The Lancet
Volume 382, Issue 9899, 5–11 October 2013, Page e10

World Report
India looks to a new course to fix rural doctor shortage



    India's 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 hurdle—a Cabinet approval—away from implementing a community health programme that could remedy the huge shortfall of primary health-care providers in the country's hinterlands.
Rural India is largely deprived of a medical workforce because allopathic doctors—who have at least a 5·5 year Bachelor of Medicine and Bachelor of Surgery (MBBS) degree—prefer urban settings. In 2011, primary health-care centres in villages faced a 12% shortfall in physicians. The country's 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 filed by public health activist Meenakshi Gautham, the government first mooted the proposal for a community health course—now called Bachelor of Science (Community Health)—in 2009. The scheme's 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 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 India's 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 course—called 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 India's problem of shortage of doctors”, Rao says.
Although the study could not persuade the parliamentary committee, it has elicited positive response from the Chhattisgarh government. 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 study's 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 India's top medical schools.
The IMA, however, remains unimpressed. D R Rai, senior vice president of the IMA, says, “If doctors aren't going to villages, find out why and fix it. Community health workers can't replace medical practitioners.”
Public health activist Gautham disagrees. “There is evidence that doctors will not go to villages. The IMA's ‘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. “We're 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 shouldn't get a ‘yes’”, she says.