Expanding primary care in South and East AsiaBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j634 (Published 27 February 2017) Cite this as: BMJ 2017;356:j634
All rapid responses
The incumbent Government of India proposes this place to be an attractive medical tourism destination ( 1 ) ( 2 ). What it forgets momentarily is that we have one of the worst health and social indicators in the world among similar economies. That fact should make us rethink our health care policies. Here the onus is on the poor primary care infrastructure. While we have still unfinished challenges of malnutrition and communicable diseases – including tuberculosis and emerging threats of microbes changing their forms, e.g. flu viruses and drug resistant pathogens -- the prevalence of non communicable diseases ( NCDs ) is rapidly rising ( 3 ) ( 4 ).
Notwithstanding what our colleague of Greece writes on this web-page, a risk factor reduction strategy, e. g. controlling high blood pressure and blood sugar in diabetes, is known to reduce the risk of future events, and turn the tide of the wave of the NCDs ( 5 ) ( 6 ). And sometimes simple preventive medicines are not available here ( 7 ).
Our Greek colleague believes that nagging visits to GPs for smoking (cessation) don’t avoid the disease (COPD). Our observation is that due to lack of awareness and health education, and (false) glorification of the habit, the masses inadvertently indulge in the practice, resulting in the morbidity and mortality which usually have a long latency period. If GPs (or somebody else) explains the link between the two (addiction and disease), the behavior of the population changes ( 8 ). Of course, that should not be the only strategy to combat the epidemic, even then that fact should also not underestimate the potentially long lasting impact of an apparently simple visit.
Then there are our compatriot colleagues who suggest a few weird ideas to address the challenge of the shortage of doctors in rural areas. In 3 tier system of Health Care Delivery, we believe that by District Health Centers, they mean District Hospitals. In his perspective on NEJM, the Chief of Public Health Foundation of India refers to our tiered system. Here he uses the term District Hospital in the same connotation ( 9 ). Then these colleagues write that around 24000 PHCs are supposedly manned by 1 MBBS doctor. Here we want to replace the term ‘supposedly’ by another word ‘actually’. In fact IMA demands Government of India to post 3 doctors for every PHC. The IMA President recently wrote a letter to the Prime Minister of our country in this regard, and its point number 8 is ‘Strengthen primary health care / rural health services ( 10 ). Its point number 3 (of the demands) is 'To post minimum of three MBBS Doctors in PHCs instead of the present system of posting one MBBS Doctor.'
However, the most wonderful imagination is to select/nominate students of the local population for training. Perhaps our colleagues may not be aware of the long-fought battle for selection for training in Medical Colleges. It ultimately resulted in a centralized examination, called NEET, and is a landmark step for improving the quality of medical education ( 11 ). What dangers lurk in the dark there if we revert back to that previous system of dubious nominations - by money, power or aquaintance - should be borne in mind before such adventurous steps are taken to practice.
Also we want to highlight that favoritism and nepotism are the traits, not entirely owned by urban folks but also by rural community here. It may be exemplified by the fact that when government plans to deliver benefits to the poor, its large portion is cornered by the elites of the our society. In some of the States the majority of BPL cards and MNREGA cards are owned by well-to-do people, and those who are already marginalized, get further marginalized ( 12 ) ( 13 )( 14 ).Similarly if deserving students - who are capable of clearing a fair examination - are subjected to such process of nomination, who will be excluded first, may be anticipated beforehand.
Another potentially dreadful impact of proposal of nomination may be aggravation of existing barriers of casteism and gender discrimination ( 15 ). These social evils already hinder our development by excluding our bright minds from the race. If the village head (Gram Pradhan) nominates only (for example) male students belonging to a specific caste/religious group, its consequences should be carefully considered. Whether such doctors have the same world view as us should be a subject of open debate. What values they imbibe since their childhood, and believe that to be norms in their milieu, may be disturbingly reflected in their medical practice later on as well.
We have very strong and deep rooted foundation of gender injustice, unknowingly costing a lot to us. Prime Minister of my country acknowledges the fact in one of his monthly radio talks, entitled Mann Ki Baat ( 16 ). Due to these pre existing biased social norms, if village head does not nominate, or nominates only a few girl students, its impact will be felt only after a gap of 6 years as that’s the duration of MBBS training here. After completion of that ‘incubation period’ when a male student (for example) starts referring obstetric cases to higher centers, rural population will start recognising its past mistakes only then.
Then our colleagues write that at CHCs, thousands of posts of specialists are lying vacant. Here we want to add that not only in CHCs, even in newly opened rural Medical Colleges and AIIMS too, that fact holds true ( 17 ). But that topic needs another separate discussion. What we firmly believe is that merit based selection process is virtuous and provides the maximum opportunity to hardworking and laborious students, otherwise being regularly (unfairly) snatched from them.
(1 ) Naqvi M A . India has all potentials to become world’s medical tourism hub. Twitter feed 2017 Feb 19 , available at https://twitter.com/naqvimukhtar/status/833234380256591872
(2 ) Correspondent . Positioning India as the next medical tourism hub. 2017 Mar 14 , available at http://www.biovoicenews.com/positioning-india-next-medical-tourism-hub/
(3 ) Rukmini S. Bansal S. Child stunting declines, but still high, data show. Hindu 2016 Jan 21, available at http://www.thehindu.com/news/national/Child-stunting-declines-but-still-...
