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How to address the shortage of qualified doctors in rural India

New Delhi: There are different suggestions doing the round. The union health minister Ghulam Nabi Azad is pushing for a new 3.5-year medical course; IMA (Indian Medical Association) says the right way to address this is to make compulsory rural health posting of MBBS graduates for one year after internship; and Bihar’s deputy chief minister Sushil Kumar Modi thinks opening a medical college in every district in the state is the proper way to achieve this? In the light of these suggestions, AalaTimes talked with some of the eminent doctors to know their thoughts on the issue.

Dr A K Debdas, associate professor, obstetrics and gynaecology, Jamshedpur Medical College, says, “This is an old disease that the government (not doctors) is suffering for the last 64 years, which I call Paracetamol Psychosis.”

“In a nutshell, this is what the clinical features of this disease is: (Paracetamol here stands for Doctors) Fever – Give Paracetamol – No remission – Give more Paracetamol – If no relief force Paracetamol by injection. Don’t try to find the cause of the fever — whether it is TB, Malaria, Kala-azar, Filaria, Infective Hepatitis etc. Of course, don’t bother to probe into those far-fetched factors — Why TB? Why Malaria? Or why Infective hepatitis? Just try and treat the fever with paracetamol because it is handy, easy to institute,” explains Dr Debdas.

Dr Debdas continues, “Diseases that the poor villagers are suffering from are not due to lack of doctors but due to lack of sanitation, lack of earning/job, lack of education and most importantly lack of roads. Sending a million of doctors will not cure these. It is a mammoth waste of government fund and trained human resource. There is such a lot of overt evidence of the uselessness of blind use of Paracetamol i.e. junior doctors. It is about time the government should think of some effective alternative.”

Dr Arunaloke Chakrabarti

Responding to the question, why not many qualified doctors are interested in serving in the rural and remote areas of the country, Dr Arunaloke Chakrabarti, professor, department of medical microbiology, PGIMER (Postgraduate Institute of Medical Education and Research), Chandigarh, says, “The reasons are very clear. All of us enjoy town/city life in our young age, except few moralists. Only in advanced age, people get fed up with city life and may go to villages.”

Dr Arunaloke Chakrabarti continues, “Facility in health care set up is very poor in villages, so little scope to do anything. There is not much scope for specialized doctors in villages. There is no scope to earn extra by engaging in private practice after job. There is no good schooling. It is a very important issue. Family, pressure is also an important issue; spouse does not like to stay in village. What’s more the issue of public wrath on doctors when they do not get treatment is another important deterrent.”

Dr S Rajasekaran, chairman, department of orthopaedic and spine surgery, Ganga Hospital, Coimbatore, offers further insights on the issue. According to him, ‘Quality Doctors’ will require ‘Quality Practice Environment’ for practising what has been learnt. “In my opinion, this is an important problem,” he says.

Dr S Rajasekaran

“Whether the patient is in rural area or urban area, the challenges in treatment of a major disease are the same. In fact, it may be more in the rural areas because the patients present usually late in the advanced stages of the disease due to lack of awareness. Many doctors would be attracted to the challenge of treating such complicated cases provided they are offered an environment with good facilities to do so. This is often lacking and is a major cause for reluctance of ‘Quality Doctors’ to settle in rural areas,” says Dr S Rajasekaran.

“There is a great misunderstanding amongst the public that doctors are reluctant to go to rural areas for lack of comfort. While this may be partially true, the bigger truth is that there is nothing more frustrating to see a suffering patient in front of you and you cannot do anything good for them even though you have the skill but the facilities are lacking. If good hospitals are established, it is a fact that many doctors will be willing to serve in rural areas,” adds Dr Rajasekaran.

According to Dr Rajasekaran, the union health minister is addressing only a part of the issue when he advocates a 3.5-year medical course. “Lack of drugs and infrastructure are as serious as lack of personnel. The government has to question itself sincerely on whether it has the funds and infrastructure to support a quality health service in rural areas throughout India. Producing more of less trained doctors with no improvement in infrastructure is not going to produce any tangible benefits to the population,” he says.

