World Report

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

India looks to a new course to x rural doctor shortage
Indias Government hopes a new community health course will help ll 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 allopathic
doctorswho 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-care
workers primarily at sub-centres.
Bearing these recommendations in
mind, as well as a writ petition led
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 con tends that the course would be
a compressed version of the MBBS and
would 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 year
suggests 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-year
community 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 prove
RMAs 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, exec utive
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, nd out why
and x it. Community health workers
cant replace medical practitioners.
Public health activist Gautham
disagrees. There is evi dence 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 o cers 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 le an a davit on the progress on
the Cabinet front. Despite the long
wait, Gautham is condent 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...
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For the Chhattisgarh study see
Social Science & Medicine 2013;
84: 3034. http://dx.doi.
org/10.1016/j.socscimed.
2013.02.018