Elite resistance and BHRC

On February 27, the Delhi High Court slapped contempt notices on the Union Health Secretary and the Chairperson of the Medical Council of India (MCI) for their non-compliance with its order of November 10, 2010, to initiate measures to introduce a “Bachelor of Rural Health Care (BRHC)” course of three and a half years by March 2011 to meet the primary health care needs in rural areas. The measures included finalising a curriculum and syllabus for the course. The order was issued following several hearings on Writ Petition (Civil) No. 13208 of 2009 by Meenakshi Gautham, a public health specialist, and the Garhwal Community and Development Society (GCDS).
On the basis of submissions by the MCI and the government (namely, the Union Health Secretary), the court had said in its November 2010 order that the MCI should finalise the curriculum and syllabus within two months (that is, by January 2011) and that the Ministry of Health and Family Welfare should start the course within another two months (March 2011). Since the order was not complied with for nearly a year, Meenakshi Gautham filed a plea to initiate contempt of court proceedings against the respondents. The court gave four weeks for the respondents to respond to the contempt notice. The respondents made their submissions in March/April.
To recall, the BRHC was envisaged as a course aimed at creating a special cadre of health care professionals to render basic primary health care to the medically unserved and underserved rural population. This was proposed following the recommendations of the Task Force of the National Rural Health Mission (NRHM) in its report of 2007 and the November 2007 resolution of the 9th Conference of the Central Council of the Ministry of Health and Family Welfare ( Frontline, February 26 & April 9, 2010). The idea of such a cadre, distinct from graduate MBBS doctors, was mooted to address the acute shortage of skilled and trained health care workers in rural India. It was meant to impart the basics of primary health care through a short-term degree course in medicine to students who had passed 10+2. They would be recruited locally and trained at a district-level college or institution. After graduation, they would be required to serve in their home regions for a given period.
Three-fourths of the country’s 0.5 million medical graduates function in and around urban areas, serving less than one-third of the country’s population, while the rural population is deprived of even primary health care. There is also a geographical imbalance in the training of what is called Human Resource in Health (HRH). Only 193 of the 640 districts have a medical college, while the remaining 447 districts do not have any training facilities, according to the Steering Committee on Health of the Planning Commission for the Twelfth Plan. The World Health Organisation (WHO) recommends 25 health care workers for 10,000 people, but India has only 19, of whom only six are certified doctors. The urban density of doctors is roughly four times the rural density (13.3 in cities against 3.9 in villages, for 10,000 people). If this estimate is adjusted for the qualification of the health care worker, the ratio becomes even more skewed – 11.3:1.9.
The primary health care infrastructure comprises sub-health centres (SHCs), primary health centres (PHCs) and community health centres (CHCs). The SHCs are the most peripheral and constitute the rural community’s first contact point with the health care system. It is at the PHC level that the village community has its first contact with a certified medical officer (MO), a qualified doctor with an MBBS degree. At present the SHCs are not designed to have medical officers and have only auxillary nurse-midwives (ANMs) and male health workers (MHWs). A CHC is a referral unit for four PHCs and has specialised services rendered by surgeons, obstetricians, gynaecologists, physicians and paediatricians.
The table shows the current gaps in HRH in the rural public health care system. The 24 per cent shortfall of qualified doctors at the PHC level is fairly significant. In fact, the shortfall has been increasing steadily in the past few years. Given the HRH requirement in 2020, this gap is likely to rise steeply, particularly if the goal of universal health coverage (UHC) is to be achieved in the next couple of decades. It is to address this critical gap that the BRHC course was proposed. The High Level Expert Group (HLEG) constituted recently by the Planning Commission has also supported the proposal. The Group’s report of November 2011 on universal health coverage says: “We recommend the introduction of a new three-year BRHC degree programme that will produce a cadre of rural health care practitioners for recruitment and placement at SHCs.” The Planning Commission’s Steering Committee on Health for the Twelfth Plan has also endorsed it.
Unfortunately, a realisation of the importance of such a cadre seems to be lacking both within the government and the MCI, the statutory body concerned with medical education, which was asked by the Ministry to design the curriculum for the proposed course.
