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Medical degree in 3.5-yrs for rural doc : TOI

NEW DELHI: A medical degree in 3-1/2 years? This could soon be a reality with the health ministry and Medical Council of India (MCI) planning a shorter medical degree for rural students who would exclusively serve the rural populace.

The hinterland, where few doctors want to serve, could soon have a dedicated corps of medical practitioners drawn from among students raised in rural areas.

After incentives failed to lure doctors to practise in remote areas, the health ministry is finalising the novel scheme along with MCI to start 3-1/2 year degree courses in medicine and surgery in institutes set up in rural areas.

Under the scheme, the undergraduate `Bachelor of Rural Medicine and Surgery' (BRMS) degree would be acquired in two phases and at two different levels -- Community Health Facility (one-and-a-half year duration) and sub-divisional hospitals (secondary level hospitals) for a further duration of two years.

The BRMS degree would be offered by institutes in rural areas with an annual sanctioned strength of 50 students. "Selection of students would be based on merit in the 10+2 examination with physics, chemistry and biology as subjects. A student who has had his entire schooling in a rural area with a population not more than 10,000 would be eligible for selection, which would be done by professional bodies set up by the Directorate of Medical Education of the state governments," the scheme noted.

MCI president Dr Ketan Desai told TOI that the idea was to get students from rural areas who were willing to work in rural areas as doctors from outside didn't want to live and work in villages. Many do not even turn up for their assignment.

Many rounds of discussion on the scheme have taken place between the ministry officials and MCI representatives, the last one being on November 17 under the chairmanship of health minister Ghulam Nabi Azad. "At this meeting, many of the operational details were discussed and rough edges ironed out," Dr Desai said.

The ministry is backing the scheme as it is finding it increasingly difficult to get adequate number of doctors to serve in rural areas to fulfil the UPA government's commitments under National Rural Health Mission-2009.

To keep BRMS graduates in the loop, MCI is also proposing a parallel mechanism to register them by state medical councils and MCI. "Registration would be granted provisionally on an annual renewal basis and would only entitle the holders of such innovative medical qualification of 3-1/2 years to practise in a rural set-up in the same district," it said.

Dr Desai was confident that the scheme would take final shape by March after incorporating the suggestions received during a workshop scheduled for February 4-5, 2010, where deans of all 300 medical colleges, vice-chancellors of all medical universities and directors of education of all 29 states would participate.

All this would be conveyed to a Delhi High Court Bench comprising Chief Justice A P Shah and Justice S Muralidhar on January 6 by MCI counsel Pratibha Singh. The HC is hearing a PIL filed by Dr Meenakshi Gautam complaining that the ministry and MCI were not paying enough attention to improving the rural healthcare system.

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BRMS no substitute for doctors,feel expert :TOI

PUNE: Lack of doctors and proper health care in rural areas cannot be corrected by compromised health workers churned out by the proposed Bachelor of Rural Medicine and Surgery (BRMS) course feel experts, who add that such degree holders will in no way substitute MBBS doctors, thus denying the rural population a right to good health.

"On one hand the health care in metros and big cities is quite advanced. On the other, rural areas where 60 per cent of the Indian population resides does not even have basic health care (primary care). This gap, however, cannot be filled by compromised health workers in the name of BRMS. It is against the fundamental right of a citizen of India where every one should be provided with quality health care of similar standards at affordable cost," said S Arulrhaj, president of the Commonwealth Medical Association a conglomeration of national medical associations of commonwealth countries.

Ashok Adhav, national president of the Indian Medical Association, said, "Factors like paucity of doctors, low doctor-population ratio (1.62 per 10,000 only), absence of doctors, lack of infrastructure facilities contribute to the absence of proper health care in rural areas. But this situation cannot be corrected by compromised health workers in the name of BRMS. The IMA strongly opposes this proposal."

Former state president of the IMA Devendra Shirole said, "If the service of qualified doctors is denied to the rural population, early detection of complicated disease conditions and appropriate treatment will be hit."

