Thursday, December 27, 2007

Ramadoss v. Striking Medicos: Is the Opposition to Compulsory Rural Service Justified?

The Union Health Ministry’s push to implement a mandatory year of rural service for medical students ready to graduate set off a firestorm of protests and criticism. The protests, though strongly felt in Tamil Nadu and Maharashtra, echoed more general resentment of the idea. Anuradha Raman writing in Outlook said:

“The 70 per cent rural population has only primary healthcare centres to turn to which, more often than not, do not even have a medical officer. It would appear there are no doctors to fill up the vacancies. In 2005-06, nearly 51 per cent of posts of surgeons, obstetricians, gynecologists, pediatricians and physicians were lying vacant. Records show that of the 6,83,682 registered allopathic doctors in the country, only one in 10 doctors works in a rural area. In light of all this neglect, isn't Ramadoss justified in his rural plans for the students? Opinion is sharply divided…”

That the measure will address this shortage has not been seriously disputed even by critics. Most of the counter-arguments put forth relate to quality. She quotes a Tamil Nadu representative to the MCI saying that the students aren't trained to serve in villages. This is another way of saying that these physicians are not fit to function independently. That being the case, they are as likely to perpetrate harm working on their own in the private sector (which, by the way, they are perfectly allowed to do being legally licensed to practice by the State Medical Council) as they are serving in a public facility. If such a serious infirmity has been detected, the question is, service or no service, why they ought to be allowed to graduate at all. He continued: “Rural health can't be treated in such a casual manner, especially when all the attention and money goes to providing the best healthcare for urban India. Relying on students to provide healthcare amounts to giving second-class treatment to rural India.” Quoting a professor of Medicine at Wardha, she added:

““There is no doubt that the imbalance of doctors in rural and urban areas needs correction. But most rural facilities in India continue to lack enough providers, equipment and infrastructure to offer effective and efficient care.” With experience in a rural medical school and hospital at Sevagram, he feels that rural and socially disadvantaged people tend to have far more serious and complex medical problems which needs more knowledge, expertise and experience. "To offer cost-effective medical care to the rural and poor people isn't's certainly beyond the capacity of young, unsupervised doctors," he says.” It is agreed that better equipment, infrastructure and experienced physicians will indisputably provide ‘first-class’/’serious’ healthcare. But the more relevant choice before us is whether sending physicians to work in the system as it exists to provide even ‘second class’/’casual’ healthcare is better than no care at all. Any reasonable observer would say that it is. All of these tangential arguments amount to little more than an unsubtle effort to camouflage their own support for the students’ self-serving stance in politically correct terms more likely to garner public sympathy. Other reasons for opposition, though raising questions of equitable treatment and a culture that allots primacy to self-interest, giveaway this fact. Asks Professor Kalantri in an article:

“Why are medical students expected to make greater sacrifices than other professionals? ….Can we really expect students who have made what is essentially an investment to forget about money and think of their professional ethics and social obligations? After all, if students pay a fortune for their education they are going to be interested in recouping that investment at the earliest. By encouraging private medical colleges the government is sending the signal that medical practice is for personal profit. Is it realistic to demand social commitment from young doctors when nothing else in the system encourages them to think and act along these lines? Are they wrong if they think solely of their careers and turn a blind eye to the problems of a rural population with no access to healthcare?”

That being said, why is the medical student community so disturbed by this suggestion? A variety of reasons may be attributed. (1) Salaries for fresh MBBS graduates vary widely across the country with hospitals in those parts of India having fewer medical colleges generally paying better. The amount of Rs. 10,000 / month reportedly being considered by the government may therefore not be appealing to everyone. (2) These are dead-end jobs (i.e. with no option to advance in that position) that offer only limited additional training, i.e., owing to the paucity of supervision and/or infrastructure, the physician himself/herself is unlikely to learn much in the form of new techniques or skills that would be useful in other better equipped settings. (3) A large number of graduates hope to go on to obtain a post-graduate degree either in India or abroad. Most of these positions can be availed of only upon passing entrance examinations that are extremely competitive and require extensive preparation. Rural service, being outside of an academic setting, is of little value – indeed, many such exams in India have traditionally tested more one’s ability to recall a voluminous collection of arcane facts rather than analytical skills more pertinent to clinical problem-solving, an approach that reduces the imminent value of practical expertise gained in any setting. From this standpoint, rural service or in fact, practice of any kind, is essentially a distraction. (4) A small but significant number usually come from families whose parents own or are part of established healthcare institutions. Such students are sometimes anxious to return home to work at such places as soon as possible and perceive no advantage in a rural digression. (5) The general lack of amenities of urban life and relative isolation add to its unattractiveness. (6) An already extended period of study and training further lengthened by a year causes some degree of envy especially in comparison to an engineer who is able to get a relatively high-paying job after only four years of education.

What then is the principal inference from the above paragraph? Medical students, around the time of graduation, are most concerned about charting their future. A majority do not see themselves working in rural areas in the long term and consider the idea a diversion from their main goal of securing their professional careers.

The Health Minister has so far stood his ground though the proposal has not yet been finalized. The students have not relented either and several political parties in Tamil Nadu have apparently extended their support to them (including the DMK and surprisingly, the CPI). Now that the storm has been weathered, it remains to be seen whether the proposal, in its current or a modified form, will return once more to the limelight in the months to come.

Can this proposal be made more palatable? Several developing countries in the past have tried compulsory posting of physicians to address rural shortages. Malaysia is a good example where a three-year period of government service is mandatory to be licensed to practice with certain options for deferral, reduction or exemption of the same. A similar system may be tried in India with a mandatory year of rural service to be completed at some point before being licensed to practice. If one wishes to proceed further to acquire a post-graduate qualification before serving, he/she may be allowed to do so. Exemptions may also be granted to those specializing in areas where academic or other major urban centers too are facing a shortage. The downside of this option is that there would be a significant element of attrition with some graduates choosing to stay abroad or giving up practice altogether thus reducing the extent of coverage. Yet, the trade-off may be well-worth it if the greater flexibility allows physicians, having completed their education, to feel relatively more secure in their careers and thereby leads to higher motivation and a stronger commitment to service.

1 comment:

புருனோ Bruno said...

If you are still interested in knowing why students oppose this, drop a note at and I will explain in detail.