Better options available

Health Minister A Ramadoss's plan to end the shortage of doctors in villages by increasing the duration of medical courses in the country and posting freshly minted medical graduates in the rural areas for a year as a part of their degree requirement, is typical of the mentality that says long-standing problems can be fixed by edict, and by wielding the stick instead of dangling a carrot.

The idea is not new, of course. Some state governments have asked for two years of mandatory rural work for a doctor to qualify for a post-graduate seat in a medical college. Some private colleges set up by religious missions impose similar conditions. But in the absence of easy enforceability, these do not work very well. If tried out on a larger scale, expect bogus certificates on rural work experience to flourish. Any solution to the problem of rural medicare should be designed with doctors' willing concurrence, if it is to work.

By one estimate (there are others too), India has over 400,000 doctors, and churns out 24,000 more each year. Sending these to the countryside for a year, Mao-style, will not achieve much in terms of increasing the total availability of doctors in the rural areas. At the same time, reports suggest that the market for doctors is getting crowded in the big cities, and that salaries are low as a consequence. Frustrated doctors therefore seek to go abroad in larger numbers. The point therefore is to make a rural posting attractive. After all, what will these doctors do in rural areas if there are no facilities to use their knowledge, and where primary health centres typically do not have medicines to give out?

It so happens that in the rural areas of states where a proper medical infrastructure exists, like Kerala, there is no shortage of even doctors with post-graduate degrees. Any new medical graduates asked to do mandatory service will promptly head for such areas, and ignore the places where medical intervention is more urgently required. That will not serve the intended objective.

The numbers also tell us that more than 40 per cent of medical graduates are educated in private medical colleges. This reflects both the failure to expand public medical education and the success of the policy of allowing private medical colleges. A joint effort by the public and private sectors could help provide better medical infrastructure in villages and small towns, along with the necessary support staff of nurses, technicians and attendants. It would also help if the public health programme got more attention""the spread of communicable diseases in recent years points not so much to the absence of doctors in the rural areas as to the failures of the public health programme.

Another relevant point, made by Devi Shetty of Narayana Hrudayalaya in Bangalore, is that if India were to allow nurses/technicians to operate certain kinds of equipment, this would both free up doctors and help the spread of healthcare. Dr Shetty has set up, with the help of the Indian Space Research Organisation, a telemedicine project connecting nine coronary care units across the country with his Hrudayalaya and the Tagore Institute of Cardiac Sciences in Kolkata; he has trained general practitioners and technicians to operate equipment, and used the services of a software firm to get the results digitised and emailed from rural kiosks. Between 2001 and July 2004, according to Dr Shetty, Hrudayalaya doctors did 9,591 telemedicine consultations. If linked with other kiosk-based services, telemedicine can even be a profitable low-cost business model. It is solutions like this that hold promise for the future, not converting doctors into bonded labour.