Whatever the disagreements about the respective roles of the public and private sector in providing medical education, it is clear that the way the system works at present does not help address the health care needs of the majority of the people. This point is important: blaming individual doctors for not performing social service is pointless. The system hasdisincentives for participation in public health activity.
Qualified doctors don't want to work in rural
phcs
where they would also have to discharge non-medical functions. Then there is the problem of shortage of medicine and equipment, and other elements of infrastructure. There are rules about compulsory service in rural areas, though they differ from state to state. Medical students are supposed to sign a bond saying they will work in villages for a stipulated period. But in most cases, states are unable to provide jobs. Vacancies are often not filled because governments do not have the money to pay salaries. "There were quite a few of us who wanted to serve in the rural areas in Madhya Pradesh after graduating but the government freed us from the bond saying that they did not have any positions," says Jacob Puliyel, a paediatrician at St Stephen's Hospital, Delhi, who graduated from the Netaji Subash Chandra Bose Medical College, Jabalpur. Ajay Gambhir, honorary secretary,
ima, who studied at the Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, faced exactly the same problem. The national health policy also suggests that a two-year rural posting should be enforced before awarding the graduate degree, but the idea remains strictly on paper. "Before getting their degree in hand, doctors should be made to work for three years in rural areas, this way they will pay for their subsidised education. They should get a certificate from the community to show that they have really worked," Sathyamala says.
State governments, however, say they have tried to give incentives to doctors -- postings of choice and sponsorship for higher education after a period of service -- and disincentives including fines against bonds if rural service contracts are not honoured, salary docking and department action. None of these seem to have worked, however. As a result, private health professionals provide 80 per cent of health care in the country.
The increasing privatisation of medical services makes it even more difficult to force doctors to work in rural areas, because it is changing the expectations of returns. "Doctors are not willing to work in rural areas because infrastructure is not put in place. Even if the doctor has to work only for a year there, circumstances should be comfortable," says A K Agarwal, dean, Maulana Azad Medical College, Delhi. "All our
mbbs students prepare for admission to post-graduate studies and 30-40 per cent of these try to go to the
us." Very few try to enter government service at this juncture and even if they do clear the exam, which would send them to rural areas, no one goes, he adds. "These student use social capital, get trained on the poor and open businesses like medical tourism, which caters to people outside the country. People have the right to ask doctors what they are getting in return," says Abhay Bang, director of the Society for Education, Action and Research in Community Health, an
ngo based in Gadchiroli district of Maharashtra.
Providing basic facilities seems to be the obvious solution. But the Centre and state governments can't seem to do that because funding for health services is minimal -- 0.9 per cent of
gdp in 2005. Funds provided by agencies like the World Bank are also not directed at public health infrastructure. For example, in 1993, the World Bank and International Monetary Fund had suggested that structural changes should be made in the field of health and there was a need to be selective in the areas where funds are utilised. Public health was not prioritised and rural areas continued to suffer.
Preventive medicine has also been a major casualty. "Students go in for medical education with a dream of making money," says Bang. This causes a shift from public health to market-driven medicine. There is a skewed distribution of specialisations, with a shortage of trained public health professionals. Seventy per cent of the people in the country suffer from common diseases like diarrhoea and anaemia but doctors are trained in treating a small spectrum of diseases like cancer and heart diseases, he adds.
Public health is taught in medical colleges as part of the syllabus for
mbbs and postgraduate courses.
mbbs courses try to ensure that students get exposed to rural training during internship as part of the preventive and social medicine syllabus, but few people take this seriously. Later, those who do not get admission in other postgraduate courses usually opt for this specialisation.
Undergraduates who are trained in public health go to rural training centres affiliated to
phcs in relatively well-connected rural areas that are better equipped than the average
phc . As a result, they are not exposed to most rural real-life situations. Amit Sen Gupta of the Centre for Technology and Development says there is no shortage of doctors in the country, the problem is in how they are deployed. Doctors are trained to work in institutional settings -- with a certain kind of infrastructure and diagnostic facilities. These doctors are not able to deliver in rural areas. Training for rural areas is not taken seriously -- students take it as a picnic. They are not equipped to handle rural areas, especially because they don't have support systems. It is a waste of money training doctors for five years and sending them to rural areas, Sen Gupta says. Better-trained auxiliary nurses and midwives, and health workers would be a better option.
The government echoes this, saying the lack of public health professionals puts a burden on medical doctors, who are trained as clinical care providers (see box:
Only schemes). It has, therefore, decided to support the Public Health Foundation of India (
phfi) in collaboration with Harvard School of Public Health (
hsps). Prime minister Manmohan Singh and the Union health minister launched
phfi on March 28, 2006. "The Planning Commission has been asked to make an assessment of the scenario of human resources for health. This is important to address the wide inequalities in the provision of services within India. While states like Kerala, Tamil Nadu and Gujarat may have acceptable standards, there are several states ... which do not have even the minimum number of institutions to turn out support staff for health care. There are also serious lacunae in the capacity of the health sector to absorb and optimally utilise extra financial resources, " Singh said
. hsps has collaborated with the Indian government, the Bill and Melinda Gates Foundation and other public and private partners to form
phfi. Work will be initiated by 2008.
phfi aims to influence public health education, research, and policy. It will bolster existing schools of public health by creating a pool of permanent faculty and establishing an accreditation agency that will standardise public health education. The
us's Association of Schools of Public Health will offer assistance.
India currently produces some 375 students each year from its 95 schools of public health and institutions -- compared to the 10,000 needed annually. The foundation "seeks to bridge a very major gap in our health education by training professionals in disciplines that relate to health, such as economics, sociology, demography and environment -- in addition to management of diseases", Singh says. Business groups and individuals are joining hands with the government to set up public health schools. The first of these is likely to be set up in the national capital region. Harpal Singh, a member of the governing body of
phfi and chairman of Fortis Healthcare, says it will be set up with a corpus of over Rs 100 crore.
Deflected attention
Most countries, especially developing ones, are focussing their energies on issues of manpower and health care delivery in who's year dedicated to increasing health workforce. It's unfortunate that in India public debate has been embroiled in the reservation issue to the detriment of basic questions of public health. The authorities are stuck in the same morass.
With inputs from Megha Prakash