Meanwhile, the 84th Central Council of the IMA said it is committed to the health of rural Indians and also unanimously and strongly objects to the proposal to introduce the BRMS course, which is a compromised MBBS course, to take care of the rural population of India. "As per article 14 of the Indian constitution, all citizens of India are equal, whether rural or urban. The IMA demands that rural Indians be offered the same standard of health care which is offered to urban Indians. We appeal to the Ministry of Health, Government of India, not to dilute the standards of health care for the rural people. The IMA is of the opinion that only an MBBS degree should be the basic allopathic medical qualification in the country," said Adhav.

Arulrhaj suggested, "At least 25 seats need to be reserved in district medical colleges for candidates who will have to work in rural areas of their choice for the first five years, with annual recertifications. After the five years, they would be free to pursue a post-graduation degree, since, by that time, a second lot of rural doctors' will come in."

Adequate allowances, facilities like rural service allowances, proper free accommodation, education allowances for children, vehicle or vehicle allowances, appropriate reservation for education and employment for children, updation of knowledge, facility for interest-free personal loans etc. should be extended to doctors working in rural areas. Implementation of the Bhore committee recommendations of three-tier system of health delivery should also be done, said Arulrhaj.

The wrong way for rural docs, Ambumani Ramdoss

The proposal to introduce a shortened medical course is a folly: it will aggravate the rural-urban divide and give a raw deal to villages.

The proposal put forward by the Central government to introduce a shortened medical course at the graduate level to serve the rural areas will only widen the rural-urban divide and impede India's role as an emerging global power. In seeking to virtually revive the Licentiate Medical Practitioners (LMP) scheme that was available before Independence, the government has taken a regressive step. And in the process it is resorting to discrimination against rural folk, who are taken for second-grade citizens deserving medical care by a brigade of ‘qualified quacks'.
The scheme involves a three-and-a-half year course that leads to a bachelor's degree in medicine and surgery. Doctors trained under this scheme will work in rural areas. They will be trained in district hospitals.
In the erstwhile LMP scheme, students were trained for around three years, awarded a diploma and asked to meet rural health care needs. It was considered a way to bridge the gap between demand and supply outside metropolitan India. The LMPs outnumbered the MBBS graduates and largely served in the rural areas. Following the Bhore Committee report of 1946, medical courses were unified into the standard five-and-a-half-year MBBS degree.
The issue is the impact of this scheme on the status of the rural Indian. In what way are rural Indians different from their urban counterparts? Do they deserve health care from medical personnel who are less qualified than those who attend to the health needs of their urban brothers? Are their well-being and lives less important than those in urban areas? This discrimination could sow the seeds of disunity and discrimination. The scheme is against the spirit of the Constitution and human rights.
The proposal is superfluous, too. Any State can introduce a short-term medical course. We do not need a centralised concept of rural service, governed by the likes of the Medical Council of India (MCI).
The need is to utilise existing personnel prudently. Today even medical colleges recognised by the MCI, numbering about 300, face faculty shortage. How is the government planning to equip the so-called rural-based institutions that will eventually churn out semi-qualified medical personnel, with faculty and infrastructure?
India has a wealth of alternative medical systems such as Ayurveda, Siddha, Unani, Homeopathy and so on, that brings in hundreds of thousands of qualified medical professionals into the health care industry. They qualify after more than four years of training. It would be easier to use this huge corps of medical manpower according to the needs of the local regions rather than create a new cadre.
Today a nurse undergoes four years of training during her or his course, whereas the proposed BRMS course is for three and a half years. The rural folk would be better off being catered to by nurse-practitioners who are more qualified than the ‘qualified quacks.'
The doctor-patient ratio in India is 1:1,700. Add to this the doctors under the traditional medical systems and the ratio comes down to about 1:700. The World Health Organisation's recommended criterion is 1:300. To reach that target, we cannot go for short-sighted and short-term measures to create a cadre of semi-qualified professionals.
We have the schemes and tools to enhance the health of our rural fellow-beings. With an exemplary scheme like the National Rural Health Mission, all that is needed is to revive and give new momentum to such schemes.
There are more than a million fully trained nurses and more than 3,00,000 Auxiliary Nurse Midwives in India. There are also more than 7,00,000 Accredited Social Health Activists (ASHAs). Then there are Village Health Nurses, Male Health Workers, Male Nurses, Anganwadi workers and so on. There is no dearth of paramedical professionals and qualified medical personnel to serve the districts and villages.
Adding one more cadre of workers who are neither here nor there will lead to state- acknowledged quackery. Already, nearly 75 per cent of India's population is treated by quacks. The proposal will only help strengthen the cause of the quacks, bestowing upon them respectability.
Already the urban-rural disparity in health infrastructure is huge. If the rural areas are catered to by BRMS personnel, it will deter qualified and experienced doctors from taking up rural assignments. It was after much thinking and cajoling that we put forward a compulsory scheme for rural service for those who desire to pursue higher medical courses. With one imprudent and rash gesture, we will do away with a good practice that was initiated with astute planning.
Ghulam Nabi Azad, my successor Union Minister of Health and Family Welfare, says BRMS personnel can be posted in Sub-Health Centres and Primary Health Centres. These already have more than enough qualified nurses who have completed four-year courses and done their practical training. So where is the need for a BRMS course that will produce medical personnel dismally equipped with only three and a half years of training?
The website of the Union Health Ministry provides details about the NRHM. Thousands of crores of rupees are being invested in the rural health sector under the NRHM to strengthen rural infrastructure. As Health Minister, in order to supplement the NRHM, I initiated a proposal for a one-year compulsory rural posting for each MBBS doctor after the internship. This faced stiff resistance from medical students. A committee under Dr. Sambasiva Rao was formed to deliberate on this issue around the country and give their recommendations. Finally, the recommendation was that anybody who aspired for a post-graduate degree should undergo a one-year compulsory rural posting. Unfortunately this recommendation came at the fag end of my tenure. Had this been implemented, every year we would get nearly 30,000 fully qualified doctors working in Rural Health Centres.
The need is to start more medical colleges in areas such as the northeast, Bihar, Uttar Pradesh, Madhya Pradesh and Jharkhand. The country has nearly 300 colleges, of which 190 are in Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and Gujarat. Uttar Pradesh, with a population of 19 crores, has only about 16 colleges. Bihar, with a population of nine crores, has eight. Rajasthan with an eight-crore population has eight and Madhya Pradesh, with a population of eight crores, has 12. If the State governments open medical colleges in all the districts, we can have nearly 600 medical colleges, rolling out nearly 75,000 MBBS graduates a year.
We have another huge health resource pool to tap from: doctors trained in Russia and China. Their services can be utilised in the rural areas.
Many doctors settle abroad. The government should take steps to prevent this drain by offering them attractive remuneration, avenues to train and upgrade knowledge and due recognition.
One school of thought favours admitting two batches of medical students in each institution every year – in the morning and in the afternoon. Clinical sessions could be alternated. By resorting to the double shift, we can double the number of medical graduates using the same