Dr Arunaloke Chakrabarti argues that the government’s initiative to develop another cadre for village will not solve the problem; rather it will bring another problem.

Dr Chakrabarti explains, “As per the government proposal these half doctors will not be given MBBS degree and their practice will be limited to the block area. It would never happen that way. Everyone wishes to get the next leap. When these half-doctors become considerable number, they would demand MBBS. Vote politics will force the government to accept. They will be upgraded to MBBS with additional one or two years training. The MCI (Medical Council of India) is no more an independent body. It would be forced to accept them and give license to practice. Then they will leave village and will practice anywhere. So, we will have a new cadre of doctors through back door! There will be conflict of interest in two groups of people (doctors from front door and back door). The crisis of doctors in the villages will remain as it is.”

According to Dr Chakrabarti, even compulsory posting for 1-3 years will also not help. “They would not serve properly during that compulsory period. Moreover frequent change of doctor will not serve good purpose in the village. Developing medical college in every district will also not solve the issue either.”

So, what should be done to address the shortage of qualified doctors in rural India?

“I feel strongly that you have to give incentives to work in villages,” says Dr Chakrabarti. “That can only attract the doctors. Incentives should come as a bundle like postgraduate selection incentive, it can happen in many forms; separate quota in good schools for the children of the doctors working in the village; 50 per cent higher salary while working in the village; better healthcare facilities in the hospitals or centres in the villages; rotation of specialized doctors from city government institutes for one or two years.”

“Beyond all these things, unemployment is slowly entering among the doctors due to too many medical colleges, not much scope in gulf and western countries. This will increasingly push doctors indirectly to go to villages for jobs,” adds Dr Chakrabarti.

Answering the question, Dr S Rajasekaran says, “My opinion may be considered radical but I strongly feel that the solution for the lack of quality doctors in India is because medical education is still vested either with the government or with the MCI approved private colleges. Here we have to adopt the system prevalent in UK and other countries where centres of excellence in different fields of medicine in private sector must be allowed to participate in education.”

“We have a situation where many large private institutions are capable of providing equal if not better educational facilities to the government institutions.  These institutions have the cream of the medical profession who are often great teachers but have moved away from government service for lack of facilities to practice what they have learnt. They are often better equipped than their government counterparts. It is a fact that 90 per cent of the health care service in India is provided by the private institutions and not by the government. So, why should we keep medical education away from them,” wonders Dr Rajasekaran.

“The government should harness the capabilities of these private health care institutions and there will be a great scope for more well trained doctors,” says Dr Rajasekaran, adding, “I do not mean diluting the standards in any way. The government must be very strict in setting of standards and the approval of these institutions but must take up the challenge of integrating the capabilities of both the public and private hospitals for the cause of better medical education in India.”

by Rajesh Barnwal

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  1. Dr Kusuma Kumari G MBBS DGO DNB(OBST&GYnae) Dr Kusuma Kumari G MBBS DGO DNB(OBST&GYnae) Thursday, September 6, 2012

    Teh basic problem in India is the training of doctors, Everyone is trianed now a days to ebcome a specialists or super specialists. There is no training to make them GPs to work in rural areas as a result you find teh avaerage MBBS doctor is not trained to work to rural areas of India and we are producin low quality doctors in India as MBBS and thats the real problem here in India Unless we solve thsi problem we will continue to rpoduce low quality GPs and teh rpoblem will continue in India/

  2. Kishori Mohan Ojha Kishori Mohan Ojha Monday, March 5, 2012

    I am all for even a shorter training course (say 2 years after 10th) in the district hospitals by The MBBS or specialists for the village doctors. We can not have an MBBS live in villages for life for obvious reasons.Can we have PhDs as village school teachers,so why do we expect MBBS OR PG doctors to live an serve in villages for ever ? Why can’t we have barefoot docs as china.At least such people will be much better than the present lot of untrained and untrainable quacks practicing Scott free in our country.We are actually ,living in a fool’s paradise hoping the MBBS doctors to live in villages where there is not much to use their knowledge and skills.Isn’t it a waste of precious public money and energy? At the most ,the MBBS docs can be required to do a stint of one or two years in the villages to learn ,teach and supervise such “barefoot docs”. Moreover we need to have mechanisms to transport sick people quickly,safely and effectively to a referral hospital.I hope some sort of policy to implement the existing laws to stop quack practice is taken soon,sooner the better.

