MEDICINE IN RURAL INDIA

  MEDICINE  IN  RURAL  INDIA

“Education  should  aim  at  making  healthy minds

And  not  just  making  wealthy  careers.”

--- Padma Bhushan  Prof. B.M. Hegde

When Titanic sank, most of the passengers of high income group (1^st class ticket holders) could be saved while most of those from lower income (3^rd class ticket holders) group could not be.  Life boats were limited in number and the 1^st class ticket holders were given preference.  Same is the case in our health care sector also.  Only the rich with deep enough pockets can get “good treatment” in high-end smart hospitals in urban areas. To know about the ”good treatment”  read the article under the heading “MODERN MEDICINE --  the Good, the Bad and the Ugly” on this blog. Go to http://www.thehindu.com/opinion/open-page/hospitality-at-the-smart-hospital/article7960656.ece to know how smart a hospital in India is with a smart lady ushering you into your hospital room with a “welcome kit” containing bath soaps, a pedicure kit, a shaving set, hair gel, comb, a ’complete guidebook for a comfortable stay’, etc., and a dietician coming to take note of your food preferences ranging from soup to palak.  At the rural end we have health services which are severely anaemic. and the rural poor severely deprived.  Ironically, India has emerged as a major destination for ‘medical tourism’,  while the unfortunate rural Indians have no place to go.

Globally, every year, nearly 3,50,000 women die while pregnant or giving birth;  about two million newborn babies die within the first day of life; and there are 2.6 million stillbirths.  And it is anybody’s guess about the morbidity and mortality due to other conditions and in other groups of the population.  Most of this is occurring in the underserved rural population in the less developed countries.  More than 3,00,000 babies die within 24 hours of being born in India each year from infections and other preventable causes.

The presence of doctors and facilities is  very much skewed -- the urban areas are better served than rural areas. Though most of the population in India is in the sprawling rural hinterland, most of the spending on healthcare is in the urban areas.  And most of the doctors prefer to live in urban areas and much of the good medical infrastructure is in the urban zones.  More than 75 per cent of the doctors are in urban areas where only less than a third of the people live.  This is the main cause for the imbalance and the deficient health care services in rural India, notwithstanding the setting up of the National Rural Health Mission.  Even if, under the “Universal Health Coverage” (UHC) of the 12^th Five-Year Plan, 129 medical colleges are added by 2017 and even if the availability of doctors is increased to 20 from the present 7 per 10,000 population, the distribution of the doctors may not be equitable as envisaged by the UHC.  It is well said that “the road to hell is paved with good intentions.”

 India spends only about 2 per cent of its GDP on public health care, which is percentage-wise less than what Sri Lanka and Bangladesh spend. It has 7 beds per 10,000 people, compared to 38 in China, 23 in Brazil and 97 in Russia.  There are only 7 doctors  per 10,000 population in India compared to 19 in Brazil, 15 in China and 43 in Russia.  Curiously, Cuba, though not a developed country, has better healthcare facilities than even developed nations like the US ! The facts show, if anything, that the quality of healthcare need not depend upon the prosperity of a nation, but on the political will.

MARKET  DYNAMICS

 An aspirant to medical education usually says: “I want to become a doctor to serve the humanity.” It is a cliché and hypocrisy.  It should have been very clear, from what has been happening during the past few decades in the medical field, that aspiring to become a doctor is based on the dynamics of a market-based and business-model ideologies of making profit, compromising with fundamental social responsibilities. The epitaphs of good planning are often written by bad motives and the demons of avarice.  Most of the men at the helm of the affairs are from the wealthy stratum (or backed by the rich) living in urban areas.  And they protect the interests of themselves and the like.

Ask anyone who has just passed MBBS examination: “What are you going to do ?”  Pat comes the reply: “Post-graduation.”  Everybody wants to become a super-specialist. What is the motive ?  It is anybody’s guess !  And what would they do after post-graduation ? Settle in rural   areas ? Nope !   That is the problem for rural India.  Our bulk requirement is just graduates, not specialists. 

