the rural areas are a grim testimony to this fact, wrote K.M. Shyamaprasad, former vice-president of the National Board of Examinations of the Ministry of Health and Family Welfare, and Meenakshi Gautham, a public health specialist (The Hindu, November 5, 2009)

The training module that the task force envisaged for the first-level primary health care practitioners was a three-year B.Sc. (Health Science) course, which would include both clinical and non-clinical subjects, qualifying them to be called Community Health Practitioners (CHPs) and not doctors. The training would comprise two years in an institution and a one-year internship, both in allopathy. It also considered a variant of the same for graduates in alternative forms of medicine ayurveda, unani, siddha and homoeopathy as well as pharmacy, dentistry and nursing as a two-year course. It recommended that government functionaries ANMs, MHWs and FHWs be encouraged to take the short course after serving a minimum of five years in a rural area. It said that the short course could be conducted by any university with a health science faculty or medical colleges, dental colleges or nursing colleges if the conditions set out by the statutory body similar to, but distinct from, the Medical Council of India (MCI), which regulates graduate degree education are satisfied.

The task force also sought to dispel the doubts of sceptics who fear that the short-course practitioner would not restrict himself/herself to the primary health care situation and would feel free to practise over the entire domain of medical conditions, which would amount to quackery. It needs to be recognised, it said, that today most of the practitioners in the rural areas are quacks in as much as they have no training. It is the considered view of the task force that in the suggested scheme the risk of quackery would stand reduced, rather than increased. Also it would result in good quality primary health care services being delivered to citizenry on a much wider scale than is available through graduate doctors today.

It also noted that the fraternity of graduate doctors had been averse to this on the grounds that it would create a twin-tracks health system under which the elite would have superior health services, and the others would have sub-standard services delivered by an inferior cadre. By insisting on health services through graduate doctors, or nothing, the task force observed, the medical fraternity has created a situation in which vast numbers got nothing. The delivery of primary health care services through short-course community health practitioners runs no untoward risks. In fact, if the delivery of primary health care services were further delayed, the unserved population would have reason to believe that the restriction, which is purportedly being enforced in their interest, is actually the vested interest of a group.

A major stumbling block, however, has been portrayed all along as a legislative one, particularly by the MCI. But it is only apparently so. The MCI has maintained that such a course is not permissible under Section (12)(b) of the Indian Medical Council Act of 1956, which states, No person other than a medical practitioner [as defined in the Schedules of the Act] enrolled on a State Medical Register] shall practise medicine in any State. The Acts Schedules effectively restricted the practice of modern medicine to those who have a minimum qualification of an MBBS degree plus one-year internship. Indeed, the MCI inserted a dissenting note in the task force report, raising the issue of restrictive provisions under the IMC Act.

However, following up on the recommendations of the task force, the 9th Conference of the Central Council of Health and Family Welfare, held in November 2007, resolved as follows: That all the State governments bring out an enabling legislation on the lines of the Acts passed by Chhattisgarh and Assam States so as to introduce a three-year diploma course in Medicine and Public Health in order to provide manpower to address rural health care needs. The Central Ministrys presentation at the conference on the NRHM highlighted the need to develop a three-year programme for Basic Medical Practice as part of the Mission. Indeed, congratulating the government on launching the NRHM, the Assam Health and Family Welfare Minister criticised the conflicting role of the MCI in promoting medical education and in augmenting manpower resources.

Assam has been a forerunner in this initiative. In 2004, it brought in the Assam Rural Health Regulatory Act to start a special medical course, namely Diploma in Medicine and Rural Health Care (DMRHC), and to provide for the establishment of a regulatory authority to enable the diploma holders to man the rural PHCs.

Similarly, on July 26, 2007, Chhattisgarh passed the Chhattisgarh Chikitsa Mandal Bill, to create a three-year diploma course called Practitioners in Modern and Holistic Medicine to fill gaps in rural medical services at the PHC level. The details of it provided in the Chhattisgarh NRHM Project Implementation Plan of 2008-09 are illuminating: The [Chhattisgarh] government, it says, is moving towards pooling a force of medical personnel from the three-year medical training programme, which has been designed and run by the State universities. These students are trained in institutions especially set up for this purpose with adequate clinical exposure and internship training in public hospitals. More recently, on December 16, 2009, the West Bengal Assembly passed the Rural Health Regulatory Authority Bill, an enabling legislation to introduce in the State a three-year diploma course in Medicine and Public Health to meet the requirements of medical practitioners in remote and rural areas. Clearly, despite the MCI stand, these three States have implemented, in essence, the recommendations of the NRHM task force.

