|
Challenges
of upgrading rural health services
The
problem of lack of doctors in rural areas is not specific
to India. It is a "syndrome" prevailing worldwide. While countries
like US and UK have been fairly successful in handling their
situations, it is time India finds a way out of this conundrum
says Soumya Viswanathan.
The
Govt of Maharashtra in the year 2000-2001 tried mobilising
MBBS doctors to villages as a pre-requisite to post graduation
but "It did not work," says G S Gill, secretary,
medical education and drugs development, Govt of Maharashtra.
"The idea was good but the students did not take it seriously.
They just went for attendance."
The compulsory rural posting has been kept in abeyance because
the posts are full. "But we may start it again in case
there is a need," adds Gill. Such initiatives fail because
they are not monitored and reviewed on a continuous basis
says Gill.
Some government officials feel that when 80 per cent of the
diseases in rural areas are specific to particular areas,
why should the government waste the resources and the money
invested in doctors to treat diseases like scabies. Even though
this thought may be echoed by several others, efforts towards
training village health workers, on the lines of China’s
barefoot doctors, by state governments have failed.
In Maharashtra, the community health volunteer scheme started
in 1978 was a failure because of improper training. Madhya
Pradesh tried to train class ten qualified as health workers
as against class four trained by Maharashtra, but did not
work as the workers started misusing their training. Dr Anant
Phadke of Centre For Enquiry into Health and Allied Themes
(Cehat) believes that NGOs have been doing a better work in
this regard. "We have trained local health workers successfully.
The training should be handed over to NGOs," he says.
While barefoot doctors have become popular in some parts of
the world, developed countries like US and UK have special
programmes for doctors to practice in villages.
Missouri-Columbia University in USA has a ‘rural scholars
program for physicians from rural areas’ because it believes
these physicians are the ones most likely to go back and live
there. Incidentally, policy makers in India are also attempting
to mobilise doctors to villages by giving seats to rural students,
since rural posting has not really set a success story. Maharashtra
government this year has introduced reservations for students
from difficult areas (hilly, tribal areas) hoping that they
would go back to practice in their area.
Meanwhile Chattisgarh government is said to be considering
a 3-year course in medicine for students from rural areas.
Gill seconds Chattisgarh govt’s stand and wants to implement
in Maharashtra too in case Chattisgarh gets a "go ahead"
from MCI. Says Dr Sachdeva of MCI, "No proposal has come
to me but MCI did react negatively to this news they heard
from sources. MCI is not in favour of any short term courses."
While 3-year course does sound like a fair chance to a person
from a difficult area to study and go back, experts are of
the opinion that these people would not go back. Dr S M Sapatnekar,
administrator, MMC, gives the Maharashtra example where it
was tried it in 1979 but flopped. "It had to stop in
2 years." A three-and-a-half year diploma course started
in Calcutta in 2000 drew widespread criticism from doctors
and Indian Medical Association (IMA) which claimed that the
endeavour is "illegal" as it does not have the approval
of the Medical Council of India (MCI).
But even otherwise practicing in rural areas is not easy.
Not because of lack of amenities but because rural medicine
is a different ball game altogether. Says Dr Govind Hoskeri,
associate professor, dept of anatomy, KEM Hospital, Mumbai,
who initially practised in a small town in Karnataka, "I
had to wait for six months to actually see a case other than
cough and cold. In MBBS, doctors are taught so much about
syndromes, which they may not see in their lifetime. The teaching
is post-graduate oriented. It is everything other than what
is required as far as rural medicine is concerned." Gill
says reserving a few seats in MBBS for those inclined towards
community and public health and imparting community health
skills would be a good move.
Recent work by an Institute in UK has indeed demonstrated
that rural GPs need to possess a broader range of clinical
skills and knowledge than their urban colleagues. In addition
to these procedural skills, rural GPs increasingly have to
develop expertise in the fields of public health, commissioning,
management, and the critical evaluation of research based
data.
As for the existing mandate of compulsory rural posting as
per National Health Policy 2002, experts feel it can work
provided government is serious. Dr Sapatnekar suggests, "Why
make it compulsory, make it attractive so that students can
pounce on it. When the carrot of PG is hanging in front of
him, why would he mind?"
"Bond
for rural practice is a matter of strategy. We must have a
rural services commission, which will adopt models as per
the state requirement. If one state does not succeed in implementing
rural posting, it does not hold true for all the others. It
depends on how they implement the various policy decisions,"
adds Dr Sapatnekar.
For the Indian situation, Dr Hoskeri suggests having small
medical colleges in the villages where doctors practicing
in that area could teach rural medicine along with the regular
teaching schedule rather than reserving seats or having 3-year
courses.
In case of Missouri-Columbia, the logistics are complex. After
first year of medical school, the rural scholars enter small-town
practices for eight weeks, where they see and ’do’
medicine within a community. Finally, third-year students
spend up to nine months in clinics and classrooms in a mid-size
Missouri town, where state-of-the-art telecommunications link
them to faculty members, databases and more. Is something
like that possible here?
|