  3. Dr Manoj Panigrahi Dr Manoj Panigrahi Saturday, February 4, 2012

    there is no shortage of doctors they are not given good facility or salary so they are not going
    i fully agree with bihar minister
    for example bhubanewar has three pvt medical college and aiims coming up but this cannot help rural india or orissa bhubaneswar and cuttack has higest no.of doctors

  4. Hemant Hemant Friday, December 23, 2011

    A lot of discussion is going on how to improve the health care delivery in rural areas. Is it by starting BRMS? or by forcing fresh MBBS docs to work in rural areas. How to overall improve the public health scenario? The answers are simple but difficult to implement in our settings. If it so, then we need long term plan; short term ones WILL NOT HELP!! Three important solutions:

    1. Decrease rural urban divide – It will solve most of the problem
    2. System strengthening- drugs, diagnostics, standard treatment guidelines, incentive to work in rural area
    3. Follow Tamil Nadu model
    You cannot manage health by not bringing public health nuisances under health (directorate of public health). For this, the need to create a separate public health directorate, in addition to directorate for medical education, directorate for health (dealing with tertiary hospitals).Primary health care delivery overall and public health in urban area, should be under directorate of public health through its cadre at the periphery. Recruit public health specialists into directorate of public health, with separate promotion avenues. In current health system (outside tamil nadu), what is the incentive for a public health specialist doctor entering into routine health services vis a vis a mbbs doctor/other specialist. Why would he enter if he has to just prescribe drugs and has to compete with others less trained than him in public health to become of SMO of CHC, then SMO of distrcit and finally DGHS state.

    It appears that the conclusion based on govt policies is that public health specialist in this country are here to churn out more specialists; they in turn churn out more specialists (academics), or stick to research with no assurity that the results will be incorporated in policy; forcing many to publish papers and improve their CV and not worry to influence policy. Only a select few who prove themselves as experts in public health are put in advisory expert panel (in this to they have to unofficially compete with those of non medical field). One needs to understand that most non-public health doctors in the country are trained to treat patients. Their are more often than not patient oriented, often choosing treatment modalities which will not be cost effective at population level. You train doctors in such manner and then expect them to manage health services as is all over iindia; more over these doctors who enter routine health services are those who have not been able to secure a PG seat (less talented). Even if they join routine health care, they keep preparing for PG entrance. What do you expect them to do? Provide high quality treatment? Add to it the lack of standards of treatment from govt side and poor supply of infrastructure and drugs in the periphery. Most of non-public health specialists working in the routine health care delivery keep arguing about how immunize coverage / birth rates / IMRs are calculated from inception to retirement, for no fault of theirs. At least they (non-public health specialist docs) need to be given reorientation course in public health before joining routine health services (from MO of a PHC to a specialist doctor at district level).

    Most public health professionals either enter research or academics as they do not have good opportunities in the routine health care. I, as a fresh MD in community medicine/PSM want to work in the routine health care delivery. Will the govt provide me good job opportunities? And please dont expect me to renounce everything and expect me to work in the rural area. I want good salary, good promotion avenues and authority in routine health and public health (environmental nuances and public health engineering) related issues. Will the govt provide this to me ? Im waiting…. (‘Me’ or ‘I’ doesnt include me but represents the voice of many public health professionals in the country)
    Lets stop firing in the dark. If we have guts lets take steps which might not please most but are in the interest in the country. Community medicine department in the country need to create effective models in their field area for the same; and advocate for similar health models. In this regard, I would also like to mention the public health professionals of this country should come under a single body/organisation (against the present two bodies) and advocate/lobby for efficient policies and interventions / health care delivery models!!!

