Availability of doctor & Paramedical staff. Health services in rural area

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             Healthcare Facilities in Rural Areas

 

  • indigenous systems of medicine; drugs and pharmaceuticals. Public health being a State subject, the primary responsibility to provide improved access to healthcare services is that of the State Governments. However, under National Health Mission (NHM) financial support is provided to State/UT Governments to strengthen their healthcare systems to provide better and easy access to healthcare services. As per Rural Health Statistics, 2014, there is a shortfall of 36346 Sub Health Centres (SCs), 6700 Primary Health Centres (PHCs), and 2350 Community Health Centres (CHCs) against the specified population norm.
  • As per Rural Health Statistics Bulletin (RHS) 2014, a total of 2225 (8.89%) Primary Health Centres (PHCs) are functioning without doctor, 9825 (39.26%) PHCs without Lab Technician and 5739 (22.94%) PHCs without a pharmacist in the country.
  • Under the National Health Mission (NHM), financial support is provided to the States /UTs to strengthen their health care system for augmentation of health human resources, provision of free essential medicines, etc. Some key support areas under NHM are:-
  • ASHAs: ASHA is a female voluntary health worker who acts as the link between the community and the public health facilities. She provides basic information regarding health and health care services and motivates people to access services from public health facilities.
  • Ambulances: Under NHM, support is provided to States/UTs to set-up a patient transport system where people can dial 108 or 102 telephone number for calling an ambulance. Dial 108 system is an Emergency Response System, primarily designed to cater to patients of critical care, trauma and accident victims, etc. 102 services is essentially the basic patient transport system aimed to cater to the pregnant women and sick children though other categories are also taking benefit and are not excluded.
  • Mobile Medical Units (MMUs): MMUs provide outreach services in rural and remote areas through a team of staff including one doctor, one nurse, one lab attendant, one pharmacist and a helper and driver.
  • Human Resources: Support is provided under National Health Mission to States and UTs for engaging health care staff at public health facilities on contractual basis, for providing incentives to doctors and other staff to work in rural and remote areas, for capacity building of staff, etc.
  • Infrastructure: Support under NHM is provided to States/UTs for establishment of new facilities based on population and time to care norms and for up-gradation of existing facilities by constructing new buildings or by renovation of existing ones.
  • Drugs & Equipment: To supplement the efforts of States/UTs in ensuring availability of drugs at public health facilities, Government of India has been providing free drugs /funds for free drugs to States/UTs under the Reproductive and Child Health (RCH) and National Disease Control Programmes for Tuberculosis, Vector borne diseases including Malaria, Leprosy and HIV/AIDS etc. Government is also encouraging the States/UTs to provide universal access to free essential medicines in public health facilities by providing funds and incentives under the National Health Mission (NHM). Up to 5% additional funding (over and above the normal allocation of the state) under the NRHM was introduced as an incentive from the year 2012-13 for those States that introduce free medicines scheme.
  • Untied Grants to facilities: Under NHM, support is given to States/UTs to strengthen Sub Centres, PHCs, CHCs and District Hospitals by provision of Untied Funds to undertake need based works for improving infrastructure and enhancing service delivery at these facilities.
  • Support for Reproductive, Maternal, New-born, Child & Adolescent Health (RMNCH+A): RMNCH+A seeks to address the major causes of mortality among women and children as well as the delays in accessing and utilizing health care services. The RMNCH+A strategic approach provides for ‘continuum of care’ to ensure equal focus on various life stages. The support to States/UTs under National Health Mission for RMNCH+A includes Janani Suraksha Yojana (J.S.Y), Janani Shishu Suraksha Karyakram (J.S.S.K), Maternal and Child Health Wings at facilities with higher case load, Integrated Management of Neonatal and Childhood Illness (IMNCI), Home Based New-born Care (HBNC), establishment of facility- based care for new-born and sick children including New Born Care Corners (NBCCs), New Born Stabilization Units (NBSUs), Special New Born Care Units (SNCUs), Nutritional Rehabilitation Centres (NRCs), Universal Immunization Programme, Rashtriya Bal Swasthya Karyakram (RBSK), Rashtriya Kishor Swasthya Karyakram and Family Planning Services.
  • Support for control of communicable and non-communicable diseases: Under NHM, support is provided to States/UTs for the control of the communicable diseases including vector borne diseases such as Malaria and Filariasis, Leprosy and Tuberculosis and for disease surveillance. Under the National Non-Communicable Disease Programmes, NHM supports prevention and control of Blindness, mental health issues, cardiovascular diseases and stroke, deafness, Tobacco related illnesses, oral health issues, Fluorosis, Iodine deficiency disorders, etc. In addition support is also provided to States/UTs for health care of elderly and palliative care.

