3-year MBBS to meet rural needs

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a)HC suggests 3-year MBBS to meet rural needs

Needed: `basic' doctors of modern medicine

a) HC suggests 3-year MBBS to meet rural needs

New Delhi, Nov 18: Taking serious note of the fact that basic health facilities

were not reaching the poor in rural areas, the Delhi High Court Wednesday in a

notice asked the health ministry to consider whether the present course can be

reduced from five years to three years.

A division bench comprising of Chief Justice Ajit Prakash Shah and Justice

S.Muralidhar asked the health ministry and the Medical Council of India (MCI) to

consider changing the MBBS curriculum so that basic health facilities can be

reached to the rural population.

" This is a very important issue. Almost 80 percent of the rural population is

devoid of the basic public health and this fact should be considered seriously, "

the court said while asking the ministry to file its response by Dec 9, the next

date of hearing.

Asking the government to amend the present educational standards, the court

said: " You have to change the over-five years' MBBS course so that doctors who

get trained don't fly to other countries or stick to the metro cities in the

wake of good earning. Educational system should be changed to three years so

that every doctor can cater to rural population. "

The court was hearing a public interest petition filed by Dr. Meenakshi Gautham,

a public health specialist, who contended that a person who completes his MBBS

can practice modern medicine as soon as the course is completed.

These graduates, the petition said, either rush to big cities or go abroad, and

therefore a large majority of people are not able to get proper medical

treatment, and are forced to depend either on untrained and uncertified rural

medical practitioners, or on quacks.

" The irony is that 80 percent of the common medical problems and ailments can be

treated at the level of primary health care and do not require attention of a

professional trained in highly academic, sophisticated, five-and a half-year

long course like MBBS, " advocate Prashant Bhushan said, and suggested the

ministry should follow the educational model adopted by China.

http://www.mb4education.com/php/news_events_details.php?nid=14263 & slinkid=2

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Needed: `basic' doctors of modern medicine

By Meenakshi Gautham & K.M. Shyamprasad

Opening more medical colleges is not the solution to India's chronic shortage of

doctors in the rural areas.

India is the largest supplier of foreign medical graduates to the United States

and the United Kingdom. Yet, its own rural areas have remained chronically

deprived of professional doctors. The historical antecedents of these shortages

could be traced to a landmark health policy document, the Bhore Committee Report

of 1946. That report constructed the concept of a `basic' doctor as one trained

through five-and-a-half years of university education. An alternative cadre of

Licentiates who were trained over a shorter duration and who formed two-thirds

of the country's medical practitioners then, was abolished, in spite of strong

dissent from several members of the committee. These dissenting comments must be

revisited in the context of India's persistently poor health indices and

inadequate health services for the majority.

The report

In October 1943, the Government of British India appointed the committee to

survey the state of public health in the country, and make recommendations for

future development. The committee chaired by Sir ph Bhore, a senior civil

servant, comprised eight British and 16 Indian members. The Bhore Committee

Report, published in 1946, was meticulously drafted and reflected its members'

profound understanding of health matters. They presented statistics on the

disease burden and attributed the poor state of health in the country not only

to inadequacies in medical services and health personnel but also to the

prevailing social ills — poverty, illiteracy, poor nutrition and unsanitary

conditions.

The report is best known for providing the blueprint for a modern public health

delivery system in India, along with the training of its personnel. Foremost

among these was the `basic' doctor of modern medicine who would be central to

the delivery of primary healthcare. These were far- reaching recommendations and

shaped the course of public health and medicine in independent India. But on

closer examination, a number of flaws are revealed.

Two classes

There were two classes of medical practitioners of Western medicine at the time

of the Bhore survey: graduates who underwent a five-and-a-half-year course in

the medical colleges, and Licentiates (LMPs) who underwent a three-to-four-year

course in medical schools. Of the 47,524 registered medical practitioners at

that time, nearly two-thirds (29,870) were Licentiates and one- third (17,654)

were graduates.

The report informs us that in the rural areas health care was delivered through

sub-divisional hospitals and dispensaries that were managed mostly by

Licentiates. Besides, there were large numbers of indigenous practitioners

providing affordable and accessible healthcare to the masses.

The Bhore Committee proposed a three-tier district health scheme. A primary unit

would be at its periphery, a secondary unit at the sub-divisional headquarters

would provide more specialised services, and a district organisation would be in

charge of the overall supervision of district-level health activities.

Though conceptually well-organised, the scheme was designed to cover only a

fourth of the population in the first five years (78,080,000 out of a projected

315 million in the report) and less than half (156,200,000 out of a projected

337.5 million) over the next 10 years. The report was silent on how the needs of

the rest of the country would be met.

