The government appears to be going all out with plans to address the shortage of qualified health personnel in India?a national commission is to be set up and the draft Bill has already been prepared to look into all aspects of training and education of all health professionals, the accreditation of institutions, the licensing of practitioners, etc. Before the commission gets into place, though, the syllabus of a new course has been finalised?Bachelor of Rural Health Care or BRHC, a three-and-a-half year course for rural students to be conducted in community colleges and district hospitals. The BRHC graduates will not be called doctors and they will be allowed to practice only in the rural areas. Similar schemes are already in force in a few states and its formalisation at a central level has attracted opposition from many, including the former minister of health and family welfare, Dr Ramadoss.

To begin with, it is well known that we have an acute shortage of medical personnel. According to the WHO benchmark, there should be 1 physician per 1,000 persons, India has about 0.6 physicians per 1,000 persons. The nurse-to-physician ratio should be about 4:1, in India it is about 2:1. The problem of inadequate supply starts with insufficient intake capacity in medical and nursing colleges and is compounded by graduates migrating, dropping out into other careers, etc. It was estimated that only about 40% of the nearly 1.5 million registered nurses were active in 2005 and there is no record of the actual number of practicing doctors in the country.

What is of most importance however is the rural-urban gap in healthcare professionals. The fact that doctors prefer to work in urban areas is well known. So, not only does the pool of qualified healthcare providers have to be increased substantially, the system must also provide sufficient incentives to keep practitioners in the rural areas.

Chhattisgarh was the first state to start a rural health cadre programme in 2003. At inception in 2000, the state had just one medical college with 100 students, only 516 medical officers were available at PHC level out of total of 1,455 posts. However, there was opposition from the MCI and the implementation process ran into many legal hurdles of accreditation, till finally the government shut the course down with only three batches admitted and placed in rural health centres. An independent survey conducted by Public Health Foundation of India this year noted that the Rural Medical Assistants had provided excellent healthcare in the primary health centres that they were assigned to.

Is this the only model possible for extending care to rural areas? Tamil Nadu is one state that has vociferously opposed the new BRHC course, the system they have in place has already yielded dividends. The state has 15 government medical colleges with 3,500 graduates annually, its rural areas have good transport links and the population has high educational standards. In Tamil Nadu, the first posting for anyone who joins the government medical service is in a PHC. They have to serve in the villages at least for a year and the government takes in close to 2,000 doctors every year in rural areas, there is in fact a waiting list of doctors registered with the government.

Dr Ramadoss?s solution was to increase the number of MBBS seats, reserving seats for rural service, increasing basic facilities in rural centres, mandating rural service to all medical graduates for one year, starting new medical colleges in rural areas, etc.

Of course, all these need to be done too. The BRHC course cannot be a one-point solution to healthcare. The point is that there is no need for a new course, if, and this is the big if, there is sufficient supply of doctors coupled with good infrastructure and incentives in the rural areas. Tamil Nadu seems to have cracked the model. The RMA scheme failed in Chhattisgarh mainly because there were no inputs from the MCI. With the central government and MCI backing the BHRC, this problem has been taken care of now, what remains is for a system that will allow the BHRC graduates to merge with the mainstream over time. Hopefully, the proposed national commission will look into this aspect as well and create a complete solution to meet the challenge of providing healthcare services to our large and diverse population.

The author is chief economist, Indicus Analytics