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Indian medical students protest over compulsory rural postings, August, 2013

Dinesh C Sharma

Although the number of health facilities in rural areas of India have increased during the past decade, convincing doctors to work in them remains a challenge. Dinesh C Sharma reports.

In the last week of November, two siblings aged 5 and 6 years died in a remote village in central India after they were given an injection by a quack who thought they had chickenpox. The village, Khodsanar in Chhattisgarh state, is accessible only by boat and is more than 40 km away from the nearest government hospital. The incident highlights the poor state of rural health care in India, a system blighted by lack of access to health-care facilities, shortages of doctors and paramedic staff, and the predominance of untrained private practitioners as the first point of care.

The rural health-care system in India is composed of three tiers. Sub-centres are manned by trained health workers and auxiliary nurse midwives, with each centre covering up to 5000 people. Primary health centres, which act as the first point of contact between village communities and a medical officer, are supposed to have a doctor supported by 14 paramedics and other staff. Community health centres are meant to have four medical specialists (a surgeon, physician, gynaecologist, and paediatrician) supported by 21 paramedic and other staff as well as 30 beds and facilities such as an operating theatre and radiology room.

Although the number of health facilities has risen in the past decade, workforce shortages are substantial. As of March 31, 2015, more than 8% of 25 300 primary health centres in the country were without a doctor, 38% were without a laboratory technician, and 22% had no pharmacist. Nearly 50% of posts for female health assistants and 61% for male health assistants remain vacant. In community health centres, the shortfall is huge—surgeons (83%), obstetricians and gynaecologists (76%), physicians (83%), and paediatricians (82%). Even in health facilities where doctors, specialists, and paramedic staff have been posted, their availability remains in question because of high rates of absenteeism.
Reasons for the shortages
These shortages exist despite India having one of the largest medical education systems in the world, with more than 410 government and private medical schools having an annual intake of 50 000 students for MBBS courses. City-bred and educated doctors are not willing to serve in rural areas, many of which still lack electricity and roads. Indian medical education is geared to train doctors to work only in tertiary care and specialised hospitals, so these areas become the primary professional aspiration of health workers, points out Vikram Patel, professor of international mental health at the London School of Hygiene & Tropical Medicine, UK. “Working in the public health sector is often a demoralising experience for doctors because their professional lives are blighted by lack of professional development opportunities, accountability, and access to even basic medical resources necessary to perform an effective role”, he adds.

Chandrakant S Pandav, head of community medicine at the All India Institute of Medical Sciences in New Delhi, feels that “undue focus on specialised care in medical undergraduate training is leading to the neglect of primary health care and family care components”, preventing young doctors from serving in rural areas. D Krishna Rao, assistant professor of international health at Johns Hopkins University, MD, USA, says that governments have done little to make rural service appealing to doctors. For instance, he says, most states don’t have a workforce policy to ensure that doctors are rotated between rural and non-rural postings, giving rise to the perception that once posted to a village it is difficult to return to a city.

During the past few decades, the central health ministry and state governments have attempted various strategies to attract doctors to rural areas, such as compulsory rural postings, linking rural postings to admission into postgraduate courses, and offering monetary incentives. Doctors trained in Indian systems of medicine such as Ayurveda, Siddha, and Unani are also being posted to government health facilities.

As a long-term measure, the health ministry in 2010 proposed a new course, a BSc in community health, to train primary health-care practitioners. The Medical Council of India (MCI), which oversees medical education, first concurred with the government on the need for such a course but later refused to approve the course, saying no one except MBBS doctors are permitted to prescribe medicines under Indian law. The Indian Medical Association (IMA) also opposes this course as well as bridge courses in modern medicine for graduates of Indian systems of medicine.

Divided opinion
The proposed course was the subject of a public interest petition in the Delhi High Court. In September, 2015, the court directed the government and MCI to start the course within 6 months. The court has suggested that the Indian Medical Council (IMC) Act is amended or a new law is enacted to facilitate the rural health-care course.

Opinion is sharply divided on this issue. “Permitting the practice of modern medicine directly and indirectly to persons not qualified under the standards of the MCI and IMC Act will result in a heavy miscarriage of public health, causing dangers to the lives of people in rural areas”, warns A Marthanda Pillai, national president of the IMA. He says the association is studying the court judgment and also working with the government to find a solution. “Given deficiencies in regulatory and monitoring mechanism in the rural health-care system, creation of new cadre of health professionals will not only lead to poor quality health care for the rural population but also result in underutilisation of existing health professionals”, adds Pandav.

Abhijit Das, director of the Centre for Health and Social Justice in New Delhi, suggested a review of overall clinical care provisioning and the development of clear standards for practice at each level of provider. “In a highly fragmented and privatised health-care system we need to do thorough mapping and then follow-up with some regulatory framework. Without such mapping, providing universal health care will be impossible.” He feels that India needs practitioners who are linked to centres of care through a referral chain.

Abhay Bang, director of the Society for Education, Action and Research in Community Health in Gadchiroli, says a 3-year BSc or a bridge course for rural doctors is “desirable and feasible”. “Medical training is not rocket science. We have trained community health workers in 30 days to deliver home-based neonatal care”, he adds.
Innovative options
While debate about a special course for rural medical professionals continues, the experiences of a couple of states with such courses might be worth assessing. Chhattisgarh introduced a 3-year diploma course for rural medical assistants (RMAs) in 2001. A similar course for rural health practitioners has been offered in Assam state since 2004. Both the states have established a separate regulatory framework for these courses but have faced legal hurdles from the IMA. “Cadres like RMA are important for strengthening rural service delivery but there are problems. For instance, in Chhattisgarh there is no clear career trajectory for the RMA, which leads to great dissatisfaction among graduates”, suggests Rao.

In West Bengal state, informal care providers in villages are being trained under a private initiative by a non-profit organisation, the Liver Foundation. “These care providers thrive on a demand–supply axis and have strong community ties in view of their utility as the only sources of care in villages. Their linkages to the community can be a potential strength in terms of being used as a health-care human resource if trained and integrated”, explains Abhijit Chowdhury, founder of the Liver Foundation and professor of hepatology at the Institute of Post Graduate Medical Education and Research, Kolkata. “At present, informal providers claim to be doctors and engage in potentially harmful practices which need to be curbed. This can happen by being cognisant of their existence and functions, not by maintaining a strategically ambivalent ostrich-like attitude that the mainstream has for them.” Around 2200 such practitioners have undergone 150 hours of training spread over 9 months, in West Bengal and Jharkhand states.
The way forward
Meanwhile, the federal government has not ruled out any option. Health Minister Jagat Prakash Nadda stated on Nov 22 that “reaching out to a vast population in a country like India requires arrangements of mid-level care providers in the rural areas. My Ministry is working in consultation with IMA and MCI for provision of rural health-care providers like trained Indian medicine doctors, nurse practitioners, and BSc [graduates] in community health”.

“Certainly task-sharing to non-physicians is a well-proven strategy for making health care more accessible and affordable without compromising quality, but health care requires teams of professionals with complementary roles in which physicians play a crucial role. There is no getting away from the fact that we do need more doctors in rural areas and in primary care more generally”, feels Vikram Patel.

The IMA wants increased government spending in health and higher salaries and other facilities for MBBS degree holders to work in villages. The government can also use qualified private practitioners on a contract basis to fill rural posts, it says.

If a permanent solution is to be found to the problem of poor health care in rural India, developing a consensus among stakeholders will be critical.