India's Public Health Care Delivery: Policies for Universal Health Care [1 ed.] 9813341793, 9789813341791

This book describes the present awful state of India’s Public Health Care Delivery, its dismal planning and implementati

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India's Public Health Care Delivery: Policies for Universal Health Care [1 ed.]
 9813341793, 9789813341791

Table of contents :
Chapter 1: Introduction
Formal Public Health Care Structure and the Pandemic
Where Lies the Deficiency?
The Health Care Activities of Non-Covid-19 Nature
The Inept Handling of Public Health Resources
Inept Handling in Maharashtra
Health Care Infrastructure at the Periphery and Covid-19
When the Governments Function Well and People Cooperate
Inept Handling of Data
The Challenge of Urban Prevalence
The Illegitimate Scare of Rising Covid-19 Numbers
The Good Statistics
The Covid-19 and Public Health Measures
Migrant Workers as a Health Issue
How Serious Was the Spread After Migration?
Migrant Labor—Whose Failure Is It?
Failure of Employers and House Owners
Was It Failure of the Central Government?
Engineered Migrations
Deaths During Migration
Herd Immunity
A Good Measure to Meet the High Covid-19 Patient Load
Non-Health Care Decisions and Actions
The Heroes of the Struggle
Down Side of Dealing with Doctors and Paramedics
The AYUSH Ministry Contribution
Chapter 2: Philosophical and Social Basis of Reorganization
Background Changes over Last 30 Years
Health Thinking: 70 Years Sans New Ideas
Some Philosophical Considerations: The Hegelian Idea
How Humans Deal with Obsolescence in General
Limitations within Health Thinking
Consequent Failure of Primary Care
Need for a Philosophical Basis for Reorganization
The Health Theorists and the Indian Scenario
Reorganization: What It Does and Does Not Mean?
Criteria for the Four Rs
Structural Reforms and the Four Rs
The Social Basis of the Context of Reorganization
The Population Shifts
Will Smart City Idea Help?
Pervasive, Iniquitous Modern Medicine: Will it Help?
Will the Public–Private Partnership (PPP) Help?
Dealing with Ancient Systems of Medicine
The New Psyche
Transactional and Litigious Mindset
Why Matters Deteriorate in Public Health Care?
Curative or Preventive Medicine?
Crowding at the Primary Care Level
NGOs and the Health Work
The Church
Panchayati Raj and the NGOs
Matters Relating to the Community Health Workers
Predicament of National Programmes
Predominance of Non-Communicable Diseases
Decline of Voluntary Sector
Incompatibility of Government and Private Sector, Including the Voluntary Organizations
Unionism, Welfare Model and Its Consequences
Quackery, Anti-Science Occultism at the Periphery
The Moribund, Incompetent and Unjust Referral System
The Hilly, Remote Tribals of the Jungle
Exclusion from the Main Tree of Health Care Delivery: A Necessity
Mobile Health Services, the Answer
Some Crucial Considerations
A Brief History of how the Structure and Function of Public Health Care Evolved
Evolution of the Primary Health Care Ideas: Community Health Workers
Dai or Village Midwife: For Safe Labour and Related Matters
Unipurpose and Multipurpose Health Workers
Mitanins and ASHAs
Supervisory Hierarchy
Primary Health Centre and the Lone Medical Officer
What Reality Do We Have in Front of Us?
Some Ideas to Work with: It Is the Quest for Alternatives
Additional Reading
Chapter 3: Shortage of Doctors and Government Medical Colleges
The Colossal Deliberately Misconceived Myth of Doctors’ Shortage
Generalization of Ratios and International Bodies
One Basic Doctor in a Population Segment
Some More Myths of Statistics and Doctor-to-Population Ratios
Medical Seats Available as of 2014 to 2015
Continued Myth and the Concern of Shortages at High Levels
Population Size, Level, Needs and Shortages: A Statistical/Theoretical Argument
Administrative Block and CHC, the Best Levels
Best Levels for Specialty Professionals
Levels Irrelevant for Calculation of Shortages
Worthless Alternate Ideas for Making Up the Shortage of Doctors in the Periphery
Public Health Care Structure in India
Government Medical Colleges: The Key Factor
Govt Medical Colleges and the Infrastructure
Work Culture
Sloth, Dirt and Corruption in Medical Colleges
A Laudable Improvement Initiative
The Selection Process of Medical Admissions
The Examination System for Admission
Aptitude Tests before Admitting a Student: The World View
The Bond System
The Externalities Needed for a Good Education Process
The Administrative Failure
Student Teacher Relationships Today
Medical College Teachers
Improving Teaching in Medical Colleges
The Results of Medical Education Today
Chapter 4: Medical Education
The Steadily Worsening Situation of Teaching in Medical Colleges
The Original Aim of Medical Education and What Happened to It
Rote Learning: Is It the Only Way to Learn?
The Traditional Individual Subject Approach: The Preclinical Years
Learning Pharmacology, Pathology and Preventive and Social Medicine
Preventive and Social Medicine
Virtual Techniques in Procedural/Surgical Learning
The New Decisions of the MCI about the Preclinical Subjects
‘New Skills’ Added to the Medical Curriculum: Communication and Vernacular Skills
Medicine, Surgery and Gynaecology
The British Didactic Model
Lecture-Based Education: A Few Words
The Clinic-Based Approach, Grand Rounds and the Post-Mortem Rooms
The Real Hands-on Learning
A Word about the Postgraduate Education and Degree
Indian Text Books for Indian Medical Education
The Examination System: On Evaluation of the Students
The State of Education of Established Practitioners, the Teaching Methods, Related Ideas and the Continuing Medical Education
Examining the CME Content and Methodology
NRHM and the Continuing Medical Education
The New Thinking about the Foundations of What to Teach
Ideas of Education: New and the Old Thinking
National Education Policy 2020, Ministry of Human Resource Development, Government of India
One Major Shift in the Thinking
On the Major Problems Plaguing the Higher Education System in India
Other Structural Measures, Ideas, Obstacles and Corrections
University-Affiliated Colleges, Its Nexus, Future and the Restructuring
The National Medical Commission Model Discarded
My General Observations on the Policy
Issue of Deemed Universities, Individual Colleges as Deemed Universities
Higher Education Teachers and the National Policy for Education
