Eleventh Plan and health care

Eleventh Five-Year Plan: There is a shortage of 5,801 doctors in PHCs and a shortfall of 4,681 specialists in Community Health Centres (CHCs).

Rashtriya Swasthya Bima Yojana: I have serious doubts about the benefits that will actually accrue to the rural poor from health insurance and the option to go to private hospitals.

The Eleventh Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome, bemoans the Plan document.

The role of health care in economic development has received increasing attention in recent years. There is a general agreement that economic growth is not merely a function of incremental capital-output ratio. Investment in man -- enhanced allocation for education, imparting skills and health care -- plays a significant role in fostering economic growth. It is, therefore, in the fitness of things that the Eleventh Five-Year Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The Plan document presents a well-conceived, comprehensive programme for the sector. According to the Prime Minister, the aim is to provide broad-based health care in rural areas through the National Rural Health Mission (NRHM).

Health care in a shambles

While the proposed structure for providing health care is adequate and commendable, what is in place at present is thoroughly disappointing. The Plan document itself bemoans: “The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome.” (The Eleventh Plan: Vol. II, page 61, para 3.1.16.) The Plan deplores the critical shortage of health personnel, particularly doctors and nurses, poor working conditions and inadequate incentives, and the low utilisation of the meagre facilities in government hospitals. Government hospitals at all levels present a picture of neglect and decline.

I shall deal with two major problems: shortage of doctors for rural service; and the desperate state of medical education.

Health care after independence

Before independence, medical facilities in rural India were rudimentary. The Community Development Block pattern of rural development launched in the 1950s was the harbinger of modern health care in rural areas. According to the approved model, every block was to have a Primary Health Centre (PHC) with 10 beds at the block headquarters and three sub-centres at carefully selected locations. The sanctioned staff for a PHC consisted of two doctors, one Lady Health Visitor and two Sanitary Inspectors. One post of Auxiliary Health Worker and two posts of Auxiliary Nurse-Midwives were sanctioned for each sub-centre. A doctor was required to visit each sub-centre twice a week. I was the Collector of Darbhanga in north Bihar from mid-1958 to the end of 1960. During my tenure, out of the 44 blocks sanctioned for the district, only 37 had become operational. Some 25 blocks had one doctor each and the rest none. Most posts of Lady Health Visitors and Auxiliary Nurse Midwives were vacant.

As chance would have it, I became Bihar’s Health Secretary in July 1962 and stayed on in the post for nearly five years. The total number of blocks in Bihar was about 600. In spite of my best efforts, very few blocks had the full complement of doctors and paramedical staff. During the severe drought of 1965-66, it was only by resorting to draconian measures that we could ensure that all blocks had at least one doctor. Most doctors had an urban background and were reluctant to go to rural areas lacking in modern amenities. There has been no significant improvement in the situation during the last four decades. According to the data given in the Eleventh Plan, there is a shortage of 5,801 doctors in PHCs and a shortfall of 4,681 specialists in Community Health Centres (CHCs).

The Eleventh Plan presents a well thought-out and comprehensive structure for health care in rural areas. The important features of the set-up are:

— 1.75 lakh sub-centres each with two Auxiliary Nurse Midwives at one sub-centre for each panchayat (five or six villages).

— 30,000 PHCs at one for a group of four or five sub-centres. Each PHC will have one Lady Health Visitor and three staff nurses. There will also be an AYUSH physician. (AYUSH is acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy).

— 6500 CHCs each with 30-50 beds. The staff will include seven specialists and nine staff nurses.

— 1800 taluk or sub-divisional hospitals and 600 district hospitals will be fully equipped to provide quality health service.

When this structure is in position, and if it functions reasonably well, we can expect a significant improvement in the quality of medical care in rural India. There will, of course, be an enormous increase in the number of medical graduates, postgraduates and nurses needed to operate the system. The baffling question is how to find the number of personnel needed to fill the vacancies and new posts.

It should be possible to recruit adequate number of doctors and persuade them to stay in the field if the three suggestions given below are adopted and strictly enforced.

— After internship, every medical graduate should be required to work for a minimum of two years in rural areas before he is granted the MBBS degree.

— Only those who have completed three years of rural service should be admitted to any postgraduate course, including the Diplomate of the National Board.

— Every postgraduate student should serve for one year as a specialist in a CHC or sub-divisional hospital before he is awarded the degree or a diploma.

These proposals are not entirely new. Assam has already made rural service compulsory for medical graduates. Some medical colleges have been encouraging fresh graduates to opt for rural service for short periods. The implementation of the proposals, of course, calls for resolute political will. The rationale for making these seemingly harsh suggestions is this. Despite the recent increase in fee, medical education is heavily subsidised by the state. It is manifestly just and fair to stipulate that those who receive medical education should serve the rural society for a short period. Incidentally, the young graduates will benefit a great deal by getting an opportunity to improve their clinical skill. There should, of course, be substantial improvement in the salary of doctors and the amenities available to them.

Shameful state

The proliferation of sub-standard, under-staffed and ill-equipped private medical colleges in recent years is an unmitigated menace. A few institutions like the CMC, Vellore; St. John’s, Bangalore; and the Kasturba Medical College, Manipal, are among the country’s best. But many private colleges lack basic facilities and are run as profit centres for garnering huge amounts as capitation fee. I hear that the present capitation fee for an MBBS seat is Rs. 35 lakh-50 lakh and for a postgraduate seat above Rs.60 lakh. For a discipline like Radiology, the amount could exceed Rs. 1 crore!

Some 15 years ago, a relative of mine had to pay only Rs. 2 lakh through a bank draft and Rs. 2 lakh in cash to get his son admitted to a postgraduate course. The Indian Medical Council has laid down arduous norms in respect of faculty, hospital beds, equipment and so on. Apparently, there is some laxity in the enforcement of the norms. I have heard that while a well-equipped college may run into difficulties, substandard institutions manage to pass muster. I have also heard of cases in which retired teachers and other doctors with postgraduate qualification are shown as visiting faculty for short periods during an inspection by Medical Council teams. No civilised country, not even a soft state like India, can allow such a scandalous state of affairs to continue. It is time the government took resolute action to stem the rot.

Some reservations

The Prime Minister in the Foreword and the Deputy Chairman of the Planning Commission in the Preface have highlighted the positive role the Rashtriya Swasthya Bima Yojana will play in providing health care to the population below the poverty line. I have serious doubts about the benefits that will actually accrue to the rural poor from health insurance and the option to go to private hospitals. As I have not personally observed the working of the scheme, I would leave it to experts familiar with field conditions to evaluate the Yojana.

Another controversial matter is Public Private Partnership (PPP) in providing health care. I do not share the optimism expressed in the Plan document about the role of private institutions in providing health care in rural India. Nor do I agree with the Commission’s enthusiasm about the role of corporate health care and the benefits flowing from the expansion of medical tourism. These issues deserve to be dealt with by more knowledgeable persons.

I shall conclude reiterating that health care in rural India and school education throughout the country should squarely be the concern of the government. Private initiative can certainly supplement the government’s efforts in these fields, but that will benefit only the affluent.

(P.S. Appu is a former Chief Secretary of Bihar and former Director of the Lal Bahadur Shastri National Academy of Administration, Mussoorie. He can be reached at: psappu@hotmail.com)

The Hindu, 23 Nov. 2009