India decides to train non-medical rural healthcare providers

BMJ 2010; 340 doi: (Published 09 February 2010) Cite this as: BMJ 2010;340:c817
  1. Ganapati Mudur
  1. 1New Delhi

    After a decade of debate the Indian government has signalled its intention to introduce a new medical education programme to train rural healthcare providers for village health centres where doctors are unavailable.

    The Medical Council of India, in consultation with the country’s health ministry, last week released an outline of an alternative model of medical education that would be open only to students who have completed all their school education in villages. Graduates from the programme would be allowed to practise medicine only in rural areas and would be prohibited from offering services in urban areas.

    The proposed four year bachelor of rural health care course will involve lessons in clinical examination, medicine, obstetrics and gynaecology, orthopaedics, paediatrics, surgery, epidemiology, and public health. It would be of shorter duration than the standard undergraduate course in modern medicine (bachelor of medicine or bachelor of surgery), which lasts five and a half years in India.

    “We expect graduates from the alternative course to be competent in 60% of the skills possessed by doctors from the standard undergraduate course of modern medicine,” said Ved Prakash Mishra, head of the council’s academic unit.

    The move towards the alternative curriculum comes more than a decade after a panel of medical experts set up by the council had said that India’s existing medication education has “utterly failed” to produce doctors who are responsive to the needs of rural communities. The panel had argued in 2000 that the content and delivery of the existing curriculum was preparing doctors exclusively for tertiary care institutions and not for primary care in rural areas.

    An ambitious plan launched in 2005 to improve rural health through funding, infrastructure, and medical staff has been hampered by shortages of doctors. Proposals by the government to make rural service mandatory for all medical graduates have remained unimplemented. The health ministry has pledged higher salaries for government doctors in the countryside, but shortages are expected to continue (BMJ 2009;339:b2781, doi:10.1136/bmj.b2781).

    A government task force on medical education estimated three years ago that 74% of India’s 760 000 doctors serve 28% of the population in urban India. India’s 300 medical colleges produce about 34 000 doctors each year, but nearly 25 000 enter postgraduate programmes or leave the country.

    “Even doctors with rural roots refuse to go back to their villages,” said Ketan Desai, the council’s president.

    About 2500 of India’s 23 450 primary health centres function without doctors, according to figures from the National Rural Health Mission. The health ministry has announced plans to deploy the graduates from the new alternative course to primary health centres and to 146 000 village health subcentres where health services are currently delivered by nurse midwives.

    Sections of India’s medical community have in the past opposed proposals for an alternative medical education programme, arguing that this would be tantamount to introducing differential standards of care for urban and rural populations (BMJ 2007;334:12, doi:10.1136/bmj.39079.507639.DB).

    The Indian Medical Association issued a memorandum last month declaring that the alternative programme would “produce substandard, half baked doctors” who would provide, at best, compromised care to rural people. Some doctors have approached Delhi High Court to oppose the move to introduce the new course.

    But the association seemed to have altered its stand this week after the Medical Council of India made it clear that graduates from the new programme would have to practise exclusively in rural areas for at least five years after graduation.

    Discord over how the proposal will be implemented persists, however. Some doctors and public health specialists are arguing that each state should be allowed to tailor its own rural health education programme.

    “A flexible state programme is likely to be more effective than a programme handed down by the council,” said Kunchala Shyamprasad, who was a member of the task force on medical education.


    Cite this as: BMJ 2010;340:c817