But after nearly three years of inaction, this issue of a short-term medical course for primary health care workers has suddenly assumed importance in the Centres policy initiatives following the filing of a joint Public Interest Litigation (PIL) in the Delhi High Court by Meenakshi Gautham and the Garhwal Community and Development Society, Uttarakhand, against the Union of India and the MCI. Arguing essentially for the implementation of the task forces recommendations and the Central Councils resolution of November 2007, the petitioners have requested the court to (a) declare Section (12)(b) of the IMC Act unconstitutional as it denies the fundamental right to health to a majority of people of India; and (b) direct the Centre to introduce a short-term course for training health workers for primary health care in rural areas and then license and regulate its graduates.

It is pertinent at this point, however, to ask how the States could introduce such short-term courses in contravention of the IMC Act and against the directives of the MCI. According to the interpretation of the IMC Act by the Supreme Court, MBBS qualification is required only for registering a practitioner in the Indian Medical Register regulated by the MCI. Education is in the Concurrent List and hence States can independently enact appropriate legislation to introduce medical courses with lesser qualification in public interest for registering in the State Medical Register, but not the Indian Medical Register. The Supreme Court has held that such health professionals can practise modern medicine and prescribe scheduled drugs after registering themselves in the State Medical Register. But there has been little or no follow-up action at the Centre on the task force recommendations and the council resolution. That is why we are seeking the courts directive for radical shifts in the medical education system, Meenakshi Gautham pointed out.

The developments in States like Chhattisgarh on the public health front and the need to respond to the recent petition would seem to have forced the MCIs volte-face. In its affidavit, it has come up with a framework for starting a course leading to a degree called Bachelor of Rural Medicine and Surgery (BRMS) to be run by medical schools and conferred by universities to which such medical schools are affiliated. In fact, the MCI evolved this framework over two meetings in December 2009 following the filing of the writ by Meenakshi Gautham and the GCDS.

However, as the petitioners point out in their counter-affidavit, the BRMS is conceptually different from what they have argued for and what the task force had recommended. Indeed the use of the word surgery betrays a wrong conceptual basis of the proposed course. Moreover, the Central Councils resolution had urged the State governments to enact enabling laws in which the MCI would have no role to play. They have further argued that the need is to take the task force recommendations forward rather than evolving new structures ab initio as the MCI was planning to do, which would call for amendment of the Schedules under the IMC Act or enactment of a new law.

Interestingly, ignoring the task force recommendations and the Central Councils resolution, the Central Ministry has, in its affidavit, spoken of BRMS as an important and significant step being formalised. Indeed, in his recent address to the Social Editors Meeting in New Delhi, Union Health Minister Ghulam Nabi Azad said that the government, in association with the MCI, was working out the details of a cadre of medical workers, through a new three-and-a-half-year BRMS course, who would work at the S.Cs and the PHCs. Interestingly, at the hearing on January 27, the court criticised the MCI for not having done anything all these years and asked the government to file a detailed affidavit dealing with the task force recommendations and the resolution of the Central Council. The next hearing is scheduled for March 10.

But more interesting is the position taken by the medical fraternity at large. The Indian Medical Association (IMA) has opposed the BRMS proposal. In its memorandum issued on January 25, the IMA says: The scheme is totally ill-conceived, impractical, retrograde, discriminating and undemocratic stepit will produce sub-standard doctors whowill be able to provide at best only compromised care to the rural masses.

The IMA is clearly obfuscating the issue deliberately or is genuinely failing to understand the proposed concept of a cadre of health workers with limited domain of service designed only to cater to primary health care in rural areas. The task force, too, has considered such views and the report has its detailed responses to them.

The IMA seems to be trying to preserve its turf. In the past six decades, the cadre of MBBS doctors has failed to serve three-fourths of the country. But what is pertinent is how the Centre responds in its new affidavit adopt the hastily conceived BRMS or implement the recommendations of the task force and the council resolution, that it was party to, in right earnest.