Debate: Can the National Medical Commission Bill address rural healthcare deficit?

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On August 1, the Rajya Sabha passed the National Medical Commission (NMC) Bill, 2019 which has a provision to train people connected with modern medical profession to practice modern medicine. The Commission intends to grant about 3.5 lakh licences. The duration of the training programme has not been specified. The licensed Community Health Providers will be permitted to independently prescribe specified medicines for primary and preventive healthcare. The medical fraternity is severely opposed to this idea, and strongly feels that the bill will encourage quackery.  

Former union secretary of the Ministry of Health Ms. Sujatha Rao and Dr. Anant Bhan who is a researcher in global health and bioethics analyse the ramifications of the Bill. Edited excerpts: 

What is the doctor-patient ratio in India, and how acute is the shortage of allopathic doctors, particularly in rural India? Is the shortage even across all states?

Ms. Rao: As you know, we don’t have a credible data on doctors and how many are actually actively practicing in the country. But estimates show that they could be about eight lakh doctors who are actively practising, which would really mean that we need an additional five lakh doctors, but that’s just a gross estimate.

The differentials come between the northern and southern states.  There is no doubt that in both in Kerala and Tamil Nadu there is adequate number of doctors. In fact, in Kerala, we hear reports of doctors being unemployed, whereas in Bihar and the northern states there is an acute shortage of doctors. Again, there is a differential between the rural and urban areas, as a large number of doctors tend to cluster in urban areas. So, even in the so called surplus states like Andhra Pradesh and Telangana, you may find it difficult to find doctors in the tribal areas or in the very backward rural areas, though overall, they may not be so badly off as the northern states.

India as a whole also has a huge shortage of specialists, of doctors with relevant skills and competencies to address the disease burden in the country. So, you may have doctors but it need not necessarily mean that they are of adequate numbers for addressing the huge demand for certain diseases which we have in large numbers. So, the whole question of doctor-population ratio as per the WHO norm doesn’t really have much of a meaning. You have to really split it and look at the issue in a more granular manner.

Dr. Bhan: With allopathic doctors, historically, we have had some degree of shortage. I think there have been attempts to try to address that by opening more medical colleges. We’ve also had many State level initiatives to increase the number of medical seats. So, I mean, there is a clear urban-rural divide; there is also an inter-State divide that is quite stark. Some states seem to be doing fairly well as compared to even probably the WHO requirements as to what an ideal doctor-population ratio should be.

But in many other parts of India, there is an acute shortage of any kind of a recognised doctor. Finally, you might have enough in terms of absolute numbers, but will they actually stay on in rural areas if they’re posted there?

What initiatives have been taken to address this shortage?

Ms. Rao: There were three broad reasons why the public policy has been weak vis-a-vis the doctors in rural areas. One is inadequate investment; two, the incentive structures have been very weak; and three, the nature of work that a doctor in a primary health-care setting is expected to do in a rural area is very different to the kind of training he gets as an MBBS doctor. So, he’s not really tooled and trained to cope with the public health issues. Public health is a very weak area of instruction in an MBBS course. We have not been able to have a proper training programme which really enables young doctors to go and work in rural areas for some time.

In terms of bridging this gap, yes, Chhattisgarh and Assam did work on having a three-year-trained physician, something like the old LMPs (Licentiate Medical Practitioners). They’re really very good. I do believe that you don’t need a full-fledged five-year-trained MBBS doctors to deal with some of the basic public health issues in rural areas.

What could be adequate, given our circumstances, are three-year-trained public health practitioners who would really address all our infectious diseases and public health requirements of the rural poor. This is how this whole business of community health worker debate started in 2010.

Dr. Bhan: From what I understand, there are three or four ways in which governments have tried to increase the number of doctors working in rural areas. One is by using incentives for practice in rural areas. We’ve had a mixed bag with that. In States like Chhattisgarh that has worked for a limited amount of time. The other model that has been used is a bond, which is that once you are trained with government support then you have to serve for a certain number of years after your MBBS or after your post graduation. That has also had a mixed bag — in some states it has been implemented, in other states it has been very poorly implemented. The third idea is having in-service, postgraduation seats. If you work for a number of years with the government, the government will have post-graduation seats available which are specifically for those candidates. I think that has helped to some extent. These are three or four models which I am aware of.  [But] I don’t think we’ve really had a comprehensive way of being able to respond to the gap yet.

Do you think short-term training of people who don’t have a medical qualification would be sufficient?

Ms. Rao: The Government of India in their anxiety to get the number are in the wellness clinics putting PHC nurses or AYUSH doctors after six months of training in public health, conducted by a nursing school in a course developed by IGNOU. I have seen them in the field and they are not good enough to cope with the challenges. I strongly believe that the LMP system can come back. I liked what they did in Chhattisgarh with the three-year course. They train them in medical colleges like any other but then restrict them for public health and develop public-health cadres. I’m not very interested in these bridge courses and six months programmes. I don’t think it can be very effective.

Dr. Bhan: The bridge course is an interesting approach. I think it is not the unqualified medical practitioners who are being trained but formal healthcare providers of some kind, whether they be nurse practitioners, or nurses who are being converted to nurse practitioners, or AYUSH doctors. All of them have some health experience.

