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BSc (Community Health): Panacea for rural health?

There is no dispute on the fact that rural healthcare in India is abysmal and drastic steps are needed to rectify the same. There is also no doubt that this involves a multipronged approach. A community health worker (Anganwadi worker, multipurpose health worker), a nurse practitioner, a pharmacist and a doctor available along with the infrastructure, medicine supply with improved connectivity (roads), electricity, safe water supply are all prerequisites to improved rural healthcare.

Dr Neeraj Nagpal

At different times in different states different schemes have been launched whereby the community health workers named differently in different states form the first line of community healthcare. Never however has an attempt been made to replace a doctor with a community health worker as is being done now under the garb of BSc (Community Health).

The fact of the matter being that though on paper we have rural dispensaries in every nook and corner of the state they fail to provide healthcare to our rural populace. The reasons are not far to seek. The buildings are in shambles with no resemblance of a hygienic healthcare facility as required under the Clinical Establishments Act. Rickety chairs and tables serve as infrastructure and even these are missing or broken. Electricity is mostly not available due to power cuts. There are no facilities of generator (how vaccination programmes are run without the cold chain is shrouded in mystery). Without proper autoclaving no procedures or surgeries are feasible in these dispensaries. Water supply even in dispensaries is from a hand pump if at all. Few of the dispensaries are approachable only by horse drawn vehicles, as buses do not travel to them.

Given the futile exercise of marking attendance in such dispensaries it is surprising that employees whether doctors, nurses or pharmacists come to work at all. This is a vicious cycle. Patients stop coming to these dispensaries as on previous visits their need at the time was not fulfilled whether because the doctor was absent, or medicines not available, or the procedure could not be done due to power cut etc. They then approach quacks, who thrive in this environment, for their daily medical needs. Also, disease does not seek to afflict a person only during office hours. To tackle patients in off duty hours appropriate residential arrangements for staff are sorely lacking.

In the Supreme Court, shortage of doctors in the country has been touted as a major problem. Government has shown statistics that India has 1 doctor for 1700 population. What has been glossed over in these statistics is that this figure is taken from the Medical Council of India (MCI), which concerns only with MBBS doctors. Are the doctors from the alternate system of medicine not doctors?

BAMS (Bachelor of Ayurveda, Medicine and Surgery), BHMS (Bachelor of Homoeopathic Medicine and Surgery) and BUMS (Bachelor of Unani Medicine and Surgery) graduates all have four-and-half-years study of their systems of medicine including basic subjects like anatomy and physiology. Their number is any day more than that of MBBS doctors. If we include them in the statistics the ratio of doctor to patient in the country will be much less than 1 per 1000 recommended by the World Health Organization (WHO).

Either we consider them doctors or we do not consider them doctors for the statistical purposes. Even these doctors with 4-5 years of graduate study are labelled as quacks by the honourable Supreme Court if they dabble in modern medicine (Poonam Verma vs Dr Ashwin Patel). How then can a truncated study duration of 3 years equip someone with knowledge sufficient to practice modern medicine.

There is also the fact that for government health services in nearly all states there are many more MBBS applicants than seats available. All doctors in Government service have to do mandatory 3-5 years rural service as per different state norms. Punjab Govt managed to rope in about 1200 MBBS doctors to serve in rural areas on adhoc basis on consolidated salary of Rs 30,000 out of which they were also supposed to pay salary of two employees. These doctors were not given any service benefits and were appointed under the Zila Parishads. “Shortage of doctors” or that “MBBS doctors do not work in villages” is then a myth created by the powers that be to further their own ends. With unemployment and underemployment existent among MBBS doctors where is the need for a special cadre of rural doctors?

The reason why the political class is keen on BSc (Community Health) and of permitting them to practice modern medicine is to be seen in a different context.

Medical education has shifted from government medical colleges to private medical colleges in large numbers. Most private medical colleges are run by politicians or their relatives and henchmen. Lot of money is involved in medical education with an MD seat being sold for Rs 2 crore; even BSc (Nursing) and BAMS courses are fetching good premiums for these colleges. This puts a lot of pressure on the management of these colleges (politicians) to get more seats and medical colleges approved from the MCI. Resistance to the same has cost the MCI dearly. It has been disbanded; adhocism prevails in appointment and removal of the Board of Governors. The entire sequence bears a close scrutiny by an independent agency preferably the Central Bureau of Investigation (CBI).

If one (MCI) member Dr Ketan Desai was corrupt (not convicted) how does it justify the dissolution of an autonomous body with elected members? By the same argument the corruption of Mr Raja and Mr Kalmadi should lead to the dissolution of the parliament.

BSc (Community Health) is simply another way of selling medical seats without interference by the MCI. This would be possible only if the powers that be are able to get some legal sanctity to the BSc CH graduates practicing modern medicine. It was rightly pointed out by professional medical associations and legal luminaries that involvement of the MCI will need changes to be made in the Indian Medical Council Act. Govt has now cornered the National Board of Examination (NBE), a body which so far concerned with governing postgraduate medical courses Diplomate of National Board (recognized postgraduate teaching qualification even in medical colleges), to now award alternate of MBBS i.e. BSc (Community Health) degree.

Doing something new which would be marketable even if it were recycled goods has been the cornerstone of political gimmicks perpetrated in our country by our esteemed lawmakers. General elections being near there is a political compulsion for the government to have in its agenda schemes, which can be touted to voters as accomplishments. That it maybe illegal or harmful for the nation’s health is inconsequential to this breed of politicians and they are willing to tweak the law to meet their desired goals.