infrastructure and faculty. This can be followed for medical, dental and nursing courses. This was accepted by the MCI for post-graduate courses when I put forward the suggestion that accommodates one more student per professor within the existing system, given the infrastructure available. Earlier one professor could take in only one postgraduate student; now one professor can take in two students without compromising on the quality of medical education, thereby doubling the intake of students to postgraduate courses, leading to optimum use of the existing resources and infrastructure.
My suggestions in a nutshell are here. Make one-year rural posting compulsory for all MBBS doctors after internship. State governments should start medical colleges in every district to create more medical graduates. Increase the number of medical graduates and post-graduates using the existing infrastructure and faculty. Focus more on the northern and northeastern States. Expand and invest more in the National Rural Health Mission. Start government-run nursing colleges in all districts. Public-Private partnership ventures can be initiated, using the district and sub-district government hospitals for the purpose. Preference should be given to students from rural areas for admission to the MBBS courses, and it should be stipulated that the graduates work for five to 10 years in rural areas. The harmonisation and utilisation of doctors who have been trained in Russia and China, who have undergone seven-year MBBS courses, to fit into the rural programmes could help. The utilisation of doctors from traditional systems for specific needs and programmes could be planned. Anyone who wants to join a post-graduate course in a government college should have done a minimum of three years in a rural posting.

