Is it too much to expect an MBBS student enjoying a state subsidised education to serve one year in rural India before he or she is awarded a degree? Well, medical students across the country certainly feel Union health minister Anbumani Ramadoss's latest move to improve rural health services goes against their interests. They feel a year in the villages, in addition to the five-and-a-half years spent studying to get a degree, is a burden they can do without. So much so, students in Tamil Nadu and Maharashtra even went on relay strike to protest the move after the health minister made his announcement. And the outrage isn't limited to them.
As Ramadoss sees it, compulsory rural service is the way to set right the anomalies in public healthcare in the country. The minister is convinced the villages are being ignored by doctors despite the government investing heavily in their education. His rationale: the government spends Rs 3.50 lakh per year on each student when he or she is required to pay only Rs 15,000 as fees, so there should be a system of paying back to society for this subsidy. According to health ministry figures, annual government spend on medical education in the country is Rs 10,000 crore.
Dr Quickfix?: Ramadoss at a convocation
Despite this huge deployment of financial resources, little has been done to correct the skewed distribution of medical colleges. Most of India's 262 colleges, churning out 30,922 doctors each year, are located in urban areas where only 30 per cent of the population resides. (Ironically, nearly 75 per cent of health services here are currently provided by the private sector.)
The 70 per cent rural population have only primary healthcare centres to turn to which, more often than not, do not even have a medical officer. It would appear there are no doctors to fill up the vacancies. In 2005-06, nearly 51 per cent of posts of surgeons, obstetricians, gynaecologists, paediatricians and physicians were lying vacant. Records show that of the 6,83,682 registered allopathic doctors in the country, only one in 10 doctors works in a rural area.
In light of all this neglect, isn't Ramadoss justified in his rural plans for the students? Opinion is sharply divided. For many, the good doctor's intentions are noble but shortsighted. Some, in fact, feels it's empty grandstanding. C.V. Bhumanandan, Tamil Nadu representative to the Medical Council of India (MCI), the apex body that registers/deregisters colleges and regulates medical education in the country, says, "The students aren't trained to serve in villages. Rural health can't be treated in such a casual manner, especially when all the attention and money goes to providing the best healthcare for urban India. Relying on students to provide healthcare amounts to giving second-class treatment to rural India." This, incidentally, goes against the minister's contention that basic treatment is better than no treatment at all.
Says S.P. Kalantri, professor of medicine at the Mahatma Gandhi Institute of Medical Sciences, Wardha: "There is no doubt that the imbalance of doctors in rural and urban areas needs correction. But most rural facilities in India continue to lack enough providers, equipment and infrastructure to offer effective and efficient care." With experience in a rural medical school and hospital at Sevagram, he feels that rural and socially disadvantaged people tend to have far more serious and complex medical problems which needs more knowledge, expertise and experience. "To offer cost-effective medical care to the rural and poor people isn't easy...it's certainly beyond the capacity of young, unsupervised doctors," he says.
Maintaining that compulsory service will not work, Kalantri offers an alternative roadmap: improve infrastructure, equipment and support staff in primary health centres; create a well-designed link between primary, secondary and tertiary healthcare; make students feel they are part of a big team caring for rural patients, pay them well, do not lengthen their medical education. In short, don't make it a painful exile.
While all this calls for investment and sensitising medical students, there is a lesson to be learnt from the experience of Christian Medical College (CMC), Vellore, which has worked out a system of instilling the right sort of ethics in its students. A minority institution, two-thirds of the 60 students it enrols each year are Christian. The latter are required to sign a bond that commits them to serve in rural areas. But instead of adding on an extra year, the curriculum has been designed in such a manner as to factor in a minimum of a few hours every week to begin with to a few weeks that students have to spend in faraway villages. The college thus instils in the students the need to understand health problems in remote villages. Students, of course, work under the guidance of an experienced medical practitioner.
According to Anand Zacchariah, vice-principal of medical education at CMC, students from the general category too are volunteering to work in rural areas now. The scheme has been in place for over 40 years and has hopefully sensitised students to the real demands of their profession. The students do encounter a stressful environment where the lack of infrastructure is sorely felt, but end up more sensitive to the problems faced in villages. The CMC experience proves that a mandatory rule vis-a-vis rural service can work. Acknowledging this, MCI president Dr Keshavan Kutty Nair now says the council has submitted a proposal suggesting changes in the curriculum to the health ministry. "We have proposed to include medical ethics and public healthcare education as part of the curriculum for at least six months," he says.
There are doctors like Anup Saraya of Delhi's All India Institute of Medical Sciences who stress the need for well-thought-out policies to address public healthcare instead of a stop-gap arrangement like compulsory year-long rural service by medical students. Saraya says the government should demonstrate its seriousness by coming up with a time-bound plan for fulfilling vacancies in the state medical services, for upgrading rural health infrastructure, and also offer academic incentives for doctors working in rural areas.
Ramadoss will seek the MCI's approval before putting his compulsory rural service plan into action. But he can also bypass the council through an ordinance or by getting Parliament approval. But to begin with, he will have to invest money. The Rs 10,000 per month incentive to medical graduates for serving in villages may seem a decent enough thing. But for doctors who dream of earning big bucks, this may simply not be good enough.