 

Primary Health Care is a vital strategy which is a backbone of Health Service delivery forour country. India was one of the first few countries to recognize the importance ofPrimary Health Care Approach. PHC was conceptualized in 1946, three decades beforethe Alma Ata declaration, when Sir Joseph Bhore made recommendations, which laid thebasis for organization of basic health services in India. Over the past decades, severalCommittees and Commissions have been appointed by the Government to examine issuesand challenges facing the health sector. The purpose of these committees formed fromtime to time is to review the current situation regarding health status in the country andsuggest further course of action in order to accord the best of healthcare to the people.The earliest committees included, the Health Survey and Development Committee (BhoreCommittee) and Sokhey Committee. Other main Committees in the Post Independenceperiod, included Mudaliar Committee, Chadha Committee, Mukherjee Committee,Jungalwalla Committee, Kartar Singh Committee; Mehta Committee, Bajaj Committeeamongst others. Some of the recent Committees include the Mashelkar Committee andthe National Commission on Macroeconomics and Health. The committees andcommissions have been headed by eminent public health experts, who have studied theissues in an in-depth manner and provided overarching recommendations for variousaspects of the health care system in India. The areas covered by them related toorganization, integration and development of health care services / delivery system acrosslevel. health policy and planning, national programmes, public health,human resources. indigenous systems of medicine; drugs and pharmaceuticals.

Rural Health Scheme: Community Health Volunteer Scheme-Village HealthGuides

Acceptance of the recommendations of the Shrivastav Committee report led to thelaunching of Rural Health Scheme in 1977, wherein training of community healthworkers, reorientation training of multipurpose workers and linking medical colleges torural health was initiated. Also to initiate community participation, the CommunityHealth Volunteer – Village Health Guide (VHG) scheme was launched on 2nd October1977. According to the VHG Scheme the village community selects a volunteer was to bea person from the village, mostly women, who was imparted short term training andsmall incentive for the work. VHG acts as a link between the community and theGovernment Health System. He / She mainly provides health education and createsawareness of Maternal and Child Health and Family Welfare Services. He / She has tokeep a track of communicable and treat minor ailments and provide first aid to thepatients.

Alma Ata Declaration – Health for all by 2000

The Alma Ata declaration of 1978 launched the concept of Health For All by year 2000.It was signed by 134 governments (including India) and 67 other agencies. The Alma AtaDeclaration in 1978 gave an insight into the understanding of primary health care. Itviewed health as an integral part of the socioeconomic development of a country. Itprovided the most holistic understanding to health and the framework that States neededto pursue to achieve the goals of development. The Declaration recommended thatprimary health care should include at least: education concerning prevailing healthproblems and methods of identifying, preventing and controlling them; promotion of foodsupply and proper nutrition, and adequate supply of safe water and basic sanitation;maternal and child health care, including family planning; immunization against majorinfectious diseases; prevention and control of locally endemic diseases; appropriatetreatment of common diseases and injuries; promotion of mental health and provision ofessential drugs. It emphasized the need for strong first-level care with strong secondary and tertiary-level care linked to it. It called for an integration of preventive, promotive,curative and rehabilitative health services that had to be made accessible and available tothe people, and this was to be guided by the principles of universality,comprehensiveness and equity. In one sense, primary health care reasserted the role andresponsibilities of the State, and recognized that health is influenced by a multitude offactors and not just the health services.13 At the same time, the Declaration emphasizedon complete and organized community participation, and ultimate self-reliance withindividuals, families and communities assuming more responsibility for their own health,facilitated by support from groups such as the local government, agencies, local leaders,voluntary groups, youth and women’s groups, consumer groups, other non-governmentalorganizations, etc. The Declaration affirmed the need for a balanced distribution ofavailable resources (WHO 1978). The declaration asserted “PHC is essential health carebased on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through theirfull participation at every stage of their development in the spirit of self-reliance and self determination.”Several critical efforts outlined Government of India‟s commitment to provide health forall of its citizens after Alma Ata declarations, which are briefly discussed below.With a view of evolving a national strategy for securing the objectives of Health For Alland to identify specific programmes for the VI Five Year Plan, The working group onHealth was constituted by the Planning Commission with Shri Kripa Narain, Secretary,Ministry of Health and Family welfare as its Chairman to review the current health statuskeeping in view the physical and qualitative implementations of plan programmes, shortfalls and deficiencies and measures for rectifying them. The report of the working Groupon “Health for All by 2000 AD” examined the contextual issues in providing health care.The report contains a variety of inter-related recommendations, setting out objectives,strategies and operational goals which are considered feasible in the obtaining conditions.It is basically set down the parameters of the problem and set out the specific health tasksand targets to the state in the simplest terms but with full belief, that the goal of HealthFor All as spelt out here is an achievable one, given the sustained will and the supportingefforts to implement the indicated tasks by 2000 AD.

