The National Medical Commission Bill 2019 was passed by the Rajya Sabha on Thursday. As the bill was being debated in the upper house of the Parliament, the resident doctors across government hospitals in the city were blocking roads, demanding that the bill be scrapped.

The medicos continued their strike on Friday, even after health minister Harsh Vardhan met representatives of the doctors’ associations. According to sources, none of the issues the associations were raising have been incorporated in the amendments of the Bill.

One of the main objections the doctors have is on licencing people from medical backgrounds to practice and prescribe allopathic medicine for primary care. While debating the Bill, senior Congress leader Jairam Ramesh said the move would “legalise quackery”.

Speaking to media persons on Friday, Vardhan said, “I addressed their (doctors’) queries and told them how NMC will work, and also explained to them the role of Community Health Providers (CHP). It should be noted that the concept of mid-level practitioners is recognised worldwide and this concept has also been highlighted by the WHO and the Lancet Journal.”

This is not the first time the creation of a new trained cadre of healthcare service providers has met with resistance. The Indian Medical Association (IMA), India’s largest doctors’ association, has been involved in legal battles with the states which have introduced courses to train people who can deliver primary healthcare in areas which remain unserved by MBBS graduates.

States vs Centre

In 2001, the newly-formed Chhattisgarh government started a three-year diploma course in Modern Medicine and Surgery under its Chhattisgarh Chikitsa Mandal Act to meet the acute shortage of healthcare providers in the state.

At the time of its bifurcation from Madhya Pradesh, the state had only one medical college with 100 seats for undergraduate students, and no nursing college. Only 35 per cent of sanctioned posts of doctors in Primary Health Centres (PHCs) were filled. Twelve of the state’s 18 districts were classified as remote, tribal and extremist affected.

Soon after the proposal for starting the diploma in March 2001, the IMA Bilaspur moved Bilaspur High Court demanding that the course be stopped. They said that medical education is a mandate of only the Medical Council of India (MCI), apex body for regulating medical education in India. This means, that while healthcare delivery is a state subject, health education falls in the concurrent list (subjects shared between both centre and states) and designing and starting new courses for medical education cannot be done by states if a central act exists and the MCI’s approval is a must. Hence, the constitutional validity of the diploma course was questioned.

“How can there be separate doctors for rural areas? If within six months or three years people can become doctors, then why do we spend so much time studying to get an MBBS degree?” says Dr Kaushalendra Thakur, state secretary, IMA Bilaspur.

The course also ran into internal conflicts with regard to its name, the curriculum design and because of the uncertainty of the status of graduates, there were huge dropouts. The name of the course was changed several times and the words ‘surgery’ and ‘modern medicine’ were removed, and within three years of its launch, the course stopped.

There were regular protests by 1,391 graduates and after much deliberation, the state posted them in remote and tribal Primary Health Centres which had the most acute shortage of doctors as Rural Medical Assistants (RMAs) to assist the MBBS doctors.

“Most of our PHCs don’t have MBBS doctors even after 18 years of state formation. Our primary care is totally dependent on RMAs,” explains Samir Garg, chief programme coordinator, State Health Resource Centre, Raipur.

The RMAs today have their role clearly designed. Besides delivering all state and centre’s health programmes, they can assist in normal deliveries, repair small wounds by stitching, drain abscess, dress burn wounds, apply splints in fracture cases and tourniquet in case of severe bleeding from limbs. If the cases don’t improve, they have to refer them to bigger hospitals.

The IMA case, however, is still ongoing but hasn’t been heard for many years now.

Assam started a similar diploma course in 2005 under Assam Rural Health Regulatory Authority Act. By 2008, as the first batch of graduates was ready, the IMA filed a case in the Guwahati High Court, which declared the diploma course unconstitutional.

The IMA won the case in 2014 and more than 800 community health workers had to stop practice. The state declared them paramedics, which meant they no longer had any authority to prescribe allopathic drugs.

“There is no provision of a diploma course for medicine in the MCI. We cannot say a disease is an urban disease or a rural disease. Teaching cannot be urban teaching or rural teaching. Shortage of doctors is everywhere, but this (diploma course) is not the solution,” says Dr Satyajit Borah, President, IMA Assam.

Borah adds that after graduating, the diploma students started calling themselves doctors and the government almost agreed to this arrangement, which the IMA staunchly objected to.

