Training practitioners to head health centres is worth trying, but with strong regulations

On August 1, the Rajya Sabha passed the National Medical Commission Bill, 2019, which provides for the training of certain health-care practitioners for modern medicine. The medical fraternity has vehemently opposed this idea and feels that the Bill will encourage ‘quackery’. R. Prasad converses with Sujatha Rao and Anant Bhan on the possible 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 areas?

Sujatha Rao (SR): As you know, we don’t have credible data. But estimates show that there could be about eight lakh doctors actively practising, which would 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 there is adequate number of doctors in both Kerala and Tamil Nadu, whereas in Bihar and the northern States, there is an acute shortage. 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 as badly off as the northern States.

India as a whole also has a huge shortage of specialists. So, you may have doctors but it does not necessarily mean that they can adequately address certain diseases. The whole question of doctor-population ratio as per the World Health Organisation (WHO) norms doesn’t really have much of a meaning. You have to really split it and look at the issue in a granular manner.

Anant Bhan (AB): 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. But in many other parts of India, there is an acute shortage. Finally, you might have enough doctors in terms of numbers, but will they actually stay on in rural areas if posted there?

What initiatives have been taken to address this shortage?

SR: There are three broad reasons why the public policy has been weak vis-à-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 from 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 that really enables young doctors to go and work in rural areas. 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 full-fledged five-year-trained MBBS doctors to deal with some of the basic public health issues in rural areas. What could be adequate 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 community health worker debate started in 2010.

AB: 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 that of a ‘bond’ — once you are trained with government support, you have to serve for a certain number of years after your MBBS or after your postgraduation. That has also been 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. The government reserves postgraduation seats specifically for those candidates who work for a certain number of years with the government. That has helped to some extent. These are the three or four models. [But] I don’t think we have 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 medical qualification would be sufficient?

SR: I have seen them in the field and they are not good enough to cope with the challenges. I liked what they did in Chhattisgarh with the three-year course. They trained them [the students] in medical colleges like any other student but then restricted them to public health. I’m not very interested in these bridge courses and six-month programmes. I don’t think they can be very effective.

AB: The bridge course is an interesting approach. I think it is not the unqualified medical practitioners who are being trained but formal health-care providers of some kind, whether they are nurse practitioners; or nurses who are being converted to nurse practitioners; or AYUSH (Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoeopathy) doctors. All of them have had 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? If they are to be deployed as middle-level care providers or community health officers, do they have adequate skills at the end of six months? And on what empirical evidence is that six-month period being decided? I think reducing the training to six months is a bit of a concern. I guess the reason they’re doing this is that it is difficult to get candidates to be trained beyond that, or maybe governments are not willing to stay at them for longer.

Do you think the short-term training of community providers will lead to substandard care for the rural population?

SR: 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 midwives, who are trained for 18 months, are already giving antibiotics and are also involved in immunisation programmes. Even if the 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-month training [courses] and force the system to churn out substandard training and we end up with people giving substandard treatment.

AB: We already allow certain kinds of health-care providers [non-doctors] to give medicines. The question is: How wide should the scope of such practice be? But I think that fundamental redesign where [such providers] will be heading the health and wellness centres is an experiment worth trying.

Who do you think should be chosen to undergo this training?

SR: Nurses, if trained well, 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 am 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 practise allopathic medicine? But then, there’s also the political [angle], where AYUSH doctors want to get into government service by becoming mid-level providers.

AB: Individuals 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 have 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 nurse practitioners going through a bridge course. The Chhattisgarh and Assam model is currently not being tried out. [But considering that] it worked fairly well for rural health care, it’s also an experiment worth looking at. However, they [these courses] faced so much opposition from the doctors’ collectives, especially the IMA [Indian Medical Association]. And that is going to be an issue whenever you try to scale up any of these programmes. Yet, we don’t really have an alternative model.

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 the absence of quality health care, 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 gathered about whether it works or not.

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

SR: 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 have a plan, then it can be a game changer.

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.

AB: 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. I think the key equation is whether this experiment is worth trying or not.