Curricular Content and the National Education Policy
Curricular Content
Professional Education
Health Care Education
Online Distant Education
Structural Reforms Within the Higher Education Policies
Identifying the Ills of Regulatory System of Higher Education
Aptitude and Attitude Testing
Experience of Aptitude/Attitude Testing World Over
Process of Medical Admissions in India
New Considerations about What Should the Medical Education Do
Problem-based learning, or the (PBL)
PBL Is Not a Part of Existing System
Innate Qualities of PBL
The Columbian Experiment in PBL
The Japanese Evaluation of PBL
Experience of Charité University in Berlin, Germany
A Pilot Study Underway in Charité University
The Australian Experience of PBL
About the PBL Sessions, the Main Stay of PBL in General
Relevance of Other Educational Methods
The Indian Experience with PBL
The Initial Shocks in Indian PBL Experiment
Important Achievements of PBL in India
Verification of the Measures of Success of the Indian PBL Courses
Why Did PBL Succeed in India?
Development of the PBL Course for India
Net Social Change from the Indian PBL
Chapter 5: The De Novo Manpower Deployment Processes
Manpower Deployment: The Greatest Government Failure
Key Questions About the Deployment Failure at PHC and CHC
Why the PHCs Do Not Deliver?
Is CHC the Best Level of Deployment?
Possibilities of Many Failures and Occasional Successes in CHC
Preparing the Manpower Purposefully
Public Health Care: Manpower Structure
Procuring Manpower to Correct Shortage: The Barriers
Additional Factors in Creating Dysfunctional Units
Crowded Hierarchy of Similar Units: PHCs, CHCs, SDH and DH
Five Undelivered Health Care Vectors with Such Health Structure
Dismantle Superfluity, Restructure
Continued Learning of the Medical Graduates
Learning in Internship in Medical College
Learning in Internship in the Three/Six Months in the Rural Areas
The System Proposed for Interns in CHCs
Posting in CHC and Issues of Postgraduate Qualification for Interns
Objections to These Suggestions
Objections by the Interns/Doctors Themselves
The Internship Format: Should It Be Preserved or Changed?
MBBS as Under Trainee After Internship
In Case of No Postgraduate Registration
Postgraduate Consultants/Specialists in CHCs
Maturation of a Specialist Degree Holder in a Consultant
Specialists in CHCs
Inter-CHC Movement and the Superspeciality Training
Full-Time Culture in CHCs
Surrender or Indifference to Public Good
More About the CHC Scenario and the Manpower Solutions
Defence of Obsolescence
National Rural Health Mission, NRHM, and Indian Public Health Standards, IPHS: New Thinking About the PHC and CHC
Bane of Continuation of Erstwhile PHCs Under NRHM/IPHS
Much Greater Need for GDMOs
Compelling Factors to Shift the PHC Officers to CHC
The First Proper Place for the AYUSH Graduates
The Bedrock for Success of This Model: Teaching
The Shortcoming: Time with Patients
Prevailing Mode of Work
Rift Between the Specialists and the Residents
Training Without Strain and Its Benefits
Making CHC a Vibrant Place to Work in
The State of Teaching and Learning
Thinking of the Entire New Generation of Doctors
What the Facilitators/Consultants/Teachers Do and Think
When and How Do the Medicos Earn?
The Anticipated Cycle: From the Entry to Exit
Chapter 6: Primary Care, Government Planning and National Rural Health Mission
Statistics and Functional Issues of Indian Public Health Care
The Sub-Centres: The Existing Structure
The Sub-Centres: Manpower and Distances
Sub-Centres: Multipurpose Health Worker (Male)
Measures Suggested by the Government of India
Financial Maintenance of the Sub-Centres
Work–Time Ratio and the Multiplicity of Community Health Workers
Community Health Workers and Primary Care
A Profile of How the Work Gets Done in the Sub-Centre Area
Reporting of the Work Done
Adverse Factors Affecting the Ground Work
Too Many Unproductive Supervisory Levels
Higher Levels of Redundant Supervision
Discrepant Views: On Ground and at the Top
The Work Profiles at the Sub-Centre Level: Too Many Questions Need to Be Asked
The Long Arm of the State
The Random, Inequitable Remuneration System for CHWs
Causes of Discrepancy
ASHA and the NRHM
Imaginative, Ingenious or Faulty Conceptualization?
NRHM: Referral and Escort Services for RCH by ASHA
NRHM: ASHA to Look After the Construction of the Household Toilets
NRHM: Other Health Care Delivery Programmes to Be Looked After by ASHA
More on Financial Arrangements for Sub Centers Under NRHM
NRHM and Its Thinking About ANMs
Issues in Recruiting ANMs
NRHM, ANMs and the Nurse Practitioner: A Colossal Misconception
NRHM: Effective Integration of Various Agencies
NRHM: Developing Capacities for Preventive Health Care
NRHM: Reduction in Consumption of Tobacco and Alcohol
NRHM and the Panchayati Raj Institutions in Health at Sub Centers
Panchayati Raj: An Evaluation
NRHM and Its Ideas of Infrastructure
NRHM and the New Thinking on Sub-Centre Restructuring
Alternate Mechanisms of Doing Field Jobs
Suggestions for Efficiency Improvement of the CHWs
Future of CHWs: The Career Path
New Roles for the Supervisory Cadre, Now Defunct
Chapter 7: Structure and Function I: The Primary Health Centres
History of the Primary Health Care Ideas in India
Bhore Committee and Primary Health Care: Less Known Facts
Assessment of Bhore Recommendations
Difficulties in Implementation of Bhore Committee
The Paradoxical Activist View about Bhore Recommendations
Evolution of Primary Health Care
Primary Health Care Structure and the Activists
Primary Health Centres: Thin and Ineffectively Spread
Government Conception of Referral System
State-Level Health Structure
PHCs Under the States
Functional Profile of PHCs and the Planning
The Design, Manpower and Infrastructure of Curative Structures at Periphery
Segregating Curative and Preventive Health Work
Current Government Thinking About PHC
The New IPHS and General Impression Post IPHS
Manpower Shortage Still the Biggest Issue
The Pathetic Story of Referral against Upgradation
The Supply Chain Management
Corruption in Supply Chain
Tender Processing for Supplies in the Government
Availability of Drug and Consumables in Public Sector and the Government Regulators
Functional Aspects of PHCs
Inadequate Coverage Under a PHC
Burnout: An Unrecognized Consequence
The Manpower in PHC under the IPHS: An Assessment
