RUHSA and the radical public health solution

There's a new state in central India which has more consonants in its name than most people might expect except perhaps a Welshman. Chhattisgarh. Their health outcomes are very poor and doctors trained in their medical schools do not work where they are most needed - the remote rural villages. The shortfall is high throughout the state and dire in the most needy places. There are plenty of health sub-centres, but almost 1/3 do not have even a nurse practitioner, let alone a doctor. This is a problem all over India, but especially acute in this new state, which has the added disadvantage of having acquired none of the medical schools subsequent to its bifurcation from Madyar Pradesh from whence it was carved. There was another problem to be countered as well. In the health professional void of rural Chhattisgarh “jhola chaap” doctors, a derisive term for unqualified practitioners, were mushrooming in the villages, making matters worse with their nefarious practices.

The obviously passionately enthused state government therefore came up with a radical & contentious public health solution. They tinkered with the medical school degree, shortening it & targeting more local, less affluent students to train them to deliver community health care. These 3-year diplomas of medicine were government endorsed & privately funded with 50% free places and the remaining at least partly subsidised. The trade off for the graduates attaining a level of skill and employment opportunity they might not have been otherwise able to afford was that they were encouraged to practice in the less attractive rural areas normal graduates would shun, thereby generating expertise and a willing workforce right where it is needed.

One of the proponents of this model was an erstwhile RUHSA graduate and, knowing how broad RUHSA's expertise is in rural healthcare and economic development, he suggested part of the training took place at here, so every one of the 1000 trainees will pass through RUHSA's wise portals. As a result, RUHSA has developed and is delivering part of the syllabus for these Rural Medical Assistants - a cadre of trainees specially designed to improve the welfare of very disadvantaged populations right at the core of where it is needed, the local community.

Unfortunately, as one might imagine the Medical Council of India was dubious and rejected the proposals out of hand before the course started but it had been designed so their approval was not in principal needed. However, the Indian Medical Association, equally threatened by this erosion of their "standards" jumped on the bandwagon and mounted a legal challenge almost immediately after the program started, causing a war of attrition with the state government whose energies became subsumed by the need to find ways and means of fighting the challenge, so withdrew their endorsement. After quite some in-fighting, this training program ceased recruiting after 3 years so there are no new trainees coming through at the moment. One can understand the arguments against embedding a two tiered system instead of increasing the value of working at a local level. It is a well recognised problem with no easy solution; Indian Health Policy (2002) describes it well. Becoming a doctor is a highly desirable career path, the opportunities to make significant amounts of money & maintain a certain lifestyle are legion. You have to be rich to be a doctor, unless you are exceptional, and coming from a certain sector of society is not going to make it likely you want to hide yourself away earning a pittance delivering basic healthcare needs to a highly disadvantaged community. However, there is also an argument that filling that need from an alternative path and gradually increasing its value over time, might have enabled the two perspectives to meet in the middle.

It is sad that this innovative program seems to have ground to a halt, but a recent review http://cghealth.nic.in/ehealth/studyreports/chhattisgarh%20experience%20with%203-year.pdf suggests that there is still an impetus behind the program. There has been an iterative approach to finding a solution and there is life in this model yet.