First National Health Policy, 1983

The responsibility of the state to provide comprehensive primary health care to its peopleas envisioned by the Alma Ata declaration led to the formulation of India‟s First Nationalhealth Policy (NHP) in 1983. The major goal of policy was to provide of universal,comprehensive primary health services. The policy emphasized the role that could be played by private and voluntary organizations working in the country to supportgovernment for integration of health services. It stressed the creation of an infrastructurefor primary healthcare; close co-ordination with health-related services and activities likenutrition, drinking water supply and sanitation; the active involvement and participation ofvoluntary organisations; the provision of essential drugs and vaccines; qualitativeimprovement in health and family planning services; the provision of adequate training; andmedical research aimed at the common health problems of the people.Meanwhile, A selective approach as an “interim” measure to the long term process ofcomprehensive primary health care implementation was introduced in many countries,including India as resource constraints made it ”not possible” to achieve Alma Ata goalswithin the committed time limit. Thus the focus shifted from the development of healthsystems and infrastructure for primary health care and ensuring health equity to severalvertical interventions based on technical justifications and cost effectiveness analysis.UNICEF also suggested its selective approach, GOBI-FFF (Growth monitoring, Oraldehydration, Breast feeding, Immunization, Female literacy, Family planning, Foodsupplement) for improving child survival. By the turn of the millennium, despite somegains in health outcomes and vast improvements in the availability of healthinfrastructure through a three-tier network, India had yet to achieve most of the goalsenshrined in its first national health policy.

Second National Health Policy, 2002

Nearly twenty years after the first health policy, the Second National Health Policy, 2002was presented. The NHP 2002 recognized as the noteworthy successes in health since theimplementation of the First NHP 1983. These successes included the eradication of smallpox and guinea worm, the near eradication of polio and the progress towards theelimination of leprosy and neonatal tetanus. The NHP sets out a new policy framework toachieve public health goals 23 in the socio-economic circumstances currently prevailing inthe country. The approach aims at increasing access to the decentralized public healthsystems by establishing new infrastructure in deficient areas and upgrading theinfrastructure of existing institutions. It sets out an increased sectoral share of allocationout of total health spending to primary health care.

National Rural Health Mission (NRHM, 2005-2012)

Recognizing the importance of Health in the process of economic and social developmentand improving the quality of life of our citizens, the Government of India has launchedthe National Rural Health Mission (NRHM) in April 2005 to carry out necessaryarchitectural correction in the basic health care delivery system. The Mission adopts asynergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreamingthe Indian systems of medicine to facilitate health care. The mission envisages aprimary health care approach for decentralized health planning and implementation atthe village and district level. The mission was made operational from April 2005throughout the country with special focus on 18 states having weak demographicindicators and infrastructure. The Plan of Action includes increasing public expenditureon health, reducing regional imbalance in health infrastructure, pooling resources,integration of organizational structures, optimization of health manpower,decentralization and district management of health programmes, community participationand ownership of assets, induction of management and financial personnel into districthealth system, and operationalizing community health centers into functional hospitalsmeeting Indian Public Health Standards in each Block of the Country.The Goal of the Mission is to improve the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women andchildren.NRHM is visualized as an architectural correction of the Indian Public health system toenable it to effectively handle increased allocations and promote policies that strengthenpublic health management and service delivery in the country. It envisages appropriatehealth personnel to be placed at different levels starting from village level in fullyfunctioning health centers with adequate linkages amongst different levels. An illustrativestructure model is depicted in below Figure showing health structures functioning atdifferent levels with a set of key health personnel performing adequate functioning incoordination with other sectors.NRHM has as its key components as provision of a female health activist in each villagecalled ASHA to promote access to improved health care at household level: a VillageHealth Plan formulation through a local team headed by the health and sanitationcommittee of the Panchayat: strengthening of rural hospitals for effective curative careand making them measurable and accountable to the community through Indian PublicHealth Standards (IPHS); integration of vertical health and family welfare programmes:strengthening of primary health care through optimal utilization of funds, infrastructureand available manpower. NRHM works on five key approaches – communitizationemphasizing community involvement, flexible financing for increased monetaryautonomy at different levels, capacity building to empower multiple stakeholders forefficient health delivery and human resource management to generate more manpowerand equipping health personnel with adequate multiple skills.