RURAL  DOCTORS

In this context it is essential to remember that for most of the medical needs of the country, the doctors need not be from the creamy layer of the qualifying examination (Plus-2, CBSE, or whatever) and they need not have great technical or intellectual capacity – what is more important is compassion, passion to serve the humanity, empathy, sympathy, sacrificial attitude, aptitude to do good, motivation, soft skills, decorous behaviour and magnanimity.  In a nutshell, he/she must basically be a GOOD HUMAN BEING.

 Even if there are no specialists in the country, the change in the morbidity and mortality due to lack of them would not be very significant.  But provision of basic medical care widely in the rural India which forms 80 per cent of the country makes a lot of difference.    All the same, we should be grateful to the specialists for spending and sacrificing a good part of their life in acquiring skills by studying, training and working very hard to pass on the benefits to us. 

 

PAUCITY  OF  FACILITIES

Doctors shun rural areas for various reasons.  Some of them are:  lack of good education facilities for their children,  limitations on upper level social life and entertainment, lower end quality of life, unavailability of decent residential accommodation,  low grade infrastructure in rural health centres, low professional satisfaction, lack of prospects for academic advancement,  very limited scope for private practice, etc.  Hence, most of them wouldn’t  happily settle down in rural areas.

  Jharkhand is one of the five states that had advertised a scheme under which specialist doctors could quote their own salaries. The others are Madhya Pradesh, Uttar Pradesh, Chhattisgarh, and Karnataka. These doctors can earn anything between Rs 3 to Rs 3.5 lakh per month, even then many doctors are reluctant to join.  Even those who joined left due to the reasons mentioned above.  This shows that unless the infrastructure is improved there is no hope for betterment of the services.

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Doctors may ask: “For the basic medical care, should we waste the talent of MBBS or post-graduate doctors in rural India?  Why not we have ‘qualified rural health care personnel’ / trained paramedical staff / midwives instead ?”  Do the rural folk belong to a species other than Homo sapiens ?  Why double standards ? All the same, it should be agreed that there should be a strong base of paramedical staff in the rural set up.  The importance of the services of midwives is well underlined in the article titled “Midwives do more than deliver babies” by Ms. Kate Gilmore --http://www.thehindu.com/opinion/op-ed/midwives-do-more-than-deliver-babies/article4756988.ece . That the Parliamentary Standing Committee had rejected the government’s proposal for a ‘Bachelor of Rural Health Care’ (Bachelor of Science – Community Health) course is a different story.
The present government (2018) is thinking of providing the 'best health care at the lowest cost' as envisaged in the 'National Health Policy', 'Ayushman Bharat' and the 'National Health Protection Scheme'.  It remains to be seen the success of this line of activity.

FAR  CRY  FROM  HIPPOCRATES

            Unfortunately,  many prefer this profession in India for a rich, respectable and glamorous life in urban areas. Secondly, it gives the social recognition that a medical degree bestows.  The investment starts from LKG to ‘super schools’ to ‘super tutions’ to one crore rupees a seat in private medical colleges (if below the cut-off marks level) to multi-crore investment in hospitals in urban land.  I hasten to add that all are not in this line.  There are many who wish to serve the humanity.    And some of those doctors from a humble and economically weak background can't play on a level ground with richer co-professionals, leading to frustration. Yet, the business attitude in the profession is inescapable, for it runs as a market oriented enterprise with cut-throat competition where there is little room for compassion and service-mindedness.  Such business can’t thrive in rural areas and hence this profession and all the connected industries throng to urban areas.  Otherwise, why our rural areas which form about 70 per cent of the country are bereft of ‘willing’ doctors to serve ?  And why every year the amounts illegally charged by the private medical colleges rose by leaps and bounds ?  And why the governments have been complicit ?  This egregious state of affairs lead to all malpractices.

SIMPLE  SOLUTION

One may go through the reports right from the Shore Committee (1962) to the Mudaliar Committee (1962) to the Shrvatsav Committee (1975) to the Bajaj Committee (1986) to the High Level Expert Group on Universal Health Coverage (2011), but one comes back to the zero 'within the box'.  

