Académique Documents
Professionnel Documents
Culture Documents
note that many of the major revelations covered a sample of 1,25,578 households (79,091 survey, which we assume is already in progress as
in rural areas and 46,487 in urban areas) and a reported in the document.
and recommendations of the NCEUS do not sample of 5,72,254 persons (3,74,294 in r ural
find any place in the analysis or in the areas and 1,97,960 in urban areas). In the 61st
round 1,24,680 households (79,306 in rural areas
strategies suggested in the report. If these and 45,374 in urban areas) and 6,02,833 persons
References
shortcomings are addressed, the “Annual (3,98,025 in rural areas and 2,04,808 in urban GoI (2010): “Annual Report to the People on Employ�
areas) were covered. ment”, Ministry of Labour and Employment,
Report to People on Employment” has the 3 Regular employees as per NSS definition (which Government of India, New Delhi.
scope to become one of the key policy is given in a special box in the report) are those NSSO (2010): “Employment and Unemployment Situ�
who work in other’s farm or non-farm enterprises ation in India – 2007-08”, 64th Round, National
documents in the context of labour and (both household and non-household) and in turn, Sample Survey Organisation, Report No 531, Min�
employment in the country. receive salary or wage on a regular basis. This istry of Statistics and Programme Implementa�
category includes not only persons getting time tion, Government of India, New Delhi.
wage, but also persons receiving piece wage or Neetha, N (2008): “Women’s Work in the Post Reform
salary and paid apprentices, both full-time and Period: An Exploration of Macro Data”, Occasion�
Notes part-time. al Paper No 52, CWDS, New Delhi.
1 Other reports are on health, education, environ� 4 If absolutely essential, such information could have Palriwala, R and Neetha N (2009): “The Care
ment and, infrastructure. been more appropriately included as appendix. Diamond: State Social Policy and the Market”,
2 � The
�����������������������������������������������
overall sample size of 64th round is compa� 5 The
��������������������������������������������������
report is grossly silent on the details (espe� India Research Report 3, Project on the Political
rable to that of NSS 61st round. The present round cially, the methodology and concepts) of this and Social Economy of Care, UNRISD, Geneva.
I
An analysis of the landmark 1946 ndia is the largest supplier of foreign country’s disease burden and attributed
Bhore Committee report suggests medical graduates to the United States its poor state of health not only to inade�
(Educational Commission for Foreign quacies in medical services and health
that vested interests may have
Medical Graduates 2008) and UK (General personnel but also to the prevailing social
played a role in shaping India’s Medical Council 2010) but its own rural ills – poverty, illiteracy, poor nutrition and
health system and the medical areas have been chronically deprived of unsanitary conditions.
profession in such a way that professionally trained doctors. We trace The report, best known for drafting the
the antecedents of this situation to India’s blueprint of a modern public health deliv�
the majority of the population
first health policy drafted by the Bhore ery system, also recommended that a
remains totally neglected. Committee in 1946. The committee im� “basic” doctor of modern medicine, with
Nothing short of legal action can posed the construct of a “basic” doctor, a 5½ year university education, would
begin to reverse the existing crisis trained through 5½ years of university be central to this system. These were
education, on a country not yet ready for far-reaching recommendations that
of health human resources that
it. It abolished the shorter licentiate quali� shaped the course of public health and
rural India currently faces. fication and disregarded systems of indi medicine in independent India. However,
genous medicine, even though licentiates a small group of the committee’s mem�
formed two-thirds of the country’s regis� bers raised serious misgivings about
tered doctors, and, together with indige� these recommendations and recorded
nous practitioners, provided the bulk of their dissenting notes (Boxes 1-3, pp 26
rural healthcare. A few of the commit� and 27). On closer examination of the
We gratefully acknowledge the help and tee’s members put up a strong dissent dissenting notes, we see the fundamental
inputs of Supreme Court advocates Prashant against these recommendations. We flaws in the Bhore recommendations.
