Instead of creating a sub-caste of rural doctors that will willy-nilly opt for the allurement of urban medical practice sooner than later and abandon the rural populace, the licentiate system of creating a cadre of non-doctors authorised to conduct limited professional practice must be revived
The Medical Council of India has recently decided to address the glaring shortage of doctors in rural India. As early as 1996 the Central Council for Health and Family Welfare, had unanimously decided to make rural medical service compulsory for new doctors. For 14 long years every Health Minister has repeated this aspiration, only to have the idea trounced by MCI as ‘unfeasible’. The council has consistently argued that doctors cannot function in the absence of “proper infrastructure”. Hence the recent decision of MCI to confront the shortage of rural medical manpower by creating a new stream of doctors drawn from rural areas, for rural areas comes as a surprise.
According to reports, these doctors would undergo a four-year course as against the five-and-half-a-year degree course prescribed for MBBS graduates. District hospitals would be used for medical training and the entrance eligibility of candidates would hinge upon continuous residence in a rural area. This way MCI hopes to catch 12th pass science students from rural secondary schools and convert them into ‘basic doctors’ and keep them rooted there. Is this fair? Is there an option?
There are 6,00,000 villages in the country, tens of thousands of which are located at a distance of more than 10 km from a Primary Health Centre and devoid of traversable roads. The amalgamation of GIS maps and census data portrayed on the website of the National Population Stabilisation Fund shows how PHC’s established in more than 300 districts out of 620 districts remain clustered in privileged talukas, even as interminable lists of villages with populations running into hundreds of thousands remain without reachable medical cover. In the foreseeable future it is unlikely that new PHCs would get established to cover the gigantic gaps that exist in the spatial distribution of rural health facilities, particularly in the Hindi belt states. It is even more improbable that new doctors moulded from the rural hinterland would agree to cater to such remote areas for long before the lure of urban practice entices them.
President of MCI Dr Ketan Desai is sanguine that “such doctors would not be interested in learning about kidney transplants and angioplasties and would instead concentrate on local diseases and basic health problems of villages.” The inequity of sculpting a second class set of doctors only for rural areas does not seem to have struck the council. As to how overworked, poorly staffed, undeveloped district hospitals that cater to thousands of patients and exist as such in more than half the districts of the country can become training ground for doctors remains doubtful. Training imparted in this milieu can hardly convey the essentials of anatomy, pathology, microbiology and pharmacology which are essential to secure grounding in medicine.
It would have been far more practical to have revived the idea of licentiates a system that was very much in practice in India, before it was abhorred by Sir Joseph Bhore in 1946, who despite strong dissension from several Indian members of his committee abolished the scheme forever. The Western medicine doctors that came into being then became the only source of medical care.
The revival of the licentiate system — preparing a cadre of non-doctors authorised to conduct limited professional practice — was recommended by the National Health Policy 2002 and later by a Task Force on Medical Education in 2007. Nurse practitioners, and medical assistants handle patients in rural areas in Canada, parts of the US and the UK even today. Policymakers in India have not considered this alternative seriously because they are influenced hugely by what the MCI and the Indian Medical Association think and want. The licentiate idea is an anathema to the MCI and the IMA, because both the bodies are strongly political and the only way to maintain and expand the constituency of voting doctors is to keep medical practice confined to doctors. Witness the brouhaha created each time there is a move to involve even the five-and-a-half-year degree holders of Indian medicine.
The way the health infrastructure is clustered in more than half the districts in India, the needs of people living there would continue to be disregarded if a workable alternative is not found. Were licentiates to be re-introduced, they would be akin to diploma holders on the engineering side. They would be eminently suited to give the first line of medical advice, provide basic treatment and to make referrals. They would have no claim to be called doctors but would function as a strong bridge, particularly if the advantages of telemedicine and mobile phones are used imaginatively. Looking at the scale of deprivation that exists in rural areas, there is an urgent need to establish a separate council to regulate the education and practice of such licentiates.
Before Joseph Bhore, two thirds of the practitioners in India were licentiates. We need to reconstruct that bridge instead of creating a sub-caste of rural doctors that will willy-nilly opt for the allurement of urban medical practice sooner than later, leaving the rural populace where they are.