India as a developing country is now well poised to become a developed country in a very near future. It is at present said to be the youngest country with the largest number of young citizens. It is not necessary to emphasize that these young people are the future of the country. Apart from that, almost 35% of India's population is not 'young', so to say. It can also safely be argued that the future of our country India rests on this 'young' populace.
However, the point of concern is the status of health of the general populace including these 'young' people is not very promising. As per modern parameters like the IMR, MMR, U5MR, immunization against diseases, nutrition level etc. etc, India's position is abysmally low. The HDI (Human Development Index) rank is 136 out of 187 countries (UNDP); out of 194 countries, India ranks 145 for Infant Mortality Rate (IMR) and Under-five Mortality Rate (U5MR), 122 for Maternal Mortality Ratio (MMR), 162 for Immunization coverage against Measles among one-year olds.
Not only that, unless hectic efforts are taken, India is likely to miss the MDG (Millennium Development Goal) target of 2015. At the current rate, the statistics shows that as against the MDG target of IMR, U5MR, MMR, and immunization against measles of 28, 42, 109, and 100%, the achievements were 42, 52, 178 in 2012 and 74% in 2009 respectively. Yes, as far as immunization against Polio is concerned, India has been declared 'Polio Free' by WHO (World Health Organization), thanks to the concerted efforts of our governments.
Besides these, there are increasing cases of micro-nutrient deficiencies causing increase in anaemic patients; undernourishment of children causing stunted growth and undergrowth; and also over-nourishment leading to increase in cases of NCDs (Non-Communicable Diseases). Increase in cases of communicable and infectious diseases is already a cause of serious concern in India.
THE GOVERNMENT AND ITS PROGRAMS:
Against this backdrop are the institutions, programs, and policies of the Government and its relevant machineries that are continuously geared to fight these alarming situation.
According to a database, India has the highest number of medical colleges in the world, and she produces 30,000 doctors, 18,000 specialists, 30,000 AYUSH graduates, 54,000 nurses, 15,000 ANMs and 36,000 pharmacists annually. The number of allopathic doctors registered with the MCI (Medical Council of India) has increased progressively since 1974, to 6.12 lakhs in 2011-which yields an adjusted ratio of one doctor for 1,953 persons.
As per rural health statistics 2012, there were 1,48,366 sub-centres, 24,049 PHCs (Public Health Centres) and 4,833 CHCs (Community Health Centres) functioning in the country, the UIP (Universal Immunization Programme), apart from public hospitals spread across the length and breadth of the country.
WHERE IS THE PROBLEM, THEN?
From the arguments and counter-arguments of various professionals and academicians, the following factors seem to emerge:
(I) The greatest problem is the scarcity of trained physicians, pharmacists, laboratory technicians, specialists, and supporting staff at the CHCs, PHCs and sub-centres in rural India. According to one estimate, the shortage is to the tune of 10% for doctors at PHCs, 18% for pharmacists at PHCs and CHCs, 43% for laboratory technicians at PHCs and CHCs, 23% for nursing staff at PHCs and CHCs, and a whopping 70% for specialists at CHCs. Forget about sub-centres, doctors are not available even in CHCs.
(ii) There is only one doctor per 1,700 citizens in India; the World Health Organisation (WHO) stipulates (lays down) a minimum ratio of 1:1,000. As per the government claim, with about 6-6.5 lakh doctors available, there is an urgent need to produce about four lakh more by 2020-50,000 for PHCs; 0.8 lakh for community health centres (CHC); 1.1 lakh for 5,642 sub-centres and another 0.5 lakh for medical college hospitals.
(iii) According to the Health and Family Welfare Department, more than 20 per cent of the posts of specialists and assistant surgeons in the peripheral hospitals from the PHCs, CHCs to the DHH level are lying vacant. Of the total 4,362 posts in the peripheral cadre for the primary and secondary level healthcare institutions, as many as 1,090 are vacant.
(iv) Another crucial problem is the RELUCTANCE on the part of young, junior as well as post graduating doctors to spend even 1 year in rural areas.