    Cheers!!
    Dr Hemant Shewade
    Junior Resident, Community Medicine,
    PGIMER Chandigarh
    hemantjipmer@gmail.com

  5. Dr. M. S. Prasad Dr. M. S. Prasad Monday, December 19, 2011

    Dear Sir
    All above comments are very valid particularly the Paracetamol Syndrome. To the very same doctor I want to inform that I served in Inchagarh in 1973. Sitting at Jamshedpur (Tatanagar), he can imagine the condition of Inchagarh in 1973. I had confidence in my clinical approach and did not require any sophisticated investigations to treat patients there. The biggest problem now is that the new generation of doctors believe in lab reports more than his/her clinical findings. A bulk of investigations are ordered without any valid indication. One should not forget Dr. Kotnis and Dr. Bidhan Chandra Roy who were dedicated to patients’ care without having access to battery of investigations.
    Dr. M. S. Prasad
    Retired Consultant & Head,
    Dept. of Paediatrics, Safdarjung Hospital & VM Medical College, New Delhi
    Presently working as Professor (Paediatris) at the BP Koirala Institute of Health Sciences, Dharan, Nepal.

  6. Dr S Hariharan Dr S Hariharan Monday, December 19, 2011

    The need of the hour is to upgrade the health care services in the rural areas,which constitutes almost
    70%-80% of our country.This itself justifies the need for a separate stream of Dept of Rural Health Services for the rural masses and another stream os Urban Health Seravices Dept. for the urban areas.

    The rural health care system should include basic doctors and all specialists.Appointments should be through separate selection process. It should made attractive by offering enviable remunerative packages and career advancement schemes.Starting separate reduced doctors’ courses,creating half-baked doctors,compulsory posting of doctors to rural areas,giving spl.weightage to PG courses for those with rural short-stays etc. are not going to solve the problems of our rural masses in the long run.

    Other basic amenities like children’s education,good housing,daily needs,transportation facilities, recreation needs and continuing medical education avenues should should be strongly developed in the rural areas side by side with the devlopt. of health services.Even the various paramedical disciplines should also be developed in the same way–as a separate stream.

  7. Dr.Kingra Dr.Kingra Monday, December 19, 2011

    I am glad that finally the government in Delhi is talking about the poor state of health of medical care in India.I have read the comments from people more knoeledgable of the situation than I.I grew up in a village in Punjab and visit my family and friends fairly regularly.What strikes me most is the lack of awareness of unsanitary conditions,not only in the villages but in towns.Obviously that leads to ill health requiring medical care.In addition to attempts to get more doctors not only in rural but also in towns,attention should be paid to LIVING conditions of the populace.But where do you find dedicated officials and civic minded people to do that.Of course the other problem is Politics.No sooner an Mla or Mp is elected,the next job is to see how one can be re-elected instead of doing peoples work.

  8. DeB DeB Sunday, December 18, 2011

    It is ridiculous. The Union Health Minister should be aware that about 30000 medical graduates pass out every year in India. Only the lack of good policy in medical services, political influence in selection and posting preference and many many loop holes in the government system are responsible for the gap between urban and rural choice. For example, three doctors are posted in every PHC in Tamilnadu. But, you would hardly any medicine other than paracetomol, cpm, cotrimoxazole, salicylic acid ointment and some cough syrupe. Who will take interest to go over there. The Union Government should support PHCs. Tamilnadu Government has separated out public health service from other health services and doctors gets appointed in public health service should serve here till his superannuation. Because of this policy, the public health services in Tamilnadu is for better than any other State in India. Awareness among the public in Kerala State is the leading force for the better public health services. Union Minister should learn these and implement in other state. He thinks that 3.5 medical graduates will stay in rural areas. He should know that even a B.A graduate in villages try to go out for opportunity. Govt. should come forward to establish a separate cadre for rural health service and provide a unique pay structure for them. Otherwise, they should establish one medical college in every district and each medical college should post their staff on rotation to rural areas. Tamilnadu Govt. has already started establishing medical colleges in each district. Union Minister should learn from these experiences from tamilnadu and impose it in other States. When there are already good solutions, why he trying to confuse and complicate the issues by promoting 3.5 doctors? The most important aspects are like in Kerala awareness, public empowerment, transparent selection procedure, good service conditions infrastructure and above all an excellent pricing policy of the drugs, reagents for investigations. 3.5 doctor policy will worsen the situation.
    There was an opportunity. The Govt. should have established all IT parks in rural areas and the rural areas would have improved and the urban rural gap must be narrowed. It established all IT parks in urban areas and spoiled the environment.