Availability of Beds in PHCs
PHC a Referral Unit for Six Sub-Centres
The PHC Medical Officer, One and One More as Essential per PHC: Profile
Closer Look at the Numbers of the PHC Medical Officers
IPHS, NRHM and the Peripheral Units
PHC Conversion to CHC Under IPHS
The Other Personnel Provided in PHCs
Pharmacist: One Post per PHC and Related Issues of Pharmacy
IPHS Recommendation: One AYUSH Doctor/AYUSH Pharmacist in Type-B PHC
Nurse Midwife (Staff Nurse)
Health Workers (Female)
ANMs and the PHC Work
Health Assistant (Male)/Health Assistant (Female)/Lady Health Visitor
Health Educator
Laboratory Technician, One Post
The Relentless Charade of Curative Care
CHC: First Curatively Oriented Unit
Principles to Dismantle PHCs Rationally, Relocate Resources to CHC
The Budgeted Manpower in PHCs
PHCs, Phased Closure: Principles, Processes and Potential Changes
New Thinking About the Staff of the PHC
Pharmacist, Laboratory and X-Ray Technicians
Nurse-Midwife (Staff Nurse), Additional Staff Nurses
ANMs, Health Worker Female, the Lady Health Visitor, Health Educator, and the Health Assistants, Male and Female
Multiskilled Group D Workers
Upper- and Lower-Division Clerks
Class IV Workers
Health Assistant Cadre
Other Gains of Closing PHCs: Improving the Quality of Quacks
The PHCs and the Non-State Players
Closure of PHCs, Deserting the Poor
Concern About National Programmes
Chapter 8: Structure and Function II: The Community Health Centres
Two Ways of Restructuring the Community Health Centres
Selection of CHCs
The Process and Consequences of CHC Build-Up
Evolution of CHC Under Government
Prehistory of the Community Health Centre, CHC
Community Health Centre Staff: Before and After the Revised IPHS 2012
Speciality Services per IPHS
Medical Officers
Nurse Midwife (Staff Nurses)
Paramedical Staff: Pharmacist/Compounder
Lab Technician
Other Paramedics
Administrative Staff
Community Health-Related Workers
Ward Boys
Driver and Other Menial Staff
Block Public Health Unit
Block Medical Officer/Medical Superintendent, One, under NRHM/IPHS
Public Health Specialist 1
Qualifications Any One of the Many
Public Health Nurses (PHN), One +One
Qualifications and Requirements
The Health Educator
Physical Infrastructure CHC Post-IPHS
Manpower in CHC Post-IPHS
Issues Related to Medical Officers
About the In-Service Candidates in PHCs
About the Fresh MBBS Graduates
Logistical Issues of the Training Itself
Other Measures to Get Fully Qualified Specialist Services in Rural Areas
A Much Simpler Scheme for Training, Admission and Deployment
MBBS General Duty Officers: Numbers, Role, Training and Related Aspects
Workload, Financial Viability and Non-Availability of Doctors
More About Specialized Training of MBBS
MBBS Trained in Internal Medicine and Paediatrics
The Government Logic and the Ground Realities about Anaesthetists
Surgery, Gynaecology
Other Worker Categories in CHC Under IPHS
NRHM/IPHS: Nurse Midwife (Staff Nurse)—Seven + Three Posts
Significant Barriers in Procuring the GNM Nurse for CHC
A Way Out for Getting Nurses for CHC
Need for a Decentralized System for More Graduate Nurses
Pharmacist/Compounder; Laboratory Technician, Radiographer
Dresser: One Post: Certified by Either Red Cross Or St John’s Ambulance Service
Ward Boys and the Ayahs, the Lady Menial Workers
Shape of Care in CHCs
Complexities of Disease Profile
More About the Role of Surgeons in CHCs
Powers of the Services in CHCs
Causes of Non-Availability of Specialists for CHCs
Facilities and Its Absence
Bureaucracy and Government Vis-à-Vis Health Care
Potential Sources of Specialists Working for CHCs
The Remedy Over the Shortage of Specialists in CHC
Teaching and Work Profile of Five Specialists
More about the Internship in CHC
Remuneration for Interns During the CHC Tenure
NRHM and CHC, Ideas for Betterment
The Law of Care Inverse to Distance
HDUs and Critical Care
Chapter 9: Structure and Function III: Expectations and Realization
High-Dependency Units
Cost an Immediate Concern
Mandatory Infrastructure and Manpower
An Existing Paradox in Acute or Critical Care
Causes of the Paradox
The Costs, Usage and Feasibility of Establishing HDUs
Meeting the Capital Costs to Raise HDUs
Logistics and Manpower in CHC/HDUs
Dynamics of Manpower Reallocation and Development
Better Nurse/ANM Development in CHCs
Creating Manpower Resources from Within: ANMs
ANM Schools Located in CHC: Other Benefits
Paramedics Outside CHCs: Facilitating Quality Enhancement
Training Ward Boys and Ayahs for Higher Skills in CHCs
Quality vs Qualification: An Important Consideration
Making Up the Shortcomings of National Skill Development Initiative
Prioritization of the CHCs and Their Placements
Some Out-of-Box Thinking
Positives the CHCs Can Achieve
CHCs Beyond the Tehsil Level
Monetary and Financial Consideration of the CHC/HDU
Saving Money Is Earning Money
Saving on Infrastructure
Saving on Doctors and Paramedics
Phased Closing of the CHCs: Frees Manpower Already Budgeted
Optimal Utilization of the Specialist Consultants
Thinking at the Level of Five CHCs as a Group
Attitudinal Changes Needed Among the Specialists
Reducing Professional and Ancillary Workers Within Health Services
Consumables and Cost Savings
Earning Sources for the CHC
User Fees for CHCs
Drugs and Its Optimal Management
Insurance Schemes as Cost Savers
CHC as an Economic Driver
The CHCs and the Non-State Players
The Sub-District Hospitals
The Naïve Planning
A Definite Presence of Private Players—A Reason for SDH Closure
Human Resources at Sub-Divisional Hospitals
Chapter 10: Structure and Function IV: The Final Picture
The New Additions
Planning Deficiencies within the New Additions
Making CHOs Available
Inadequate Scope for Work of Coordination
Difficulties Created in the Management of CHCs
Adding More Functions, Services and Workers as Revised Guidelines: NRHM Ideas
Medical Rehabilitation Services: National Programme for Health Care of Elderly
Oral Health, Dental Care and Dental Health Education Services: One Dental Assistant
School Health
The Third New Functionary and New Functions as Planned
The Fourth New Functionary: Public Health Nurses
Advantages of a Community Health Officer at the CHC
Geography for Operation for the CHO
Functions of the CHO Vis-à-Vis CHWs in CHC
Critique of the Issues Related to the National Programmes
National Programmes and the Covid 19 Pandemic Challenge
