With or without bridge courses

Rural Medical Care

By Dr S Saraswathi
(Former Director, ICSSR, New Delhi)

A short-term Bridge Course for practitioners of Ayurveda and other traditional medicine proposed in the National Medical Commission (NMC) Bill to enable them to practice modern medicine has been dropped by the Union Government in response to widespread protests by doctors and total rejection by the Indian Medical Association (IMA). Now, it is for the State governments to take appropriate measures to strengthen Primary Health Centres in rural areas.
Bridge Courses, an academic invention, started in Canada nearly 50 years ago and adopted elsewhere, provide a formal partnership between two post-secondary institutions that offer students with advanced standing in a degree programme at one institution in recognition of previous academic experience in a similar field of study at another institution. Such a course would have opened admission in allopathic medicine to practitioners in AYUSH hospitals.
The object of the proposal to introduce a Bridge Course in medicine is to equip 1.5 lakh village sub-centres facing acute shortage of doctors estimated at 5 lakh with adequate professionals. But the IMA and allopathic doctors see in this idea room for backdoor entry of unqualified medical practitioners, and unscientific mixing up of different systems that would lead to disastrous consequences — in short non-professional handling of a highly professional matter.
There is a scramble for admission to medical education all over the country which provides guarantee for high remuneration and high status in the society. Entrance examination is tough and entry into private colleges involves enormous cost. Those who have entered cannot be expected to welcome widening of the entry point, human nature being what it is.
The IMA recently organised a Mahapanchayat of Doctors to protest against the proposed National Medical Commission (NMC) Bill. Similar panchayats were organised at State level also. The Bill seeks to create a new regulatory framework to replace the Medical Council of India (MCI). The IMA claims that the Bill has created more problems than what it solves.
Health is one of the most important index of human development like education which requires some drastic prescriptions to overcome its deficiencies. But, there is no quick-fix solution. Different systems of medicine are popular in India. Faith in indigenous systems which was waning is presently growing in India perhaps as part of the realisation of the value of ancient knowledge and traditional practices and scientific approval of several traditional medicine and methods.
India is expected to grow its health sector and become one among top three healthcare markets in the world in terms of incremental growth by 2020 and 5th largest employer providing direct and indirect employment in the health sector with total workforce of nearly 5 lakh in 2015. Health and wellness is not a commercial and purely economic activity to make us happy over its physical expansion and employment prospects. A glance through the crucial statistics pertaining to healthcare speaks volumes on its inadequacies.
One of these is doctor-patient ratio which was 1:1,674 in 2015 against WHO’s recommendation of 1:1,000. This record was worse than that of Vietnam, Algeria, and Pakistan and ridiculous in the context of India becoming a destination for medical tourism. Brazil and China are far better with less than 1,000 patients per doctor.
Another is hopeless shortage of doctors in rural areas compared to urban. About 70 per cent of India’s population lives in rural areas, but only 3 per cent of doctor population. However, disparities in healthcare are a universal phenomenon with high rate of uninsured patients in rural compared to urban areas. It became a research priority in Canada in 2002 when the National Commission on the Future of Healthcare revealed important disparities between the two in dimensions like infant mortality.
In reply to a question in Rajya Sabha, the Government has stated that of the total 25,650 Primary Health Centres (PHC) in the country, 15,700 (61.2 per cent) function with just one doctor. There is not even a single doctor in 1,974 (7.69 per cent) PHCs. This is flagrant violation of the guidelines set by the Indian Public Health Standards to appoint at least two doctors and three nurses in every full time PHC. Lab technicians and pharmacists are luxuries for PHCs as 9,183 (35.8 per cent) and 4,744 (18.4 per cent) respectively were shown as running without them.
Doctor shortage is pointed out as one of the serious health management failures in the report of the Parliamentary Committee on Health and Family Welfare presented in March 2016. The problem has become more serious as a bigger role for PHCs is envisaged under the National Health Policy 2017 to provide “assured health services to all” besides immunisation to cover several aspects like screening for non-communicable diseases.
Statistics show that on 31st March, there were 23,715 doctors in PHCs, which was less than one per Centre while the total number of doctors in the country was 1,041,395 indicating their overwhelming congregation in urban centres. Worse still is continuing rapid migration of doctors to cities – nearly 3,000 in the last one year. No amount of incentives for service in rural areas will work in the absence of extension of all urban amenities and urban standard of living in rural areas. The problem, therefore, is not confined to professional ambitions of doctors, but stretches to developmental issue.
Article 47 of the Constitution under the Directive Principles of State Policy enjoins the State to raise the level of nutrition and the standard of living and improve public health among its primary duties. While medical statistics show a picture of absolute shortages in every aspect of healthcare, non-statistical reports of apathy, discriminations and even denial of treatment by medical personnel and institutions demand a thorough overhaul of medical education and profession. For, increase in the number of doctors is not enough to enhance medical ethics.
Worse than population-doctor ratio and doctor-patient ratio, or density of doctor population, discriminations shown between patients and cases of callous disregard for patients’ condition and denial of proper treatment are unpardonable professional crimes common in all parts of the country.
TV news channels have shown the pictures of a patient lying in a hospital bed with his amputated leg used as a pillow; of a grieving man carrying the dead body of his wife on his shoulders as he was denied ambulance service. Patients are tied to their cots in another place to prevent them from falling when the doctors went on strike. Instances of sharing cots and beds in times of emergencies are not wanting. Denial of treatment for a sick person for want of Aadhaar Card made news in another place. Accident victims forced to go from place to place is a common problem. Private hospitals in most places do not start treatment until initial payments are made to the hospital. Cost of treatment is discussed first.
With endless problems, health sector is most difficult to handle. Doctors may have effectively barred entry of AAYUSH practitioners in allopathic medicine. But, they must come forward with constructive suggestions to cope with shortage of doctors particularly in villages. We have to bridge rural-urban areas with or without Bridge Courses. —INFA