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Rapid Responses: Rapid Responses published:
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Doctors and Rural India..do we understand this ?
- Dinesh Bagmane (5 January 2007)
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Rural Practitioners India.
- Jacob John (8 January 2007)
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India may benefit from barefoot doctors
- Richard Fielding (10 January 2007)
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Second-class care for 'second-class' citizens
- M J S Zaman (10 January 2007)
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Incentives & Infrastructure & Implementation.
- Shachi Pradhan (10 January 2007)
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Government versus Doctors
- Farhat Mirza (11 January 2007)
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Dangerous decision
- Muralidharan Parthasarathy (11 January 2007)
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Let's change the bathwater.
- Arvind Dayal (19 January 2007)
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Circumventing responsibility: Licencing Quacks
- Dr. Ajoy Kumar Sodani (12 February 2007)
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community practioners in rural India
- sriramashetty vengopal O.B.E, BIRMINGHAM B16 9JT (13 February 2007)
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India has no proper GP training system!!
- Dr Sumithra Joseph (2 October 2009)
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Dinesh Bagmane, Clinical Research Fellow Southampton General Hospital Southampton SO16 6YD
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This is a very interesting debate which has been ongoing in India for few years.The training modules in India is different from the training in the UK.So doctors qualified(MBBS)still need to do structured senior house officer training which should include specialities which will of help in the community. There is always demand for the doctors to work in the rural community but what the authorities or the government is not completely understood is the infrastructure level poovided to the doctors in these villages.Few of my friends who choose to take up this service with pride always have the feeling of undertreatment from the government.There are no proper housing,electricity and proper means of communication,transport and last but not the least is that the doctots are underpaid. Its well appreciated that there are plans for a structured programme now which will help the doctors who wants to work in these places where sometimes there are no A & E for miles more confident and they could deliver better patient care. All these programmes should be given a fair trial.To make it work the govenment should understand the reasons behind the lack of interest by the young doctor community for not to take up this rural work otherwise we will end up in s situation where no doctors want to go and work in the rural India wheere the majority of population live. Competing interests: None declared |
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Jacob John, Neurosurgeon,Bishop Benziger Hospital & Holy Cross Hospital,Kollam,Kerala,India. Kollam-691001,Kerala,India.
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The proposal to have Doctors posted in rural areas after three year training is a welcome step as far as the Indian health scenario is considered.Indian rural set up is facing an acute shortage of qualified medical practitioners.Even basic medical,obstetric and surgical services are not available to nearly 80% of Indian population.The MBBS curriculum is not a competency based training.It produces doctors who provide the workforce for the big corporates in the metropolis.MBBS graduates are not competent to deal with the common community health problems independently.There is an overemphasis on specialisation to the detriment of the population at large.The mushrooming of capitation fee based private medical colleges cannot address this problem.The young doctors are not willing to go the rural areas even for a short period.The mainstream medical community and their organisations have never thought about this in a befitting manner and offered any solution.But they come out with opposition in the name of "Quality" whenever a public spirited reform is introduced.Of late,the National Board has started Post Grauation in Rural Surgery which is another welcome step.So I feel every socially conscious doctor should support this initiative to have community practitioners after training. Competing interests: None declared |
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Richard Fielding, Professor University of Hong Kong
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In the rural areas of China, barefoot doctors, peripatetic health care providers with basic skills set and treatment bag were once the only source of health care and they are credited with making significant contributions to alleviating many of the more persistent problems of rural communities. They continue to serve a pivotal role even in today's propserous China as the inverse care law continues to hold sway there as in India. I do think India would benefit it's impoverished rural communities by such a move. As for requiring doctors to serve a compulsory rural internship, this was one of the initiatives of Salvadore Allende while he was briefly the socialist president of Chile. The Chilean Medical Association objected to this as does the Indian Medical Association. I applaud the courageous decision to recommend this approach. Competing interests: None declared |
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M J S Zaman, Clinical Research fellow University College London