This article is by former Union Health Minister; published by Hindu on 27/02/10

BAMS/BHMS not practicing their pathies:Dr.Ashok Adhav,IPP,IMA

Sub: Shortage of qualified doctors in rural areas and proposal to start BRMS course. Respected Sir/Madam,

We know about the shortage of qualified doctors in rural health services and Govt. of India�s proposal of starting BRMS course as a solution to this problem.

Why Govt. should not first investigate the reasons behind this situation?

Govt. should have discussed with the appropriate people from doctors association, medical institution, medical organizations, various medical bodies etc. when with less numbers of graduates available in the past. Qualified doctors were joining the rural health services then what happened to them now as almost 35,000 qualified medical graduates being produced every year in India. This clearly proves that fault lies with Govt. (either central of state) appointment policies.

1.There is no formal categorization of PHCs and CHCs (e.g. most difficult, difficult and not difficult).

2.No fair posting and transfer policy of the department, with lot of political interference.

3. The Proposal to start BRMS is a retrograde step: Health and Family welfare Department, Government of India and Medical Council Of India had over a period of time abolished Medical Diplomas like LMP, LIAM , LCPS , MCPS etc to ensure that every citizen is provided with uniform quality of Health care.

4.Adhoc posting policy (usually posting orders for 3 or 6 months or 11 months, and on completion of this period, doctors have to follow a process of further continuation). There are so many doctors who are working with this adhoc arrangements for more than 10 years. During this period, they do not get their annual increments and other privileges admissible to a regular government employee.

5. CIn majority of the states, initial adhoc postings need to be confirmed or regularized by respective state�s public service commission. And PSC does not advertise these posts annually.

6. In majority of the difficult primary health centers in rural areas, where, government wants to post doctors, basic living facilities (quarter, safe water supply, electricity back up support, communication facilities, transport facilities, etc) are not available. The rural primary health centre where he will be serving will not get regular support in the form of regular drug supply, necessary equipments, nurses and paramedical staff,.

7. Transfer policy is purely dominated by political system and also in majority of instances; monitory transactions are involved in transfers. The system never assures a medical officer that if he has completed his first tenure of 2-3 years at a difficult PHC, he/she will never be posted in his life time to these PHCs again.

These are the some of the reasons that qualified doctors are not present in current rural scenario. There is no greatness in blaming the doctors. If somebody has to blame, one must blame the apathetic Govt. policies. Govt. has only given slogans like Health is Wealth, India Lives in Villages but not acted accordingly. The Govt. has never increased the budget for health, and when budget is not there and rampant corruption is there, nobody should expect better results.

Health system totally depends on a qualified doctor at the helm of affairs but today he is ruled by the beaurocrates and these IAS fellows decide the various health programme and policies. These are the root causes of this disaster named, �Shortage of qualified medical doctors in rural area�

Create a conducive working atmosphere at PHCs for a medical officer to stay and efficiently discharge his job functions. Its not that the doctors are not willing to join PHCs, it�s the government who is creating a situation there by even the willing doctors are refrained from providing services to the needy rural population.

Nobody should blame doctors! IMA is the largest NGO of qualified medical graduates. In its Central Council Meeting held at Hyderabad has unanimously rejected the idea of staring BRMS course creating a artificial differentiation between urban and rural population which is totally inhuman and against the spirit of Indian constitution and Alma Ata declaration as well.

Suggested solutions:

1.Categorize PHCs and CHCs in to most difficult, difficult and not-difficult health institutions (GOI has already developed criteria for such categorization for EAG states).

2.Strict policy of posting of fresh graduates only to most difficult and difficult PHCs only (this will automatically reduce political interference).

3.Categorize all health institutions in the district as sub taluka level, taluka level, sub divisional level and district level institutions.