There is no magic wand to improve healthcare in rural areas. Posting a doctor in a rural dispensary of today with his hands tied for want of infrastructure, medicines and equipment is akin to hanging a photograph of a doctor in the dispensary. It serves no purpose except on paper. Because qualified doctors are demanding these facilities it is now prudent to replace them with hopefully a more pliable army of qualified quacks in the form of BSc (Community Health) graduates (Rural Doctors). Plus there is money to be made in starting these new courses for rural doctors.

Dr Neeraj Nagpal
Convenor, Medicos Legal Action Group
Ex-President, IMA Chandigarh
9316517176

9 Comments

  1. Dr Us Dr Us Tuesday, November 26, 2013

    Foreign doctors for the babus and netas and legal quacks for Bharat Mata. Gross injustice to our poor rural folk. 67 years after independence the poor get the gift of legalized quackery.

  2. Dr Jayaraman Nambiar M Dr Jayaraman Nambiar M Thursday, November 21, 2013

    I wanted to join a rural Hospital After my MD, But people made eme difficult to join ther

  3. Dr. Naresh Dalal Dr. Naresh Dalal Wednesday, November 20, 2013

    I endorse the views expressed by Dr. Neeraj Nagpal. Really the political class is misusing or wasting the resources and money of this country in their own interests. They have no interest in public need. Time has come to teach them a befitting lesson. Get ready for the coming elections. I agree with the opinion of existence of BAMS/BUMS doctors, they can be empowered to meet the shortage of doctors. There is no need of new courses like BSc CH to replace the qualified doctors.

  4. Dr Pradeep Arora Dr Pradeep Arora Tuesday, November 19, 2013

    The message of this revealing article is very obvious and need not be fudged by unnecessarily raising other issues which are not directly relevant . 1) There are more qualified doctors already available than required to saturate rural vacancies. 2) The deficiencies in rural healthcare is largely due to poor infrastructure , lack of equipment and sub-optimal incentivization of medical personnel.

    Starting a new course is hardly a cogent solution and exposes a duplicitous approach of political leaders and executives who have ratified such a move. On one hand, there are hyper-regulations of the ilk of clinical establishment act in name of uncompromising quality ; and on other hand legitimacy is being lent to a new breed of quacks for sake of political expeditiousness and populism. It is a weird paradox, and highly deplorable too. Where are those who raise a clamor on medical negligence? Isn’t it as state sponsored systemic medial negligence ? These quasi medicos wont have any allegiance to any code of conduct /ethics also. That makes them unbridled, untrammeled lot, foot loose and fancy free. These phony semi-docs would surely wreak havoc with healthcare of unsuspecting ruralites. Government should be in all readiness to take flak of their misdoings .

    Again kudos to Dr Neeraj Nagpal for a nicely researched and crisply worded article . His writings reflect a sense of purpose and sincerity for the good of medical fraternity. We badly need crusaders of his kind , as the profession is going through difficult times.

  5. Dr Kirti N Saxena Dr Kirti N Saxena Tuesday, November 19, 2013

    Apart from doctors, nurses are also important caregivers in the medical profession. In India , nurses are not allowed to prescribe any treatment in sharp contrast to the west where nurses are not only allowed to prescribe basic medicines but also work as nurse practitioners. They also specialise in fields such as ICU care and midwifery. There is no doubt that there is shortage of doctors in India but not enough support is being given by the nursing profession

  6. Dr. Sunila Sharma Dr. Sunila Sharma Tuesday, November 19, 2013

    I agree with the views of Dr. Neeraj Nagpal and would like to reiterate the need for monitoring of health practices in all the states of India and generating the data of doctors [MBBS,Unani,Ayurvedic,homeopaths etc] residing and settled within a radius of 5 to 10 kms .

    May be Journalists, News channels and News Papers can pitch in with the services of their experts for collection of such data first and then help with implementation phases.

    The state planners need to rope in and appoint doctors[pvt./retd./free lancers] residing locally after providing the minimal infrastructure necessary for primary and secondary health care centers and offer them practice with payments as per locality economic conditions.

    Planning and Implementation structures should be borrowed from Tamil Nadu and Andhra Pradesh and implementations should be done with dedication and without self interests by locally influential people.

  7. Dr Neeraj Nagpal Dr Neeraj Nagpal Tuesday, November 19, 2013

    Dear Dr Vikash
    I will answer your point relevant to this issue of BSc CH. We have conducted surveys and have recently started another one which I would recommend you participate in. The results have been kept in public domain so that you remain informed of views. My bias does not matter. Fact is a rural person deserves the same level of healthcare as an urban. If we wish to compare, what is better 1) MBBS, 2) AYUSH practicing within their own speciality 3) Ayush Doctor practicing allopathy 4) BSc Community Health trained in non teaching hospitals for 3 yrs 5) Unqualified quacks. Our point is there are more MBBS doctors willing to serve than there are jobs available. Why are we forcing MBBS doctors to start pvt practice in rural area. It is the job of the state to provide health and hence provide Government doctors in rural area. Because we spend measly 2.03 % GDP on health and our voters are too ignorant to object, blame of poor healthcare delivery is conveniently shifted by Govt on to MBBS doctors unwillingness to serve in rural areas.

  8. Dr Vikash R Keshri Dr Vikash R Keshri Tuesday, November 19, 2013

    We should also consider the the ground reality in rural area before taking a side

  9. Dr Vikash R Keshri Dr Vikash R Keshri Tuesday, November 19, 2013

    With due respect, I see the views of authors to be biased towards so called trained doctors. If we are really concerned, we should first oppose the Selling of medical degree by private institutes because they too are no better than quack.

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