THE REAL CRISIS:
Do all these mean that the problem can be sorted out by increasing the number of medical colleges as well as number of seats in each medical college? I think, the answer is in the negative. Yes, one can say that by doing this the number of doctors may increase in future. However, if they remain unwilling to be posted for the compulsory 1 year period in rural areas, the demand of doctors in sub-centres, PHCs, CHCs is NOT going to be met, and with it the grim situation of the health of the country is not going to improve. In other words, the real issue is NOT the dearth of doctors, but their unwillingness to work in rural areas. ARE YOUNG DOCTORS REALLY TO BE BLAMED?
THE CASE 'FOR' DOCTORS:
Among the various allegations and counter-allegations, the following arguments for the doctors are worth considering:
(I) With a limited number of seats in Government Medical Colleges, the cost of studying for a medical degree is anywhere between 10 lakhs to 60-70 lakhs, apart from a minimum period of 7 years of study. Most of this is generally funded through Banks and other such agencies. Naturally, the graduating doctors are more concerned with the repayment of the loans. Spending 1 more year after studies without being able to repay the loan is just unacceptable for them.
(ii) The condition prevailing at the CHCs, PHCs, and sub-centres - such as the infrastructure facilities, availability of instruments, drugs and medicines, electricity etc. - is very poor.
(iii) Most of the graduating doctors are not used to living conditions prevalent in rural areas.
(iv) It is unjust to ask from a specialist doctor to act as a general physician. So, doctors studying for Masters degree find it below their dignity to work in rural areas as general physicians.
(v) The education syllabus itself is skewed without any specific rural health training. More troublingly, the entire system is focused only on curing problems. There is no attempt to provide comprehensive health care and little training on how to prevent diseases, promote health or rehabilitate patients.
(vi) The graduating doctors are quite unacquainted with the indigenous, cheap medicines available in rural areas. Also, they don't know the system that is working in rural healthcare networks - whom to contact for complaints and rectification, supply mechanisms in place in rural areas etc.
THE CASE 'AGAINST' DOCTORS:
Let us now turn our focus on the arguments that goes against them. these can be summed up as follows:
(I) Although infrastructure is weak in India, it is ludicrous to think that all the medical cases in rural areas need 'ultra-modern' facilities. It is a fact that most of the fatalitites occur in rural areas due to diarrhea and malnutrition. Apart from these, there are cases of colds and coughs, back and body aches, sprains, wounds and cuts. These, it is quite known, do not require any 'fancy' equipment to diagnose and treat. Of course, there will also be cases of delivering babies or doing a few appendix operations. Those require advanced equipment. But 80 percent of the ailments can be taken care of in the villages itself.
(ii) Augustine Veliath, a health communication specialist formerly with UNICEF in India, says, "These students take subsidized education from government colleges, and at the first instance, they jump to greener pastures abroad. Nobody's telling them not to go. All the government is saying is: give something back to society. To the poor of this nation. Sure, it'll be tough. But they're young. And this is an adventure. I'm surprised these young people can't see that."
(iii) Social service, ethics for doctors etc should not be sacrificed for the sake of personal benefits only. There are cases where some doctors have thought the solution out. A case in point is that of Chhattisgarh. Dr Binayak who studied at the Christian Medical College in Vellore, Tamil Nadualong with his academic wife Ilina Sen helped 10,000 workers pool their earnings to build Shaheed Hospital in Chhattisgarh, which is still running today. The couple also taught Adivasis paramedical skills - those Adivasis now run their own health centre. Can the young doctors not take lessons from such doctors?
THE WAY OUT:
Given the strength of 'for' and 'against' arguments, the following list of suggestions may work:
(I) Instead of asking the young professionals to stay for 1 complete year at a stretch at these 'backward' centres, it may sound quite acceptable that they be asked to stay there for 3-months every year stretched for 4 years, thereby making the stint equal to 12 months. This would considerably reduce the scarcity of doctors at these health centres.
(ii) Some Medical Colleges may be established in rural areas, and specifically reserved to produce doctors for serving in sub-urbs and villages only. Admission to these colleges must mean this. Also, a majority of students admitted to these colleges must come from rural backgrounds.
(iii) The government must ensure at least some basic facilities to help these young professionals adapt to the living conditions in rural areas.
(iv) There must be a time-bound effort to improve the infrastructure to the level that is a must in rural areas. Government spending must increase considerably in the health sector.
Let's hope the good intentions prevail in the end, both on the part of the government and the graduating doctors.
Author of 'Blow The Final Hammer At Your Interview' at http://www.amazon.com I may be contacted at avp221002@yahoo.co.in
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