Doctor, doctor where are you?

I am rejuvenating a note I had started a few months back on reading an article on doctor availability in rural areas by Krishna Rao in The Hindu a few dasy back.

CN Halli Taluka Hospital in Tumkur district

Chikkanayakanahalli taluka hospital in Chikkanayakanahalli taluka in Tumkur district. Being a taluka hospital, it is supposed to cater to the hospital needs of 219,000 people in this taluka. The National Rural Health Mission (NRHM) launched in 2005 declares that the aim of the mission is to “…undertake architectural correction of the health system to enable it to effectively handle increased allocations…policies that strengthen public health management and service delivery in the country”. And indeed, allocations have improved – hospitals and health centers now have more money than before, on which there is much less control from district and state level bureaucracies. With participation of locally elected members, sometimes being constructive, it can even lead to well-spent funds. Understandably, however, there have also been some negative consequences at some other places – ranging from poor judgement on what the money should be used for to corruption in other places. But, increasingly the availability of “untied funds” for PHCs, taluka hospitals and district hospitals has resulted in quick decision-making on drugs and other consumables, but in most places, the core problem remains not of material resources – the problem is of “doctors”.

In the case of Chikkanayakanahalli, a hospital for over 200,000 people is not staffed well enough to provide good quality maternity care services. If a pregnant woman who requires an emergency caesarean surgery comes here, she is likely to be referred out. This is in spite of the need for such facilities at every taluka. There are many other taluka hospitals like this all over – either they do not have a blood storage unit, or lack a team of specialists to provide such services. On the other hand, getting qualified doctors to stay in remote primary health centers after 6 years of back-breaking medical education in one of the 30-odd medical colleges of Karnataka is also apparently a problem. And blaming the doctor for not taking up such an assignment is to blame the most proximate of causes in a long line of causes going up to elitist medicine taught and practiced to deep-rooted inequity in our population itself. Indeed, a qualitative study in Chhattisgarh concluded (unhelpfully for the short-term, but..) that:

Further, in a low-income setting such as India, questions of rural workforce adequacy cannot be addressed in isolation, but need to be tackled as part of broad agenda of social development that include strengthening public service systems and empowering communities.

The situation is much worse in several of the North Indian states, perhaps also in several regions in Northern Karnataka as well. One solution being talked about a lot is the 3-year rural doctor course, that Chhattisgarh piloted successfully, but gave up due to a variety of reasons, including the

… anticipated opposition of the medical doctor community represented by the Indian Medical Association (IMA) and the interests of the students themselves and their desire to be given appropriate status as medical doctors.

There are of course several moral and ethical problems in adopting such an option for “rural” healthcare, while continuing an (apparently) well-educated urban medical professional. But, frankly, I do not see the doctors being prepared for rural practice any way in our existing medical colleges. Our medical curriculum somehow promotes a cultural misfit, who is ill-equipped to function as a team leader of a small health centre. S/he is trained to fit as a cog into a huge wheel of a large tertiary hospital – better so, if it has well-developed protocols and regular training programmes and CMEs. There is also the options of nurse-practitioners, which is adopted in other health systems. It really is time to try out such solutions for rural health care, rather than depending on the MBBS-trained doctors to fill posts everywhere. Not easily done though, the mighty ego of the medical profession will not easily accept such “half-baked” doctors, it seems, in spite of evidence showing that the MBBS doctor often does not perform significantly better in primary care than these “half-baked” ones!

Which doctors for primary health care?An assessment of task shifting among primary care clinicians -Krishna D .Rao from IPHIndia

Anyway, the Aug. 31st Hindu Op-Ed by Krishna Rao sums up the problem pretty well. There are not straight-forward answers, definitely not one solution that will work across India anyway.


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