The question is: Will a six-month course be enough? And what exactly does it train them to do differently than what they were already doing, and what is expected from them? If they are to be deployed as middle-level care providers or community health officers do they have the adequate skills at the end of six months? And on what empirical evidence is that six month period being decided?

Is six months enough to train someone to even circumscribe allopathic medical practice? Do we have the level of confidence? Do we have any background data which can tell us that that is indeed the case? There is a fair bit of focus on training in hospitals. But what exactly will be the focus and what would be the result of this kind of an experiment we will know in time. I know that in some States a couple of batches have started or already getting completed.

I think reducing the training to six months is a bit of a concern. I guess the reason they’re doing it is probably it’s difficult to get candidates to be trained beyond that, or maybe governments are not willing to stay at them for longer.

I’m less worried about having a non allopathic doctor leader team at the health and wellness centre. But on what basis are they deciding that this kind of training is enough is something I worry about.

Will the short-term training of community providers lead to substandard care for the rural population?

Ms. Rao: For whatever reasons,  doctors are not going to rural areas and there is a huge gap between demand and supply. Now, there has to be a sort of short-term measure. Auxiliary nurse midwifes, who are trained for 18 months, are already giving antibiotics and involved in immunisation programmes. So there is a need to have some drug prescription powers being delegated to nurse practitioners. Even if nurses stay for 16 months or 18 months as a nurse practitioner, then it’s going to be a game changer.

But then there must also be a focus on quality. Our bureaucrats are constantly looking for numbers. So they come with all the silly ideas of three and six months training and force the system to churn out substandard training and we end up with people giving substandard treatment.

Dr. Bhan: We already allow certain kind of health-care providers who are non doctors to give medicines, use a limited number of antibiotics. So it’s not the case that we are not already doing it. The question is how large should that envelop of practice be? But I think that fundamental redesign where they will be heading the health and wellness centre is an experiment worth trying.

Who do you think should be chosen to undergo this training to become community health providers?

Ms. Rao: Nurses, if well trained, can be a great asset. Or you can have, like in Chhattisgarh, the three-year trained rural medical practitioners. AYUSH doctors provided with some public health training could be a great asset. But I’m wondering whether that’s the appropriate cadre to bring in as AYUSH by itself has so many strengths. Why on earth are we getting well qualified AYUSH practitioners to practice allopathic medicine? But then, there’s a huge political [angle], where AYUSH doctors want to get into a government service by becoming mid-level providers.

Dr. Bhan: Individuals who are currently being considered are certified health providers of some kind. They are not qualified to be allopathic doctors but they are qualified to be nurses or AYUSH doctors.

The individuals who have been considered for even the middle-level care provider positions are people who are within the health system already, or who are trained in some way already and could be taking on this additional position. So, it’s in a sense retraining or additional training for them.

There are two models for health and wellness centres — AYUSH doctors going through a bridge course, or a nurse practitioner going through the bridge. The Chhattisgarh and Assam model is currently not being tried out for the health and wellness centre. It is an interesting model to look at because some of the evidence which has been gathered shows that they were quite promising. And they did fairly well in terms of rural medical and healthcare provision. So that’s also an experiment worth looking at. But they face so much opposition from doctors’ collectives, especially the IMA. And that is going to be an issue whenever you try to scale up any of these programmes… they will not allow some of these experiments to happen. Yet, we don’t really have an alternative model which works right now where we can ensure quality rural healthcare.

Further, unless we try out some of these experiments, we will never know and the status quo is not something we should be finding acceptable any longer. I think we’ve had rural populations and large sections of the population suffering for many years due to absence of quality healthcare, and that needs to change. And if that requires certain experiments to happen, those should certainly be tried. But [it should be tried] with regulation, with adequate planning, with adequate lead time, with evidence being gathered about whether it works or not.

Do you foresee a situation where the solution in the form of community health providers becomes a bigger problem than the shortage of doctors we face today?

Ms. Rao: It depends on how the designing and implementation goes along. If they [the government] do it all in a hurried way, then the prognosis is not going to be good. But if they do it in a systematic, well laid out plan with lot of application of mine then it can be a game changer. So it all depends on how they’re going to roll out this initiative. If the NMC does focus on improving the quality of doctors, if there is a slight more expansion and we create about 100,000 doctors every year who are well qualified, well trained, then there large number of doctors.

But perceptions of patients are changing, preferences are changing, people are not willing to settle even for a nurse. In a State like Kerala, they’re not willing to look at even MBBS doctors, they only want specialists. So, these partially trained people may not get preference and may fall by the wayside.

Dr. Bhan: For better or worse, we have to see how the experiment goes. I think a continuous redesign, actually having a strong evaluation framework, a strong regulatory governance framework is extremely important. My sense is that if the experiment fails, it will be abandoned before the number of these providers is too high. So I’m not considering a situation where there’s 3.5 or 4 lakhs of them going astray, and then we have no way of being able to track them.

I think the key question is whether this experiment is worth trying or not, and if we are going to try it, whether we’re going to do it purposely, properly and with a framework which allows us to really know if that’s the right model or not. Or, how are we going to rejig or redesign the model as its as its evolving also needs to be focused.

It is not just enough to implement schemes or run programmes, it is also important to keep evaluating the approaches and see if those are working. If they’re not working we should abandon them and trying to come up with an alternative one which works. I don’t think we should stick to a plan.

Published in The Hindu on August 9, 2019

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