About the Existing National Programmes
Independent Verticals
Did Things Go Wrong with National Programmes? Where and How?
Executive Integration of national programmes
How Will It Now Change with the New Structure?
What Does the New Model Mean?
Rectifying the Deficiencies in Executing National Programmes
Illustrating Changes in Greater Detail
National Tuberculosis Control Programme (NTCP)
The First Model and its Shortcomings
Detection and Treatment of Tuberculosis: Unusual Issues of Animal TB
RNTCP, DOTS and Human Disease in India
DOTS: A Bag of Mixed Issues and Disappointments
The DOTS in Actuality
DOTS, the Programme and Some Difficulties
The Biological Issues about Tuberculosis
Possible Causes behind the Rise of (MDR) Tuberculosis
The Toit Review and Drug Delivery in TB
Discrepancies in Treatment Data and Development of Resistance in TB
INH or Isoniazid Resistance through Different Inactivation Rates
Bedaquilline: The Breakthrough Anti-TB Drug
Extra Pulmonary Tuberculosis: An Absent Feature
Some Thoughts on Eradication of Tuberculosis by 2025 the Indian Initiative
National Blindness Programme
Debulking Disease Load in a Community
The Idea of a Programme, a Process and a Tradition
Mass Campaigns and Gynecological Disorders: A Success Story and a Model
Analysis of the Strengths of the Proposed Model of CHC
Bed Strength of 50
Not a Top-Heavy Model
Superspecialities in CHC
Contribution of Superspecialists to CHC Population
The Most Valuable Effect of Such a Huge Exercise
Blood Storage, Transfusion Facilities and CHC
Blood as a Carrier of HIV AIDS, Hepatitis B and C Viruses
Sufficiency and Efficiency of Ten CHCs in a District
Future of CHC: How Will It Develop Further?
Level of Medical Care Quality
The District Hospitals
Chapter 11: Health Institutes and Voluntary Health Work
The Idea of an Institute
Prehistory of Health Institutes
Defining an Institute
Trusts and Ownerships
Characteristics of an Institute
Power, People, Expanse and Service Quality in Institutes
Money and the Institutes
Not Just Financial Honesty
The Institutional Culture
The Large-Sized Institutes
Managing Institutes Well
Optimization of Work in Processes
High-Cost Gadgetry and the Institutes
Institutional Mindset of Specialists Needed
Institutes: The Standard Bearer and the Bench Mark
Institutional Performance
On Government Colleges, DNB Centres and Decline of Teaching
Issues with State-Owned Institutes
Summery Regarding the Health Institutes
Voluntary Agencies and Health Work
Perspectives in Health Action by Voluntary Agencies
Definition of Voluntarism
Characteristics of Voluntary Agencies
The Psyche
The Primary Health Care Voluntary Agencies
Think Tanks of Primary Health Care
Limitations of Think Tanks
Certain Negative Elements of the Think Tanks
Think Tanks of Secondary-Level Health Care Activities in VAs
National-Level Voluntary Agencies
The Journey of Voluntarism
Voluntary Work and Market Economy
More Models to do the Work
The Christian Voluntary Medical Work
Problems of Christian Ideology
Skilled Procurement of Government Funding
Neglect of Non-Christian Service Organizations
Funders and Primary Care Unholy Nexus
Continued Government Neglect and the Voluntary Agencies
The Paper VAs
Unhealthy Influence in the Voluntary Sector
Sociopolitical Voluntarism
Left of Centre Organizations
Gandhian–Sarvodaya Approach
Organizations with Nationalistic Fervour
Government and Voluntary Agency Collaboration
The Follow-Through
The Issues
Appendix A: Work Profiles of Community Workers and PHC Medical Officer
Duties of Medical Officer, Primary Health Centre
Job Responsibilities of Medical Officer at the PHC under NRHM and Now under IPHS
Curative Work
Preventive and Health Promotional Work
Duties Common to All the Activities under Package of Services for MCH
Universal Immunization Programme (UIP)
National Vector-Borne Disease Control Programme (NVBDCP): Treatment and Prevention
Kala Azar
Acute Encephalitis Syndrome (AES)/Japanese Encephalitis (JE)
Control of Communicable Diseases
Sexually Transmitted Diseases (STD)
School Health
National Programme for Control of Blindness
Training: All PHC Staff and ASHAs
Administrative Work
Other Non-Communicable Diseases: Diagnosis, Prevention, Treatment and Referral
Ear, Nose, Throat Disorders
Common Psychiatric Disorders
Metabolic Diseases
Management of Medical Supplies
Appendix B: Controversies Surrounding the AYUSH System of Medicine
Ambivalence over the AYUSH Systems and its Doctors
Serious Neglect of the Other Systems of Health Care
Corrections Undertaken
The Anguish of an AYUSH Graduate
A Disturbing Exclusion of AYUSH Graduates in Health Care
Mainstreaming AYUSH Doctors in Hospitals and Public Health Care
The Contentious Bridge Course
Many Questions about the Issue
Q. Trainability of AYUSH to Acceptable Level of Competence
Q. AYUSH Learning Modern Medicine Systems
Q. AYUSH Doctor Achieving Same Level of Understanding as an MBBS
Q. About the Limitations of AYUSH Doctors as is Believed
Controversies and Opposition over AYUSH Status in Modern Health Care System
Sketch of the Agitation against NMC and its Critique
Wrath and Counterarguments of the IMAs: Likely Reasons Behind
The Story on the Side of AYUSH
IMA must Face the Inevitable
Welcoming New Initiatives to Make AYUSH a Better System
Improving Quality of AYUSH Colleges
Standardizing Ayurvedic Formulations
A Step Further in Standard Ayurvedic Drug Manufacturing
Major Errors Committed by the Government with Respect to AYUSH
Populism against Status of AYUSH as a Science: Undesirable Trends
Appendix C: Urban Poor and Health Care Delivery
Overview of the Health of the Urban Poor
Constituents of Urban Poverty
Differences in Urban and Rural Public Health Structure
Understanding of National Urban Health Mission of Urban Poor Health
Differences between the Urban and the Rural Poor
Effective Available Curative Health Services in Urban Areas
Limited Contributions Paramedical Personnel can make for Health of Urban Poor
Issues of the Most Vulnerable Groups
Establishing Connections Necessary for Better Health of Urban Poor
Issues of Behaviour among the Urban Poor
Curative Services under NUHM
National Health Programmes for Urban Poor: Another Disposable Programme
Many Matters of Irrelevance in the Urban Health Mission Document
More about the NUHM Document
Problems of Targeting the Poor on the Basis Of BPL Cards

