Political Economy to Address Physicians

Political economy to address physicians' deficiency

A policy analysis of three-year medicine course in the state of Chhattisgarh, India 1. Introduction- Human resources are central to all public health systems and a considerable share (42% of government share on health expenditure worldwide - WHO report 2006) of resources allocated to public health goes towards them (Public health workforce: challenges and policy issues; Robert Beaglehole and Mario R Dal Poz). Health workers in adequate numbers, in the proper places, and properly trained, motivated and supported are the backbone of an effective, equitable, and efficient public health care system (Rao, K. D. et al). Determining and achieving the 'right' mix of health personnel is a major challenge for most healthcare organisations and health systems with two thirds of health workers are in public sector and one third of them are in private sector. The challenge of shortage in health care organisations is true for health service providers and health management and support workers respectively (The World Health Report 2000. Health Systems: improving performance). 1.1 Public health workforce in India- India's health workforce is mixed and diverse in nature with presence of different cadres of health workers offering health services in different Indian systems of medicine. As per the revised national occupation of classification (NOC) 2004, the health service providers constitute allopathic physicians to practitioners of Indian system of medicine (Ayurveda, Yoga, Unani, Sidha and Homoeopathy- collectively known as AYUSH) and paramedical workers from nurses to midwife and a range of other supportive staff (Directorate general of employment and training, Ministry of labour, Government of India). There is informal sector of health care providers called registered medical practitioners or quacks which are major workforce in rural and urban slum areas. As per the study of Rao. K 2009, about 25% of health care providers belonged to this informal sector. In pre independence era two classes of allopathic doctors were present in the health work force: medical doctors who underwent a five-and-a-half year course and Licentiate medical practitioners (LMPs) with three to four year course. About two third of the rural practitioners were LMPs (Priya R 2005, Gautham M, 2009). The unease of medical doctors and their resistance towards LMPs forced the government to abandon the LMP course in the years following independence. Considering the WHO definition of health professionals (physicians, nurses and midwives) there were 2,168,223 health workers in India in 2005, meaning a density of approximately 20 health workers per 10,000 population. The estimated shortage of health workers is considered around 20% (WHO standard of 25 per/10,000) (WHO, 2007, GOI, 2005) in India. Presently, the doctor population ratio is 1 per 1,598 persons or 62.5 per 100,000 population with wide inter-state variations such as 1 doctor per 471 persons in Delhi, 1 doctor per 714 persons in Punjab and 1 doctor per 26,000 persons in Chhattisgarh (Health workforce in India, WHO 2007; Human resource for health in India, Policy Note #2, Datta, K.K., Public health workforce in India: career pathways for public health personnel, 2009). As per the World Health Report (2006), the density of health workers is directly proportional to the outcome of health especially in vulnerable groups like maternal and child. Several national level policy, plan and review documents outlined insufficient numbers of doctors in government health care service provision throughout the country, both general medical officers and specialists, and the issue has been a matter of government concern for some time (7th five year plan, planning commission, 1985-89, Govt. of India; Bajaj Report, 1987; National Health Plan, 2002). It has again become the subject matter of discussion with significant government efforts to scale-up health care delivery through the National Rural Health Mission (NRHM). The Government of India has increased its financial allocation to health through the NRHM and the new Indian Public Health Standard (IPHS) - norms for health facilities that, to be achieved, will require many more doctors to enter public health service (Indian Public Health Standards). In the given context, a new state Chhattisgarh was created in India, in November 2000, on the basis of high tribal population (32%). Burdened with the poor health infrastructure and human resources from the parent state and based on contextual influence of deficiency of allopathic physicians in rural public health services, the ruling Congress party state government tried to address the multitude of health care delivery issues by creating a new cadre of health workers through the 'three-year course', now called Rural Medical Assistants (RMAs). This study will address the policy issue of human resources in health in the given context with an analysis of different actors, content and processes involved in managing the problem and its consequences (both positive and negative) in the health care delivery system. I also intend to analyse the perspective of skill mix, integrated workforce planning, human resources and service planning, evidence- informed interventions for human resource development & terms of employment and working conditions in health sector reforms. I will make use of local data, literature and personal experiences, interviews and observations. The Walt and Gilson (1994) health policy analysis framework, the Kingsdon model of agenda setting and J. Gaventa (2006) power cube to describe the power relationships with regards to participation and analysis of power and process of policy making for better health outcomes will be used from the literature modified for the local context. The lessons learnt during the study course will be used to analyze the policy process.