Primary health care resources in IndiaInfrastructure

Health Infrastructure is an important indicator to understand the healthcare deliveryprovisions and mechanisms in a country. Health Infrastructure indicators is subdividedinto two categories viz. educational infrastructure and service infrastructure.Educational infrastructure provides details of medical colleges, students admitted toM.B.B.S. course, post graduate degree/diploma in medical and dental colleges,admissions to BDS & MDS courses, AYUSH institutes, Nursing courses and Paramedical courses.Medical education infrastructures in the country have shown rapid growth during the last20 years. The country has 314 medical colleges 46 with total admission of 29,263 (in 256Medical Colleges), 289 Colleges for BDS courses and 140 colleges conduct MDScourses 21547 and 2,783 respectively 47 during 2010-11. There are 2028 Institutions forGeneral Nurse Midwives with admission capacity of 8033248 and 608 colleges forPharmacy (diploma) with an intake capacity of 36115 49 as on 31st March, 2010.Service infrastructure in health include details of allopathic hospitals, hospital beds,Indian System of Medicine & Homeopathy hospitals, Sub centers, PHC, CHC and bloodbanks.There are 12,760 hospitals having 576793 beds in the country. 6795 hospitals are in ruralarea with 149690 beds and 3748 hospital are in Urban area with 399195 beds. Rural andUrban bifurcation is not available in the States of Bihar and Jharkhand.Medical care facilities under AYUSH by management status i.e. dispensaries & hospitalsare 24,465 & 3,408 respectively as on 1.4.2010.There are 1,47,069 Sub Centers, 23,673 Primary Health Centers and 4,535 Community Health Centers in India as on March 2010. Total No. of licensed Blood Banks in the Country as on January 2011 are 2445.

Sub Centres (SCs)

The Sub-Centre is the most peripheral and first contact point between the primary healthcare system and the community. Each Sub-Centre is required to be manned by at leastone Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male HealthWorker (for details of staffing pattern, and recommended staffing structure under IndianPublic Health Standards (IPHS) see Annexure I). Under NRHM, there is a provision forone additional second ANM on contract basis. One Lady Health Visitor (LHV) isentrusted with the task of supervision of six Sub-Centers. Sub-Centers are assigned tasksrelating to interpersonal communication in order to bring about behavioral change andprovide services in relation to maternal and child health, family welfare, nutrition,immunization, diarrhoea control and control of communicable diseases programmes. TheSub-Centers are provided with basic drugs for minor ailments needed for taking care ofessential health needs of men, women and children.54 The Ministry of Health & FamilyWelfare is providing 100% Central assistance to all the Sub-Centers in the country sinceApril 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- perannum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs andequipment kits. The salary of the Male Worker is borne by the State Governments. Underthe Swap Scheme, the Government of India has taken over an additional 39,554 SubCenters from State Governments / Union Territories since April, 2002 in lieu of 5,434 Rural Family Welfare Centers transferred to the State Governments / Union Territories.There are 1, 47,069 sub centers functioning in the country as on March 2010.

Primary Health Centres (PHCs)

PHC is the first contact point between village community and the Medical Officer. ThePHCs were envisaged to provide an integrated curative and preventive health care to therural population with emphasis on preventive and promotive aspects of health care. ThePHCs are established and maintained by the State Governments under the MinimumNeeds Programme (MNP)/ Basic Minimum Services (BMS) Programme. As perminimum requirement, a PHC is to be manned by a Medical Officer supported by 14paramedical and other staff.56 Under NRHM, there is a provision for two additional StaffNurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centres. It has 4 – 6beds for patients. The activities of PHC involve curative, preventive, promotive andFamily Welfare Services. There are 23,673 PHCs functioning as on March 2010 in thecountry.