In 2015, the state community health practitioners, graduates of the diploma course, approached the Supreme Court where the case is ongoing.

In all these years of practice, there has not been a single adverse case either in Chhattisgarh or in Assam which was handled by a rural health practitioner, says Garg. In fact, studies by the National Rural Health Mission on these states’ models have only suggested that access to healthcare in areas where health practitioners are present has gone up several times.

Studies on mid-level practitioners also show that their presence in the community reduces the cost of healthcare, referrals to tertiary hospitals are fewer reducing their load and the trust the communities develop on the rural practitioners diminishes the role of quacks.

“If a person is trained over three years, who can identify the serious cases, who can rationally give drugs, and if he or she is well connected either to private or public doctors so that the referrals are seamless, that would just transform the landscape of this country,” says Meenakshi Gautham, Research Fellow Health Systems and Policy Analysis at London School of Hygiene and Tropical Medicine.

Gautham adds that the vacuum created in areas where there are no doctors is filled by quacks who are spoiling the cases. Having trained practitioners will actually improve healthcare rather than spoil it as alleged by the IMA, she says.

In 2010, Gautham filed a PIL in the Supreme Court to introduce a bridge course. The court directed the MCI to design the curriculum for the course, but no concrete steps could be taken and the MCI was dissolved the same year.

“In areas where there are no doctors, people don’t care whether the person treating them had an MBBS degree or not. They were getting better with the community practitioners and their trust on them increased gradually,” says Sanjay Das, senior community health practitioner, Assam.

The government has, in the past, tried to incentivise doctors monetarily if they serve in rural areas. Extra marks for post-graduate entrance exams were given to students who serve in rural areas after completion of MBBS. National Rural Health Mission (NRHM), started in 2005, tried to decentralise healthcare, pumping more money into the starved sector. But none of these initiatives could retain MBBS graduates in most of the rural areas. Doctors remain concentrated in cities while the sub-centres and primary and secondary health centres are run by nurses and paramedic staff across many states.

“None of these schemes have succeeded. If doctors are posted in PHCs, they get themselves transferred to district hospitals,” said Vinay Aggarwal, Member, MCI and Past National President, IMA. The IMA stresses that the rural centres lack basic infrastructure, hence no doctors would like to serve there.

Gautham agrees. And this is precisely the reason why the health systems need to change, she says.

“Villages in India are really isolated. Money is not the only incentive that is going to work. You need a life. Who will you socialise with? We need people who are recruited from those kind of surroundings and then trained and supported over the years,” she adds.

Rural health centres being served by nurses and mid-level practitioners is a global phenomenon. NHS clinics are managed by nurses. South Africa has clinics run by nurses. And currently even in India, many sub-centres and PHCs are run by ANMs. There are close to 2,000 PHCs in India without a doctor, as per 2018 data.

“There simply aren’t enough doctors,” says Garg.

At the centre, the National Health Mission in 2015 started a six-month bridge course by IGNOU where qualified nurses are trained to give primary care. These graduates are then placed in Health and Wellness Centres (HWCs) which are being expanded under the Ayushman Bharat Scheme. “Across the country, 9,000 such graduates are already working and another 9,000 will join the workforce very soon,” explains Garg.

Government’s website states that the HWCs will be “equipped and staffed by an appropriately trained Primary Health Care team, comprising of Multi-Purpose Workers (male and female) and ASHAs and led by a Mid-Level Health Provider (MLHP).”

Recently, Jharkhand started a similar diploma course and its first batch of fresh graduates will be out soon.

While the NMC Bill is unclear on how and when the community workers can practice and prescribe, it clearly limits the numbers of licenced practitioners to one-third of the total qualified doctors in that region. Anything above primary there, the community workers will have to work under the supervision of an MBBS doctor.

Health minister Harsh Vardhan also tweeted that a separate registry will be maintained for such practitioners. He also said that the course for training of CHPs will be put in public domain.

With the NMC Bill, pushing for a central legislation on licencing community health practitioner and one of the biggest centrally sponsored programme – Ayushman Bharat – promoting mid-level practitioners in healthcare, the states are hopeful that working on alternative solutions for meeting acute shortage in human resources in healthcare may finally see concrete measures.

And the minister rightly puts it: “The NMC Bill is a visionary revolution to reform the medical education sector. Those who are not able to understand it (now) will realise its benefits in the coming years," Vardhan said.