Padma Prakash: Quotas, of a different kind

MOOT POINT

Last year, 26,449 students entered 242 medical colleges in India, according to the data available on the website of the Central Bureau of Health Intelligence. Only five years before the numbers were: 189 colleges with an intake of 18,168. It is these numbers that, it is being envisaged, will rise in order to accommodate the 50 per cent quotas being proposed. How much of an impact will this have on changing the social composition of the medical student community?

What of the associated health science disciplines so crucial to the delivery of health care? According to one source, there are 1.28 million registered nurses, though the Nursing Council of India does not seem to have updated figures. The CBHI puts the figure at 839,862. There were 979 nursing schools offering post-matric, three-year general nursing diplomas and 78 colleges offering post higher secondary four-year degree courses in nursing. No reliable data are easily available on their intake, but considering that only 2 per cent of nursing personnel are degree holders, the degree colleges are admitting only a minuscule proportion of nursing students. Of the registered nurses, if data from one state are anything to go by, half are working abroad. Since the demand for nurses is rising rapidly, the shortfall is being made up by unrecognised nursing schools and informally trained hospital aides, gravely affecting the quality of care. What is the social composition of the nursing community?

Over the decades, although every committee to look at health care has made radical recommendations on the need to upgrade nursing as a profession, little has happened. Today in the hospital hierarchy the nurse is a subordinate with no decision-making powers. Several studies over the years have documented the abysmal professional status of the nurse in India that is closely linked to her social status. Equally important is the fact that there are no avenues open for upward professional mobility. Some states like Tamil Nadu allow nursing diploma holders to acquire a degree through a special intake at that level. But overall, nursing education is in bad shape. Those who enter the profession are, inevitably, the socially and economically disadvantaged.

Why not integrate nursing and medical education such that there are synergies created? Why not create an opportunity for nurses to enter the medical stream and also, more radically, allow medical students to opt out and move into nursing streams? This might laterally increase intake in nursing colleges, and provide an impetus for upgrading training. It is in the context of the current debate on quotas that this makes sense. One of the arguments for reservations is to change the current social composition of the student population in medicine. The assumption is that a socially and economically disadvantaged student will, apart from all else, bring to bear a different outlook and perception on her training. If trained nurses were to be allowed into medical colleges, their perceptions and therefore the outcome of medical education would be enormously enhanced in favour of better care. What if, instead of including quotas for OBCs, a smaller proportion of seats were earmarked for those with nursing backgrounds (provided other conditions with regard to minimum education levels were to be met)?

This is not as far-fetched as it sounds. Some states have one or two seats for what is termed "nursing stream" candidates. However, there is little information on whether these are ever filled by legitimate candidates with a nursing background. In many countries, the intake for medical colleges is based on factors other than rankings in qualifying exams. Nurse practitioners can and do often enter medical school and qualify to practise. As in fact do students with academic backgrounds in sociology or psychology.

Such suggestions have been dismissed in the past on the grounds that this will provide a "backdoor" entry into medicine. What if it does? Reform in medical education has always been hamstrung by elitist arguments such as these. Historically, the licentiate courses in medicine (later abandoned), it must be remembered, were introduced by the colonial government to provide for personnel in lower-level hospitals even while ensuring the preservation of the pristine status of medicine and its practitioners. All reform measures post-independence""such as the three-year "community doctor"""have continued to take the same route. It is in part this elitism that has so pointedly opposed quotas in medical college intake.

Broadening the base of intake into medical streams is imperative today. Relegating quotas on the basis of social and economic backgrounds is one way, but a measure that is inevitably self-limiting. Integrating the different streams in health care, by broadening entry requirements on the basis of prior experience or training, also ties in with the new team approach to care that is increasingly replacing the hierarchical doctor-nurse-patient system prevalent in India.

Allowing the entry of nurses into medical education will also change the gender structure and bias in medical practice. Today women comprise 39 per cent of the undergrads in medicine, with the proportion falling sharply at the post-graduate stage. Given that some 80 per cent of trained nurses are women, such a move may well enlarge the number of women doctors. Most importantly, it will take the noble profession of nursing out of the boondocks to which it has been relegated.