One of the main reasons for the government’s soft-pedalling on the issue is the opposition to BRHC from the largely urban-centric fraternity of medical professionals, which seems to influence the MCI as well. The Indian Medical Association (IMA) has attacked this course and has resorted to placard-carrying processions and dharnas in different parts of the country. Now it has called for a nationwide strike on June 25 to protest against many of the government’s policies relating to health. The BRHC is among the policy decisions the IMA opposes, and it calls it “sub-standard”. It is not clear how the IMA has come to this conclusion when the curriculum and syllabus are yet to be finalised, unless it is privy to the deliberations of the Board of Governors (BOG) of the MCI. The High Court issued the contempt notice because the BOG failed to come out with a course and notify it as it was required to do.
“Life of a person living in the rural areas,” the IMA has argued in its statement, “is as important as the life of a person living in urban areas. As such there are no diseases confined exclusively to the rural or the urban areas. By introducing separate set of medical professionals exclusively for rural India, the government is in fact resorting to discrimination against rural citizens by treating them as second class citizens. This is violating Article 14 of the Constitution of India [Right to Equality].” It has also put forth other non-workable and infeasible propositions to address the shortage of medical professionals in rural areas.
Its elitist and urban-centric perspective is revealed when it argues thus: “Doctors not going to rural areas is the problem of governance. Adequate allowances and facilities like rural service allowances, proper free accommodation, and education allowances for children, vehicle or vehicle allowances, appropriate reservation for education and employment for their children, sabbatical leave for academic enhancement of doctors, allowances for attending academic conferences for updating their knowledge, facility for interest-free personal loans should be provided to doctors serving in rural areas. This will attract doctors to rural areas.” Clearly, the IMA is completely missing the rationale of it all.
If evidence was required to prove why the IMA and other opponents of this course are wrong, a study carried out by Krishna D. Rao, associated with the Public Health Foundation of India (PHFI), in 2009 in a region of Chhattisgarh provided it. The study made a comparative assessment of the performance of different types of clinical care providers working at the primary health care level. The region chosen for the study was one where the public sector could not provide adequate medical officers at PHCs. Interestingly, Chhattisgarh was one of the first States (besides Assam) to create a cadre of rural health care providers called rural medical assistants (RMAs), who were trained for three and a half years and interned for a year. RMAs are currently serving several PHCs where there are no medical officers. However, the IMA opposed this course and forced the Chhattisgarh government to shut it down after it had run for a few years.
The study compared medical officers, RMAs, AYUSH doctors and paramedical staff (nurses and pharmacists) in their capacity as the main providers of clinical services at PHCs. It found that medical officers and RMAs are equally competent to manage conditions commonly seen in primary health care settings. AYUSH doctors are less competent, while paramedics are the least competent. This was true for infections and chronic and maternal health conditions and for a range of patient types, from infants to adult men and women.
Overall, the study found that in primary health care settings, clinical care providers with shorter-duration training were a competent alternative to physicians. The findings of the study thus endorse the introduction of rural cadre such as the RMAs of Chhattisgarh or those with the proposed BRHC degree. “Indeed,” said the study, “limiting BRHC graduates to serve only at sub-centres, as is currently proposed, is under-utilising their potential in a rural environment of physician shortages.” The study noted that many States were posting AYUSH doctors to fill the vacancies of medical officers at PHCs, but it expressed doubts about the appropriateness of this practice.
The study made a related, and important, point that successful primary health care is built on the trust and rapport between the health care worker and the community. Emphasising the importance of the health care worker’s continued engagement with the community, the study countered advocates (like the IMA and the MCI) of human resource policies that involve placing medical professionals in PHCs for a short duration (for instance, compulsory rural service for a few years). “In some ways,” the study said, “the debate over whether non-physician clinicians are a reasonable substitute for physicians misses the point because the correct comparator is not the physician but the situation where no physician is present. Non-physician clinicians offer a substantial improvement over the latter.”At present there seems to be some sort of a stand-off between the government and the MCI on the issue. This is clear from the statements made by Health Ministry officials and the Minister on different occasions. According to a report in The Hindu on April 5, 2011, Keshav Desiraju, an Additional Secretary in the Ministry, stated that the MCI did not want to notify the course because in its opinion the course was not medical training and was not meant to produce doctors. “But we certainly are not scrapping the course,” he said.