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It is interesting reading this article in light of the huge debate my article in this issue (1) has generated. Left to the whim of individuals to decide what they want to do, adverse consequences often result. The brain drain from developing countries and the Indian doctors (of mostly higher castes?) setting themselves up in lucrative private practice serving their own elite castes whilst government hospitals and local clinics remain in a state of disarray are examples. A global health worker crisis exists. (2) Being a doctor is such a priviledge and such an important role in society. But individuals will always want to look after themselves – that is human nature. Hence, societies as a whole must look to what is good for the whole society. This is not communism – but social justice. By all means encourage free enterprise and business and health-for-all- but make sure that opportunities are equitable. Doctors need to be encouraged to work in rural India – or inner-city London – and must be renumerated adequately so they can look afterselves, their families and society. Or they will all go and work in leafy surburbs, lucrative specialities – or move abroad. Under-priviledged communities should not be given second- class solutions, and simply accepting that 'doctors will not work there' is not good enough. 1. “We don’t need another 400 plastic surgeons”: Zaman MJ BMJ 2007;334:44 (6 January) 2. WHO World Health Report 2006. “Working together for Health” http://www.who.int/whr/2006/en/ Competing interests: None declared |
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Shachi Pradhan, Psychiatrist Chertsey,Surrey.U.K. KT1 6OAE
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This article has been thought-provoking and also encouraging.As I come from an Indian medical background,I can quote personal & peer experiences,as trainees which only shows the plight of rural medical practice in India. I think,we need a massive overhauling of the medical services provision and thereby training. The rural postings as a trainee are not taken seriously as there is no definite structured curriculum strictly followed or monitored.Some trainees take it as a 'vacation',with no eyebrows raised.The importance of rural training needs to be emphasised by the managers by-regular assessments and monitoring and yearly postings starting from a very junior level to understand rural medical needs.Incentives maybe given in form of- stipends, certificates,prizes,career progression etc.Medical education in India is Exam oriented and not competency -based,which makes it difficult for trainees to focus energies on rural postings as they are training mostly in medical college clinics,wards only.We do have PHC's,but they are never optimally equipped and remain understaffed and so not a lucrative place to work in. If the government can have some policy of investing money in all the existing PHC's and make them equivalent to a modern,satellite hospital with tertiary referals to the apex hospitals and decent lodgings,with all basic,modern amenities,transport etc,i feel,doctors may stay on.The current corporate medical giants can be encouraged to do so as rural India is still an untapped resource which is 80%of the Indian population.Currently corporate hospitals are mushrooming and congesting every lane of all major metros only,catering to the priveleged few. I also am aware that it will take a major overhauling of the system,starting from basics,but the first step needs to be taken to begin this cycle of change in the Indian medical system. Competing interests: None declared |
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Farhat Mirza, Doctor Osmania General Hospital, Hyderabad, India
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Today Indian doctors prefer to go abroad because of better pay scale and training. I think the Indian government should set a standard and improvise, so that they can retain their products. In other countries for example the UK, the NHS has a centralised system with hardly any private practice. At the same time the pay scale and training is also up to the mark. Pay of an intern who is supposed to do compulsory three months rural posting is low. The government should consider that after passing final MBBS and working hard doing night duties you don’t deserve to be paid so less. Then how do you expect doctors to survive in an expensive world. I know its difficult looking at our population but the government should try. From the government’s point of view the idea of community practitioners is very attractive, quite similar to the UK system where nurses are being trained in streamlined skills like endoscopy, minor injury management and in the future something as specialised as angioplasty. But the framework of the community practitioners training is a bit unclear at the moment and their efficacy might be questionable. So it is going to be quite a hard work for the government to introduce this system and ensure patients well being. Pilot courses should be started and the practitioners should be thoroughly accessed which might take number of years and in the end one is not sure all the effort and money spent is going to be worthwhile. Would the government rather not increase the pay scale hit at a blind spot. Competing interests: None declared |
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Muralidharan Parthasarathy, SHO Surgery Milton Keynes General NHS Trust , Milton Keynes , MK6 5LD
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Dear Sir, It is a shocking proposal from the Indian health ministry to create a parallel stream of medical practitioners , to improve the rural health care system. In this era of mordern medicine , this proposed move is a rather backward move.Having been trained in the Indian system , I do agree that the rural areas are underserved.It is not surprising that 38% of specialist posts lie vacant in primary health centres in rural areas (1).Just consider a few scenarios... imagine a cardiologist working in a set-up with no oxygen cylinders,ECG machines,leave alone thrombolysis , defibrillation facilities;a cardiothoracic surgeon in a place with no wide bore cannulas , leave alone chest drain sets. Coming to the proposal by the health ministry , there are many questions to be answered. 1.What is the guarantee that the so called community health practitioners stay in the rural areas? 2.How much needs to be spent to develop the infrastructure needed to create these parallel stream of medical practitioners , and is it really worth? 3.Won't it increase the already existing pool of quacks, which the government is struggling to control? 4.When even the medical curriculum is not competency based , is this going to be one? The real step forward would be, 1.To allocate more funds to improve the infrastructure of the rural health service which is possible with a boosting economy 2.Incentives to doctors who are willing to work in rural areas like for example (a)separate allocation of specialist seats to those working in rural areas for more than two years ( as in the southern state of Tamilnadu) (b)increased pay , especially for specialists working in rural areas. 1.Doctors criticise proposal for community practitioners in rural India BMJ 2007; 334: 12-f Competing interests: None declared |