4.Decide on the tenure for each place of posting (e.g. first two years at most difficult PHC, followed by next two years at difficult PHC and then posting at a good functioning PHC /CHC). Assure that once a medical officer completes his/her tenure, he/she will never be posted back to same category of institutions. If this policy is strictly followed, a medical officer who has put on 7-10 years of service, will be posted at taluka level and after 15 years, essentially at district HQ (for education of his/her children) (Government of Himachal Pradesh is strictly implementing its posting, transfer policy, and in spite of laser number of medical colleges, most difficult and hilly terrain, there are less than 20% vacancies at PHCs in Himachal Pradesh. If one state can enforce such policies stringently, why GOI should not enforce other states to follow such policies)

5.Special monitory incentives for difficult posting (e.g. government of Madhya Pradesh has agreed to sanction an incentive of Rs. 25000 to a doctors for posting at difficult PHCs. This is over and above his salary. Thus a newly recruited doctor will get around Rs. 50000 per month).

6.Other incentives could be in the form of special reservations for post graduations for doctors who have completed at least four years of service at most difficult and difficult PHCs.

7.Most important � Get away with adhoc posting policy. Issue regular posting orders, so that they get all privileges admissible to a regular government employee.

8.Accommodation: Construct PHC building with at least two quarters for doctors, two quarters for nurses, a quarter for pharmacist and two quarters for CL IV staff. Considering total construction, this can be completed in six months. Get away with construction through PWD. Hire a private agency for this construction. Thus within one year all most difficult/difficult PHCs will have their building and quarters.

9.Other incentives to doctors: Communication incentives, hiring of a vehicle for transport and field visits, incentives for recreation (e.g. audio-visual aids, books, etc), additional leave for 15 days in a year, etc.

The government is not in a position to have sufficient faculty in its medical colleges, and always play jugglery by just showing faculty on papers or temporary transfers at the time of MCI inspection. This has totally jeopardized quality of present medical education. And, the government gives a blind eye to this serious situation.

Over and above, now, if these new colleges cum up, from where we shall get minimum required faculty? Proposal of allowing retired teachers of medical colleges (after 65 years) to go to the districts (where these new colleges would come up) for teaching up to 70 years is just theoretical. A teacher, who is well settled by 65 years in a big city, will never like to go to district at the fag end of his carrier. This will be again posting just on papers and a visiting professor once in a week.

Why, the government is shying away with its responsibility of improving governance (posting, transfer policy, additional incentives, regular posting, accommodation to doctors and paramedical staff, removing political interference and monitory transactions in posting and transfers, etc)

A huge financial cost would be involved for creating physical infrastructure at district level where it is proposed to start such colleges. If the government purposefully utilize these funds for creating infrastructure in rural areas (PHC building, quarters, other basic infrastructural facilities), declares substantial incentives for doctors and even for nurses, improves governance and create a conducive working atmosphere, there is almost 100% probability to get MBBS doctors for all PHCs.

Government does not have any monitoring mechanism and will to ensure that BRMS doctors will essentially practice in rural areas only. Experiences show that majority of BAMS/BHMS doctors are not practicing their own pathy and government is just a silent observer and is not in a position to take any actions. This would also hold true for BRMS doctors.

A PHC medical officer is expected to attend medico legal cases, write medico legal reports and attend court cases. A BRMS doctor will have no competency for this and also legal sanctions.

A PHC medical officer is expected to perform regular vasectomy and tubectomy operations (family planning program is the most important component of a PHC). As per Supreme Court�s verdict, only MBBS doctor is qualified to perform these skills. This also hold true of MTP and also for provision of basic obstetric and neonatal medical emergencies. If the government is seriously concerned about reduction of infant mortality, maternal mortality (important MDGs) and total fertility rate, BRMS doctors just can not provide these critical services.

Dear friends IMA�s highest decision making body has already passed a resolution against the need of starting such irrelevant ill conceived BRMS course. No individually is above Central Council decision. All the available evidences shows that qualified medical graduates are willing to join but Govt. own policies are not favorable. Govt. was to blame doctors for neglecting rural population which is absolute lie.

Every one of us care for the health of rural populace, however the medicine �proposed by Govt. is dangerous itself�! So, dear friends we must remain united and fight against this �Govt. endorsed� quackery. (BRMS) Thanking you, in anticipation.
With Warm Regards,

  • Dr Ashok Adhao

IPP National IMA HQ
New Delhi

  • Dr Anil Laddhad
President, IMA

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