2. Context

2.1 Indian context

Demographic profile-The republic of India is a country in South Asia. It is the 7th largest country in the world with 2.1-2.3% of world's land area and 2nd most populous country in the world after China with 1.16 billion population (United nations statistic division 2007). It is pluralistic, multilingual with 1652 different languages and dialects (census of India, 1961, language in India) & multiple political parties both at national and regional level. It is constituted of 28 states and 8 union territories. India is the biggest democracy in the world with democratically elected governments at national and sub-national up to village level. Socio-economic and health status-After being colonized by United Kingdom for more than 200 years and getting independence in 1947, India has grown remarkably becoming 12th largest economy (1235.975 billions, 2941 USD per capita) and 4th largest in purchasing power (International monetary fund, World Economic Data base, 2009) in the world. The growth has reflected in health and social sector also as poverty was reduced from 51.3% in 1977-78 to 27.5% in 2004-05 as per criteria of Planning Commission of India. The life expectancy at birth has also doubled from 37 in 1951 to 65 years in 2000. Infant Mortality Rate has declined from 146 in 1951 to 54 per 1000 live births in 2005 (National Health Policy 2002, National rural health mission, health profile). However there is disparity in health and socio-economic welfare in different regions and caste groups in India. As per the constitution of India, 4 castes have been recognised; general, scheduled castes, scheduled tribes and backward classes with the current estimates of 25%, 7%, 16% and 52% respectively (census of India 2001). However, these achievements are not sufficient to satisfy the health needs of the people. The nation still lags behind in health outcomes more than many other developing countries. Although it accounts for 17% of the global population, it contributes one fifth of the world's share of diseases, a third of the diarrheal diseases, tuberculosis, respiratory and other infections; a fifth of nutritional deficiencies, diabetes, cardiovascular diseases, and the third largest number of HIV/AIDS cases in the world (Report of the National Commission on Macroeconomics and Health, 2005). Role of the states in health care provision in India- Constitution of India through its article 21-"no person shall be deprived of life" and 47-"Primary duty of state is to raise level of nutrition and standard of living of its people and improvement of public health" delegates the responsibility to states to protect, ensure and maintain the health rights of its people. Health system in India- The health system in India is a mix of different systems of medicine which are parts of two groups of health care service providers. These are public and private health care sector. Private health care sector is the dominant health care provider both in rural and urban areas (WHO India country office 2007). It means that the financing of health service is mainly private through out of pocket at the point of delivery of services. Public health system in India- The public health system has two distinct health care delivery infrastructure; rural and urban. The Indian rural public health care delivery system is a 4 tier system from sub centre (SHC), primary health centre (PHC), community health centre (CHC) to district hospital level based on the population criteria under jurisdiction. The sub centre should cater 3-5000 population and manned by health workers male & female whereas Primary health centre should cater 20-30, 00 population and staffed by 15 different health staff including 2 medical doctors, community health centre should envisage 80-120,000 population with 25 staff including 4 specialist medical doctors with finally a district hospital catering the entire district population (Indian public health standards, Bhore committee) There has been a significant increase in public health infrastructure. There was one Primary Health Centre (PHC) for 75,000 population in 1981, whereas, on an average 31,652 population are covered under a PHC as of 2001 almost reaching the target of a Primary Health Centre for 30.000 population (Bulletin on Rural Health Statistics in India, 2009). The average population coverage of community health centre is 173641 (Bulletin on Rural Health Statistics in India, 2009). Rural health infrastructure vis-A -vis coverage area & distances from the village- The average area of SHC is 21.35 sq km, PHC is 132.93 sq km and CHC is 729.2 sq km. With regards to average radial distance from SHC, PHC & CHC is 2.61 km, 6.5 km & 15.23 kms respectively (Bulletin on Rural Health Statistics in India, 2009). With regards to population coverage the average population covered by SHC, PHC & CHC is 5084, 31,652 and 173,641 respectively. The following diagram illustrates the rural health care system in India Urban health system includes a district hospital and network of health centres through the local governmental bodies called municipal corporations in big cities and towns. In big cities and towns there are civil hospitals, Urban family welfare centres (UFWC), health posts and post partum centres. UFWC and Post partum centres are the nodal point for provision of reproductive and child health & family welfare services. Apart from these, there are dispensaries and hospital for employees in formal sector through the Employee's state insurance scheme (ESIS) and Central government health scheme (CGHS) Private health sector- The private sector includes both 'for-profit' and 'not-for-profit' health care providers. The informal sector is also prevalent in the country in the form of faith healers, traditional birth attendants and other unqualified medical practitioners. There are also private pharmacies which also do dispensing of medicines without any formal prescription of physicians. In all, there are health care institutions ranging from general practitioners and one bedded clinics to big nursing homes and corporate hospitals dispersed according to their motive of maximising the profits. Status of physicians in India - With available data there were 920,000 registered doctors in India in 1991, including all the systems of medicine out of which 365,000 were from the allopathic stream and rest from other Indian systems of medicine. Out of total allopathic doctors 75% were working in private sector. The recent figures of medical council of India 2007, state that there are 683,682 allopathic doctors registered in different state medical council and practising. With 72% of India's population being rural the total number of doctors working in rural public health sector i.e PHC & CHC are only 23,858, which corresponds to only 3.7% or 1 doctor per 3,112,820 population in rural public health sector. In another words 60% of physicians are in urban areas and 70% in private sector of health (WHO India 2007). There are large numbers of medical practitioners in the informal sector as well, they are often the first point of contact, mainly in rural and urban slum areas. As per the study of Rao K (2009), 25% of allopathic practitioners belong to this informal sector out of which 42% are in rural and 15% are in urban areas. Another study by Banerjee A in Rajasthan state in 2003, reports that 41% of private medical practitioners had no accredited medical degree. Census estimates adjusted for qualification, which are based on the self reported occupation in National Sample Survey Organization (NSSO) shows that there are 3.8 physicians per 10,000 population than 6 per 10,000; nurses are 2.4 per 10,000 population than 5.8 per 10,000 population; Midwives are less than 1 per 10,000 population than 2.5 per 10,000 population and overall density of health workers is 8 per 10,000 population than 20 per 10,000 population estimated by census of India 2001. Considering the rural-urban distribution of health workers in India (2005), there were large mal-distributions between rural and urban areas in the country with-in the states and there are intra state and intra district variations. The density of physicians in rural area is 3.3 per 10,000 population with regard to urban presence of 13. 3 per 10,000 population, four times higher than rural areas. With regard to other health professionals like nurses & midwife, it is 4.1 per 10,000 population in rural area to 15.9 per 10,000 population in urban area and overall density of health workers in rural area is 10.8 per 10,000 population than 42.1 per 10,000 in urban area. Health Financing- Being the 12th largest economy in the world, India spends 4% of total expenditure on health as proportion of gross domestic product with almost three times increase in per capita government expenditure on health (PPP $) from 12 to 33 in 1995 to year 2008 respectively. But still out-of-pocket expenditure as proportion of private expenditure on health remains almost constant between 91.5 to 89.5 % from 1995 to 2008, one of the highest in the world (WHO, updated national health accounts 2008). Health Policy Trend- The health policy in India dates back to 1920s when British rulers established research into the highly prevalent disease 'leishmaniasis' (then commonly called as British Government disease) in Bengal state (Dutta 2005) and this communicable disease control oriented approach continued even after independence with introduction of many health programmes and action plans for the control and eradication of major communicable diseases after Bhore committee's recommendations. Still the National Health Policy (NHP) in India was not framed until 1983 and since then India has built up a vast network of health infrastructure and initiated several national health programmes impacting the health sector: adoption of the National Health Policy in 1983, 73rd and 74th Constitutional Amendments in 1992, National Health Policy (NHP) in 2002, introduction of Universal Health Insurance schemes for the poor in 2003, and inclusion of health in the National Common Minimum Programme (NCMP) of the UPA (United Progressive Alliance) Government in 2004. Under this programme, health care is one of the main focus areas, where it is decided to scale up the government expenditure in the health from the prevailing 0.9 % of GDP to 3% of GDP over the five years (2007-2012), concentrating on primary health care. The National Rural Health Mission (NRHM) was envisioned for improving the health service delivery in an integrated manner and has been operationalized since April, 2005 throughout the country. Special attention is on 18 states of the country including the state of Chhattisgarh. The NRHM proposes strategies and sub strategies to improve the health status of people. The main strategy is to up grade 100% PHCs for 24 hours referral service, with the provision of two medical officers (one male and one female) on a need based criteria.