Then what is the solution ?  It is very simple. It may sound undemocratic to the wealthy and to those with vested interests.  And it may sound quixotic to those who can’t think outside the box.

For admission into medical colleges, select only the candidates who have the aptitude to help the needy, the willingness to serve the disadvantaged rural masses, the service-mindedness, the mindset to accept minimum salary and facilities, and the sentimental attachment to backward areas. 

 But, as it is very difficult to assess these qualities in an individual, even with psychometric assessments, before selecting candidates for enrolment into medical colleges, a simple solution would be to allot all the government controlled seats only to those who execute a bond to serve in rural areas for a minimum period of 15 years as is the case in the Armed Forces Medical College where one is bonded to serve in the army for a minimum period of 15 years.  This would automatically filter off those unwilling to have a career in rural areas.  Yes, this needs political will and genuine interest to help the rural folk.  And, more importantly, the medical infrastructure in the rural areas must be upgraded vigorously.  Else, it would be an exercise in futility to post talent without making use of it.  For more on this subject read the excellent article by Dr. K. R. Antony titled  “Who should be entering our medical schools ?” -- http://www.thehindu.com/opinion/open-page/who-should-be-entering-our-medical-schools/article4750732.ece  .

NOT  A   SOLUTION ?

This solution may only provide the physical presence of doctors in rural areas, but that alone is not going to address the health care needs of the  huge rural population.  Men and materials, to some extent, may be provided, but what is of crucial importance is the passion to serve and the compassion to help the needy which should come from the bottom of the hearts of all in the field, from the last grade worker to the doctor, which can’t be ensured by the government.  It is commonplace that many doctors  posted in rural areas, in many parts of the country, make  perfunctory visits to the health centres, spend some time attending  the patients and get back to their towns  to reside and do private practice,  may be because of the adverse conditions prevailing in rural areas which are already detailed above.   After all,  the ‘15 year-bonded labour’ of this ‘simple’ solution may also end up this way !  Then, where are we headed ?

 Somebody may come up with another ‘(not) simple’ solution – ban private practice and pay them ‘fat’ salaries.  “Even then, what to do if they continue the ‘malpractice’ through back door,”  you are going to ask, citing the example of Andhra Pradesh where private practice was banned for all the government doctors and yet most were doing the ‘malpractice’.  God, help ! What seems not have won much attention is the fact that the medical profession has largely shed its “nobleness” and opened shops across the world, much like the hotels – one star to seven stars.  More and more people are subscribing to the “animalistic doctrine of ‘Work – Consume – Die’ culture, dressed in subtle and gross deceptions.”  We are living in the ‘dog-eat-dog’ world with all the grey economy and vested interests!

                            Alas !  materialism has the tremendous power to override humaneness !  The poor will always remain poor.  Rural will always remain rural !

                                       I know, you are leaving this page with a sense of déjà vu !

              Finally,  if the government has a political will, there is a very effective but drastic solution.   The government is to:

1. Take over all the private medical colleges and ensure a uniform mode of selection of candidates. 
2.  Provide employment to all the candidates passing out of the colleges.  
3. Totally abolish 'private practice ' by the employed.  
4. The government has to take  over all the private hospitals and institute 'Universal Medical Care',   something like the 'National Health Service' of the U.K.  

I wrote in media of such solutions even four decades ago (Indian Express, March 3, 1974;  The Hindu, June 2, 1976;  The Hindu, June 21, 1978;  The Hindu, June 15, 1988;  more and many more).  Any objections to such reforms may be considered only as a smokescreen to hide the vested interests and the real truth - the truth being the abysmal degree of the present medical care and the exploitation of the patients across the country.

THIS  IS  AN  ABRIDGED  TEXT  OF  MY  ‘SCRIBBLING’.      FULL  TEXT  WOULD  BE  POSTED  LATER.                                            --  T. Rama Prasad