Citation preview

Sanjeev Kelkar

India’s Public Health Care Delivery Policies for Universal Health Care

India’s Public Health Care Delivery

Sanjeev Kelkar

India’s Public Health Care Delivery Policies for Universal Health Care

Sanjeev Kelkar Pune, Maharashtra, India

ISBN 978-981-33-4179-1    ISBN 978-981-33-4180-7 (eBook) © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-­01/04 Gateway East, Singapore 189721, Singapore

Dedicated to Prof V R Joshi, my mentor, who blessed me to go to tribal areas for work and My wife Dr Sanjeevanee MS, who introduced me to the world of Community Health


Conventionally, this section acknowledges those who helped shape a book. In this case it is not just that but a mention of a lifelong gratitude to all those who shaped me and my thinking to make this work possible. I entered medicine with great reluctance and had quite a bit of trouble over sciences. People I got connected with in medicine made me a man and a medico. My professors, the unparalleled teachers and human beings, were the first to lay down my fundamentals in clinical medicine, surgery and neurology. In postgraduate years, Late Prof V. S. Ajgaonkar was my first teacher. He was a great humanist. As I approached the last phase of my postgraduate years, Prof V. R. Joshi took me under his wings for all the final refinement I could absorb. He is a noble man. He encouraged me in those remote 1980s to go to tribal areas after my MD. Late Mr B. G. Vasanth, an automobile engineer, and Mr B. S. Seshadri, an income tax officer, stood support of me and my wife rocklike in the most difficult and yet enviable years of our life in the tribal areas in South India for over ten years. Those years taught me to go for solutions for the various difficulties we had, and anyone who works in rural areas in delivering health care has. We did it by experimenting with many different models that could solve rural India’s health problems. One of the few persons who appreciated our work then was Prof R.  D. Bapat, KEM Hospital Mumbai. When I came back with my wife and two children to urban settings in early 1990s, it was Late Dr Manohar Salpekar, Late Dr G. M. Taori with vii



Late Dr P. S. Bidwai, who helped, taught and settled us to a stable life in CIIMS, a tertiary care hospital in Nagpur. Coming from the ten-year rural stint, my rehabilitation and development in high-complex medicine was done by my colleagues in CIIMS. The contacts, which accelerated my growth in the technology of education and to experiment with it in India, were from the University of Newcastle, New South Wales, Australia. Drs Jean McPherson, Judith Scott, Kerry Bowen, John Marley, ex-vice chancellor, Richard Gibson and Kathy Byrne. Nearly 80 highly qualified Indian doctors from AIIMS and other prestigious institutes like CMC Vellore and a few non-doctors who worked with me to carry out these experiments I mention with gratitude. Their contribution will get reflected in the chapter ‘Medical Education’ and the ‘Problem-Based Learning’. Cotntributions of Mrs Anandhi Sigh and Mr MV Prasad for the success of Newcastl university program is greatly appreciated. Diabetic Foot Society of India, DFSI, was formed with the fortunate association of many stalwarts like Drs Arun Bal, Sanjay Sane from Pune, K. R. Suresh from Bengaluru, Ashok Kumar Das, dean Pondicherry and advisor non-communicable diseases, GOI.  Thousands of doctors were trained by DFSI, which created a revolution in diabetic foot. For the supportive role I played, it was not just huge learning but my identity has got associated with it now. My days spent in the headquarters of CARE Hospitals Hyderabad with Dr N. Krishna Reddy led to a completely novel and successful development of outpatient insurance. Since the time I went to tribal areas for work and after marrying Sanjeevanee. I have had the pleasure to be associated with many activist medicos. Many of them wrote daringly on various issues. The activists of Medico Friends Circle, Voluntary Health Association of India, New Delhi, Community Health Centre in Bangalore, All India Drug Action Network, PPST from Kerala, Dr Abaji Thatte, Drs Sujit Dhar, Dhanakar Thakur, from National Medicos Organization, Bhaskar Kalambi from Vanavasi Kalyan Ashram, Mumbai, Catholic Hospital Association of India are people from whom I have imbibed a lot about health issues. It was a strange mix of people fired by different ideologies, ready to suffer for the cause of health. The richness you get from such associations is for you alone to understand. Dr Kayathri Perisamy, Colombo, was of great help in contacting Sri Lankan health policymakers. The discussions helped bolster my thesis. I am thankful to my friend Dr Jayeeta Bhattacharya for bringing me in



