Has the HC just thrown a lifeline to doctor-starved rural India?

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Has the HC just thrown a lifeline to doctor-starved rural India?

The problem

  • Rural India is reeling from a shortage of doctors, medical personnel
  • They have nearly 70% of the country's population, but only 33% doctors
  • To address this, a 3-year course to train medical personnel was proposed

The fix

  • MCI opposed the proposed course, saying it would degrade quality
  • Now, Delhi HC has ordered that it be implemented within 6 months
  • Supporters say it would bring much-needed relief to rural patients

That rural India desperately needs more doctors is depressingly clear.

According to the National Health Profile published by the Central Bureau of Health Intelligence, only a third of all government doctors are posted in rural areas even though nearly 70% of the country's population lives there.

Guidelines issued by the WHO mandate at least one doctor for every 600 people. In India, the ratio is 1:1800.

This state of affairs has persisted for a long time. Has the government done anything about it?

The health and family welfare ministry set up a task force in 2007 to study the shortfall of health personnel in rural areas and recommend how to rectify it.

The task force suggested compulsory rural posting of fresh MBBS graduates and creation of a new cadre of healthcare workers that would require just three years of training, instead of the five years mandated for doctors.

The latter proposal effectively meant introducing a new three-year medical course. But it drew severe criticism from the medical fraternity, with the Indian Medical Association calling it a "dangerous and retrograde move". A parliamentary standing committee also rejected the suggestion.

This, however, didn't stop the cabinet from approving, in November 2013, a three-year BSc Community Health in all state universities.

The course, the proposal went, "would train practitioners in conducting normal deliveries, pre-natal and anti-natal care and vaccination as well as in treating diarrhoea, pneumonia, tuberculosis, fevers and skin infections". They would, however, not be qualified to treat or diagnose more serious diseases.

After completing the course and six months of internship, they would be under an obligation to serve in rural areas for at least five years. Thereafter, could undertake a two-year bridge course and get an MBBS equivalent qualification.

Only, the course never saw the light of day.

To the rescue

Nearly two years later on 2 September 2015, the Delhi high court, hearing a petition filed by advocate Prashant Bhushan, pulled up the health ministry and the MCI for failing to implement the course.

Responding to the petition, the MCI laid out these objections to the proposed course:

  • A 'science graduate' won't have enough knowledge and expertise to substitute for a qualified MBBS doctor or a specialist medical practitioner.

  • For a BSc Community Health graduate to practice as a doctor, the Indian Medical Council Act would have to be amended. Currently, such a graduate can only work under the supervision of an MBBS doctor.

  • The introduction of the course is the prerogative of the states and the MCI has little say in the decision.

The court though wasn't convinced, and ordered the MCI and the Centre to make necessary changes to the curricula and start introducing the course within six months. If this isn't done, the court warned, it will hold officers concerned in contempt.

WHO guidelines mandate one doctor for every 600 people. In India, the ratio is 1: 1800

To rebut the MCI's state subject argument, the court pointed out that Assam couldn't implement a similar programme because it didn't get approval from the MCI and the central government.

Indeed, Jharkhand and Chhattisgarh have also agreed to introduce the course while Goa and Puducherry have expressed reservations.

But even if the course is introduced, how exactly would it help? Supporters have put forth the following arguments:

  • It would help make up part of the shortfall of doctors in rural India and give people access to at least basic healthcare.

  • A BSc Community Health graduate would be capable enough to identify and treat a range of common diseases that are easily treatable at the primary health centre level.

  • Bhushan told the court that the current system, in which only MBBS doctors, can prescribe scheduled drugs is ill-suited to the country's needs as most common ailments don't require the intervention of specialised doctors.

Finding fault

Not everyone is convinced. "We are sceptical. Sending half-baked doctors without an MBBS degree may promote quackery," says Mihir Banerjee of People for Better Treatment, an NGO that campaigns against medical malpractice. "Just because it's rural does not mean a place deserves any less than a qualified doctor."

AV Jayakrishnan, secretary of the Indian Medical Association's Kerala chapter agrees. "MBBS is the basic course for all medical doctors. Any further dilution can be detrimental to healthcare. Less qualified doctors won't be able to diagnose complex life-threatening diseases. There should be no discrimination against rural areas in this respect."

Jayakrishnan claims the course is part of the government's plan to certify homeopathic and ayurvedic doctors as qualified medical practitioners.

If you want more doctors, increase MBBS seats, don't start a diluted course, says IMA's KK Aggarwal

"The court wants BSc graduates to become doctors. This is not possible. If you want more doctors, increase MBBS seats in medical colleges. You don't have to start a new diluted course," says KK Aggarwal, finance secretary of the Indian Medical Association.

So, if introducing a "diluted" course isn't the ideal solution to the chronic lack of decent rural healthcare, what is?

It's simple, says Jayakrishnan. Instead of trying to change the minimum eligibility to be a doctor, the government should use funds under the National Rural Health Mission to establish more hospitals and medical institutes to train better qualified practitioners.

This, however, doesn't address the problem of MBBS graduates evading rural postings.

"MBBS students undertake a bond that they will work in a rural district for a year after completing the course. It's a criterion to qualify as an MBBS," says a graduate from a premier medical college in Maharashtra.

"The policy's implementation though depends largely on the states. I, myself, have been evading the bond since I passed out this year."

He is reluctant to serve in rural areas, the graduate says, because they lack the basic amenities required to treat a patient. And if something goes wrong, the blame often goes to the doctor.

"In some places, doctors have been killed by relatives of patients since the authorities there have very little power," he adds.

These concerns may have merit but the high court felt they are trumped by the greater public interest that introducing the proposed course would serve.

The course certainly isn't an ideal solution, but it likely would provide much-needed relief to some of the country's most marginalised population. That's reason enough to give it a try.

Vishakh Unnikrishnan

Vishakh Unnikrishnan @sparksofvishdom