February 15, 2010

by Praful Bidwai

The argument that any compression of the five-and-a-half years of education based on the allopathic medical system by 18 months would produce poor-quality doctors of no use to the rural population is unconvincing. A majority of rural people, totalling 450 million, have no basic healthcare facility in their neighbourhood. As many as 700 million Indians have no access to treatment of a health problem which has been diagnosed as needing further attention.

Having access to even a “barefoot doctor” who knows his/her basic science and can handle common illnesses is of great value to the villager. Indeed, it can greatly reduce the unacceptably—and shamefully—high number, one million, who are estimated to die every year because of poor healthcare access. “Barefoot doctors” achieved a lot in China in the 1950s and 1960s.

India, with a population of 1.1 billion, has only 750,000 registered doctors. The US, with 300 million people, has 780,000. And the US has one of the developed world’s worst, most unequal and expensive health systems. The number of hospital beds in India per 10,000 people is only 7, as against the global average of 40. Most deplorably, the average US citizen is looked after by more Indian doctors than is the average resident Indian!

The case for raising more doctors, nurses and other auxiliary medical staff is unassailable. A person who undergoes three-and-a-half years of education and another six months’ internship is more than a “barefoot doctor”. Unlike Ayurvedic, Unani or homoeopathic doctors, who routinely practise and prescribe restricted allopathic medicines, s/he will have a pretty solid foundation in the medical sciences, including anatomy, physiology, and preventive and social medicine.

S/he would also be acquainted with the principles of various disciplines including immunology, epidemiology, pathology, radiology and pharmacology and can work in national programmes dedicated to diseases like tuberculosis and malaria. S/he wouldn’t have the proficiency of a fully trained MBBS. But s/he would be able to do 70 to 80 percent of the latter’s work, including the most important functions of Primary Health Centres (PHCs).

The PHCs are the critical, and yet the most poorly-performing, part of the Indian healthcare system. Reviving and strengthening them will save lakhs of lives and greatly reduce suffering. The proposed Bachelor of Rural Medicine and Surgery (BRMS) programme can make a huge difference to the PHCs—not least because MBBS degree-holders are loath to work in villages.

Efforts to persuade them to do so have all failed. Over the past decade, more than 100 new medical colleges have been opened in India. But this hasn’t increased the number of doctors working in villages. A proposal of the early 1990s to make rural service compulsory for medical students for two years was also shot down as “impractical” and “discriminatory”—loaded terms which cover up the narrow interest of a small, avaricious group responsible for denying healthcare to the public.

Let’s face the truth. India’s healthcare system is a scandal. It’s so expensive that only those who buy insurance can afford health services—if that. They aren’t even 5 percent of the population. The rest have to make do with quacks or a creaking funds-starved public healthcare system, in which only a couple of programmes like child immunisation work—and not satisfactorily. India’s public expenditure on health has stagnated at 0.9 percent of GDP, the same as in some of the poorest and war-ravaged countries such as Afghanistan, Rwanda, Ethiopia or Congo.

A majority of India’s 23,000-odd PHCs are understaffed to the extent of 70 percent-cent (doctors) and 50 percent-plus (lab technicians and male health workers) and lack much of the equipment and medicines they are supposed to have, including beds, X-ray machines, oxygen cylinders, and childbirth facilities. Less than a fifth have filled a majority of their sanctioned strength, including a certain number of MBBS doctors, auxiliary nurses-cum-midwives, etc. Staff absenteeism is rampant. In most PHCs, not even one of the many essential drugs they’re supposed to stock is available throughout the year. PHCs are responsible for treating only 5 percent of the diseases of rural people.

Thus, the backbone of the Indian healthcare system—which could achieve much through preventive medicine and treatment of common diseases, besides spreading awareness about the non-medical aspects of health, including nutrition, sanitation, and safe drinking water—has broken down. The picture is dismal in scores of secondary and tertiary hospitals too.

Most of these are run on paltry and shrinking budgets, and are overcrowded and patient-unfriendly. They are not demand-, but supply-driven, designed to suit the doctor’s routine, not the patient’s convenience. For instance, out-patient hours are only in the morning. The patient loses the entire working day if s/he visits the OPD. Most obnoxiously, public hospitals no longer dispense subsidised medicines or surgical facilities even to the poorest. Most well-funded institutes like AIIMS charge lakhs of rupees for “packages” like heart bypass surgery.

This amounts to outright denial of treatment to the poor, who must bankrupt themselves on account of an illness in the family, to which they are considerably more prone than the upper one-tenth of the population. Solid empirical research, now cited by the Planning Commission, shows that ill-health is among the top three factors responsible for throwing the not-so-poor below the poverty line. A single illness like heart disease, not to speak of cancer, can wipe out all family assets, including subsistence-farming land.

The Indian medical profession, even more privatised and driven by the profit motive than in the West, is primarily to blame for this appalling state. Its greed ensures that the poor are systematically milked—all the way from excessive diagnostic tests, to expensive consultation, to costly after-care. Collusion between the referring general practitioner (GP) and the specialist/consultant is widespread.

A Mumbai-based pathologist friend tells me of a huge referral racket. The GP refers a patient to a pathologist for 16 parameters. In reality, s/he privately tells the pathologist that s/he is only interested in three parameters. The pathologist enters false computer-generated “standard” values for the remaining 13, but gets paid for all 16; he shares the loot with the referring doctor. Over-prescribing of diagnostic procedures and costly medicines is widespread, as is Caesarean-section delivery.

The lure of filthy lucre is drawing large numbers of doctors away from government-run medical institutions into private practice where they can earn 20 or even 50 times more. Mass desertions from public hospitals have deprived many of nearly one-third of their staff. The AIIMS exodus is the latest instance. The process is even more insidious at the district level. Doctors are among the most upwardly mobile of Indians and belong to the top 5 percent of the urban population.

We must stem the rot by urgently rebuilding our public health system. GDP growth will mean absolutely nothing unless it’s translated into general welfare in which health plays a central role. A scenario in which GDP grows by 8 percent, but one-third of the population lives in near-famine conditions with a body-mass index of less than 18.5 (the under-nourishment borderline, 25 indicating obesity), and cannot perform basic human functions is obscene and indefensible.

That’s exactly where India stands today. The scenario can only change if we establish real rights to food security and primary healthcare. This means bringing the state down to the people and making it accountable to the underprivileged.

The proposed BRMS would only make sense if the graduates it generates are integrated into a radically revamped infrastructure to which the right to healthcare is central. Or else, it will only cater to students from rural areas who prefer to work in cities or towns where they can make money by exploiting ordinary people. The government’s plan falls woefully short of such an ambitious effort, which is both necessary and desirable.

The privileged lobby of registered doctors, which has fattened itself on the backs of the poor in league with Big Pharma—the cabal which dominates the medicine production industry—is hell-bent on opposing the BRMS. This deadly cartel must be broken in the public interest. Big Pharma must be prevented from corrupting the medical profession through bribes, promotions and conference sponsorship. Doctors whom society subsidises generously must be made to repay their debt to the tax-payer. What we need is not some “public-private partnership” which further privatises healthcare delivery, but a national health service which makes access to healthcare free and universal—and helps dismantle the greatest scam in the public sphere in India.