Bhushan, Indira Unninayar, and Pranav present the dissenters’ comments and
Sachdeva into leading this debate towards a
argue that even today India needs an 1946 Scenario: Two Classes of Practi-
legal platform.
alternative cadre of primary healthcare tioners: There were two classes of medi�
Meenakshi Gautham (gautham.meenakshi@ providers for rural areas. cal practitioners (of western medicine) at
gmail.com) is a post-doctoral fellow with the
the time of the Bhore survey: University
Institute of Health Policy and Management,
The Bhore Committee Report graduates who went through a 5½ year
Erasmus University. K M Shyamprasad
(chancellor@mlcuniv.in) is Chancellor In October 1943, the government of British degree course in medical colleges, and
of the Martin Luther Christian University India appointed a Health Survey and Deve licentiates who went through a shorter
in Meghalaya, India and a cardio-thoracic lopment Committee to study the state of three-four year course at medical schools,
surgeon.
public health in the country, and recommend graduating with a Licence of Medical
Economic & Political Weekly EPW september 18, 2010 vol xlv no 38 25
COMMENTARY
Practice (LMP). According to the commit� Great Britain as the gold standard. The new scheme would benefit only a section
tee’s estimates, there were 47,524 regis� committee also rejected the inclusion of of the Indian population, “Public health
tered medical practitioners in the country indigenous systems of medicine and its over the remaining four-fifth to one-half
of which the majority-nearly two-thirds practitioners in the new medical scheme; of the country…will atrophy. There will be
(29,870) were licentiates and one-third they considered these systems “static in no personnel like the licentiates even to
(17,654) were graduates. conception and practice” (Box 3). help the regions and institutions which
From descriptions of health services in will come under neglect” (Box 2).
the report we learn that registered medical Cassandras in the Committee: Six mem�
practitioners were unequally distributed in bers of the committee, five Indians and Post-Colonial Migration of Doctors:
rural/urban areas. For example, in Bengal one Briton, put up a brave dissent. They The dissenters’ views proved prophetic.
the ratio of doctors to population in urban repeatedly argued that in view of India’s They said that the “basic doctor would
areas was 3½ times more than in rural manpower shortages, the country should not w illingly fit into the rural scheme”.
areas and in urban Sind it was 49 times use every possible means, including the History stands witness that Indian
more (p 14, Vol 1). Nonetheless, much of shorter licentiate course, to increase the doctors have integrated more easily into
rural healthcare was delivered through number of trained personnel. They pointed the health systems of the richer western
subdivisional hospitals and dispensaries out that England had abolished licentiate countries, than they ever did in rural
that were managed mostly by licentiates. teaching only after 100 years and Russia India. In the 1960s, when the rural health
Indigenous practitioners formed another relied extensively on “feldshers” (medical scheme, as envisaged by the Bhore Com�
large body of healthcare providers who assistants) to run 48,000 dispensaries. mittee, should have served at least half
according to the report provided affor They noted with anguish that since the the Indian population and employed
dable and accessible healthcare to the
masses (ibid). Box 1: Only One Type of Doctor and Single Portal of Entry
Bhore Committee: Having regard to the limited resources available for the training of doctors, it would be to
Blueprint for a Modern Health System – the greater ultimate benefit of the country if those resources were concentrated on the production of only one
No Role for Licentiates or Indigenous and that the most highly trained type of doctor, which we have termed the ‘basic’ doctor.
There should hereafter be a single portal of entry into the medical professions and that portal should be
Systems: The Bhore Committee pro� the Universities….We are confirmed in this view by the reasons advanced by the Inter Departmental
posed a three-tier district health scheme Committee (the Goodenough Committee) on Medical Education in Great Britain in support of University
for post-independent India. A primary Medical Education.
Dissenters’ Comments: In view of the overall shortage of doctors we feel that the early realisation of this
unit would be at its periphery, a second�
ideal must be sacrificed to the immediate needs of this country…We should be prepared to use every possible
ary unit at the subdivisional head means in India, including the adoption of a shorter licentiate course, to increase the production of trained
quarters would provide more specialised medical personnel. Once the output of such personnel has sufficiently increased, then it will be possible to place
greater emphasis upon the quality and length of training and to insist upon the production of basic doctors only.
services, and a district headquarter
Nearly two-thirds of the total number of registered medical practitioners in India are licentiates and the rest
organisation would supervise all health graduates. The former have been an important feature of the growth of western medicine in India and no section
activities in the district. of the profession in the country have greater service of humanity or medical science to its credit.
Though conceptually well organised, a The “basic doctor” will not willingly fit into the rural scheme, except under conditions of destitution.
