editorials

Doctors for Rural India

What of the proposal to create a cadre of doctors exclusively for rural India?
ne of the main obstacles in the delivery of adequate medical services to Indias rural population is the reluctance of medical graduates to serve in rural areas. Various carrot and stick measures pursued by the government have had limited success. The latest performance audit of the National Rural Health Mission (NRHM) rues that the shortage of service providers at different levels across the country continues to pose a challenge. Now, following a public interest litigation (PIL) filed in the Delhi High Court, the central government has mooted the idea of an alternative undergraduate medical education programme that will train rural doctors, the Bachelor of Rural Medicine and Surgery (BRMS) course. Already, a sizeable section of the medical fraternity has voiced its protest against it. In districts which do not have medical colleges at present, persons from rural areas will go through a three-year course on basic anatomy and diagnosis and treatment of common ailments through medical schools attached to government hospitals. The eligibility will be based on HSc (class XII) marks from the notified rural areas of the district, and the graduates will be expected to work in the countrys 1.45 lakh sub-centres in their respective states. They will also assist regular MBBS doctors in the primary health centres (PHCs). The registration will be on a yearly basis and there will be strict monitoring to ensure that the graduating doctors do not practise in urban areas for a specified period. It is hoped that the scheme will help destroy the hold of quacks in rural areas. In 1946, the report of the Bhore Committee recommended that the basic doctor should be trained through five and half years of medical university education (including internship). It sought abolishment of the existing system of licentiate medical practitioners (LMPs) who underwent a three and half year course and, coupled with practitioners of alternative medicine, dominated the rural medical services field. The dissenting members of the committee had warned that the MBBS graduates would be unwilling to serve in the villages. Now, each of the sub-centres is supposed to have an auxiliary

nurse midwife (ANM), a female and a male health worker. The PHC is supposed to have a medical officer and an Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy(AYUSH) doctor on a contractual basis. However, as the NRHM audit points out, while contract workers have been engaged to fill vacancies and 6.16 lakh Accredited Social Health Activists (ASHAs) have been appointed, the shortfall of medical care providers needs effective attention. In the 15 states it surveyed, 11% of the PHCs were functioning without an allopathic doctor, while in 28 states and union territories, an AYUSH doctor had never been appointed. The report of the Task Force (2007) under the NRHM was of the opinion that the belief that only graduate doctors can deliver competent health services needs to be critically examined. It pointed out that 74% of the graduate doctors live in urban areas, serving only 28% of the national population. It also examined the option of a short training course after which the practitioner would be licensed to provide medical services within a notified package of primary healthcare. The problem of shortage of medical service providers in rural areas is one that most countries face. Chinas famous barefoot doctors scheme to counter this has been a great success and a much imitated example. Nevertheless, the Indian Medical Association has criticised the governments move saying it will churn out substandard doctors who will provide compromised care to rural patients. Another section of doctors, who have started an online petition against the governments decision, says that rural patients are being treated as inferior citizens. However, the Task Force pointed out that by insisting on health services through graduate doctors... the medical fraternity has created a situation in which vast numbers get nothing. Also, the experience of China and other Asian and African countries, forced to deal with similar problems, shows that training persons from rural backgrounds to deal with common basic health problems is generally the way to go. However, the need is to desist from looking at the solution as a populist measure for quick results.
A relevant question to ask is: What was Mr Nehrus original policy, and in what way can it be said to have undergone a change now? When the Chinese first crossed into our territory and occupied large chunks of it, there were three courses of action open to the Indian Government. It could (a) mobilise all its physical resources and try to throw out the Chinese by force; (b) ask the Chinese to withdraw voluntarily and then sit round a table with us to discuss and, where necessary, make minor adjustments of the present border; (c) quietly accept the new position. It chose the middle course of demanding that Peking should vacate its aggression of Indian territory and then negotiate minor adjustments of the McMahon Line and New Delhi. Does Mr Nehrus latest letter to Mr Chou En-lai depart from that policy?

From 50 Years Ago

Vol XIi, No 8, february 20, 1960

editorials

A Reversal over China?

The Prime Ministers rather sudden invitation to Mr Chou En-lai to come to Delhi for talks on the border dispute has once again brought the whole of his China policy under fire from the Opposition. Mr Nehru has been accused of having reversed his previous policy of firmness, and of having brought national humiliation to the country as a result of his reversal. It is necessary to examine these

charges and see how far they are justified. The first point to be noted is that this tremendous indignation against the reversal of policy in regard to the China question comes from the very people who were tremendously indignant about the original policy from which the reversal is now supposed to have taken place. This is hardly reasonable. If the original policy adopted by the Prime Minister was as bad as the Opposition made it out to be, there ought to be, if anything, jubilation at the fact that the policy is being reversed. But the Opposition is nothing if not versatile: it can be indignant with anything. Mr Nehru was originally charged with a lack of firmness; now we learn that he had in fact been admirably firm at the start, and it is only now that he is showing signs of weakening.

Economic & Political Weekly EPW february 20, 2010 vol xlv no 8