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Dr Araveeti Ramayogaiah
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India lives in villages. India’s MBBS doctors are averse to step in there! India thinks in terms of alternative professionals to its rural population and that is the reason why a B.Sc. Community Health course was approved by the UnionCabinet. According to census 2011, of the 121 crore population in India, 83.3 crore people live in the villages. India’s public sector rural healthcare (RHC) consists of a sub centre (SC) for every 3000 to 5000 population and a primary health centre (PHC) for every 20,000 to 30,000 population and an Accredited Social Health Activist (ASHA) for every 1000 population.
A SC is the peripheral out post. It is an interface with the community at the grassroot level. It is manned by two female multipurpose health assistants (MPHAs) and one male MPHA. Before launching of MPHW programme, the designation of female MPHA was Auxiliary Nurse Mid Wife (ANM). They are called as Front line Health Workers. Most of the curative, preventive and promotive services are provided at the SC level. A PHC is the corner stone of Rural Health Services, the first port of call to a qualified public sector doctor in the rural areas.
The model emerged as the outcome of the 1946 Bhore committee, 1962 Mudaliar Committee, 1973 Kartar Sing Committee, 1975 Vastav Committee, 1983 National Health Plan and 2005 National Rural Health Mission (NRHM).
A PHC is manned by a Medical Officer (MO) with a team of nursing and paramedical personnel. MO is the custodian of health for 30000 and odd population and is the leader of a team comprising about 40 to 50 staff. MO can make or mar the PHC.
An ASHA is an addition from NRHM. An ASHA is the replication of China’s Barefoot doctor and the WHO’s Community Health Worker (CHW) programme implemented by several nations in the 80s.
MO, ANM and ASHA form the backbone of Rural Health Care. A MO at cephalic end leads, an ANM at the middle delivers and an ASHA at caudal end liaisons with the community. This is the best model in the world and envy of many nations. If this model is failing to deliver, there is something wrong in the implementation. Tinkering in any form and adding new cadres is not a remedy and is a disaster.
As per the Rural Health Statistics (RHS) 2011, we have 1,48,124 SCs and 23,887 PHCs and are short by 35,762 SCs and 7048 PHCs for 83.3 crores of rural population (68 per cent of total population as per census 2011). The sanctioned medical officer posts are 30051 and 26329 are in position. India produces about 45,000 MBBS doctors annually. 70 per cent of one year output is more than enough to man all the PHCs. India’s Medical Council register has about seven lakh registered MBBS doctors!
Aspiration of young MBBS grads in the 70s
“After how many years of graduation in MBBS, do you get the job?” was the usually question faced by every MBBS student when I joined medical school in 1968. The stock answer by every student used to be – “After five to six years!” Doctors with five to six years of standing practice used to jump to work as a Medical Officer of PHC despite earning twice or thrice as much as a MO. A MO is a born Gazetted Officer and is a very glamorous post. It is a prestigious position in society.
The aspiration of 80 per cent of MBBS students during the 70s was to settle as general practitioners in their native villages. The leading politicians of Andhra Pradesh, late Dr YS Rajasekhara Reddy, Dr DL Ravindra Reddy and Dr MV Mysora Reddy practised in their villages before joining politics. Distinction students and gold medallists also settled at MBBS. Students who could have easily got a PG seat also used to settle for basic qualification. Alas, now no where in the country an MBBS is starting a clinic for general practice. The irony is that policy makers of our country think in terms of starting new speciality courses in general practice. In that scenario what is the role of a MBBS doctor?
The need of the hour
In India, health is always talked in terms of medical colleges, GDP, doctor population ratios etc. India does not talk health in terms of infant mortality rates (IMR), maternal mortality ratios (MMR) and life expectancies. In India health means medical care. The word ‘health’ very often misused for the word ‘medical’. India thinks in terms of expanding medical colleges to meet the demands of rural areas for doctors. In our country, it is easy to get a medical college than a functional sub centre. Two years back, a leading English weekly asked a famous, highly revered doctor to write an article on health needs of the country for its New Year issue! The core content of his article was the need to create more opportunities for MBBS for becoming specialists! My curiosity on the content of the article dried down immediately after reading! I actually looked for solutions to reduce IMR and MMR from the article! A south Indian state in India brought an NRI and appointed him as a Chairman to study and recommend changes needed for improvement in healthcare. Isn’t an Indian medical professional with wide exposure and success behind him/her the right person to do that job?