(4 ) PIB .Health Ministry releases results from first phase of NFHS 4. 2016 Jan 19 , available at http://pib.nic.in/newsite/PrintRelease.aspx?relid=134608
(5 ) Hunter D J, Reddy K S. Noncommunicable diseases . N Engl J Med. 2013 Oct 9, available at . http://www.nejm.org/doi/full/10.1056/NEJMra1109345#t=article
( 6 ) Reddy K S. Regional roadmaps for reducing premature deaths from NCDs. Lancet 2015 Oct 20 ,3 (12) e725- e726 , available at http://dx.doi.org/10.1016/S2214-109X(15)00212-0
(7 ) Manganavar B. Reimagining the response to NCD in India 2014 Dec 30 .BMJ blog ,available at http://blogs.bmj.com/bmj/2014/12/30/bheemaray-manganavar-re-imagining-th...
(8 ) Reddy K S , Arora M. Tobacco use among children in India : A burgeoning epidemic . Indian Pediatrics 2005: 42; 757 -761 available at http://www.indianpediatrics.net/aug2005/aug-757-761.htm
( 9 ) Reddy K S. India’s aspiration for universal health coverage. 2015 July 2. N Engl J Med 2015 :373 ;1-5 , available at http://www.nejm.org/doi/full/10.1056/NEJMp1414214#t=article%5C
( 10 ) Memorandum of demands of IMA , available at http://www.imabihar.org/wp-content/uploads/2015/11/Memorandum-of-Demands...
( 11 ) IMA State wing bats for NEET , 2016 May 15 ,Times of India ,available at http://timesofindia.indiatimes.com/city/chandigarh/IMA-state-wing-bats-f...
( 12 ) Davel K. Gujrat to remove undeserving from BPL list . Times of India 2016 Apr 21 , available at http://timesofindia.indiatimes.com/city/ahmedabad/Gujarat-to-remove-unde...
( 13 ) Prabhu N. Three fourths of Karnataka poor . Times of India 2015 Aug 12 , available at http://www.thehindu.com/news/national/karnataka/threefourths-of-karnatak...
( 14 ) SC gives nod to CBI probe of alleged misuse of NREGA funds . First Post 2014 Mar 14, available at http://www.firstpost.com/india/sc-gives-nod-to-cbi-probe-of-alleged-misu...
( 15 ) India ranks 148th in the world for numbers of women MPs ,says a new UN report .Scroll 2017 Mar 16 ,available at https://scroll.in/latest/831953/india-ranks-148th-in-the-world-for-numbe...
( 16 ) Jha P. An India for girl child: Modi’s Mann Ki Baat echoes in Haryana village . Hindustan Times 2016 May 28 ,available at http://www.hindustantimes.com/india/an-india-for-the-girl-child-modi-s-m...
( 17 ) Mishra A. Huge doctor shortage hits AIIMS regional chapters . Hindustan Times 2016 Aug 21, available at http://www.sundayguardianlive.com/news/6151-huge-doctor-shortage-hits-ai...
All the WebPages are accessed at the time of submission of this rapid response.
Competing interests: No competing interests
Expanding primary care in South and East Asia: A child should be selected for MBBS course from the PHC milieu itself so as to fill the posts of doctors in rural areas
In India there is a 3 tier system of Health Care delivery in rural areas: Primary Health Centres (PHCs), Community Health Centres (CHCs), and, above them, District Health Centres (CHCs). There are around 24,000 Primary Health Centres, which are supposedly manned by 1 MBBS doctor with approx. 14 other staff. The Govt. of India, Ministry of Health and Family Welfare statistics(1) show that nearly one-third of these posts (800 doctors) are not filled (http://mohfw.nic.in/WriteReadData/l892s/3503492088FW%20Statistics%202011...).
PHCs should have the support of a referral system to CHCs and DHCs above them. According to the Govt. of India report, there are around 4,800 CHCs in India with a requirement of 18,000 specialists but only 7,000 are occupied.
We submit that a doctor should be selected/nominated from the milieu of the PHC in the rural area and trained; this will lead to filling of these vacant posts.
Competing interests: No competing interests
Cardiovascular diseases are first in patient morbidity and mortality, especially in the Western World.
As expected, periodic primary prevention screening health checks exploring cardiovascular risk occupy a large part of GP clinical time and effort.
This UK study adds evidence to the known concept that screening health checks are ineffective, costly, and counterproductive. 
In a recent analysis of all available studies, cancer screening has never been shown to “save lives”. 
Thus, GP primary screening against both the first and the second most common causes of patient morbidity and mortality, proved ineffective.
Medical errors are the third leading cause of death in the Western World, certainly avoided if nannying visits to general practitioners/family doctors are drastically reduced.
GPs even fail to follow simple cancer prevention guidelines. 
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death, but since smoking and air pollution are its most common risk factors, nagging visits to GPs don't help avoiding this disease.
Even a third of adults with previous diagnosis of asthma and chronically treated, never had the disease. 
Motor vehicle and firearm accidents are the fifth leading cause of death, but, understandably, they are not preventable by GP visits.
Suicides and self-harm traumatisms are the sixth leading cause of death, but GPs could not reduce them , probably because recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. 
Health checks do not even manage to identify and treat pre-diabetic patients. 
Concluding, frequent visits and health checks to family doctors do not seem to reduce specific morbidities and mortalities from the seven most frequent diseases that afflict patients.
After these embarrassing findings, policy strategists in the West must rethink primary care’s gatekeeper role, and those in Asia must abstain from implementing such inefficient healthcare models.
Competing interests: No competing interests