contact with Palgrave Macmillan and its perceptive editor Ms Sandeep Kaur, who went through the MSS carefully and made many valuable suggestions. I am grateful to Ms Sandeep for that. Lastly, it is my surgeon wife Sanjeevanee who brought to me such insights in medicine as I had never imagined. She stood against all odds in our somewhat hazardous life in tribal rural areas, reared our children and participated in all our adventures daringly. I am eternally grateful to her. In all these years I learnt to guard myself from taking a dogmatic position, not to express with an air of finality and force any idea or a remedy as wonderful, but deal with it as an evolution of understanding at that time. I kept myself free from getting bound by an ideology or an ism. This allowed me to accept the good works, remedies and opinions and contributions of those, without agreeing with many other things such people might be doing. Hostility towards other ideas or ideologies is a form of ghetto that prevents synthesis of commonalities and valid comparisons of different actions and viewpoints. In addition to this, my widespread and continuing interest in the humanities fostered by my father gave me a much wider view than I may have had otherwise.

The five criteria to deliver health care are accessibility, affordability, quality, equity and justice. Any health infrastructure or policies not able to deliver these will have to be ruthlessly scrutinized, reoriented or discarded and new workable ones described in this volume added.



1 Introduction  1 2 Philosophical and Social Basis of Reorganization 31 3 Shortage of Doctors and Government Medical Colleges 59 4 Medical Education 89 5 The De Novo Manpower Deployment Processes145 6 Primary Care, Government Planning and National Rural Health Mission179 7 Structure and Function I: The Primary Health Centres217 8 Structure and Function II: The Community Health Centres259 9 Structure and Function III: Expectations and Realization301 10 Structure and Function IV: The Final Picture341




11 Health Institutes and Voluntary Health Work389  Appendix A: Work Profiles of Community Workers and PHC Medical Officer427  Appendix B: Controversies Surrounding the AYUSH System of Medicine449 Appendix C: Urban Poor and Health Care Delivery471 Index483



Accreditation Council for Continuing Medical Education Aravind Eye Hospital Acute Encephalitis Syndrome Annual Facility Surveys and External Assessments All India Drug Action Network All India Institute of Medical Sciences Auxiliary Nurse Midwife Accredited Social Health Activist Ayurved, Yoga and Naturopathy, Unani, Siddha and Homoeopathy Bachelor of Ayurvedic Medicine and Surgery Block Extension Educator Bachelor of Homeopathic Medicine and Surgery Banaras Hindu University Basic Minimum Services Block Research Group Crude Birth Rate Cartridge-Based Fully Automated Nucleic Acid Amplification Test Central Board of Secondary Education Central Council of Ayurvedic Research Certificate in General Duty Assistance Community Health Centre Community Health Workers Continuing Medical Education Consumer Protection Act Clinicopathological Correlation Dilatation and Curettage Delhi Cantonment Board xv




District Hospital District Health Mission Diplomate of National Board Delhi Jal (Water) Board Directly Observed Treatment Short Course District Planning Committee Diploma in Public health District Resource Group Department of Science and Technology Employees State Insurance Corporation Elimination of Lymphatic Filariasis Foreign Contribution Regulation Act Fixed Dose Combinations First Referral Unit General Duty Assistant General Duty Medical Officers Globalization, Privatization and Liberalization Goods and Services Tax Health Assistant (Female)/Lady Health Visitor Health Assistant (Male) Hepatitis B Surface Antigen Health Care Delivery System Hepatitis C Virus High Dependency Unit. Human Immunodeficiency Virus High-Level Expert Group Health Worker (Female) Health Worker (Male) Human Resource Indian Administrative Service Indian Council for Medical Research Indian Council of Social Science Research Indian Certificate of Secondary Education Integrated Child Development Scheme Integrated Disease Surveillance Project Indira Gandhi National Open University Integrative Learning Activities by System Indian Medical Association International Monetary Fund Indian Medical Council Act Indian Medicines Pharmaceutical Corporations Limited Infant Mortality Rate


INH Isoniazide ICUs Intensive-Care Units IPHS Indian Public Health Standards IPP India Population Project ISM & H Indian System of Medicine and Homeopathy ISCR Indian Society for Clinical Research ISRO Indian Space Research Organization JE Japanese Encephalitis JIPMER Jawaharlal Institute of Medical education and Research JLI Joint Learning Group JFMC Joint Forest Management Committees JSY Janani Suraksha Yojana LCPS Licentiate of the College of Physicians and Surgeons LHV Lady Health Visitor LMSs Learning Management Systems MBA Masters in Business Administration MCD Municipal Corporation of Delhi MCH Maternal and Child Health MCI Medical Council of India MCD Municipal Corporation of Delhi MCQs Multiple Choice Questions MDR Multi-Drug Resistance MHA Ministry of Home Affairs MMR Maternal Mortality Rate MMR Mass Miniature Radiography MMU Mobile Medical Unit MNC Multinational Corporation MNP Minimum Needs Programme MO Medical Officer MOHFW Ministry of Health and Family Welfare (GOI) MPH Masters in Public Health MPHW Multi-Purpose Health Worker MRP Maximum Retail Price MTP Medical Termination of Pregnancy MTP Act Medical Termination of Pregnancy Act (amended) MUHS Maharashtra University of Health Sciences NAM National AYUSH Mission NDA National Democratic Alliance NMC National Medical Commission NBE National Board of Examination NCHRH National Commission for Human Resources for Health NDA National Democratic Alliance





