8/12/2019 Lancet Report

1/1

World Report

www.thelancet.com Vol 382 October 5, 2013 e10

India looks to a new course to fix rural doctor shortage

Indias Government hopes a new community health course will help fill medical posts in rural

areas. But the Indian Medical Association is against the idea. Dinsa Sachan reports.

The Indian health ministry is just one

hurdlea Cabinet approvalaway

from implementing a community

health programme that could remedy

the huge shortfall of primary health-

care providers in the countrys

hinterlands.

Rural India is largely deprived of a

medical workforce because allopathicdoctorswho have at least a 55 year

Bachelor of Medicine and Bachelor

of Surgery (MBBS) degreeprefer

urban settings. In 2011, primary

health-care centres in villages faced

a 12% shortfall in physicians. The

countrys 148 124 sub-centres, which

are the closest stops for primary

care for people living in villages, are

currently only manned by midwives.

During the past decade, many

expert committees have advocated

deploying mid-level health-careworkers primarily at sub-centres.

Bearing these recommendations in

mind, as well as a writ petition filed

by public health activist Meenakshi

Gautham, the government first

mooted the proposal for a community

health coursenow called Bachelor of

Science (Community Health)in 2009.

The schemes main critic has been the

Indian Medical Association (IMA), a

national trade union of doctors. The

IMA contends that the course would be

a compressed version of the MBBS andwould dispatch unprepared doctors

to villages, putting the health of their

inhabitants at risk.

A parliamentary committee took

note of the matter in 2011 and

presented a report in the parliament in

March this year, criticising the course

on grounds similar to those given by

the IMA. However, the government

informed the Delhi High Court on

April 18, during the hearing of a

contempt petition, that the health

minister was going to go ahead and

seek Cabinet approval for the course.

If the Cabinet gives a green light to

the course, it would clear the path for

implementation.

Although the IMA argues that the

programme would create a rural-urban

divide, some evidence suggests the

opposite. A study published in Social

Science and Medicine earlier this yearsuggests that mid-level health workers

are a viable solution for Indias health-

care problem.

In 2001, the state of Chhattisgarh

started its own version of a 3-yearcommunity health programme to

address the shortage of medical

practitioners in its villages. The

products of this coursecalled

Rural Medical Assistants (RMAs)

have been in service since 2008.

The study showed RMAs perform

as well as MBBS doctors when it

comes to diagnosing ailments such

as pneumonia and diarrhoea. Lead

author Krishna D Rao, of Public Health

Foundation of India, a non-profit

organisation, says the results proveRMAs are adequately trained to handle

rural health care. The study clearly

shows that clinicians with a shorter

duration of training, such as RMAs, are

the answer to rural Indias problem of

shortage of doctors, Rao says.

Although the study could not

persuade the parliamentary com-

mittee, it has elicited positive

response from the Chhattisgarh gov-

ernment. T Sundararaman, executive

director of National Health Resource

Centre, and a coauthor, says, The

study made it clear to the state

government that the RMA model is

a workable model. Encouraged by

the studys results, the Chhattisgarh

government is now investing in

nurturing its existent RMA cadre by

sending them for refresher trainings at

the Christian Medical College, Vellore,

one of Indias top medical schools.The IMA, however, remains un-

impressed. D R Rai, senior vice

president of the IMA, says, If doctors

arent going to villages, find out why

and fix it. Community health workers

cant replace medical practitioners.

Public health activist Gautham

disagrees. There is evidence that

doctors will not go to villages. The

IMAs doctors or nothing approach

for primary care has succeeded in

keeping millions of people in persistent

deprivation for years, she argues.Vishwas Mehta, a joint secretary in

the health ministry, says the ministry is

committed to the implementation of

the course as well as other rural health-

care reforms. Were also looking

at upgrading the status of Ayush

(alternative medicine) practitioners

to public health officers by providing

them with a bridge course. A proposal

for mandatory internships in rural

areas for fresh MBBS graduates

was also mooted recently, he tells

The Lancet.In a hearing on Aug 29, the Delhi

High Court asked the government

to file an affidavit on the progress on

the Cabinet front. Despite the long

wait, Gautham is confident that the

Cabinet will eventually approve the

course. The current Union Cabinet has

experienced and well informed minds.

If the ministry presents its case well,

there is no reason why they shouldnt

get a yes, she says.

Dinsa Sachan

The study clearly shows that

clinicians with a shorter

duration of training...are the

answer to rural Indias problem

of shortage of doctors...

USArm

y/SciencePhotoLibrary

For the Chhattisgarh studysee

Social Science & Medicine 2013;

84:3034. http://dx.doi.

org/10.1016/j.socscimed.

2013.02.018