3.0 Analytical frameworks used

Gill Walt & Lucy Gilson (1994) have proposed a 'policy analysis triangle' systematically about the interrelationships among policy content, process, context and actors, in policy development. The triangle can be elaborated more on three dimensional axis with regards to relationships. For better analysis, the framework of Walt G. and Gilson, L. (1994) is used in a modified form analysing interrelationship among context, policy content and actors and their impact on the process which has also been used in European Commission supported project of Health Policy-Making in Vietnam, India and China (HEPVIC 2005). Kingdon's (2001) model of agenda setting helps to understand how certain issues get onto government policy agenda and suggests that policy is made through three independent process; the problem stream, the politics stream and the policy stream. The constellation of factors coming together creates an opportunity of an issue to be on the agenda. Gaventa (1996) analyses power through the model of power cube: the levels, spaces and forms of power. The Gaventa power cube framework can be used to assess the possibilities of transformative action in various political spaces.

4.0 Problem Analysis

4.1 Contextual background to the problem analysis- The state reorganisation commission was setup in 1954 to look into the need of creating new states and a new state (the 26th in India) Chhattisgarh was crafted out of a large state Madhya Pradesh in central part of India on 01 November 2000 by Madhya Pradesh Reorganisation commission in 2000. It is geographically the 9th largest state, covering 135,194 square km, it is 17th in rank by population size of 20.1 million (2001 Census). The population is dispersed with a density which is half that of the national average i.e.154 for the state as against 312 per sq km for the country (Census of India 2001, Chhattisgarh vision document 2010) with 40% of the land areas is classified as forest lands. Of the 18 districts of the state, 12 are classified as remote, tribal and extremist-affected areas. Socio-economic and health status- As per the census 2001, 89% population of the state is underprivileged with one third of state's population tribal, the highest among the large states, 12% of scheduled castes and 45% of other back ward classes. The 61st round of National sample survey organisation of ministry of statistics and programme implementation has estimated (based on uniform recall period of 30 days), Chhattisgarh to be the 3rd most poor state in the country with 40.9% population below poverty. With regard to key health indicators; infant mortality rate and maternal mortality rate are 70 per 1000 live births and 397 per 100,000 live births respectively, much lower than the national figure of 39 per 1,000 live births and 330 per 100,000 live births (State health profile, National rural health mission). Despite winning the 4th J.R.D Tata award for population and reproductive health programmes in 2008, the state is facing challenges in multitude of health like deficiency of human resources in rural health services, malnutrition, communicable diseases like leprosy- highest prevalent in the country with prevalence of 2.4 per 10,000 population, tuberculosis and chloroquine resistant falciparum malaria, only 18.1% institutional deliveries, only 59.3% children fully immunised and other aspects of health care delivery. Health financing in Chhattisgarh- Chhattisgarh spends 3.4 % of public expenditure as share of state expenditure which is 0.7% of public expenditure as share of Gross state domestic product. Like other states it receives grant in aid from the federal government and other financial supports for the national health programmes. Rural health infrastructure & training capacity- The rural health infrastructure in the state is on the same pattern elsewhere in the country i.e. Subcentre, Primary Health Centre, Community Health Centre & District Hospital. But the population coverage of all the tier of health service is poor than the country average. This can be explained better in the following table 1.