Paramedical staff play a crucial role in rural health and medical care. However, the state does not take them into confidence during policy making. Small pox eradication is due to their committed work and sacrifices. Due to their hard work, India is free from the endemic of poliomyelitis. An ASHA is capable of diagnosing deadly falciform malaria and initiating treatment within 15 minutes, a great public health revolution. But, as the medical officers do not lead them, they do not work adequately. They don’t have a role model to follow and the net result is all round dysfunction.
It is not at all difficult to position a MBBS at PHC. Without changing the model of medical education, we can’t improve medical care. We should have proper policy on creating MBBS and their deployment.
“Make up your mind how many doctors the community needs to keep it well. Do not register more or less than this number; and let registration constitute the doctor a civil servant with a dignified living wage paid out of public funds,” said George Bernard Shaw in ‘The Doctor’s Dilemma’. Is it not relevant to Indian situation for policy making on today? Alas, hundred years after ‘The Doctors Dilemma’, we could not grasp what Shaw said.
Recommended measures
A single window policy of recruitment with a fixed tenure at remote PHC, plain area PHC, upgraded PHC, PG opportunity, career advancement to every MBBS is the right policy to tide over the crisis. Compulsion or coercion to work in rural areas as a student is unethical and irrational. In no other profession, students are insisted to work in rural areas. Rural people also require experienced doctors. Their lives can’t be left to raw, inexperienced doctors who are continuously replaced by a new batch every year. Doctor patient relationship is not one of short term but is one of sufficiently long term. MBBS belongs to the nation. MBBS is the outcome of blood and sweat of people of the nation. They are not sacrosanct and people are not untouchables! The irony is that people are also getting alienated from the PHCs by themselves and resorting to their own solutions! State is a myth for them!
B.Sc Community Health
MBBS can’t be substituted with any other cadre. After brooding over Bachelor of Rural Medicine and Surgery (BRMS) ad Bachelor of Rural Health Care (BRHC), the union cabinet settled on B.Sc. community health much against the wishes of ‘The Parliamentary standing committee on Health’. Any alternative to MBBS is a cure worse than disease. Alas, many elitists are supporting this! It is discriminatory.
The early reports suggest that the proposed graduates will be positioned at SCs. The reports also indicate that they form an intermediary cadre between MO and ANM. It is also given to understand that they play a role in promotion of and protection of health.
The proposed graduates can’t be a substitute for MBBS at PHC. The SCs are already manned by two female MPHAs and one male MPHA. This is foolproof and working well. There is no role for these new graduates at SC level. There are several intermediary cadres already in the system between MO and ANM viz., Multipurpose Health Supervisors (MPHSs), Multipurpose Health Extension Officers (MPHEOs), Public Health Nurses (PHNs), Health Educators (HEs) and Community Health Officers (CHOs). There are already other cadre of professionals existing with 3 to 3 ½ years formal training. They are B.Sc nurses and general nursing midwifery trained nurses. The proposed graduates face career advancement problems with existing cadres. The new graduates can’t be designated as CHOs as such a cadre already exists and is a Gazetted Post. India’s private and corporate sector doesn’t employ them. Every health functionary is an inherent promoter and protector of health and there is no role for the proposed new cadre to play such a role. The new cadre definitely do not opt to settle in private practice and even if they want they are not eligible. In this country everyone except modern medicine doctors visualise a career in a government service. The new cadre is an economic burden without tangible results in commensuration with the efforts and investments. This may lead to a new brand of unemployed graduates who will be an organised pressure group on the state.
Traditional practioners in India is a reality as along as professionally trained persons do not go to the community. Quackery or glorified quackery or quackery by scientifically trained persons or quackery to benefit corporates continues to exist and survive in this country as along as the present economic model exists. Let wisdom dawn over the state so that it does not burden people of this country with another cadre!
What we think as unacceptable today are summation effects of at least three decades of misdeeds committed by most of us. Trying to tinker without going into roots is escaping from truth and avoiding reality. Tinkering at best gives minimal transient and apparent results and at worst destroys or reverse already achieved progress. In a running kleptocracy, morbid individualism and crony capitalism, many refuse to agree and even listen to this. Indeed it is an unfortunate phase of our times!
“Build healthcare systems based on principles of equity, disease prevention and health promotion. Strengthen public sector leadership in equitable health care systems financing, ensuring universal access to care regardless of ability to pay. Invest in national health work forces, balancing rural and urban health workers density” are some of the key recommendations of WHO report on closing the gap in a generation. Let our policymakers rise to the report!
The author was also Former Medical Consultant – Indian Institute of Health and Family Welfare- Hyderabad and Former State Coordinator, Breastfeeding-Promotion Network of India, Andhra Pradesh
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