The Rural Doctors

In a bid to provide primary healthcare services in rural India,the Ministry of Health of the Government of India has proposed a 3.5 years abridged medical course. The idea is to churn out doctors willing to work in rural communities faster. The proposal mooted by the health minister Ghulam Nabi Azad has drawn mixed reactions from various quarters. Many have argued that by introducing an abridged diploma course the government will be playing with the lives of the rural folks. The essential argument is that even the basics of medicine can not be taught in such a short period of time. Others have taken a contrary view, pointing out that replacing today’s rural quacks with doctors having a basic formal medical education will be a huge plus.

In rural India, where more than 60% of India lives access to good quality healthcare is minimal. The government has spent millions of rupees in trying to provide primary healthcare in these areas and has met with little success. The twin problems of medical infrastructure and trained people has stymied government effort for long. Of these, it can be argued that the infrastructure problem is rather easily taken care of, the government just has to find the will power and the money to build primary health centres. The bigger problem is of finding qualified and trained doctors to work in rural areas.

Forcing newly minted doctors from government-run medical colleges, which offer subsidised education is a sub-optimal solution. These doctors hailing from large urban centres have no desire to work in rural, underdeveloped areas, where they can not possibly have the lifestyle that they are used to. The divide between Bharat and India has ensured that the chasm is too big to bridge and these doctors and their patients have almost nothing in common.

In rural India today, primary healthcare services are largely provided by a class of quacks, masquerading as doctors. Illiterate rural folks have no idea of the knowledge or formal qualifications of these ‘doctors’. They do not have the courage or the wherewithal to find out the antecedents or the past experience of these physicians and the entire system works on blind faith. Usually, these quacks have some knowledge of medicine largely acquired by having worked as assistants to doctors in big cities. Thus, they are able to continue the charade by prescribing commonly used OTC medicines and some wide spectrum antibiotics, for almost all ailments. Many people recover from common ailments, those who do not or grow steadily worse are referred to real doctors in nearby towns and cities.In remote and far-flung areas, things are even worse. Faith healers and babas of various hues treat people using ’jhaad-phoonk’, which are nothing but ancient pagan rituals. This is the terrifying reality of the 21st century rural India.

In this context, it makes eminent sense to have a cadre of rural doctors with some formal medical education. They would be able to provide far superior care than what is presently available in rural India. That the government proposes to hire rural youths in this program will ensure that these doctors continue to live and serve in their own communities. Unlike, their urban counterparts, these doctors do not run the risk of being fish out of water in this environment.

The government should now swiftly move forward towards evolving a mechanism for setting up rural medical colleges and lay down guidelines for enrolling rural youths in these courses. It should set up a few rural medical institutes and a regulatory body to regulate the proposed system. The government must also apprentice these rural doctors in government hospitals for at least 6 months so that they learn the practice of medicine from senior and more qualified doctors.

This solution I know is far from ideal. It also smacks of a certain class bias (more qualified doctors for slick city dwellers, under-qualified and not as well-trained doctors for poor rural folks), but such is the reality of the urban and rural life in India that even an idea like this has its distinct merits.

The Government's Apathy to Healthcare in India

The Union budegt presented last month by the finance minister, Pranab Mukherjee, is hugely disappointing for the healthcare sector in the country. For many years now people associated with healthcare in the country have been waiting for big-ticket reforms in the sector, but the government has been turning a deaf ear. This year too, the story is no different.

The healthcare services in the country are not only woefully inadequate but also unevenly distributed. The healthcare industry, which is hugely dependent on private enterprise is just not attracting enough investments. Setting up and managing a hospital till it breaks even and makes money requires huge upfront investments. Presently, India has 860 beds for a million people, way below the WHO's norm of 3960 beds for a million people. Studies by E&Y and KPMG have indicated that India needs to add 100000 beds per year for the next 20 years to reach close to this figure. This alone entails a spend of Rs. 50000 Cr. per annum. Compare this with what the government proposes to spend on healthcare in the next financial year, Rs. 22300 Cr. While this is 14% more than what the government spent last year, this amount is clearly insufficient.

The National Rural Health Mission, the flagship government programme for providing healthcare services in rural areas is riddled with inefficiencies. The government-run Primary Healthcare Centres are usually understaffed, ill-equipped and provide the most basic level of healthcare. Rural and semi urban India also needs good professionally managed secondary and tertiary care hospitals, which provide reasonably good quality healthcare at affordable rates. It seems that the government does not have the will power or the resources to usher in healthcare reforms.

Amazingly, the private sector entrepreneurs are willing to step in and bridge the gap. All they need is a little help from the government in the form of tax holidays, duty reduction or abolition of duties on medical devices, easy availability of funding from government institutions at soft rates, longer payback periods and land at concessional rates. The government should also set up a regulatory body, a watchdog, which will keep an eye on hospitals being set up through this mechanism. The watchdog is critical as it will establish guidelines for setting up the hospitals, monitor progress, ensure quality through regular audits, lay down a fair pricing mechanism and in general ensure that the private sector, while availing of government policy benefits delivers on the promise of efficient, good quality and easily accessible care.

This is really not too difficult to achieve. Look at how private participation has revolutionized telecommunications in our country. Today India has more than half a billion mobile phone connections, the tariffs are the lowest in the world and even remote, far-flung and fairly inaccessible areas are connected (I had my phone working in the Nubra valley in Laddakh). The phones generally work, the services are efficient and the private sector companies, who had the foresight to start early are making profits. Some are even planning to go global and compete with the best in the world. The TRAI, which is the government watchdog is seen as an impartial and fairly efficient body, doing its job of advising the government on policy matters and ensuring compliance and a level playing field amongst all the operators.

No country can progress and aspire to be an economic superpower unless its citizens have access to good quality healthcare services. Considering India's size and a population of over a billion people, (the majority living in rural areas), it is imperative that the government kick-start reforms in this critical area sooner than later. If no significant policy initiatives have been announced this year, can the healthcare industry bodies (like those associated with CII and FICCI) lobby with the government, initiate debate and fuel informed discussion amongst all stake holders so that public opinion can be rallied in favour of these reforms.

Healthcare services impact the health of the nation. It is time all the healthcare stakeholders including the government sat together to prepare the blueprint for the next generation healthcare services for the country. This is very important because, unless we have robust, universally accessible, reasonably priced healthcare services for our citizens, all our claims about being an economic superpower will remain hollow and truly meaningless.