Mandatory Rural Service - a Conundrum

A lot of furore has been created over the health ministry’s proposal to make a year’s rural service mandatory , post internship for the award of the MBBS degree. Understandably so , many might say – yet in spite of much introspection and soul searching , I have personally not been able to decide which way to put my weight . Claims on both sides have some iron clad points in favour of them. The solutions are not that simple , as the roots go deeper than most people realize , or if they do realize , then do not like to get their hands messy probing into such depth.
As a young medico , who has witnessed the struggles of the system , I still get more than the odd pang of guilt at the overwhelming shambles in which the health care setup of the country lies (yeah ! yeah ! Call me humbug !) . Lets examine in detail both sides of the coin and then attempt to offer possible solutions.

THE HEALTH SETUP & MAGNITUDE OF THE PROBLEM

At the outset let us examine the care setup in the country – to state that it is pitiful would an understatement. Why this should be so in spite of 60 years of democracy and , as we would be led to believe , a booming economy , is beyond the scope of this discussion. Dedicated volumes could be written on the same. Let it suffice for the moment that the population is bursting at the seams , basic sanitation is conspicuous by its absence , and the captains of the men of death – the likes of Messers Tuberculosis and Malaria are remarshalling their forces with hitherto unseen hostility. Add to it India’s overwhelming participation in the propagation of global pandemics like HIV and infectious hepatitis. There is a shocking absence of basic obstetric care with unacceptable rates of maternal and infant mortality even in the urban centers. The brunt of this is borne in the rural areas, from where, a sizeable number of figures do not even reach the health statistician’s desk.
The infrastructure in the primary health setup is grossly inadequate with the staff lacking proper training and experience. Feeding off this lack in trained health care personnel and the prevalent socio-cultural superstitions and taboos , quacks abound in multitudes and indulge in downright barbaric criminal practices. Back in undergraduate days , our professors would come up with tales witnessed by them in the rural setup such as administration of intravenous milk , use of sharpened metallic objects as abortifacients and so on. Is there anything to suggest that such practices are still not prevalent in today’s day and age.
It goes without saying that the 2 prime requirements of the rural health setup are trained personnel and optimal infrastructure. A trained medical officer is the natural leader of such a system. Presently the number of doctors in the primary health system are markedly deficient and hence the attempted move to make rural service compulsory for all doctors. It is logical that the fresh crop of doctors should be the ones to attempt to bridge the gulf between the rural and urban health setup. Ideally they would be the ones to initiate some kind of scientific and ethical protocol to combat the terrifying practices that are prevalent. At the very least , sanitary conduct of labour , recognition and management of major emergencies, basic environmental hygiene , family planning , reproductive and child health should form part of the charter of responsibilities of the medical officer.

So as myopic as ever , we pass the legislation to make a year’s rural service mandatory and then sit back and give ourselves a congratulatory pat. Before even starting with the case of the doctors , the move will not achieve anything significant simply because of the sheer lack of infrastructure. Our rural centres lack basic amenities such as oxygen cylinders, emergency drugs like adrenaline and atropine , iv fluids and ambulance facilities for urgent referral to higher centres….the list is simply endless. You put 5 doctors per PHC and they will not be able to make any difference with the existing infrastructure.


DOCTORS – FORCED HUMANITARIANS ?

Let us now consider the case of the students and the young doctors. The problem is quite simple here – as the present scenario stands , the best a medico can do post schooling is 5 ½ yrs for MBBS plus 3 yrs of PG , equaling a minimum of 9 years till the completion of post graduation, which in today’s setup is absolutely imperative for any decent employment with some sort of permanence. However , even this arithmetic is for the select few , what with many colleges and universities still exceeding the basic 5 ½ year stipulated period for the completion of the MBBS curriculum. As for PG, it is either the exceptionally brilliant ,or the monetarily privileged who are able to secure a seat in the first attempt , with most students requiring at least 2 attempts and many going on to 3 or more.
So you have a young doctor , typically from a middle class Indian family , nearly 30 till he/she is sufficiently able to sustain himself independently. Just imagine – nigh on 10 to 12 years of dependence on the family post schooling. Most of us would cringe at the thought of the same , especially with the booming corporate and IT sectors which provide lucrative incomes at much younger ages. For all that has been written about the BPO industry, the fact remains that it offers quick money, easily the biggest drawing card for the modern youth. Already school going children are shying away from pursuing medicine as a career. The reasons for the same are the ones I have just named – too long a time to get settled coupled with inadequate financial remuneration. If such a thing did exist upon a time , the so called nobility of the profession and work for a ‘social cause’ is perhaps the last thing the macroscopic majority of students look for in a prospective career. I am not trying to be judgmental here as everyone is completely free to choose a career as per their priorities in life. However the fact remains that there is a steady decline in the quality of the students entering medicine , ironically the one branch where basic intelligence and quality should not be compromised.
In the midst of all this , the mandatory clause for rural service has implications deeper than simply 365 days of physical service. The frenetic pace at which medical science moves has given a new dimension to the age old method of studying . The internet now forms an integral part of the same along with the revered monstrous textbooks. With the ever increasing trend of postgraduate medical exams being centered around molecular biology , genetics and receptor mechanisms coupled with numerous online coaching services and preparatory exams – the one year hiatus would just widen the gulf in front of the student to secure that elusive PG seat. In addition it would spell the virtual death knell for the sizeable amount that have their eyes fixed on foreign universities for their post graduation. Sitting in a primary health care centre in some far flung corner of the country is hardly the ideal way to prepare for USMLE.

SOLUTIONS ???

Well , I have no idea whatsoever else perhaps I would never be asking so many questions. As I have mentioned earlier , the roots are much deeper than we care to admit , and embedded firmly in the age old socio-cultural norms that shall forever prove the nemesis of the country. Merely posting a large number of doctors to rural centres is hardly the answer to cope with the health care problem of a country with a sixth of the world’s total population , and yet spending less than 3% of its GDP on health services. It is only an ad hoc measure akin to reservations for the backward classes. The basic issues of education of the masses , population control , environmental sanitation are the ones to be tackled , and unfortunately the government happily chooses to play the ostrich when confronted by these issues , by burying its head in the ground.
On a different level, perhaps we might look to revamp the entire system of medical education in India , amalgamating post graduate and undergraduate training, similar to the system followed in the US.
It is tempting to say that doctors should be paid better for their government services but as ever this idea is laughable. The salaries proffered by the government health services are a poor joke when compared to the dividends reaped in the private sector.
Can we perhaps privatize the health sector in some manner , if not anything else , at least operationally while the policy making can still be done at the government level. There would be many hindrances here which I’m not aware of and will require the likes of my economist friend Shyam to enlighten us. The one thing I am sure of is that though the cost it will incur would not be acceptable to the powers that be, it will at the very least ensure better cost-effectiveness and cost benefit.

For the moment I end here . Further ideas might be forthcoming on hearing views to the questions I have put forth.