Rains, and reasons for why there is a shortage of doctors in India

I haven’t been posting lately because I have been rehearsing for a performance tomorrow, and it turns out I can really only do one thing at a time. But today I’m sitting in front of the computer again because I’m really anxious. It’s been raining since yesterday evening non-stop. If it goes on like this, I’ll have to cancel the program. The auditorium I’m performing in is inside a temple and really lovely, but open to the elements on two sides. With this much rain, it will not be possible to keep the water out. I finally plan a solo after three years, and I somehow managed to schedule it for the worst weekend of rains this year. I can’t decide whether to laugh or cry.

Besides preparing for the show, I’ve been doing a lot of thinking lately about how the poor access medical care in cities, about which I’ll post more later. In the process, I came across this really brilliant editorial in The Hindu that explains why there is a lack of doctors to serve the poor and rural areas in India.

Like in the US, getting a medical education in India is reserved for elite students. There are only a limited number of accredited medical schools, and getting in is both extremely expensive and difficult. The quality of medical education is very good. Similar to what happened with IT, we’ve created a system in India which produces a small number of extremely well trained doctors. The system supplies the elite with extremely good medical care. India is also the largest supplier of foreign medical graduates to both the US and the UK, and the best private hospitals here are so good that “medical tourism” is a popular alternative to Western care. But the system vastly underprovides doctors for the poor, a problem that has been well documented for rural areas.

The op-ed, written by Meenakshi Gautham and K. M. Shyamprasad, argues that this lopsided system was a product of the recommendations of the Bhore Committee, set up by the British in 1943. Staffed by eight British and 16 Indian members, the report created a “blueprint for a modern public health delivery system in India, along with the training of its personnel.”

At the time, Western medical care was provided by two kinds of practitioners- graduates who did five and a half years at medical colleges, and Licentiates, who did a three to four year course. Nearly two thirds of the 47,000 odd registered medical practitioners were Licentiates, and these Licentiates staffed most of the rural clinics. But the Bhore Committee recommended abolishing Licentiates, and directing all medical schools to produce only highly qualified doctors. They reasoned that this would result in better trained doctors serving rural populations.

But the system did not quite work as planned. Rather than highly trained doctors serving rural people, qualified doctors stayed in cities or emigrated, leaving rural areas completely underserved, a situation which has continued till today.

The authors of the op-ed suggest that the members of the Bhore Committee based their recommendations on the British model of public health at the time, since the members were either British or had close connections to Britain. Committee members believed that “there was no role in the modern medical scheme for indigenous systems of medicine and its practitioners,” without accounting for the fact that India with its vast area and entrenched poverty, was not exactly the same version of modernity as Great Britain. The op-ed argues for creating a category of basic doctors like Licentiates again to solve the crisis in medical care in India.

This is exactly the kind of analysis I love – when Western rules or standards are brought into a society in which they simply do not fit, it results in poor outcomes. Ralph Gakenheimer at MIT has pointed out how similar things happen all the time in engineering. Standard widths for pipes and roads are transplanted from one country to another, without accounting for differences in the way that people in different societies use these things. Clearly, there has to be more thought given to developing modern systems that suit the modern Indian society.

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3 comments
  1. nice write, hope you managed to have your show. Have you read Barefoot doctors ?

  2. Suman said:

    Hi Nithya, let me know how your performance goes; i hope that the rains subside so that you don’t have a rain-out. Will there be a video? I want to see it! thanks for this article. I don’t know much about health care in India but as the Hindu article notes there are very interesting models in Africa of community health practitioners (CHPs) that are trained and deployed to rural areas. I was surprised that India did not have an equivalent system.

  3. nraman said:

    To all those who are wondering: Performance canceled! Waiting for the rains to subside before I reschedule. Sad, but at least I’m in great shape after daily 2 hour rehearsals.

    @dobighazameen: i have not read barefoot doctors. I also found many books by that name — are you referring to the chinese system?

    @suman: can you suggest a good reading about community health practitioners? It sounds very interesting.

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