4.2 Elements of issue as a health policy & political problem

In this context a Congress-led political party took over the governance at the time of creation of state (in November 2000) with upcoming general state assembly (in Indian context a state senate is called as an assembly rather than parliament which is at federal level) elections in 2003. The biggest challenge the state government had faced in the health sector was the challenge of human resources in health. Table 4 explains the existing human resource at different levels at the time of state formation (2002-03) and in 2006-07. The distribution of health professionals across the regions of the country is an important determinant for physical access of health care in the community (Nigenda G., 1997; Wibulpolprasert S., 2003). Chhattisgarh being no exception and a new state experienced the deficiency of human resource in health as well as mal-distribution as most of the human resource in health remained with the parent state of Madhya Pradesh with poor infrastructure in public sector of health specially the rural areas. It still is facing the same problem even after the 10 years of coming into existence. With regards to tackling the shortage of health professionals (doctors, nurses and midwives) the existing capacity to produce trained health professionals at the time of creation of state was very limited. This can be understood by table 5 mentioning the existing capacity to produce trained human resource in health and at the time of creation.

Present Status

• One medical college with capacity of 100 students per year
• One private (for profit) college of nursing admitting 30 students per year in undergraduate nursing course
• 2nd medical college opened in August 2002, got recognition in 2006 with 50 intake capacity
• 3rd medical college opened in July 2007 with 50 intake capacity (yet to be recognised by MCI)
• Government college of nursing with 33 intake capacity (2005)
• Two nursing colleges-post graduate nursing course
• Ten nursing colleges-undergraduate course
• Four nursing colleges-diploma in nursing

With the constraints of limited resources and allocation of resources, the particular interest of government was to address the challenge with respect to physicians. 4.3 Policy options within the contextual setting- Two options were mainly considered by the ruling government; open new medical colleges and scaling up of intake of existing medical college. The other option which was a brain child of Chief Minister himself, to explore the possibility of starting a new cadre course on the pattern of LMP which was practiced in states of Assam & West Bengal but abolished after the recommendations of Bhore committee in 1946. The ruling congress party government considered developing a new 'three- year course' to train medical professionals or 'three-year doctors' as it was then popularly known to serve in rural areas with four reasons

1. Candidates from rural areas are more likely to serve back in rural areas and thus can address the issue of physician's deficiency at rural health services;
2. Less opportunities for them to get engaged in private practice in urban areas and thus can retain them at rural health service;
3. This new cadre can replace the unqualified medical practitioners in informal sector;
4. All this is possible within the three years life span of the political government

4.4 Policy development

Identification of actors with regard to level of power and their position- There were many actors which affected policy process through direct and indirect influence pertaining to their powers, interests, ideologies, personal experience and skills. These actors were

• Politicians both at central, state and local level
• Bureaucrats in Ministry of Health
• Medical Council of India
• Indian Medical Association
• Judiciary
• Private sector in health
• Beneficiaries or service users
• Media
• Others

In the formulation of the policy of starting a three-year course for medicine there were three key actors; State Government, Medical Council of India and Indian Medical Association (a professional body of doctors). In other sense these three actors represented the three different level of powers in the Gaventa cube; the Central Ministry of Health represented by the MCI as an autonomous body which gives its recommendations to the ministry of health for issuing the official notifications, the state government representing the power at state level and Indian Medical Association representing the power at district level. Stakeholder analysis with regards to their power and interests shows that state government was so powerful that it managed only few key stakeholders and engaged them in the dialogue through communication, advocacy, meetings etc. rest of the stakeholders were either informed or monitored for their opposition or protests. Except the state government all the key actors were in opposition for this course. Analysis of interrelationship of places, forms and level of power- Not being a coalition government, (coalition governments are quite common in Indian political scene due to lack of clear mandate) there was no barrier to take major reforms but the time period to remain in the power as a government in the state was limited to only three years to make any sort of impact in the form of visible result.

