More health professionals for rural IndiaBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8339 (Published 07 December 2012) Cite this as: BMJ 2012;345:e8339
- Soumya Shivkumar, freelance writer, Mumbai
India’s rural health centres are acutely short of qualified staff. The central government hopes that a new three year degree to create non-physician clinicians will solve this problem. The bachelor of science degree in community health is to be launched in April 2013.1
A condensed form of the MBBS degree
However, controversially, the course is a condensed form of the full bachelor of medicine and surgery (MBBS) degree, and the curriculum has been drafted by the Medical Council of India, which licenses MBBS graduates to practise as doctors.
“Even at the end of five and a half years, doctors who are posted in rural areas might not be able to identify a problem. How could a three and a half year course [including six months’ rural internship] equip them to treat a patient?” asked G K Ramachandrappa, president of the Indian Medical Association (IMA), which has about 190 000 doctor-members.2 He insisted that because this is a paramedical course, graduates must not be registered by the Medical Council of India or the states.
But the government is pressing ahead. “Many people die at primary health centres because of lack of basic treatment, like saline and hydration. Mothers die during delivery, and there is no time to transport them to a hospital. Even if only basic treatment is given, we can only save so many lives,” said Kavita Narayan, head of the hospital services unit at the Public Health Foundation of India (PHFI), a public-private initiative based in Delhi, and a member of the high level expert group that proposed this idea as essential for universal health coverage.
Care at “subcentres”
Narayan told the BMJ that the aim is to provide better care at rural centres, beginning at “subcentres.” These clinics are often the first point of contact between patients and the primary healthcare system. They try to encourage behavioural change, and they provide services related to maternal and child health, family welfare, nutrition, immunisation, diarrhoea control, and control of communicable diseases. Subcentres can dispense basic drugs for minor ailments.
The foundation claims that in Chhattisgarh, for example, which has an acute shortage of doctors, health workers have shown themselves to be at least as good as doctors at managing malaria.3
Graduates to practise only in rural areas
Graduates of the new course would be allowed to practise only in rural areas—that is, at one of the 4809 community health centres, 23 887 primary health centres, and 148 124 subcentres.4 Subcentres are supposed to be staffed by at least one auxiliary nurse midwife or female health worker as well as one male health worker. But a recent paper reported that two thirds (64.6%) of male health worker posts at subcentres are unfilled.5 About one in 50 (1.9%) female health worker posts is unfilled at primary health centres and their outlying subcentres.
Even when rural posts are officially filled, some incumbent medical officers draw their salary but do not attend the centre, Narayan explained. In these circumstances, paramedical staff are left to treat patients.
Despite the restrictions on where the new graduates will be allowed to work, the IMA has opposed any new such qualification from the outset. Even though the government has promised that these new graduates will not gain the title “doctor,” the IMA does not support the government’s decision to allow them to practise allopathy.
“Let them work as community health workers and assist doctors, but not act as doctors,” Ramachandrappa told the BMJ, and that is the unanimous view of the IMA. “If an ayurveda or homeopathy practitioner cannot prescribe allopathy, how can a bachelor of science in community health do it?” he asked.
“Given the right salary, environment, accommodation, and infrastructure, doctors will go [to rural areas],” he said. Ramachandrappa disagrees that the association opposes the new course because doctors in villages may lose their jobs were a community health graduate come to work. “We are doing well and have enough work. We are not worried,” he said.
Suganti Iyer, assistant director, legal and medical, at Hinduja Hospital in Mumbai, told the BMJ, “Four fifths of Indian people live in villages, but if educated people do not want to settle there, how can these people get medical care? If a nurse can take care of a patient after a three year course, why can’t these graduates?” She said that the cost of salaries, good facilities, and accommodation needed to attract doctors to villages would have to be borne by taxpayers.
Requirements for the course
Central government has decided that eligible candidates will have completed their entire schooling and have earned minimum qualification of (10+2)—that is, education up to grade XII—with science subjects, and they must come from a specified rural area. “We don’t know whether there will be an entrance examination. This will probably depend on criteria set by respective states,” Syeda Hameed, a member of the government’s planning commission, told the BMJ.
Srinath Reddy, president of the PHFI, said that the proposal is to select local candidates and train them at district hospitals because tertiary care is not relevant to these students. “By strengthening services at grassroots level, we can bring about ‘task shifting,’ whereby doctors can be used to perform better functions,” he said. The foundation has also found an acute shortage of doctors in some states in north and northeast India, he said, for example, Assam, where the course might start sooner.
Health workers’ pay and infrastructure will have to provide enough incentive for new graduates to stay in rural areas. And the states would be responsible for mechanisms to prevent graduates moving to urban areas and attempting to practise as unqualified doctors, said Hameed.
The bachelor of science degree in community health is a reinvention of the bachelors degree in rural healthcare that the government proposed in 2011. The change of title reflects the idea that graduates can practise in any community setting and not only subcentres. The course is likely to come with the conditional offer of employment for five years.
The government has also directed the Medical Council of India to include one year’s rural internship at the end of the 4.5 year MBBS degree, attached to the health ministry’s National Rural Health Mission.6
Cite this as: BMJ 2012;345:e8339
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.