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Arvind Dayal, Health Programme Advisor Aga Khan Foundation, 137 Rudaki Avenue, Dushanbe, Tajikistan 743003
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The Indian Health Ministry's proposal for developing a new cadre of health provider must be welcomed.The resistance of the organised (read Medical Associations) sector is predictable and understandable. Despite 60 years of existence as a country most rural areas continue to be seriously underserved. Graduates of modern medicine have stayed away in droves and forced rural inhabitants to seek health care from unqualified practitioners. With predictable results. Various inducements to get doctors to work in rural India have not succeeded. There may be very valid reasons for doctors not to wish to live and work in the villages. However this does nothing to improve the plight of rural India. How long should we go on pushing a model of health care that does not deliver? It is time for innovation and the Health Ministry must be commended for biting the bullet -being fully aware of how the formal medical establishment will react. We should not hesitate to innovate and try out models that are different from established ones, which often originate in other countries. Careful and constant attention to curriculum content, registration, re-registration norms and CME requirements would be helpful in maintaining quality. Primary Health Care should be the focus. Safe Motherhood, illnesses of childhood, management of life threatening emergencies, trauma, participation in DOTS, Family Planning etc should be included. The Physian Assistant (PA) model in use in the US could provide some pointers on developing professionalism among the new cadre. This would include thinking of further avenues for development of this cadre such as MSc in Health Science, etc Considering the nature of their duties and the generally conservative rural setting a very large proportion of the practitioners should be women. In addition to providing better access to women patients, having large numbers of women trained as practitioners would give a boost to the status of rural women providing them opportunities for development apart from their traditional roles linked to hearth and home. Qualified MBBS doctors must not consider these persons as interlopers but as members of the health care team. They should even consider getting involved by providing internships in their hospitals, clinics and build linkages with them. The baby's still there and its time to change the bathwater. Competing interests: None declared |
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Dr. Ajoy Kumar Sodani, Director Neuroscience Centre SAIMS Medical College, Indore, MP,India
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The main reasons of non willingness of medical doctors to work in rural area are 1) Poor infrastructure: many of the district level hospital have no fair (leave aside good) pathological or radiological service available. In rural setting labs are non existing and doctors are forced to work in primitive condictions. This leads to huge increase in error rate and self humility. 2) Political and administrative interference: The doctors are forced to work like "slaves" to authority. Off the record many doctors working in rural or tehsil level admit that they are forced to perform post-mortem on road sides or in the open fields. Again leading to erosion of self esteem. 3) Poor Living conditions: Lack of: good schools for kids, clean water, recreation facilities and peer group for social activities. Govt. can attract doctors by filling these gaps, but largely has not shown any desire to do so. Instead by providing un-trained persons govt is trying to not only undermine the image of doctor community as a whole but also the health of illiterate population who any way can not differentiate between a doctor and a quack. -ajoy sodani Competing interests: None declared |
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sriramashetty vengopal O.B.E, retired G.P.past president O.D.A. 24,melville rd, BIRMINGHAM B16 9JT
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I saw this article only today as I am on my holidays in India. On my frequent visits to India I visit my own village and surrounding rural areas, and I am appalled to notice non-existent health care and primary care. The rural population entirely depends on quacks who are not qualified to practise. These so called practitioners exploit the villagers.Many times patients die in travelling long distances to seek medical care. I have visited some primary health centres where there is no doctor or any ancilliary staff. The qualified doctors in India are reluctant to work in rural areas with a pretext of lack of facilities. Unless these doctors go to such areas and ask for appropriate facilities these PHCs cannot be improved. Governemnt of India's initiative to create community practitioners is commendable. A three year training programme should be enough to treat and refer patients for proper medical care. It is better than nothing as it stands. Along with this initiative I suggest mobile medical units staffed by properly qualified doctors and facilities for investigations and simple x -ray facilities. These mobile units can cover a cluster of villages and give support to the proposed community practitioners. Some young interns could be attached to such units along with the qualified doctors so that they could gain experience in rural health care. Doctors who may be critical of this proposal should come out of their cosy urban practices and see for themselves the dehuminising experience of rural population in seeking medigal care. Competing interests: None declared |
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Dr Sumithra Joseph, Doctor, Bellala,Kuttikole,India 671541
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Most Doctors who do MBBS in India now are untrained to practice in rural areas. They study Medicine in Cities with tertiary care Hospitals and have no idea of rural health care. I feel the eduaction system in Medicine in India is not suited for rural area practice.Its high time that Indian Goverment chnage this system and take interest in making rural GPs. India has many private Colleges now here only criteria for admission is money. These Hospitals have very less clinical materials to teach students When they pass out they have only degress and no skills. Competing interests: None declared |
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