4.5 Analysis of policy process

Immediately, after taking the leadership by the Congress party in November 2000, there was a formation of a three members committee constituting the professors of medical college to look into the various options to address deficiency of doctors in the state, certainly with a hidden mandate to give the option which is applicable and gives results within the span period of three years, before next political elections (interview with Dr Aadile, Director of Medical Education, MoH, Chhattisgarh). To the expectation, committee suggested the option of starting a three-year medicine course on the pattern of standard medicine course of four and half years for physicians, but reduced version of it. Government took quick decision in proposing option to Medical Council of India with-out consulting any further with different key stakeholders like professional bodies, research institutes etc or looking into the legal and ethical issues or any kind of alliance building. The power of the government expressed in the visible form with out creating any space for the participation be it invited, closed or claimed at least in the matter of deciding on the formulation of new policy. The medical council of India was prompt in responding and immediately refused the proposal of the course simultaneously with another refusal of a proposal to open a medical college from a private sector in one of the districts on the ground of norms and standards not conforming to the set standards and lack of infrastructure and logistics respectively (MCI annual report 2001, 2007). Claiming and using the power of the State Government as per the Concurrent list of Constitution of India with regard to responsibilities of a State in protecting and promoting public health, and for respecting, protecting and fulfilling rights of its citizen (National human rights commission, Public health and human rights, report and recommendations 2001), Government of Chhattisgarh went ahead with the proposal of starting the new course.. After expected refusal from the MCI, the State Government was still committed to initiate the course and high level officials in the Ministry and experts were invited within the department of law, health and general administration to come to a strategy for implementation. The agreement was to create an autonomous medical board through a legislation which implements three-year course. In this case MCI would not have to approve the course. Within no time the special session of the State legislative assembly was convened and the CCM act was passed on 2nd March 2001 with the name of the course termed "Diploma in modern medicine and surgery". The administrative process was hastened to officially start the CCM and proposal was sent to ministry of finance for the approval. Ministry of finance, a powerful stakeholder and in opposition by its position objected to financial liability for the government. The consensus was sought again to contract out the implementation to the private (for-profit) sector and appointing the civil servants as the members of the CCM as an additional charge to avoid any financial commitment. The approval of ministry of finance on 29th March 2001 cleared the way for the creation and functioning of CCM. Being a hot issue and political priority in the circle of Ministry, the administrative clearance was smooth and after the approval of the cabinet meeting, the final approval by the Governor of Chhattisgarh on 16th May 2001 cleared the entire path for the implementation process.

Policy implementation process

Creation of CCM and its role The CCM comprised the Director of Health Services as President, the Dean of the Medical College in the State capital as Vice-President and a District Chief Medical Officer to be as Registrar. With such limited initial capital and human resources in CCM, the new body was a limited institution but authenticated with enormous powers. The powers given to this autonomous body were more than the medical council of India (MCI), another autonomous body established under the MCI act of 1956 enacted by parliament of India, which is responsible for accreditation, registration, regulation & ethical conduct of different medical courses and institutions in the country (MCI act 1956). The powers given to CCM included-

1. To initiate the process of contracting out & identify the private sector for starting the new institutes for the three-year course
2. To formalise the syllabus and initiate the admissions process
3. To have power to change the syllabus of the course
4. To look into financing of the course like tuition fees etc. for the three-year course
5. To be responsible for undertaking the examinations process; and
6. To be the registration body for graduates from the three-year course.

Privatisation of medical education- There was no objection from the ministry of finance because of clear understanding about non public funded entities for three-year course. Private funded institutes with public interest were a big step which can be understood by the figure9.

Standard Operating Procedure

The expression of interest was floated with a condition to open the institute in rural area close to district hospital for clinical trainings. The minimal operating procedures yet to be finalised and finalisation of the last two years of course curriculum, three participants were selected out of 15 bidders to open the institutes. The members of CCM being civil servants with additional charge as member had limited experience in determining the minimum standards of infrastructure and course development. The initial mandate was to start only three institutes with intake capacity of 100 students per year for each one of them but on the contrary, another three institutes were opened in the later part of 2002 with intake capacity of 150 as against 100. The staff and infrastructure for all the three institutes seemed to be in-sufficient as understood in interviews with key stakeholders. The staffs were senior physicians in district hospitals and visiting faculties from medical college. Some of the district health officers also came for teaching with no previous experience of medical teaching. Selection criteria for the selection of students once again was influenced by the fact that it was a private funded course and the seats were distributed in three categories; i) Free merit seats- 50% (75 seats), ii) Payment merit seats- 33% (53 seats), iii) Non resident seats (NRI)- 15% (22 seats). The criteria of selection was to interview the applicants based on the cut off points of 75% in the higher secondary school leaving examination with biology one of the compulsory subjects. The first advertisement saw a good response with over 9000 applications within 20 deadline days and applicants were allotted the institute as per preference of choice and against vacant seat. For the admission of third batch even the interview did not take place and admissions were given directly in the institute. One reason was the low interest of the students due to two critical events; one was the legal issue of course name and content and second was the administrative resistance to continue with this course. Overall, 2200 students were selected in all the six institutes for three consecutive years but only 1391 completed the course as rest of the students dropped out due to uncertainty of the future of the course explained in table 5

Course fee, curriculum & teaching faculty

Each candidate paid USD 1,000 (INR 45,000) as a yearly course fee excluding the seats for Management & NRI quota, which were sold many folds of the standard fee structure. The course curriculum was designed and approved by eminent medical experts and professors and approved by a committee but to arrange for faculty remained a problem due to un-availability, hiring & remuneration issues. The teaching was arranged through experienced district hospital officers and visiting medical college faculty from State capital. Table 6 explains the curriculum of the course. Critical events and future pathway- Over the course of time three critical events changed the entire pathway for the policy of starting three-year course. These critical events are- (i) Public interest litigation (PIL) by Indian medical association in high court in May 2001 (ii) Strikes and agitation by the students in 2003, 2004 & 2006 (iii) A new political ruling party formed the government in November 2003.

