Medicine and public health are not the same, even if they are most often confused and idealised as one. The medicine course has a clinical focus, and medical students in India often dream of a prosperous life in the US or Europe. The idea of public health comes with an inherent duty to serve the poorest in the country, no matter what the working conditions are.
The aspiration of a doctor-to-be and the reality of public health needs in India today couldn’t be more divergent.
The Modi 2.0 government has mooted a separate cadre called ‘community health providers’ in a fresh law that attempts to bridge the gap between the two. Ironically, it finds itself in the same soup as the Ajit Jogi-led Congress government found itself in 2001-03 when it launched a dedicated public health cadre to address exactly the same end – letting the state’s rural population access mainstream healthcare services.
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Doctors’ groupings have been strongly protesting, saying the move will dilute the discipline of medicine by creating a parallel insufficiently qualified medical cadre with prescribing power, and in that sense ‘legalise quackery’.
They are not completely wrong in their claims but by letting status-quo prevail for decades, India today is in a situation where illegal ‘quacks’ are practically running the medical show in villages. An alarming 57% of allopathic practitioners are without medical qualification, reckoned the WHO in 2016. In villages, this number shoots up to 80%. Various estimates including one of Indian Medical Association’s own peg the number of ‘quacks’ at somewhere between 1-2.5 million.
These ‘quacks’ have thrived because no amount of pull factors – offering extra money or extra marks to enter difficult to crack PG courses or push factors – forcing doctors to sign bonds to serve a few fixed years in rural settings have historically made it palatable for a critical mass of doctors to serve in the country’s hinterland. Ramping up doctors’ cadre will take time, and even if their numbers swell, there is no guarantee that their aspirations will change and they would willingly serve in the countryside.
In that context, a new cadre of ‘community health providers’ proposed in the National Medical Commission Act is probably the only plausible short to medium-term solution on the horizon to experiment with and evaluate. But even those who wish to support the concept find themselves tongue-tied because no one knows who these ‘community health providers’ will be and how they would be trained.
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This is one of doctors’ cribs as well, and a legitimate one. A member of the parliamentary panel that discussed the bill at length has come out charging that this bit was not part of the proposed law they deliberated upon, hence they don’t have the faintest idea about what’s on the government’s mind.
There isn’t a way to hack the health minister Harsh Vardhan’s thoughts. But applying logic, the plan to build a community health cadre could involve training either one or more of these four categories—the nurses, and/or grass-root level health workers such as ASHAs and Auxilary Nurse Midwives, the practitioners of alternative medicines – known collectively as AYUSH doctors, a freshly trained public health cadre or the very controversial million plus ‘quacks’.
Of the lot, training a set of senior experienced nurses and allowing them to prescribe medicines in primary healthcare may prove the least controversial. Partly because this model has been tried and tested in parts of the US, the UK and Canada for years now with encouraging results. But India’s shortage of fully trained nurses, at around two million is more acute than its shortage of doctors pegged at around six lakh. And diverting existing nurses to take on doctors’ parts in rural healthcare practices could mean a full blown crisis in availability of nursing staff. Even then, readying a nurse cadre is cheaper, less time consuming, and less resource guzzling than preparing new doctors.
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In the case of AYUSH doctors, Maharashtra has already begun allowing them limited range of prescription through a six months bridge course. But many experts warn against it for two reasons – a few months bridge course is too short to equip the healthcare professional with necessary skills to do abortions, and other minor surgical procedures which are a must if one has to effectively lead healthcare practice in rural settings. This process may also take some of the alternative medicine practitioners farther away from their original root healing systems which warrant rigour and discipline of a different order.
It’s not clear what would happen to the million plus ‘quack’ population, many of whom are practising in the countryside and enjoy strong community support. Will they be co-opted in some role in the new order or would they be left out as a new set of unemployed? There have been scattered projects in West Bengal (by a non-profit organisation named Liver Foundation) which are trying to bring unqualified medical practitioners into mainstream by offering them some training, and making them promise that they wouldn’t prescribe medicines labelled for restricted use and wouldn’t prefix ‘Dr’ to their names. The government is unlikely to bestow this set with prescribing rights, but if it does, that may open a can of worms. Most doctors and public health experts have been absolutely allergic to the idea.
If the government has the patience to train for three years a new batch of public health cadre, like Chattisgarh did in early noughties, build a career progression pathway for them, and keep the referral system well-oiled by syncing their work with doctors at a higher lever centres, the idea may prove worthwhile to try out. Initial evidence and anecdotal reports showed that Chhattisgarh model was working quite decently. Assam replicated it even though in Chattisgarh it had to be abandoned under stiff opposition from doctors. But one reason it worked well was that it drew its cadres from local rural people, who wouldn’t leave for greener pastures.
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States like Tamil Nadu which have done well on health indicators have a separate public health cadre too, but they draw candidates from the common pool of medical students. However at a time when, medical colleges are already facing faculty shortages, and the country is ambitiously increasing the number of doctors, finding trainers for these dedicated public health programs may prove challenging. The structure could resemble pre-1956 India, when there were two levels of medical professionals – full MBBS and Licentiate in Medical Practice (LMPs).
The LMPs were abolished by Bhore committee in 1952, as the panel probably hoped that future doctors would turn ‘social physicians’. Again the confusion between public health and medicine. If done in haste without attention to quality of training and candidates, eventually this two-layered medical ecosystem could face the quintessential human rights question – are poor lives in rural lndia less than equal to not deserve a fully trained doctor’s attention?
Anyone who has experienced the crumbling public health system, and fleecing private healthcare system in India, while caring for a patient knows that change is the only way out. The present government has taken steps to prioritise health, an essential human right that previous governments had given up on, dreading that their interventions would make the mess messier and a preconceived notion that healthcare doesn’t translate into votes. Connecting the dots, it appears that the BJP government probably wants this 3.5 lakh strong community health cadre to man the 1.5 lakh health and wellness centres it promised in its election manifesto.
But any path the Modi 2.0 government takes from here-on will be riddled with challenges and decisions that affect life and death, and therefore the secrecy surrounding its plans is baffling. Only if they lay their cards on table before rolling out their action plan, can they reduce the chances of erring. After all, doctoring lives, not doctoring numbers is the end-goal.
Soma Das is a business journalist and the author of The Reluctant Billionaire.