The wrong way for rural doctors- Anbumani Ramadoss

The proposal to introduce a shortened medical course is a folly: it will aggravate the rural-urban divide and give a raw deal to villages.

The proposal put forward by the Central government to introduce a shortened medical course at the graduate level to serve the rural areas will only widen the rural-urban divide and impede India's role as an emerging global power. In seeking to virtually revive the Licentiate Medical Practitioners (LMP) scheme that was available before Independence, the government has taken a regressive step. And in the process it is resorting to discrimination against rural folk, who are taken for second-grade citizens deserving medical care by a brigade of ‘qualified quacks'.
The scheme involves a three-and-a-half year course that leads to a bachelor's degree in medicine and surgery. Doctors trained under this scheme will work in rural areas. They will be trained in district hospitals.
In the erstwhile LMP scheme, students were trained for around three years, awarded a diploma and asked to meet rural health care needs. It was considered a way to bridge the gap between demand and supply outside metropolitan India. The LMPs outnumbered the MBBS graduates and largely served in the rural areas. Following the Bhore Committee report of 1946, medical courses were unified into the standard five-and-a-half-year MBBS degree.
The issue is the impact of this scheme on the status of the rural Indian. In what way are rural Indians different from their urban counterparts? Do they deserve health care from medical personnel who are less qualified than those who attend to the health needs of their urban brothers? Are their well-being and lives less important than those in urban areas? This discrimination could sow the seeds of disunity and discrimination. The scheme is against the spirit of the Constitution and human rights.
The proposal is superfluous, too. Any State can introduce a short-term medical course. We do not need a centralised concept of rural service, governed by the likes of the Medical Council of India (MCI).
The need is to utilise existing personnel prudently. Today even medical colleges recognised by the MCI, numbering about 300, face faculty shortage. How is the government planning to equip the so-called rural-based institutions that will eventually churn out semi-qualified medical personnel, with faculty and infrastructure?
India has a wealth of alternative medical systems such as Ayurveda, Siddha, Unani, Homeopathy and so on, that brings in hundreds of thousands of qualified medical professionals into the health care industry. They qualify after more than four years of training. It would be easier to use this huge corps of medical manpower according to the needs of the local regions rather than create a new cadre.
Today a nurse undergoes four years of training during her or his course, whereas the proposed BRMS course is for three and a half years. The rural folk would be better off being catered to by nurse-practitioners who are more qualified than the ‘qualified quacks.'
The doctor-patient ratio in India is 1:1,700. Add to this the doctors under the traditional medical systems and the ratio comes down to about 1:700. The World Health Organisation's recommended criterion is 1:300. To reach that target, we cannot go for short-sighted and short-term measures to create a cadre of semi-qualified professionals.
We have the schemes and tools to enhance the health of our rural fellow-beings. With an exemplary scheme like the National Rural Health Mission, all that is needed is to revive and give new momentum to such schemes.
There are more than a million fully trained nurses and more than 3,00,000 Auxiliary Nurse Midwives in India. There are also more than 7,00,000 Accredited Social Health Activists (ASHAs). Then there are Village Health Nurses, Male Health Workers, Male Nurses, Anganwadi workers and so on. There is no dearth of paramedical professionals and qualified medical personnel to serve the districts and villages.
Adding one more cadre of workers who are neither here nor there will lead to state- acknowledged quackery. Already, nearly 75 per cent of India's population is treated by quacks. The proposal will only help strengthen the cause of the quacks, bestowing upon them respectability.
Already the urban-rural disparity in health infrastructure is huge. If the rural areas are catered to by BRMS personnel, it will deter qualified and experienced doctors from taking up rural assignments. It was after much thinking and cajoling that we put forward a compulsory scheme for rural service for those who desire to pursue higher medical courses. With one imprudent and rash gesture, we will do away with a good practice that was initiated with astute planning.
Ghulam Nabi Azad, my successor Union Minister of Health and Family Welfare, says BRMS personnel can be posted in Sub-Health Centres and Primary Health Centres. These already have more than enough qualified nurses who have completed four-year courses and done their practical training. So where is the need for a BRMS course that will produce medical personnel dismally equipped with only three and a half years of training?
The website of the Union Health Ministry provides details about the NRHM. Thousands of crores of rupees are being invested in the rural health sector under the NRHM to strengthen rural infrastructure. As Health Minister, in order to supplement the NRHM, I initiated a proposal for a one-year compulsory rural posting for each MBBS doctor after the internship. This faced stiff resistance from medical students. A committee under Dr. Sambasiva Rao was formed to deliberate on this issue around the country and give their recommendations. Finally, the recommendation was that anybody who aspired for a post-graduate degree should undergo a one-year compulsory rural posting. Unfortunately this recommendation came at the fag end of my tenure. Had this been implemented, every year we would get nearly 30,000 fully qualified doctors working in Rural Health Centres.
The need is to start more medical colleges in areas such as the northeast, Bihar, Uttar Pradesh, Madhya Pradesh and Jharkhand. The country has nearly 300 colleges, of which 190 are in Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and Gujarat. Uttar Pradesh, with a population of 19 crores, has only about 16 colleges. Bihar, with a population of nine crores, has eight. Rajasthan with an eight-crore population has eight and Madhya Pradesh, with a population of eight crores, has 12. If the State governments open medical colleges in all the districts, we can have nearly 600 medical colleges, rolling out nearly 75,000 MBBS graduates a year.
We have another huge health resource pool to tap from: doctors trained in Russia and China. Their services can be utilised in the rural areas.
Many doctors settle abroad. The government should take steps to prevent this drain by offering them attractive remuneration, avenues to train and upgrade knowledge and due recognition.
One school of thought favours admitting two batches of medical students in each institution every year – in the morning and in the afternoon. Clinical sessions could be alternated. By resorting to the double shift, we can double the number of medical graduates using the same

infrastructure and faculty. This can be followed for medical, dental and nursing courses. This was accepted by the MCI for post-graduate courses when I put forward the suggestion that accommodates one more student per professor within the existing system, given the infrastructure available. Earlier one professor could take in only one postgraduate student; now one professor can take in two students without compromising on the quality of medical education, thereby doubling the intake of students to postgraduate courses, leading to optimum use of the existing resources and infrastructure.
My suggestions in a nutshell are here. Make one-year rural posting compulsory for all MBBS doctors after internship. State governments should start medical colleges in every district to create more medical graduates. Increase the number of medical graduates and post-graduates using the existing infrastructure and faculty. Focus more on the northern and northeastern States. Expand and invest more in the National Rural Health Mission. Start government-run nursing colleges in all districts. Public-Private partnership ventures can be initiated, using the district and sub-district government hospitals for the purpose. Preference should be given to students from rural areas for admission to the MBBS courses, and it should be stipulated that the graduates work for five to 10 years in rural areas. The harmonisation and utilisation of doctors who have been trained in Russia and China, who have undergone seven-year MBBS courses, to fit into the rural programmes could help. The utilisation of doctors from traditional systems for specific needs and programmes could be planned. Anyone who wants to join a post-graduate course in a government college should have done a minimum of three years in a rural posting.


This article is by former Union Health Minister; published by Hindu on 27/02/10