Legal issues and their influence on the course

The professional body of doctors, IMA, sought judiciary support in high court objecting the name of the course, its duration and content against the standards of allopathic doctors. Government acted swiftly in anticipation of legal influence on the course and changed the name of the course to "Diploma in alternative medicine" to remove the two words 'surgery' and 'medicine' from the title of the course. Also, there was inclusion of other subjects like acupressure, magneto-therapy, physiotherapy, bio-chemic medicine etc into course content to justify for the name of alternative medicine. There were many issues which were still unresolved, which made government to act in defensive way to avoid legal barriers. These issues were-

1. Transparency in admission process
2. Finalisation of the course content
3. Accreditation of graduating students by diploma or certificate
4. Hiring of teaching faculty and their remuneration
5. Institutional provisions related to standards
6. Provision of stipend during internship
7. Future carrier pathway

Administrative ignorance for the course and subsequent events

Despite the strong political interest and use of its powers there was still lack of alliance building within the ministry. Another important step taken by the government was to relieve the secretary health, who is an administrative head of the ministry of health, from the task of three-year course. Instead, the task was delegated to a senior professor of public health department in the medical college who was given a political post of 'officer on special duty' (OSD). The role of the OSD was to act as a link between president of CCM and secretary health. But on the contrary OSD was asked to report directly to chief minister than to secretary health or director of health services. This arrangement was made to consider the work overload on secretary and director but negative externalities of this step less and less information sharing and more communication gap between CCM, secretary and OSD. The pending legal issue and mounting pressure from the students forced the OSD to suggest a proposal of affiliating the institutes to universities and change the name of the course to 'Diploma in holistic medicine and paramedical course'. The idea behind this proposal was to relieve CCM from the responsibilities of conducting examinations in the face of adverse verdict of the high court and accreditation of the course from the State Paramedical Council which will attract less resistance from paramedical bodies having less power, in the face of country wide criticism of the course in the media and elsewhere. This step proved to be wrong as the process of affiliation with universities delayed the examination of all the batches by six months to one and half year and agitation by the students against the 'paramedical' word in the diploma, which means that this course was no longer a medical course as posed at the time of admission and advertisement.

Strikes & agitation by the student

Lack of initial preparation into development of the course and standard operating procedures led the course on a path of confusion and uncertainty among students and their families. The change in the name of the course was enough for the students to express their dissent on future outcome of the course. There were three strikes and demonstrations by the students in January 2003, July 2004 & December 2006. The first strike forced the government to drop the word 'paramedical' and re-name the course to "Diploma in modern and holistic medicine", the second strike again made the new government to change the name of the course to "Practitioner in modern and holistic medicine" and the third strike which was the longest and most crucial one forced the government to increase the duration of internship from six months to one year and assure the students for the government job security and recognition of the course by the state medical council. Table 7 explains the delay in course.

New government formation by another political party and subsequent policies

The Bhartiya Janta Party (BJP), another national political party formed new government in November 2003 after general elections in the state. Understandably the three-year course was no longer a priority. Further admissions for three-year course were stopped in after the third batch as the course had already seen a difficult future outcome with uncertainties. Government decided to have a fresh look at the course with change in leadership both at political & administrative level with new health minister, secretary of health and no longer an OSD. Immediately, after taking over government faced 2 strikes by the students and finally announced officially to stop the course on 1st September 2008. However, government had still to find an answer to use this trained human resource in health.

Subsequent events and final outcome

Article 41 & 46, of part I of constitution of India, iterates the responsibilities of a state to protect right to education and promote educational rights of all classes with special emphasis on weaker sections of the community. With regards to medical education, state medical council can not contradict against the recommendations of MCI for accreditation, regulation and approval of a new course unless the course is recognised by a state medical council (MCI act 1956, Supreme court decision on civil appeal no 152, 1994). The CCM did not enjoy this status as it was neither a legal body nor registered in the state medical council. Recognition of course under paramedical council also failed due to students' strikes. However, still a person can practice medicine if registered under a separate state medical register in a state medical council for a separate course (Section 15(2) b, MCI act 1956). Different options were considered, right from creating a new post (both medical and para-medical) to appoint them under already existing vacant para-medical positions. Some options were refused by finance ministry and some did not draw attention of graduates. Provision of a second medical officer at PHC on contractual basis under Indian Public Health Standards (IPHS) and fund availability through the NRHM saw some ray of hope. Considering the existing vacant positions of doctors in PHCs and status quo for foreseeable future, finally, it was a prudent step to post all the graduates to vacant remote PHCs under the new name of 'Rural medical assistants' (RMA). The words medical assistant was welcomed by the graduates and they willingly accepted this arrangement. Remuneration was fixed at USD 180 (INR 8,000) as against USD 340 (INR 15,000) for medical doctors and this was never a financial burden for the state government even in the scenario of ceasing the fund from NRHM in near future, state finance budget taking up this activity. The postings started in 2008 after RMAs finished one year of internship comprising of one month posting in SHC, three months in PHC and four months each in CHC and district hospital. Table 8 explains the postings of RMAs in different districts according to the classification. The provision was made to appoint all the male RMAs to PHCs and females to CHCs considering the different aspects of security, access and other enabling conditions.