New Delhi Municipal Corporation National Entrance and Eligibility Test National Finance Commission National Family Health Survey Non-Governmental Organizations National Health Protection Scheme National Health System Resource Centers National Institution for Transforming India Neonatal Intensive-Care Unit National Institute of Science Communication and Information Resources National Licentiate Examination National List of Essential Medicines National Leprosy Eradication Programme Novo Nordisk Education Foundation National Medical Commission National Medicinal Plant Board National Rural Health Mission National Sample Survey Organization National Tuberculosis Institute National Tuberculosis Control Programme National Urban Health Mission Problem-Based Learning Professional Development Course Panchayats (Extension to Scheduled Areas) Act Pharmacopoeia Commission for Indian Medicine and Homoeopathy Polymerase Chain Reaction Primary Health Centre Public health Engineering Public Health Foundation of India Poly DL-lactide-co-glycolide Prevention of Money Laundering Act Prime Minister’s Office Pradhan Mantri Swasthya Suraksha Yojana Public–Private Partnership. Preventive and Social Medicine Press Trust of India Panchayati Raj Institutes Public Service Commission Public works Department Reproductive and Child Health Rogi Kalyan Samiti (Patient Welfare Committee)


RNTCP Revised National Tuberculosis Control Programme RMOs Resident Medical Officers RMP Registered Medical Practitioners RSBY Rashtriya Swasthya Bima Yojana RSSDI Research Society for Studies in Diabetes in India SBA Skilled Birth Attendants SC Sub-Centre SDH Sub-Divisional Hospital SDG Sustainable Development Goals SGPGI Sanjay Gandhi Post Graduate Institute SHGs Self-Help Groups SICU Surgical Intensive-Care Unit SHSRC State Health System Resource Centres SPIC ES Student centred, Problem-based, Information gathering, and integrated/Community-based elective and systematic reforms TUNNDA The University of Newcastle Novo Nordisk Diabetes Academy UGC University Grants Commission UHP Urban Health Posts UHRC Urban Health Research Centre UIP Universal Immunization Programme UKPDS United Kingdom Prospective Diabetes Study ULB Urban Local Bodies U5MR Under 5 Mortality Rate UPA United Progressive Alliance USP Unique Selling Proposition VAs Voluntary Agencies VBDs Vector Borne Diseases VLE Virtual Learning Environment XDR Extensively Drug-Resistant (Tuberculosis) WHO World Health Organization




Public health care has been deteriorating over decades now. In all these years the totality of the scenario in its history, development and unbiased critique in a single volume was not available. It was divided into different segments of the health literature and policy documents. Each dealt with a specific vertical. The thought process about what can or should be done was also limited to each vertical. Some aspects received much more attention and many others were treated almost cursorily. This book is written to provide a totality of the picture of public health care delivery and what can be done to make it better. New ideas are at times considered not feasible, especially when they draw people out of their comfort zones. Sometimes these are considered absurd. However, the more absurd an idea may seem, the more it is possible that it could have a kernel of truth to it that will have future substantial possibilities. The idea of and policies needed for universal health care were to be the backdrop of this volume when it was submitted in mid-February 2020, for prepublication processes. Then all of a sudden the Covid-19 pandemic started and shook the whole world health wise, and devastated it economically and psychologically. We considered it essential to provide a brief overview of the Covid-19 situation and assess the role, contribution and relevance of public health care delivery in India vis a vis this disease. The same consideration was extended in my volume India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021), published in January, 2021. For me it was a lifetime opportunity to test the many © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




elements, observations, shortcomings, other injurious effects and contribution of the public health care sector I have discussed in this volume during the fight against Covid-19. It was also a lifetime opportunity for me to weigh the measures suggested by me with respect to the public health sector about its suitability and effectivity today against this new background. In my 49 years in medicine I have never found the health system of any country prior to 2020 in such great difficulties. Covid-19 as a disease, its pathology, the controversies surrounding it, its future course, mutability and vaccines, the world scenario of health care, both public health and private health care delivery methods, their shortcomings, attitudes and effectiveness vis a vis Covid-19 are discussed in the volume India’s Private Health Care Delivery: Critique and Remedies (Kelkar, ibid). The volume also covers the contributions, attitudes, deficiencies and shortcomings of the Indian private health sector vis a vis Covid-19. This volume will therefore exclude these topics.

Formal Public Health Care Structure and the Pandemic In the main this covers the largest sector of public health care delivery— the sub-centers, the primary health centers, the community health centers and the sub-divisional or the taluka-level hospitals with the largest health armies. Before going further into the discussion it must be stated that Indian public health care delivery as it stands is expected to be effective in pandemics and epidemics. The large national programs are a surrogate for testing to see if this has worked or not. It has not worked this time. As reported in this volume, it is not even geared to handle small localized or state-level recurring endemics. Hence there is little point in examining or emphasizing the public health care failures in the Covid-19 situation. The attention of the reader is directed to all the structural changes described in many of the chapters here which will perform better in such situations. From the district hospitals to medical colleges the utilization of public health care facilities seems to be better during Covid 19. Where Lies the Deficiency? The cry of neglecting the public health care sector on various counts, raised for the last 60 years of low budgetary provisions and its failure during Covid-19, has gone up as expected. However, I believe that this is a