In October 2011, a news report said that the Union Health Minister Ghulam Nabi Azad had given a three-week deadline to the MCI to endorse the new course, failing which the Ministry would issue a directive to it to introduce the course. According to him, the course had the backing of all the State governments.
“We want an MCI stamp on the degree so that it is universally recognised,” the Minister said. “The syllabus is ready, and it is need-based. If the MCI endorses it, students will get the confidence that the degree has a standing,” he added.
In fact, in its response to the contempt notice, the Ministry has stated that it had prepared the BRHC syllabus and curriculum in October 2010, which was sent to the MCI for its comments on October 28 that year. In response, the MCI sent its detailed comments, based apparently on the report of its Chairman of the Undergraduate Working Group, to the Ministry on December 28. These comments suggest that the MCI and the Ministry are not on the same plane on the nature of the course.
The MCI wanted the course to be redesignated as BSc in Rural Health Sciences. It added that the holder of this degree would not be qualified to practise independently as a fully competent medical practitioner. It also opined that the subject content included in the syllabus was too vast and might not be feasible. It suggested that the course should be redesigned to meet the generalist approach to the basic concepts of preventive medicine, symptomatology of disease, early management of common diseases (mainly acute conditions) and early recognition of complicated and complex problems.
In response, the Ministry said on January 25, 2011, that the MCI should stick to its previous stand as the issue (of the course name and syllabus) had already been discussed comprehensively.
Specifically, the Ministry clarified to the MCI that a person trained in BRHC should be allowed to treat independently all those conditions for which he/she has been trained within the overall set-up of an SHC and outside at the PHC/CHC level. On February 2, the Ministry asked the MCI to finalise the curriculum expeditiously and notify the course. In response, on February 7, the MCI again insisted that the course be called BSc (Rural Health Care) and added that it could be modified according to the local needs of each State.
It is pertinent to reiterate the recommendation of the NRHM’s Task Force. The course, it said, “was not aimed at producing short-course health practitioners with an open licence to practise across the entire allopathic domain but towards establishing a short-course training wherein non-clinical principles would be meshed with clinical training. The graduates of this course would be licensed to provide medical services within a notified package of primary health care.” So it is somewhat puzzling how this entire debate arose about the vast contents of the course or the degree holder becoming a fully independent medical practitioner.
Interestingly, neither respondent has submitted to the court a copy of the proposed syllabus for the course. Further, the so-called report on the course that the MCI has submitted to the court is nothing but an e-mail exchanged on December 23, 2010. The MCI, which has been opposed to the idea right from the beginning, appears to be confusing the issue deliberately to delay the introduction of the course.
Between February 2011 and December 2011, despite the urgency demanded by the Ministry, the MCI did not take any steps towards finalising the course. Even in the MCI/BOG meeting of December 5, 2011, the topic was only discussed peripherally and there was no focus on finalising the syllabus or notifying the course.
From the responses of both the Ministry and the MCI to the contempt notice, it appears that since the Parliamentary Standing Committee also started independent deliberations on the BRHC course in January 2011, both thought it prudent to put the issue on the back burner. In his response, the Chairman of the MCI/BOG has stated that he appeared before the Standing Committee on December 27, 2011, and assured the panel that the MCI would finalise the course by April 2012.
Accordingly, the MCI /BOG deliberated on the BRHC on January 6-7, 2012. Action plans and a road map for introduction of the course have apparently been drawn up. The MCI is now calling it BSc (Community Health Care). On the basis of the experience of Assam, it has also called upon the Ministry to draft a piece of legislation for the introduction of a short-duration medical course. The Parliamentary Standing Committee is yet to submit its report, and it is not clear if the MCI will make public the course before that. It is not even clear if the Ministry has accepted the new nomenclature for the course and whether it is involved in these deliberations of the MCI.