Job descriptions of RMA

In lieu of basic minimum package of service provision as per the national health policy 2002, all the RMAs were given responsibility to provide minimum services thereby improving the service delivery and access of the community to public health services. The important tasks allotted to them are following-

1. Curative services for common diseases and ailments and use of essential generic drugs available at PHC & CHC
2. Preventive and promotive health services
3. Referral of cases after primary treatment support
4. Maternal and child health services except the caesarean section and invasive contraceptive procedures
5. Simple surgical procedures like wound suturing and dressing, abscess drainage, applications of splints in fracture cases etc.
6. Assist in implementation of all national & state health programmes
7. Attending regular meeting of the supportive staff
8. Any other responsibility assigned by the medical officer in-charge of that health facility or by the state

Policy influence at central level

India committed to improve the health service delivery and quality health care in alignment of MDG saw new minister of health after the new government took charge in 2008. The new minister also faced the same challenge of having limited workforce in public health sector. In order to address the human resource crisis he visited some countries to have an understanding of it and in the process visited China. He was quite impressed with the arrangement China has made giving more emphasis on task shifting and training cadres in basic minimum package of services. On return minister consulted with the technical body of the ministry and in the process invited high level officials from Chhattisgarh to share the experience of RMAs policy process and implementation. On 6th February 2010 Government of India announced to launch a new course of 'Bachelor of Rural Medicine and Surgery' (BRMS) to fill the gap of physicians in rural health services. It still needs to be passed by the Parliament of India, a supreme body to make it as legislation.

Policy output

Within this context and policy development & implementation RMAs have been posted in rural remote PHCs and CHCs. They have started functioning but its still early days to comment on their performance. But, as a matter of fact that coverage of the PHCs & CHCs has improved with regards to availability of a person trained in modern medicine. A recent study has been conducted by Public Health Foundation of India and its partners (2009), comparing the performance of RMA with physicians and medicine dispensing ISM practitioners and others (Rao, 2010). 5.0 Discussions- Analysis of RMA policy response by the state of Chhattisgarh has ignited the longstanding issue of idealism of ethical medical practice in rural areas and the reality of absence of physicians in rural areas of India.

Reasons for shortage of physicians in rural areas and need for policy options

In reply to a question in the Upper House of the parliament, Government of India notified that there is no shortage of physicians in the country with regard to aggregate numbers, estimated to be 683,682 i.e. 6 per 10,000 population, in 2007. Still, only one in 10 physicians works in rural area (Press Information Bureau of India, 2007). Multi-factorial reasons for the rural-urban mal-distribution are related with social determinants, working and living conditions, better income opportunities, higher work satisfaction and lack of continuing medical education in villages (Kalantri S., 2007). Also, every year 40% of medical graduates go for specialisation after which no body opts to serve in rural areas. This may further worsen if trend continues like in Egypt where 62% of physicians are specialists (G. Gaumer, 1999) As per the document of Government of India for its National Health Policy 2002, most of the ISM trained professionals are practising westernized medicine due to poor regulations and regional bias. Although, this kind of practice is violating the Supreme Court's ruling of 1996 and 1998, prohibiting ISM practitioners from practicing modern medicine but this has been facilitated by the absence of physicians in rural and economically backward areas of the country and also with the training of traditional healers in modern medicine in their teaching institutes (Burman P., 1998; R. Bilimagga, 2002). This kind of access to modern medicine and mushrooming of private pharmacies in India has somehow responded to the demands of the community and hence it has remained a top-down policy approach by the governments and bureaucrats and not bottom-up approach where community gets involved in policy process.

Ethical Issues on practice

The medical education in India in public sector is highly subsidized against the privately funded institutes where the students have to personally finance their expensive studies. This can be considered an investment which will pay dividend after the completion of studies. With 50% of medical graduates out of total 30,000 yearly passed outs, coming from private medical institutes, it's useless to expect them to serve in rural areas with no incentive of any kind (MCI, 2007). The mechanisms are lacking to orient medical graduates to repay their subsidized education as an ethical and moral obligation in the form of ensuring equity and equality of health care services to the society. Lack of family medicine in medical curriculum and less than 3% of seats for Community Medicine as a post graduate degree in the medical institutes are also one of the reasons apart from societal pressure for the medical graduates to go for specialisation. The issue of ethical obligation becomes further complex when there are precedents that more than 56% of medical graduates migrated internationally form one of the premier medical institutes of the country between 1956 and 1980 (Khadria B., 1999; Kaushik M., 2006)

Privatisation of Medical education and its effect on the rural health services

Chhattisgarh government decided to privatise the RMA course in alignment with the policy trends of federal government. India adopted structural change (as advocated by World Bank) in its policy of medical education thus opening it to private 'for-profit' sector in health with a public health goal of providing trained human resource of physicians to bridge the gap among 'what is required', 'what is produced' and 'what is available' to serve in the rural areas where more than 60% population of India live. As per 2007 figures of MCI, the number of privately funded and managed medical institutes are 49.8% (134 out of 269) of the total medical institutes in India and still growing at an enormous pace which is almost an increase of 900 percent since 1950 till 2004 (Mahal A 2007). At current rate more than 30,000 physicians are produced every year which is 4.5% of total number of physicians in India, estimated to be 683,682 in 2007 (Press Information Bureau, Government of India 2007). This has although led to improvement in aggregate numbers of physicians but simultaneously has increased regional inequities and mal-distribution of physicians in rural and urban areas (Mahal A. 2007).

