Health for all: Bridge course a good option : The Tribune India

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Health for all: Bridge course a good option

There has been a hue and cry over the National Medical Commission (NMC) Bill ever since it was introduced in Parliament, to replace Medical Council of India (MCI) Act.

Health for all: Bridge course a good  option

Upping competencies: Enhancing skills of nurses etc can improve healthcare system.



Vikrant Prabhakar
Associate Professor of Community Medicine, Adesh Medical College & Hospital, Kurukshetra

There has been a hue and cry over the National Medical Commission (NMC) Bill ever since it was introduced in Parliament, to replace Medical Council of India (MCI) Act. Sensing resentment and opposition, the government referred the Bill to a parliamentary committee for review and recommendations. The Indian Medical Association, which was spearheading the opposition, upped the ante, which culminated in a 'mahapanchayat' against the Bill. The resentment was against certain provisions of the Bill. They include the 'exit' licentiate exam for medical graduates, nominated (rather than elected) members in the commission, low representation of state medical councils in the commission, and a 'bridge' course for non-allopathic medical graduates, thereby allowing them to practice limited allopathy. The government responded by tweaking those provisions like increasing the number of state members, making final MBBS exam as licentiate exam and allowing states to take a call on bridge course, as per the requirements.

By opposing the bridge course, the IMA has scuttled possible reforms in health sector reform, and thereby conceded the advantage it had for improving the working conditions and ecosystem for future doctors in government service per se, and primary health service delivery in the country.

The status 

The primary healthcare system needs a major restructuring. The human resource availability is deficient, the spread of health resources in skewed in favour of urban areas, with rural and semi-urban areas bearing the brunt of a non-existent formal healthcare system, and inadequate availability of consumables and equipments. Most rural areas are dependent on unregulated, unstructured healthcare system consisting of quacks, registered medical practitioners, and AYUSH practitioners. These health care providers (HCPs) follow pathies with combinations of drugs, supported by steroids. However, they fulfil all requirements of a quality healthcare system — timely, appropriately priced, addressing expectations, and available, but fail on one requirement — adequacy of treatment provided. Unfortunately, the treatment provided by them is perceived adequate by their consumers, as it addresses their immediate need. But it leads to high proportion of drug resistance, emergence of super bug and evolution of simple ailments into chronic and life-threatening conditions.

The background

There has been a shortage of healthcare providers in rural and other under-served areas like urban and semi-urban slums. The governments have tried many options to make such postings lucrative. Rural postings have been incentivised, both by additional monetary incentives and by providing preference in post-graduate admissions. However, these solutions have been temporary, as they never addressed the root cause of reluctances of medical professionals to serve in such areas.  

Unfortunately, governments believe that forcing doctors to work in rural areas will improve the situation. These unwilling HCPs will never be able to create sustainable and accepted quality healthcare. Moreover, these reluctant doctors will be up against an existing system which fulfils the immediate healthcare need. This forced availability of doctors will neither be cost-effective nor sustainable.

The opportunity

The government formed a committee to suggest the remedy for revamping the health system in India and restructuring the MCI. Based on the recommendation, it came up with the NMC Bill, which was preceded by National Health Policy 2017. The creation of mid-level HCPs through bridge course had the potential to be the game-changer. The 'Bridge Course' was to address the proposal for creation of a mid-level care provider for the expansion of primary care and to provide service at sub-centre and other peripheral levels, as envisaged in the national health policy in 2017. This cadre of service provider was to be developed by upping the competencies of AYUSH doctors, BSc nurses, pharmacists, GNMs etc by providing skill enhancement trainings and providing them conditional licensing and enabling a legal framework and making them available in under-served areas. Enough checks were introduced in the Bill to ensure the quality of the course. The NMC, in collaboration with the other regulatory bodies, was to develop the course content and prescribe the limits within which these HCPs would work. The most stringent check was 'veto' given to every member of the commission for approving bridge course and licentiate conditions. Absolute approval was required. There is no reason to believe that more than 20 experts of allopathic medicine will allow the passage of 'suboptimal' bridge course and licentiate conditions.

Rather than opposing this provision, the IMA should have pressed for appropriate implementation of this provision. 

NMC Bill had the potential of:

1 Making 'appropriately' qualified HCPs available in those underserved areas. Bridge course content and appropriateness of licentiate requirements could have been revised with progress over time.

2 These HCPs would have been culturally and socially suitable to serve in these underserved areas, thus addressing the issue of availability and absenteeism.

3 As these HCPs will be registered, it is easier and feasible to regulate them, thus making their services adequate.

4 Their availability to address the need for primary care will ease pressure on the government. The services of allopathic doctors than can be better utilised in secondary and tertiary care. This has the potential to improve work atmosphere for future generation of doctors.

The contention is, what if these bridge HCPs are not properly regulated? Are we not putting the health need of people in inefficient hands? Many non-corporate hospitals take the services of AYUSH practitioners during evening and night. A majority of the nursing homes are dependent on experienced but unqualified technicians. With this approved bridge course, there is scope for regulation. If the government could regulate just one-third of these bridge qualified practitioners, along with regulating just one-third of chemists in the rural area, more than half of inadequate and inappropriate treatments provided by this unregulated sector could have been prevented. How this will translate into saving drug resistance and strengthening 'health and well-being' is anybody's guess. Better regulation could have exponentially increased the benefits.

This would have translated in a win-win situation for everyone. The government could achieve last mile availability of HCPs, allopathic doctors could better utilise their expertise in secondary and tertiary care, beneficiaries get quality care, and mid-level HCPs get mainstreamed, besides job creation. 

All this is now a distant dream. Additionally, by letting states to decide, the government has taken away the veto power from NMC and thereby the scope of developing quality mid-level HCPs.  This at best is a half measure.

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