It takes a village cadre
India’s rural healthcare vacuum needs to be urgently addressed……Shomikho Raha
India’s rural healthcare vacuum needs to be urgently addressed……Shomikho Raha
The recent announcement about training a cadre of medical practitioners for rural healthcare is a landmark decision, not because it is a novel idea, but because it is being promoted by the Medical Council of India (MCI). A 2007 taskforce to government proposing a similar scheme, in fact, shied away from MCI support, suggesting that a separate independent statutory body be created instead.
The history of a short-course rural health practitioner, reduced from the five-and-a-half-year MBBS course, is a long and chequered one. Its implementation has been ineffective or incomplete in the past largely because of the opposition of doctor associations and the MCI, which feared a dilution in the status and quality of its elite medical corps.
So why the change in stance now? In blunt terms, there is a continued absence of skilled practitioners of primary healthcare, more than 60 years post-independence, through most of rural north India and the Northeast, compounded by remarkably high incidence of reported absenteeism.
This year, however, students will compete for the 24,455 MBBS seats in recognised medical colleges (and for the thousands more still deemed unfit or pending MCI recognition). That many of these colleges, about 45 per cent, are located in the four southern states of Andhra Pradesh, Karnataka, Tamil Nadu and Kerala does not help. Further, that these students tend to pursue postgraduate studies, braving several attempts for a much fewer number of seats, inclines their career aspirations towards specialist hospitals in towns or cities, rather than the rural government healthcare centres where posts remain vacant. This explains, to an extent, the full-blown crisis of scarcity of doctors in rural areas even as statistics show 0.7 million doctors registered with the MCI, working in the country.
Doctors graduating now are much less likely, with more global and private sector opportunities, to commit themselves to rural illness, and may even be ill-equipped to better the preventive care public health environment in remote areas. Nor is the far-overdue clarion call of the government, under NRHM, to empower the nursing cadre going to provide the solution. Several factors militate against this possibility: the low status accorded to nurses across the country (except arguably Kerala) than in most of the world, the real gender and cultural issues of predominantly female nurses in India providing care to males in the rural north, and finally a genuine concern about the quality of nurses trained in a rapid 35 per cent increase in only three years (till the latest 2008 data) of general nursing and midwifery institutions (mainly in the private sector, and as geographically skewed as medical colleges). The prospect of the short-course rural health practitioner therefore fills an urgent void in the landscape of trained healthcare providers available in the health system and it is this stark writing on the wall that the MCI now acknowledges.
Reports suggest that the government intends the first batch to enrol in August, which bears an uncanny parallel to the timeline the Chhattisgarh government adopted in 2001 to open institutes to train such rural healthcare practitioners. The proposed Bachelor of Rural Health Care will be different from the Chhattisgarh diploma in important ways, including a shorter internship to accommodate more teaching in the four years. The course will be approved through a state legislative assembly ratifying an amendment to the State Medical Councils Act, rather than creating a wholly new statutory body as was done in Chhattisgarh to bypass the MCI. The schools will be government-run, linked to remote district hospitals, instead of being private ones. Applications will be drawn only from designated rural districts.
Urgency, nevertheless, often comes with haste. The immediate challenge of doctors opposition and legal bottlenecks to get the schools started should not overshadow steps for long-term sustainability, as happened in Chhattisgarh. Little concern on the long-term future of the graduates (after completion of their five-year government service bond), continued fuzziness on them being called doctors and almost no mention of creating support institutions to supervise quality of these schools and availability of skilled faculty (in already overstretched manpower at district hospitals) hark back to Chhattisgarh where the institutes were forced to shut. It will be worth considering, right at this early stage, how to frame a bridge-course for these graduates after mandatory service, which makes them eligible to take PG examinations. Allowing them to enrol later at the Indian Institutes of Public Health may allow them to further their careers as public health managers, which our health systems mostly lack. The Chhattisgarh experience suggests that these graduates will take up posts in the most remote rural postings where no doctor previously ventured. But in this experience there lies a warning for government: dont underestimate the needs of the students as their motivation will stem from opportunities for career advancement and their desire for quality education being met. Rural postings devoid of any performance incentive are an incomplete solution.
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