Nonetheless, the committee recommended that the Licentiate qualification be

abolished, all medical schools be upgraded to colleges, and all available

resources be directed into the production of only one type of doctor. He or she

would have the highest level of training — a five-and-a-half-year university

training, similar to what the Goodenough Committee had proposed for Great

Britain as the gold standard. The committee believed that there was no role in

the modern medical scheme for indigenous systems of medicine and its

practitioners: these systems were considered " static in conception and

practice. "

Six members of the committee, five Indians and one Briton, put up a brave

dissent. They repeatedly argued that in view of the manpower shortages, the

country should use every possible means, including the shorter Licentiate

course, to increase the number of trained medical personnel. They pointed out

that England had abolished Licentiate teaching only after 100 years and Russia

relied extensively on `feldshers' (medical assistants) to run 48,000

dispensaries. They noted with anguish that since the new scheme would benefit

only a section of the Indian population, " Public health over the remaining four

fifth to one-half of the country… will atrophy. There will be no personnel like

the licentiates even to help the regions and institutions which will come under

neglect. "

Prophetic

The dissenters' views proved prophetic. They said that the " basic doctor would

not willingly fit into the rural scheme. " India's six decades of chronic

shortages of doctors in the rural areas are grim testimony to this fact. They

argued that " while a majority on the committee can abolish the licentiate, they

cannot prevent other practitioners, practising a variety of systems of medicine,

taking his place. " Time has proved this also to be a prescient observation.

Studies show that since Independence and even today, much of health care at

first contact in rural India is delivered not by qualified doctors but by

informally trained and unlicensed private practitioners.

What happened to the highly trained basic doctor of the future?

The Bhore Committee estimated that around 15,000 doctors would be needed in the

scheme in the first five years, and around 30,000 over 10 years. As the number

of medical colleges roughly doubled during this period (from 19 in 1946 to 42 in

1956) it can be estimated that the number of graduates also doubled.

It is difficult to obtain exact data on how many graduates entered the health

system over 10 years, but almost all of India's Five-Year Plans and national

health policies since 1947 have lamented the shortage of doctors in the rural

areas.

What is definitely known is that around 10 years later, in the early 1960s,

nearly 18,000 graduate doctors from the Indian sub-continent migrated to the

U.K. in response to Health Minister Enoch 's call to save the U.K.'s

rapidly expanding National Health Service (NHS) from a staffing crisis. In

November 2003, a BBC documentary " From the Raj to the Rhondda: How Asian Doctors

Saved the NHS, " acknowledged the contributions of doctors from the Indian

sub-continent to Britain's most deprived areas, where no British doctor was

willing to go.

Even today, the second largest proportion of doctors registered with the U.K.'s

General Medical Council, by country of qualification, is from India: they number

25,720, or 11 per cent of the total. India also provides the largest pool of

international medical graduates to the U.S.

Turf protection

Medical historians point out that the Indian doctors who collaborated with

colonial rule were the ones who stepped into positions of power after 1947.

Their socialisation into the western model meant that the " development of

medical practice in India did not follow the pattern that was being advocated

for developing countries at the time. Indian degrees were quite suitable for

working in England, but probably totally irrelevant for working to the benefit

of the vast majority of the Indian population. " (Professor Aneez Esmail, 2007)

Ironically, even less-trained providers can efficiently deliver primary care.

However, efforts to revive a Licentiate type of cadre, as recommended by the

National Health Policy 2002 and outlined by a Task Force on Medical Education in

2007, have been non-starters. This is due to resistance from a section of the

country's medical fraternity which carries a turf protection mindset, supported

by obstructive legislation contained in the Indian Medical Council Act of 1956.

An alternative

In view of the obvious deficiencies in India's overall rural infrastructure, it

is unlikely that the rural areas will have a sufficient number of doctors over

the next several decades. Thus, the solution to India's doctor shortages does

not lie in building more medical colleges. A better alternative would be to draw

from other countries' experiences of developing mid-level practitioners:

Clinical Officers and Medical Assistants in Africa, Physician Assistants in the

U.S., Nurse Practitioners in Canada, and the rural doctors in China who number

more than a million. These cadres are typically trained for three years and

empowered to provide clinical services. Studies so far suggest that their

performance and outcomes are in no way inferior to that of doctors trained for

longer periods.

In the short term, India must also upgrade the skills of existing unlicensed

rural practitioners and empower government nurses and pharmacists to take on

additional tasks. An alternative to the IMC Act is the Drugs and Cosmetics Act

that empowers States to recognise practitioners other than MBBS-holders to

provide a limited range of medical care services. Chhattisgarh has invoked this

power to create a three-year diploma course for Practitioners of Modern and

Holistic Medicine.

(Meenakshi Gautham, PhD, is a public health specialist

(gautham.meenakshi@...);K. M. Shyamprasad, M.Ch., FRCS, is a former vice

president of the National Board of Examinations, MoHFW, India (

shyamprasad@...). Legal inputs have been received from Indira Unninayar,

Supreme Court Advocate.)

http://www.hindu.com/2009/11/05/stories/2009110554760800.htm