Community Health Centres (CHCs)

CHCs are being established and maintained by the State Government under MNP/BMSprogramme. As per minimum norms, a CHC is required to be manned by four medicalspecialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Roomand Laboratory facilities.58 It serves as a referral centre for 4 PHCs and also providesfacilities for obstetric care and specialist consultations. As on March, 2009, there are4,535 CHCs functioning in the country.

First Referral Units (FRUs)

An existing facility (district hospital, sub-divisional hospital, community health centreetc.) can be declared a fully operational First Referral Unit (FRU) only if it is equipped toprovide round-the-clock services for Emergency Obstetric and New Born Care, inaddition to all emergencies that any hospital is required to provide. It should be noted thatthere are three critical determinants of a facility being declared as a FRU: i) EmergencyObstetric Care including surgical interventions like Caesarean Sections; ii) New-bornCare; and iii) Blood Storage Facility on a 24-hour basis.

Current Situation of the Human Resources compared to 2005 (Before NRHM)

The launch of the NRHM in 2005 marked a turning point in human resource for health.The commitments of the centrally-funded scheme to provide the funds needed to closethe human resource gaps between the posts that were sanctioned by the state governmentsand the posts that were required to meet the new standards, dramatically changed thesituation. This led to the appointment of almost 1,06,949 more skilled service providersin the public health system by March 2010, of which 2,460 were specialists, 8,624 weredoctors, 7,692 were AYUSH doctors, 26,993 were nurses, 46,990 were ANMs and14,990 were paramedical. This was one of the largest increments to the public healthworkers in recent times. Also NRHM funds have also enabled the revitalizing of thecommunity health worker programme in India and the ASHAs over 7, 00,000 signifies amassive increase in health workers in the country.When we compare the manpower position of major categories in 2010 with that in 2005,it is observed that there are significant improvement in terms of the numbers in all thecategories. For instance, the number of ANMs at Sub Centres and PHCs have increasedfrom 133194 in 2005 to 191457 in 2010 which amounts to an increase of about 43.7%.Similarly, the Doctors at PHCs have increased from 20308 in 2005 to 25870 in 2010,which is about 27% increase. Moreover, the specialist doctors at CHCs have increasedfrom 3550 in 2005 to 6781 in 2010, which implies an appreciable 91% increase in 5 yearsof NRHM. By analyzing the state wise picture, it may be observed that the increasein the ANMs is attributed mainly to significant increase in the states of Andhra Pradesh,Assam, Goa, Haryana, Jammu & Kashmir, Karnataka, Madhya Pradesh, Maharastra,Manipur, Mizoram, Nagaland, Orissa, Punjab, Rajastan, Uttarakhand, Uttar Pradesh andWest Bengal. Similarly there is a significant increase in the number of doctors at PHCs inthe states namely Andhra Pradesh, Jammu & Kashmir, Karnataka, Kerala, MadhyaPradesh, Punjab and Rajasthan.

 

The key core strategies under NRHM are :

  • Train and enhance capacity of Panchayat Raj Institutions (PRIs) to own, control and manage public health services.
  • Promote access to improved health care at household level through the village level worker , ASHA
  • Health plan for each village through Village Health Committee of the Panchayat.
  • Strengthening sub centers through better human resource development, clearquality standards, better community standards, better community support and an untied fund to enable local planning and action and more multipurpose workers.
  • Strengthening existing Primary Health Centers through better staffing and human resource development policy, clear quality standards, better community support and an untied fund enable the local management committee to achieve these standards.
  • Provision of 30 – 50 bedded CHC per lakh population for improved curative care to a normative standard. (Indian Public Health Standards defining personnel,equipment and management standards)
  • Preparation and implementation of an inter-sector district plan prepared by district health mission, including drinking water supply, sanitation, hygiene and nutrition.
  • Integrating vertical health and family welfare programmes at national, state,district and block levels.
  • Technical support to national, state and district health mission for public health management.
  • Strengthening capacities for data collection, assessment and review for evidence base planning, monitoring and supervision.

Supplementary Strategies under Mission

  • Regulation for private sector including the informal Rural Medical Practitioners(RMPs) to ensure availability of quality service to citizens at reasonable cost.
  • Promotion of Public Private Parternership for achieving public health goals.
  • Mainstreaming the Indian System of medicine (AYUSH) revitalizing local health traditions.
  • Reorienting medical education to support rural health issues including regulation of medical care to medical ethics.
  • Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.

