[Reader-list] Needed: ‘basic’ doctors of modern medicine

[Kshmendra Kaul]

Dear Jeebesh
 
Thank you for sharing this. Excellent.
 
Will be passing it around.
 
Kshmendra


--- On Wed, 1/6/10, Jeebesh <jeebesh at sarai.net> wrote:


From: Jeebesh <jeebesh at sarai.net>
Subject: [Reader-list] Needed: ‘basic’ doctors of modern medicine
To: "Sarai Reader-list" <reader-list at sarai.net>
Date: Wednesday, January 6, 2010, 1:13 PM


dear All, Enclosed is an excellent essay on grave errors that created  
the mess of todays health infrastructure. The only MBBS doctors  
syndrome has done immense damage to the way we relate to our bodies in  
time of distress, more so in areas where there are non available. The  
arguments in the essay are excellent and poses some fundamental  
rethinking. also enclosed is a news item of a PIL by the author of the  
essay in the Delhi High Court. warmly jeebesh

http://beta.thehindu.com/opinion/lead/article43383.ece

Needed: ‘basic’ doctors of modern medicine

MEENAKSHI GAUTHAMK
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 Joseph 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 Powell’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 at gmail.com 
);K. M. Shyamprasad, M.Ch., FRCS, is a former vice president of the  
National Board of Examinations, MoHFW, India ( shyamprasad at nlhmb.in).  
Legal inputs have been received from Indira Unninayar, Supreme Court  
Advocate.)

----------------

http://www.indlaw.com/search/news/?62795492-a700-49cf-b62f-c88a4ccea1ed

Delhi HC issues notice to Centre, MCI on practice of non-MBBS persons
The Delhi High Court issued notices to the Centre and the MCI, seeking  
its response on the petition filed by an NGO which sought the court  
intervention to allow non-MBBS people to practice in rural areas.

A bench comprising Chief Justice A P Shah and Justice S Muralidhar  
directed the Health Secretary and the President of Medical Council of  
India (MCI) to file their response on the PIL seeking to decriminalise  
practice of medicine by non-MBBS persons.

The Court issued the notice on a petition filed by a doctor Meenakshi  
Gautam seeking it to direct the government to introduce a short term  
course for training health care workers so that shortage of doctors in  
rural areas could be solved.

Dr Meenakshi said Indian Medical Council Act which suggested one year  
imprisonment for practicing medicine by non-MBBS persons, should be  
amended.

The law, at present, does not allow alternate medical professionals to  
practice medicine, so the rural areas where the MBBS students were not  
willing to practise, were lagging behind in medical facilities, the  
petitioner said.

She said the Government should devise three-year courses for health  
care so that these workers could provide medical services in the rural  
areas.

UNI
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