JOIN USThe Union health ministry’s announcement of its proposal to introduce a three-and-a-half year Bachelor of Rural Medicine and Surgery (BRMS) course has raised questions and concerns in the health care community. The abbreviated medical course is for students from villages that will be trained as doctors locally to meet the need for health care personnel in rural India.
Utopian as this may sound, there are many controversial aspects to this plan which could be addressed at the consultation this month when deans of colleges will meet the health ministry and the Medical Council of India (MCI) officials to discuss the viability of such a scheme.
The question is why doctors are reticent about working in a rural setting? Any young doctor is clearly aware of the desperate need in rural areas and is trained in community health and rural postings to effectively respond to such needs. However, the doctor alone cannot solve all the health problems in a village. The determinants of health include clean water, sanitation, shelter, access to food, a means of livelihood, education and local health facilities of a reasonable standard. All this is tragically lacking in vast areas of India and cannot be solved just by parachuting a doctor into the locality. Health care cannot be viewed in isolation and unless the government brings such infrastructure to the villages, it will be near impossible to raise the local standard of health.
Budget allocation
The government spends a meagre four per cent of the budget outlay on health, which speaks volumes of its seriousness to effect changes in this field. A large percentage of the health care burden is carried by private hospitals in urban areas and mission hospitals in semi-urban areas.
In 1996, the ministry of health proposed to make one year of rural service compulsory but this was not supported by the MCI who deemed it unfeasible, citing poor infrastructure and inexperience of young doctors who would be sent there. Why would a new BRMS graduate work in the village if laboratory, treatment facility and availability of medicine are poor and access to clean water and livelihood remain unchanged? It would be natural for him to seek an environment that is conducive where he can practice effectively, leading him to migrate to the cities.
Academically, it would be difficult to decide just what to leave out of the curriculum in this shortened course. Our MBBS course of five-and-a-half years in India is among the shortest in the world covering basic exposure and training in all subjects required to equip a doctor to diagnose, treat and prevent disease. In a critical discipline such as medicine, it is prudent to accept only the highest standards of knowledge and training.
Dr Desai of MCI has said that the training of the BMRS students will take place at ‘rural institutes’ and district hospitals. With a few exceptions, most district hospitals are understaffed, overwhelmed by patients and very poorly equipped. Is this a desirable training ground for the rural doctors? It is ironical that the MCI has set high standards for medical colleges and teaching hospitals in urban areas but is prepared to compromise where the BRMS course is concerned. The proposed ‘rural institutes’ will take years to materialise and could also lead to the familiar problems of admissions, nepotism and corruption, in a rural setting.
It would be far better to focus all resources on training a cadre of health workers and nursing practitioners as recommended by the task force on medical education. They can be equipped to deliver first aid, assist in normal deliveries and refer complicated cases to the hospitals.
Health workers could be agents of health education and preventive health schemes, trained and employed in the villages. Using telemedicine and mobile communications, they can access advice from qualified doctors and bridge the rural-urban health care divide. This will also pre-empt any confusion that could arise with a dual medical qualification.
Meanwhile, the government should increase the budget allocated to health care and infrastructure development in the villages. Higher salaries and all incentives must be offered to doctors who work in PHCs and district hospitals to meet their basic requirements so that they can remain in the rural area with their families.
The National Health Bill promises access to health care as a part of every citizen’s Right to Life. Though commendable, the ministry of health has a responsibility to every citizen to ensure that, in this process, India’s standards in health care and medical education are not compromised.
(The writer is a medical consultant and ethicist)