Quality of medical education in privately funded institutions

Rapid growth of private medical institutions has shown its effect on the quality of education as understood also with the RMA course with in-sufficient staff and infrastructure. Despite laws for infrastructure and quality standards set by MCI, poor implementation of it has led to decline in quality of medical education (MCI regulations act 1999, Government of Andhra Pradesh Medical rules 2004). There are evidences for poor staff & infrastructure (including hospital beds) in private medical institutes as well as corruption in the admission process and high fees in different quota seats and in MCI, affecting the quality of medical education (Dutta R.,2002; Deccan Herald News, 2004; Tilak J., 2002; Kumar S., 2004). Understandably, with two fold increase in production of physicians from 12,000 to 24,000 from 1980 to 2004, the un-availability of faculty in medical institutes can be imagined (Mahal A., 2007).

Policy options to address the physician deficiency in rural areas

To address the problem of availability of physicians at rural public health services, there have been many strategies practiced in the past in India. Each option is having its strengths, weaknesses, opportunities and threats as well as positive and negative externalities. These options are

• Positive discrimination for rural area candidates in medical education;
• Subsidized medical education for rural candidates;
• Compulsory rural services after medical graduation;
• Open new medical colleges in rural areas;
• Scale up of intake capacity of existing medical colleges;
• Contracting-out and Contracting-in;
• Workforce management;
• Incentives (financial and non-financial);
• Non-physician medical practitioners.

In the past many approaches like preferences to rural candidates for medical education, compulsory rural practice, opening up of medical colleges in rural areas, penalising physicians for not following the rural service bond etc. have been practiced in India to attract young doctors to the rural health services but many of them could not succeed to attain the desired results (Kalantri S 2007). The Government of India, in 2007, tried to impose mandatory one year rural internship before awarding the medical graduation degree to the students after their course as is practiced in other countries like Singapore and Malaysia where mandatory National Health Service is for three years (K. Ramdoss 2007; Press Information Bureau, Government of India 2007). Incentive approach both financial and non-financial is one of the important strategies tried in many states of India like positive discrimination for specialization for in-service physicians, practiced in Haryana state and higher salary structure for physicians to serve in remote rural areas practiced, in the state of Himanchal Pradesh, Uttarakhand and Chhattisgarh (Rao et al 2010). But it involves a human resource in health (HRH) policy and plan at national and sub-national level as also advocated in the 'WHO guidelines for policies and plans for human resources for health in WHO African region'. Compulsory rural services is already in practice elsewhere in the state of Tamilnadu (after medical graduation) and in Maharashtra as a pre-requisite for specialisation after medical graduation. Opening up of medical colleges in rural areas (as in the state of Gujarat) and scaling up of intake of existing medical colleges have also not succeeded to attract physicians to work in rural areas although, MCI announced to open 100 more medical institutes in rural areas in coming years (DNA news, 2009). Public-private partnerships in the form of contracting-out the primary health care to NGOs like in the state of Karnataka (Prashant N. S., 2008) or contracting-in doctors from other states has also not worked out due to issues of accountability, co-ordination and regulation. Even direct recruitment of physicians from the technical directorate as happened in the state of Haryana or taking decisions on posting of physicians to remote rural areas centrally like in the state of Uttrakhand has also failed due to nepotism, regulations and control. Failure of all the policy responses is due to inability to consider context, cultural belief and practices and lack of a human resource policy plan at national and state level.

Need for non-physician clinicians and evidences elsewhere

Each country has developed its own way to address the deficiency of physicians at first line health services. Trained non-physician clinicians have provided curative, preventive and promotive services as a minimum package of activities where there is shortage of physicians. This coping mechanism is seen both in developed and developing countries. This cadre is known by many names like clinical officers, health assistants, nurse practitioners or health post aides (Tamas Fulop MIR, 1987; Mullan F., 2007; Huicho L., 2008). As per the study of Mullan F (2007), non-physician clinicians are present in 25 out of 47 sub-Saharan African countries. In some African countries they are the mainstay of the health care delivery system in absence of physicians and provide curative as well as some surgical services also (Mc Cord C., 2009). Even in Asia, the strategy of bare foot doctors in late 1970s was in practice which was a similar kind of attempt to address the scarcity of physicians. In India also similar practice was in vogue in the form of Community Health Workers in 1970s (Haines A., 2007). In India, there is a strong debate on the exclusive cadre for rural health services and many key stakeholders have expressed their views against it (IMA Kerala, 2010; Mudur G., 2010; Ramdas A., 2010)

Conclusion

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