Year : 2012 | Volume
: 56 | Issue : 1 | Page : 1--3
Involvement of young doctors in the rural health services of India
Professor and Head, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India
Professor and Head, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012
|How to cite this article:|
Kumar R. Involvement of young doctors in the rural health services of India.Indian J Public Health 2012;56:1-3
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Kumar R. Involvement of young doctors in the rural health services of India. Indian J Public Health [serial online] 2012 [cited 2020 Sep 26 ];56:1-3
Available from: http://www.ijph.in/text.asp?2012/56/1/1/96947
Since independence, India has made considerable progress in population health. Fertility and mortality rates have declined in most states. However, with the current pace, India may not be able to achieve health related Millennium Development Goals, as required investments are yet to be made in the health sector, although a beginning has been made by the National Rural Health Mission (NRHM), which is facing several constraints. Notable among these constraints is the insufficient deployment of human resources, especially doctors in the health institutions located in the rural areas. A careful analysis of the situation is required to find medium to long term solutions to this problem in addition to advocating for short term measures such as 'rural doctor'/'physician assistant'/'licentiate of state medical faculty (LSMF)' etc.
Due to the socio-economic and technological changes that have swept the country in the last two decades, the influence of 'market' is growing in medical profession also. The long cherished goal of medicine to serve humanity is under serious threat. Most doctors now prefer to work in the comforts of urban hospital environments compared to the rural primary health centers, where facilities are far from optimum for practice of medicine as well as for living a decent life. The incentives currently offered by health services, such as hardship allowance or reservation of few postgraduate seats for those, who have done rural service, are not sufficiently appealing to attract allopathic doctors to rural areas. Health System, i.e., Medical Council of India (MCI), Medical Profession, i.e., Indian Medical Association, and Health Services, i.e., Central and State Health Departments should design a set of sufficiently powered incentives so that most doctors voluntarily choose to work in rural areas for some time in their career pathway.
Keeping society healthy is the prime task of the doctors. That is why, rather than only managing patients in the cozy clinics, doctors should also be involved in planning, organizing, implementing and evaluating health promotion and disease control programs. Hence, principal task, of those who are engaged in medical education, is to produce doctors who are not only capable of diagnosing and treating patients but also have competency in preventing disease and promoting people's health. They must be familiar with the physical and/or social conditions, in which majority of Indian people live and work, i.e., rural areas.
National Rural Health Mission should build a suitable environment that encourages young doctors to work in the healthcare institutions of rural areas. NRHM can work with Medical Council of India and medical colleges/institutions for planning, implementing, monitoring and evaluation of a residency program (house Job) for training of young doctors in rural health. NRHM residency program can have following features to attract young doctors to rural areas.
NRHM residency in rural health should be at least for 1 year duration. The stipend should be at par with the residency programs of medical institutions, such as AIIMS and PGIMER etc. The counseling and placement for NRHM residents should be done at medical college campus by the NRHM using walk-in interview method during last 3 months of internship as is done in management and engineering institutions. Selection should be done strictly on merit basis, and candidates should be able to choose from the vacant positions according to their merit. Those who successfully complete the NRHM residency, should get a weightage of 25% (or more) marks in the entrance test for post-graduation. NRHM should prepare a list of rural health institutions in consultation with MCI where resident doctors can be placed, with specification of approximate patient load, existing mentors, residential facilities (can be rented), available mode of transport to the institution (frequency / day), distance from nearest town / city etc.
NRHM can also prepare a specialty-wise list of rural health institutions for residency in family medicine / primary care, community medicine, general medicine, surgery, gynecology and obstetrics, pediatrics, anesthesia, laboratory medicine, public health etc. Those who have completed NRHM residency for 1 year (in a particular specialty), should be able to have transfer of credits to the medical college / institution residency program, in case they get admission into postgraduate course in the same specialty or allied specialty. The institutions offering NRHM residency should be monitored through nearest medical college by the Medical Council of India. Each medical college should be allotted 1-4 districts (~15 million population) in its catchment area for nurturing and monitoring the NRHM residency program. NRHM should provide sufficient funds to medical colleges/MCI for implementation of NRHM residency program so as to provide benefits to field mentors and medical college / institution facilitators (financial incentives for participation in continuing profession education programs).
Medical colleges/institutes should also conduct 'on campus' as well on 'field site' short courses of 1 to 2 week duration for orientation of young doctors, who have opted for NRHM residency on issues such as, primary medical care, field epidemiology, program management, and counseling etc. Technological advance in communication, which has led to the shrinkage of space and time, should also be harnessed for continuing medical education of young doctors working in rural areas. These opportunities must be enhanced for creation of technically competent and socially responsive doctors.
A 3 tier monitoring system should be designed for NRHM residency program, i.e., reports from: (a) Field Mentor with whom the resident is working, (b) In-charge of the Rural Health Institution / Civil Surgeon / Chief Medical Officer, (c) Medical College / Institutions / Medical Council of India. Those who volunteer for the NRHM residency, should be awarded a special certificate - 'Served Rural People of India'- by the Minister of Health and Family Welfare.
Even those, who are enrolled in postgraduate courses in medical colleges currently, can also be considered for placement in suitable rural medical institutions for certain period of time (6-12 months). Incentives should be created for medical teachers also to take a sabbatical for rural health institutions (for 6-12 months). This could be given credit while considering for promotion / annual increments, beside a certificate, recognizing their 'service to rural people of India'. Similarly, incentives should be created for state medical service doctors (mentors of NRHM residency) for working in medical colleges / institutions for 6-12 months. Thus, at any point in time, about 20% of medical faculty should be exchanged with health service doctors in the catchment area of the medical colleges / institutes. Those who have worked for NRHM residency should get preference in recruitment for regular / permanent positions, and those who have mentored NRHM residents should get preference in selection as teachers / trainers in medical colleges / institutions.
Recently, medical seats have been increased in under-graduation as well as post-graduation level in most medical colleges. About 40,000 medical graduate and about 20,000 post-graduates pass out every year from ~350 medical colleges. Most of the young doctors, either study at home to prepare for entrance examinations, or work in urban areas, mostly in private sector for long hours at very low salary. The recruitment process for medical officers in most of the state and central government health service is cumbersome, infrequent, and arbitrary. Hence, it is expected that a transparent, timely, and merit-based competitive recruitment process to NRHM residency program would attract doctors to rural areas. Similar programs should also be piloted for senior residency in selected secondary level hospitals, located in rural areas.
The effect of 'market' oriented policies on medical profession need to be investigated in local contexts so as to provide evidence for advocating a reversal of those public policies that do not promote involvement of doctors in rural areas. Academic programs in medical colleges should build values and skills among health professionals for promoting rural health and for mobilizing public opinion in favor of these policies. Building partnerships with civil society organizations and social movements is also vital at this stage.
Making basic health care accessible to all is a big challenge in India. To confront this challenge, doctors need to be deployed in rural health care institutions in sufficient number, using some of the approaches mentioned above. Sufficient number of positions should be created for young doctors in the public health system so that they can make an impact on population health. There is a need to mediate between the 'interests' of the medical profession and that of the society so as create an environment that enables young doctors to achieve their full potential along with making contribution to rural health service. State should perform its 'stewardship' role more effectively in collaboration with MCI for involving young doctors in rural areas in order to achieve the goal of rural health mission in the foreseeable future.