The decisions of bodies, like the Health Survey and Development Committee, are often taken not so much
primary flaw in this scheme was that it on facts garnered or their evaluation, but on ideologies which dominate the minds of their members. They
was designed to cover only around one- must have the Goodenough Committee findings prevail, even though there be so little in common between
fourth of the population in the first five the educational, economic, political or medical developments of England and India. Russian experience and
achievements must be ignored, nay rejected, even when the fate of institutions common to both Russia and
years (78,080,000 out of projected 315 India, such as medical schools for licentiates, was concerned.
million in the report) and less than half The question of post-war improvements in medical education has been considered recently in England by
the population over the next 10 years the Goodenough Committee. Two classes of medical practitioners, licentiates and graduates, have existed in
(1,56,200,000 out of projected 337.5 England, as in India, for over a century. The Goodenough Committee has recommended the abolition of licentiate
teaching in England. This recommendation has influenced greatly several members of our committee. In a hurry
million). The report was silent on how to conform they have unfortunately ignored the fact that the GE Report describes the abolition of licentiate
health needs of the remaining population teaching as the “final stage” of an “evolutionary development”. We are of the opinion that the final stage of
would be met. evolutionary development is not one of India’s achievements yet. From the point of view of medical development,
India is said to stand today where England stood 100 years ago, the USA 75 years ago, and Russia in 1917. England
Nevertheless, the committee decided was in no hurry in the last 100 years to abolish the production of licentiate doctors, why should India be coerced
to abolish the licentiate qualification and to take this step on the eve of momentous changes in its future?
recommended the upgrading of all medi� An important feature of evolutionary development in England was progressive urbanisation. Only 20% of
England’s population was rural before this war. It is 90% in India. England with her high urbanisation percentage,
cal schools into colleges. It reasoned that
is only contemplating giving up licentiate production now. If Japan with 50% urbanisation stuck to licentiate
as resources were stretched, they should production, if Russia with vast stretches of territory and a vast rural population has perfected rural medical relief
all be directed into the production of by strengthening enormously her production of Feldshers (medical assistants), why must India abandon a well
tried and useful institution?
only one type of doctor in the country
Keeping in view the very urgent need for doctors and more doctors, we are strongly of the opinion that the
(Box 1). He or she would have the highest production of Licentiates should continue till the increased number of medical colleges has produced “basic
level of training – 5½ year university doctors” in the proportion of at least 1 to 1,500 of the population. Until such time provinces must not be coerced
training, similar to what the Good into closing the existing Medical Schools – Sir Frederick James, Vishwanath, P N Sapru, N M Joshi, Pandit L K Maitra,
Khan Bahadur A H Butt
enough Committee had proposed for
26 september 18, 2010 vol xlv no 38 EPW Economic & Political Weekly
COMMENTARY
More than 75% of India’s medical pro� travel is on foot. The clear message that 2008), with clearly defined competen�
fessionals work in the private sector, and comes through is that rural communities cies. Mid-level cadres are usually trained
these are no more available in rural areas need a primary healthcare provider for an average of three years following a
than those in the public sector. Most private within easy walking distance from every basic schooling. They are not doctors but
medical professionals are concentrated in village home. can diagnose and treat a variety of com�
urban areas (GoI 2005). There are around 6,00,000 inhabited mon illnesses. Studies (ibid) suggest that
In the absence of professionally villages in India, and around 60% of their performance and outcomes are in
trained doctors, informally trained and these are small ones with less than 1,000 no way inferior to that of conventionally
unlicensed private practitioners deliver population (Census of India 2001). trained doctors.
much of healthcare at first contact in Villages are scattered and each village
rural India (Kumar et al 2007), treating may have smaller hamlets at a distance Legal Scenario and
common illnesses mainly with allopathic from each other. As this situation repre� Current Developments
medicines. The Bhore Committee dis� sents a huge need for primary healthcare The idea of mid-level practitioners
senters had argued that “while a majority providers, we consider it unlikely that trained over shorter periods has been
on the Committee can abolish the licen the country’s present medical education mooted in the past in India too: by the
tiate, they cannot prevent other practi� model with its annual production of country’s National Health Policy 2002,
tioners, practising a variety of systems 30,000 urban centric doctors (Sood and more recently by a Task Force on
of medicine, taking his place”. Time 2008), trained through an expensive 5½ Medical Education for the National
has proved this also to be a prescient year course, can meet this need substan� Rural Health Mission (GoI 2006). Each
observation. tially or cost effectively. time it has been shot down by the medi�
Village-based practitioners provide An efficient alternative for the long cal fraternity, supported by the Indian
their neighbourhood communities with term would be to draw from the experi� Medical Council (imc) Act of 1956 that
easy and all-time access to basic health� ences of developing mid-level practition� prohibits any health cadre without a
care; an enormous advantage in rural ers like clinical officers, medical assist� graduate medical qualification from
areas where road and transport infra� ants in Africa, and various types of nurse practising modern medicine. Nonethe�
structure is deficient, and the best way to and non-nurse practitioners (Lehmann less a few Indian states have enacted new
Available from
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28 september 18, 2010 vol xlv no 38 EPW Economic & Political Weekly
COMMENTARY
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