  9. Saroja DalNetri Saroja DalNetri Sunday, December 18, 2011

    Unfortunately one wakes up from the slumber to find that there is a shortage of doctors in India
    Very few realise that tere is shortage of expertise also. When the OPD crowd has swollen 10 folds and IPD fourfourlds- four patient on a bed is a common site in any medical college then why medical council has not increased the seats in Post graduation
    A New fact came to light that MCI expert has allegedly asked one medical college in Chennai to take class of all the 250 students simultaneously in a single hall not to split them in batches even though the medical college authorities made all the arrangements in order to have a better focus by limiting the number to 50 per class.
    Here one wonders as to who are the MCI inspector and what concept they have about teaching of medical sciences? IN a mobocracy and leader dominated psyche, they view medical teaching too as some thing similar to the crowd of Ana Hazare or Mayavathi’s rally!

  10. Prof. Manoj Sharma Prof. Manoj Sharma Sunday, December 18, 2011

    I have been writing for almost last five years about the need of Mini Medical Colleges in every district.
    Well indeed this is the only solution to the transmigration of patients to metropolitan towns or bigger cities.
    I have seen this in Varanasi 35 years back when whole of Bihar was getting treated there and now the same phenominon in New Delhi where even for a sneeze the dictum is to catch a train to Delhi.

    The post in the Mini medical colleges should be on rotatory basis although a heavy prize has to be paid. But this is what will bring about the much desired change as also desired by Mahatma Gandhi’s dream of Gramya Swarajya.

    These mini Medical Colleges with undisturbed MBBS course( that indeed the best one in the world for settings like India and even for developed countries) will create a new health statistics that are sadly lacking for policy makers and preventionists.
    This will also solve the problem of shortage of seats and deprivation for those who aspire to become doctors but not able to get admission due to the reservation policy where substandard stuff is inducted for this profession connected with human life.
    The city Head quarter Distric hospitals are the ideal place to start these mini medical colleges with student strength between 25-50 students only.

    Post graduation seats in the existing medical colleges need to be increased multifold as there is shortage of faculty even in the present medical colleges.The problem will take few years to settle then

  11. s.narayanan s.narayanan Saturday, December 17, 2011

    The government dilutes recruitment criteria for candidates belonging to SC,ST,& OBC ignoring others who claim by merit , and those who avail these concessions should be made to serve in rural areas for a specified period in return.

  12. subrahmanyam subrahmanyam Saturday, December 17, 2011

    There are no shortage of doctors regarding that let has no second thoughts.For doctors to go to rural areas they have to be totally free from local political influence,free from public harrassment,selection process should not be merit based and tenure shold be defined.
    subrahmanyam,jipmer

  13. Dr.A.Laxmaiah Dr.A.Laxmaiah Friday, December 16, 2011

    Shortage of medical professional in India is true, however, even available doctors are not willing to join in the health care services to serve in rural/tribal areas due to inadequate facilities available in the villages. In some of the states lot of medical colleges are available and in some states, very few medical colleges existed. Therefore, steps may be taken by the Govt. to open more number of colleges in each state where very few colleges are available and facilities may be provided those who are willing to serve in the rural /tribal areas and higher allowances may be paid to the doctors those who are willing to work in the rural and tribal areas.

  14. KP RANA KP RANA Friday, December 16, 2011

    Its a lie that there is any shortage of doctors in India. The government policies are at fault. Goverment does not wish to pay doctors. If there is a job there r so many aplicant every where in India. If the remuneration is absurdly low and they want to hire the doctoirs on contract basis to harashs them for ever with their clearical commands then there will always be shortage of atlest trained pofessionals.

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