 

Analysis

  • Rural health care in India faces a crisis unmatched by any other sector of the economy. To mention just one dramatic fact, rural medical practitioners (RMPs), who provide 80% of outpatient care, have no formal qualifications for it. They sometimes lack even a high school diploma.
  • In 2005, the central government launched the National Rural Health Mission (NRHM) under which it proposed to increase public expenditure on health as a proportion of the GDP to 3% from 1%. But increased expenditure without appropriate policy reform is unlikely to suffice. Experience to-date inspires little confidence in the ability of the government to turn the expenditures into effective service.
  • Rural India consists of approximately 638,000 villages inhabited by more than 740 million individuals. A network of government-owned and -operated sub-centres, primary health centres (PHCs) and community health centres (CHCs) is designed to deliver primary health care to rural folks.
  • Sub-centre is the first contact point between the community and the primary health care system. It employs one male and one female health worker, with the latter being an auxiliary nurse midwife (ANM). It is responsible for tasks relating to maternal and child health, nutrition, immunisation, diarrhoea control and communicable diseases.
  • Current norms require one sub-centre per 5,000 persons, one PHC per 30,000 people and one CHC per 120,000 people in the plains. Smaller populations qualify for each of these centres in the tribal and hilly areas. Each PHC serves as a referral unit to six sub-centres and each CHC to four PHCs. A PHC has four to six beds and performs curative, preventive and family welfare services.
  • Each CHC has four specialists — one each of physician, surgeon, gynaecologist and paediatrician — supported by 21 paramedical and other staff members. It has 30 indoor beds, one operation theatre, X-ray and labour rooms and laboratory facilities. It provides emergency obstetrics care and specialist consultation.
  • Despite this elaborate network of facilities, only 20% of those seeking outpatient services and 45% of those seeking indoor treatment avail of public services. While the dilapidated state of infrastructure and poor supply of drugs and equipment are partly to blame, the primary culprit is the rampant employee absenteeism. Nation-wide average absentee rate is 40%.
  • The employees are paid by the state, with the local officials having no authority over them. Not surprisingly, many medical officers visit the PHCs infrequently and run parallel private practice in the nearby town. ANMs are frequently unavailable for childbirths even if the mother is willing to come to the PHC. Though PHCs are supposed to be free, most of them informally charge a fee. Under these circumstances, even many among the poor have concluded in favour of private services.
  • public health services have done poorly even along the income distribution dimension. According to a 2001 study, the poorest 20% of the population captures only 10% of the public health subsidy compared with 30% by the richest 20%. The share in the subsidy rises monotonically as we move from the bottom 20%. The justification for the government provision of health services on income distribution grounds does not find support in the data.
  • To make improvements in the delivery of health services, at least three reforms are urgently required. First, it is time to accept the fact that the government has at best limited capability to deliver health services and that a radical shift in strategy that gives the poor greater opportunity to choose between private and public providers is needed.
  • This can be best accomplished by providing the poor cash transfers for out-patient care and insurance for in-patient care. Once this is done, a competitive price must be charged for services provided at public facilities as well. The government should invest in public facilities only in hard to reach regions where private providers may not emerge.
  • Second, the government must introduce up to one-year long training courses for practitioners engaged in treating routine illnesses. This would be in line with the National Health Policy 2002, which envisages a role for paramedics along the lines of nurse practitioners in the United States.
  • The existing RMPs may be given priority in the provision of such training with the goal being replacement of all RMPs by qualified nurse practitioners.
  • Finally, there is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. Taking into account the evolution of medical colleges and assuming that doctors remain active for 30 years after receiving their degrees, there are at the most 650,000 doctors in India today.
  • With a population of 1.1 billion, this implies approximately 1,700 people per doctor. In comparison, there are just 400 people per doctor in the United States and 220 in Israel. Whereas private colleges and institutes in engineering, computer applications and business fields have mushroomed in response to the demand, the same has not happened in the medical field.
  • The Indian Medical Council (IMC) zealously controls the entry of new colleges and keeps the existing medical colleges on a short leash. Recently, it threatened to effectively close down as many as six of the eight medical colleges in Bihar because they were in violation of its guidelines on how many senior positions could be left unfilled at any time.
  • Given low salaries, colleges face serious difficulties in filling the positions. The result has been extremely slow expansion of capacity in many states. West Bengal has added just two medical colleges since 1969, Rajasthan three since 1965, Punjab three since 1973, Delhi one since 1971 and Bihar two since 1971.
  • Only Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu have achieved satisfactory progress. This must change. The IMC perhaps needs to relax its norms and the government needs to make salaries competitive to adequately staff the existing colleges and open new ones.