The hearing on the contempt case is slated for early July. Things may become somewhat clearer then, nearly five years after the Task Force made its recommendation to ensure better rural health care.

A different perspective on sexual assaults on women in India

After recent much-publicized incidents of molestation and khap panchayat fatwas, there have been a lot of discussions, finger-pointings and public outrages. Obviously accused will be punished, but the everyday incidents, which do not get much publicity, will remain unaffected unless we dispassionately discuss and find solution to the problem of “sexual assaults on women in India”. For that to happen, we have to look at the issue as a social phenomenon, not as a problem of an individual. We have to put away our rage and look at individual manifestation as a symptom of deeper social problems. Demonizing all men as perverts and whole Indian society as patriarchal society having sick rotten value can take us nowhere. So, lets go into the basis of the issue.

Every society has some moral values which are based on the history and the environment of that society. We must be very clear from the onset that no value system or morals are right or wrong. Righteousness of value system depends on the place of that particular society in time and space. Nobody has right to say that his/her moral values are purer than somebody else. I would even go to the extent of saying that even a cannibal is morally correct in his/her position, if he truly believes in those values. Second peculiar thing about value system is that it changes with change in technology, but the process of change in value system is very slow, compared to pace of change in technology. In the mean time there exist two sets of value system in a single society. India is going from one of those changes.

As all of us know, the empowerment and sexual liberation of women is not in tune with the traditional value system. So people holding traditional value system see a modern woman as a delinquent. This view, typically found among people born before 60s, is cause of tacit and even vocal support of larger society to the incidents of sexual assault on a modern woman. Society always finds mechanism to punish delinquents, by enforcing laws, by mob behavior or by social comments. I will emphasis on the point that, in my opinion, there is nothing wrong in their value system and they have every right to protest against the supposed delinquent. Law can not, and at-least society will not punish anybody who seems to uphold the value system of society. So intelligentsia of society, which is not more than 5% of total population should forget that larger society is going to oppose these acts any time soon.

You will hear many say that society which worships Durga/Saraswati treats its women so badly. But these comments are with no theoretical basis, because the society which worships durga doesn’t find modern women fitting in its idea of a proper woman. That is why you will find a minister supporting diktats of khap panchayats in UP, people not coming forward to help a girl who is molested by crowd for drinking alcohol in Asom, or any aunty in your neighborhood telling a girl not to dress provocatively. This view of society may change with the changing time and meanwhile we can not blame people for their attitude, because they are just being good citizen, following their value systems and doing what is right in their opinion. In moral science, intent to do right thing is more important than content of that deed. So the society is going to face this tussle until a value consensus is developed on social issues. Education can play an important role in changing that attitude. But confrontation should be avoided with older lot, if we can, over such issues in our already divided society, because as I already said, nobody is right or wrong, they just have different values. Read an incident based on kissing in public issue here

After the above analysis, mind asks, if social delinquency of modern women is the main cause of sexual assault then why so called traditional women face these problems. In modern indian society men have created an image of perverts for themselves. Touching woman bodies in buses, leering after women in public places, frequent sexual advances in offices and heavy popularity of item songs are some examples of such behavior. If we think about root cause of this problem, then mind wanders to a deeper problem of value-system mismatch in modern indian society.

Before going deeper in sociological analysis of “growing sexual assaults on women in India” I would like to narrate an interaction I had with an auto-rickshaw-wallah in Delhi. I was going from IIT Delhi to Greater Kailash to meet one of my friend 2 years back. This auto-wallah had a picture of Lord Shiva on one side of his speedometer and that of Gandhi on the other side. I have a habit of talking with auto drivers when I find something interesting in their auto. So we have had a discussion about religion and Gandhi and all kinds of moral issue. You know how knowledgable and moral a man on streets of India really is, about worldly affairs.

