Indian plan for rural healthcare providers encounters more resistance

BMJ 2013; 346 doi: (Published 27 March 2013) Cite this as: BMJ 2013;346:f1967
  1. Ganapati Mudur
  1. 1New Delhi

A three year old proposal by India’s health ministry to establish new cadres of mid-level healthcare providers for rural areas that lack medical graduates has encountered opposition from an Indian parliamentary panel on health.

The panel has asked the health ministry to abandon the plan and instead increase the number of medical colleges in rural areas and make one year of rural service mandatory for all medical graduates.

The panel’s recommendations are identical to suggestions by the Indian Medical Association, a non-government body of about 250 000 doctors, which has campaigned against the proposal.1 The government and the Medical Council of India jointly made the proposal in February 2010.2

The president of the Indian Medical Association, Kalikuttynadar Vijayakumar, said the association was pleased with the panel’s recommendations. “We’re very happy that we were able to convince the panel’s members to accept our views,” Vijayakumar told the BMJ.

But many senior doctors and public health experts are hoping the health ministry—which has the right to reject the panel’s recommendations—will convince the panel that India urgently requires mid-level rural healthcare providers and will go ahead with its plan.

Vinod Paul, one of several experts who testified before the panel, told the BMJ: “Delaying this would be unethical and immoral.”

“A delay would mean continuing to deny even primary care to people who have no near access to physicians” said Paul, a neonatologist and the head of paediatrics at the All India Institute of Medical Sciences, New Delhi. He led a medical team that has designed the curriculum for a 42 month course for training in community and rural healthcare.

The course, open to senior school graduates (that is, those with 12 years of schooling), will be taught in rural health schools linked to district hospitals. There is still uncertainty over when the first course will begin, although originally it was intended for this year.

Public health experts have long been worried about India’s skewed distribution of doctors—the country has about 13 doctors per 10 000 population in urban areas, but only three doctors per 10 000 population in rural areas.

The health ministry plans to call the rural healthcare providers “community health officers” and expects that states will post them in village health subcentres. India’s 148 000 subcentres are currently served only by auxiliary nurse midwives.

The community health officers would be expected to promote preventive care, provide emergency and ambulatory care for uncomplicated conditions (including infections and non-communicable diseases), and refer patients with serious conditions to doctors. The health ministry said that they would not be allowed to call themselves “doctors” and they would have no option for private practice.

The idea of rural healthcare providers has evolved over the past decade amid concerns that limitations in faculty and funds would preclude an increase in the number of medical colleges in rural areas and that mandatory rural service would be impractical.

Kunchala Michael Shyamprasad, a cardiothoracic surgeon and former member of a government task force on medical education that had called for such a programme in 2006, told the BMJ: “Forcing doctors to serve in subcentres will not work—their hearts and minds will remain in cities. It’s unfortunate that the [parliamentary] panel disregarded several recommendations from committees of doctors and health experts since 1999 and chose to accept the same repetitive arguments we’ve heard from the Indian Medical Association.”

The Indian Medical Association has claimed it is resisting the plan because three years’ training is not enough for someone to deliver quality healthcare. “We are trying to prevent differential levels of care for rural and urban populations,” Vijayakumar said.

But health officials say a programme launched a decade ago by the state of Chhattisgarh and experience from other countries demonstrate that uncomplicated medical conditions can be handled well by non-physician care providers.

A study in Chhattisgarh has found that doctors and non-physician rural medical assistants posted in primary health centres were “equally competent” in managing conditions such as malaria, pneumonia, tuberculosis, pre-eclampsia, and diabetes.3 However, the study also found that the overall quality of care in the primary health centres was poor, irrespective of who provided clinical services.

Krishna Rao, who led the study and is a health economist with the Public Health Foundation of India, a research and training institution in New Delhi, said: “The results suggest that a shorter duration of training need not necessarily translate into inferior quality of care.”


Cite this as: BMJ 2013;346:f1967