Last month, West Bengal Chief Minister Mamata Banerjee asked the Health Department to consider starting a three-year diploma course for medical practitioners, who would then serve in primary health centres (PHCs). This is not the first time that such a proposal has been considered in the country. India has nearly 1 lakh MBBS seats, but there continues to be a massive shortage of doctors in rural areas. Will a shorter course help bring in more medical professionals to serve where they are needed or will it erode the structure of medical education? Sudha Seshayyan and Soham D. Bhaduri discuss the question in a conversation moderated by Zubeda Hamid. Edited excerpts:
What do you think of West Bengal Chief Minister Mamata Banerjee’s proposal?
Sudha Seshayyan: I don’t think this is a good idea at this point. One, the diploma course may not train trainees adequately to deal with the conditions in rural areas. We tend to think that since there are not many doctors in rural areas, we could send in people who spend less years in training. But rural areas may not have adequate facilities, infrastructure, or transport. If these trainees are left to deal with an emergency or a critical care situation, will they be able to do that? Two, in the future, what will be their status? [However,] we do have paramedical staff like physician assistants. Maybe they can be trained better to deal with emergencies and then [we can] transport the patient or move in doctors [where needed]. That would be a better idea than this three-year diploma.
Soham Bhaduri: There exists a general aversion among professional doctors to practice in rural areas. It’s not just about how many doctors we produce, but how we get them there (rural areas). That entails costs to recruit doctors, to retain them, and to take into consideration the turnover. In West Bengal, the number of doctors per 10,000 population is below the national average. So, it makes sense to drive a cadre of doctors who are capable of providing first-level care to the rural countryside, if not of handling critical situations. The proposal for PHCs is a bit askew: PHCs are the most essential rung of the healthcare infrastructure and should possess doctors who are fully trained. But we can consider mid-level healthcare providers who function in sub centres, a rung below PHCs. The recent National Medical Commission (NMC) Act [also] makes a provision for community health officers.
Sudha Seshayyan: I agree; we could think of a mid-level healthcare professional who can deal with the immediate situation and [then] try and transport either the patient or the appropriate medical facility (equipment). And it does cost to get full-fledged doctors to rural areas, but that should not prevent the government from doing this, [for] healthcare is a basic amenity.
Is this a discriminatory move, because we are then providing less qualified practitioners for rural populations and more qualified practitioners for urban settings?
Sudha Seshayyan: Yes, it becomes discriminatory. Health awareness among the rural population is not very good. Many may not have the means or resources to get the medicines [they need]. In such situations, [if] you have somebody who is a little less qualified, just because you want to think that everyone is [being] given appropriate medical attention, it’s not a fair deal at all.
Soham Bhaduri: There are two perspectives. One, the entire range of healthcare professionals who serve at sub centres have a crucial role to play in ensuring continuity of care. The ASHA cadres have played a tremendous role in improving health awareness. Second, we need to differentiate between fiscal realities and fiscal ideals. The State has a prime responsibility in ensuring that everybody gets the highest attainable quality of care. But the realities on the ground preclude us from choosing between perfection and any solution at all.
On the discrimination point: if you say we don’t have the perfect solution on the horizon, and you don’t do anything at all, that engenders an even bigger discrimination.
Sudha Seshayyan: There can be never an ideal solution. There needs to be some kind of an interim arrangement when there are not enough fully qualified doctors. But calling [such] a course the equivalent of a full-fledged medical degree [is not correct]. Think of these rural medical practitioners in the future: at some point, there will be academic discrimination. We’ve had, if you go back to history, the Licentiate in Medicine and Surgery and so on. But we are at a point where we cannot afford to have differentiated degrees. That apart, we need to bring in a system where we make our full-fledged medical graduates realise their social obligations. We do have adequate medical graduates, but we have to take steps to motivate them to go to rural areas.
Are compulsory rural postings helping in this regard?
Soham Bhaduri: On attracting doctors to rural areas, we have tried a lot of means over the years. There [have] to be hard incentives, and even incentives have failed. The NMC recently proposed that it wishes to do away with the bonded service. This may not be a good option because in settings that are already deprived of doctors, the marginal gains that arise from having doctors through bonded rural service are higher. We should be looking at ways to recruit more doctors into rural areas rather than retaining them, because recruiting practitioners and retaining them are two different ballgames. To retain them in rural areas is not going to be possible for at least 30-40 years because ultimately, rural doctor shortage is a development problem.
Sudha Seshayyan: I’ve been a medical teacher for many years. I’ve noticed that [graduates] do not want rural service as they are a little scared they will get stuck there for ages. So, we have to create a system where there is a continuous chain of doctors in rural areas: somebody comes in, maybe serves for two or three years, and then gets out. Several systems of motivation have been tried but have not worked out. But we cannot just say, ‘Okay, we failed’ and leave it [at that]. You don’t create an alternative cadre of doctors just because regular doctors don’t want to go to rural areas: that’s acknowledging that full-fledged doctor need not go to rural areas. That would increase the problem [and] would create a larger divide. If we are trying to say our rural population will not get sufficient health care primarily because they are in the rural areas, we are defeating the goals of democracy.
Soham Bhaduri: If you look at the short-term courses across developed and developing countries, they provide care of a quality that is largely equivalent to [that of] doctors. So, the accusation that rural and urban areas are being held up to two different standards of care, at least at the sub centre level, would not apply. So, mid-level practitioners at the sub centre level is, I believe, a very important requirement today.
There is a wide disparity in the spread of our medical colleges. Is this something that needs to be tackled to address rural shortages?
Sudha Seshayyan: The density of medical colleges in certain areas is high, while in certain other areas it’s low. But apart from increasing the number of medical seats, maybe we are not [teaching medical graduates] the right kind of medical ethics. We’ve had situations where medical graduates compare themselves to engineering graduates and say. ‘if they earn at the end of four years, we need that too’. You cannot sacrifice your training for the sake of a job. We may have adequate numbers (of colleges), but density-wise, we’ll have to do something to redistribute them, or maybe increase numbers in areas where there is low density.
Soham Bhaduri: Medical college distributions follow the general iniquity patterns in India: most medical colleges are concentrated in the southern States and some in forward States like Maharashtra and Gujarat. What exacerbates these patterns is that about 85% of the seats are reserved for candidates from within those States. So, it’s an important policy question for us to address. I don’t think purely private investments will be able to deal with it; it’s going to be government investments. As we see over the last decade, government medical colleges have shown a remarkable increase in numbers. We have good examples from other countries. For example, Myanmar redistributed nursing colleges to decentralise nursing education from Yangon. It has shown great improvement not just in terms of redistributing medical colleges and having representation across provinces, but also in terms of rural retention, because much more than incentives, pecuniary or intangible, recruiting doctors from rural areas and placing them there is one of the evidence-based solutions to improve rural retention.
Dr. Sudha Seshayyan is former Vice Chancellor, The Tamil Nadu Dr MGR Medical University; Dr. Soham D. Bhaduri is Health Policy and Leadership Specialist; Editor-in-Chief, The Indian Practitioner