When we were passing from Saket, there was a group of young girls, wearing short skirts, talking loudly, having fun. They passed in front of auto, when it was standing at a red light. The auto-driver abused them, calling sluts and other related words. When I questioned and requestioned his morals on this issues, he admitted that main problem was that he sees sexually attractive females everyday, but as he was living away from his wife, he has to control his sexual urges. This deprivation leads to frustration against those females unconsciously. I appreciated his honesty. Few weeks later, if my memory didn’t fail me, I saw his name as the accuse of a rape case in newspaper. I support whatever punishment court grants him, but I somehow felt sadness for him at that time.

Let us consider two paradigms here. In traditional indian system, age of marriage was just after attaining the puberty, ie 13-14 years. So the value system dictates that there shall not be any pre-marital sexual relation and prime importance was given to virginity and modest behavior. There was very less spatial mobility, so people lived with their spouses whole life. In modern western system age of marriage is 25-30 years. So the value system allows sexual relations before marriage. But in modern indian society we are seeing hotchpotch of the two systems. The age of marriage is raised due to career orientation and awareness about safe motherhood. But the value system still frowns upon pre-marital sex. This has created an army of sex-deprived individuals among 15-25 age group. They may subscribe to modern value system or they may not; but in order to follow basic instincts, they indulge in heinous acts of sexual assaults at the first possible opportunity.

According to a newspaper report less than 25% urban and less than 15% rural people experience pre-marital sex in India. Like right to food and water, denying a person right to sex, when his/her body demands it (after age of 15), is a gross violation of human rights. On top of that, socially imposed guilt in pornography and masterbation makes life difficult for a large set of people. These are the people who talk about liberation of women but indulge in sexual harassment if given any chance.

Males and females, both experience such deprivation, but stringent social restrictions and physical structure of human body makes rape by a female far less likely. The society should provide for right to sex to every human being above 15 years age to curb problem of sexual assault. Punishing a deprived person for act of stealing or looting that thing reminds me of Amitabh Bachchan movies. Here individual is not at fault but social structure is. Only new social structure, not any law, can take care of this situation. Some genius mind in pre-historical times invented concept of marriage and monogamy to provide sexual gratification to everybody in society. Same kind of innovativeness is needed in new social setup.

After analyzing social and psychological premises of sexual assault, we can go one level deeper, to biological problem of sexual assault. The question why only males are culprit of such malice in every society, has an evolutionary answer.

Thousands of years of hunting-gathering, agriculture and even manufacturing has put women in a disadvantageous position physically. The mothering role confined them to the household and male took charge of physical work. But with the advent of service society, physical attributes and mothering roles are no longer a handicap for women and it has put male-female on equal footings. The respective physical changes corresponding to service society will happen in thousands of years, till then males are going to face an increasingly tough task of controlling their stronger bodies and hormones. They have to adopt and blend into the new rules of the game. Ofcourse transformation is going to be turbulent, but none-the-less necessary. Meanwhile society has to answer one more important question ofhow to share responsibility of raising our youngs in new social setup where males and females are doing same kind of jobs on equal footings.

If above article in any way seems to suggest that I am supporting sexual offenders, then I must make it clear that I whole-heartedly support most stringent punishment, according to law, in these cases. My point being that although women are obvious victims of this value consensus crises, but men are not having too much positives either. As a social scientist, the responsibility lies on us to create new value system which is good for all members of society and to create such society where an individual is not punished for the wrongs done by social system. Social structures and social values decides to a large extent our acts. The mismatch between official laws and unofficial feelings can give birth to many more Guwahati incidents. If we want a change and want to move away from this situation, then we must create a new value system which is not necessarily western, which takes its cues from everything good that exists in any society. Open discussions without naming individuals can be a positive start. We are living in a turbulent time, lets not loose hope.