gross simplification of the matter and that low health expenditure is irrelevant to the present pandemic conditions. As has been repeatedly emphasized in this volume, it is structural faults like duplication, redundancy, undue emphasis on primary care, the work time ratios at all levels and the enormous wastage of money in faulty schemes, as well as many other aspects that have been outlined in the Covid-19 period. Those who are shouting about the public health care inadequacies of funding have never even remotely considered understanding or offering solutions to these aspects, which are where the fault lies (see below). The real need during Covid 19 pandemic was for simple isolation facilities, which are not difficult to obtain. India conducts elections involving 1.3 billion people. Procuring these facilities is a simpler matter. This was not handled well by many state governments. The challenge was in establishing higher care centers for which the facilities under both central and state governments were inadequate. The point is that the situation could have been substantially improved but has not been in several states. However, many states have still done their job well. A rational understanding of these numbers is required for action, rather than worry. The Health Care Activities of Non-Covid-19 Nature In general, non-Covid-19 acute care was left to function in all the private sector entities as well as in the district hospitals in the public sector. The routine activities were shut down to prevent unnecessary contact among people and to create bed capacity for Covid-19 patients. India’s growing number of non-communicable diseases have added their own burden to infectious diseases, which had been on the decline for many years. To this a pandemic was added with extremely rapid spread, high mortality rates among the susceptible and those with co-morbidities such as diabetes and heart ailments. The public health infrastructure in most parts of the country has been far from adequate to meet these challenges and was overwhelmed early in the pandemic. The poor states have had to struggle the most during serious outbreaks. There have been other yearly recurring contagions of menacing proportions, like the encephalitis epidemic in the summer of 2019, which have somehow not troubled the system as much as expected. Later migrant labor was another issue that put stress on the system.



In the primary health care domain something similar seems to be happening. The postponement of case-finding campaigns for tuberculosis (TB) and other related activities and routine immunization-related activities took a hit that resulted in at least 5 million children missing out on being vaccinated. The lockdown has compromised the Ayushman Bharat, Pradhan Mantri Jan Arogya Yojana’s (PMJAY) ability to reach out to critically ill people living below the poverty line, including those afflicted with cancer (Express News Service, May 7, 2020). The scores and scores of measures to cope with these situations discussed over six chapters here can be seen as relevant to answering these questions. Covid-19 has created one more vertical in the care profile as a temporary battle but long-lasting new national program. The inadequacy of structural planning and work function time mismatches that have caused this situation have been discussed extensively in this volume.  he Inept Handling of Public Health Resources T The inept handling of available public health care resources is another serious aspect. Fifty-one days after the announcement of lock down, the largest Hindu Rao Public Hospital of the Municipal Corporation of Delhi North had not taken off for its conversion to Covid-19 facilities. It is a 980-bed hospital, with a staff of 600 doctors, 350 nurses and 300 allied workers. There was a lack of various elementary necessities such as PPE equipment, adequate security; timely staff salaries were not paid for up to three months. Poor maintenance of simple things like temperature guns show the everpresent apathy (Rajput Abhinav, June 16, 2020) which has also been depicted in this volume. It is obvious that the AAP government did not use the lockdown properly. The lack of coordination visible in Maharashtra also indicates this apathy and inept handling. On 14 June 2020  Home Minister Amit Shah had to step in and announce several measures to address Delhi’s worsening Covid-19 crisis. It took AAP nearly 50  days to ask the center for help with 500 railway coaches or 8000 isolation beds to Delhi to make up for the shortage. When testing all over the country had been ramped up to 100,000 tests, adding three more types of tests for mass application, AAP was sleeping for 50 days until the center stepped in, doubling the testing in the next two days and tripling it in six. The Delhi government did nothing to enlist the cooperation of the private sector, which has a large bed capacity. Their issues should have been discussed in these 50 days and a solution determined much earlier. With high number of testing Delhi recorded positive cases in continuously rising high numbers after 14th June, daily and hospitals filled to capacity and patients suffering greatly.



I nept Handling in Maharashtra This has added to the woes of public health care. It is difficult to know about  the interaction between the bureaucrats and  their political bosses. Neither seemed to have a correct  appraisal of the situation. The  orders finally issued reflected this. One thing is obvious though: the bureaucracy became the decision makers, those very people who do not have as good an understanding of health care as do practicing doctors. The final outcomes in the form of circulars and advisories have often been conflicting and therefore confusing to an average doctor or a small nursing-home owner. This was a salient feature from March and will overflow in to the next year. However, one of the most sinister factors is the complete indifference for weeks on end after the lockdown for the suffering patients and unwillingness to do anything substantial for them by ramping up the public health facilities in Maharashtra. No importance was given to the provision of simple observational isolation facilities that could be easily housed in schools and colleges and such other large structures and preparation for those needing more observation. Instead jumbo facilities were created. Intensive care in the absence of any planning suffered terribly, and experiences in this regard at Sassoon General Hospital in Pune or Sion and KEM in Mumbai were horrible. Of the 18 large public sector hospitals in Mumbai only four were built in independent India. This can be viewed as a scenario of long-term neglect. But when the class four staff disappeared from KEM Hospital in Mumbai and refused to work, no action was taken. This class has repeatedly disrupted Municipal  hospital functioning in Mumbai in the past four decades despite being the recipients of all kinds of perks. The Maharashtra Essential Services Maintenance (MESMA) Act 2011 has been invoked but not put into action to date (https://www.facebook. com/107242304256980/posts/142804354034108). The lack of sensible management of caseloads by balancing the evolving situation of Covid 19  protocols was obvious.  The  laws and procedures existing in non-pandemic times were not adapted to deal with the ground realities, another glaring failure, noticed in the disposal of dead bodies in Mumbai. It is impossible to understand why this could not be managed efficiently when the Epidemic Disease Act was applied, invoked and used for threatening private practitioners. The delays in coordinating with and seeking cooperation from the private sector are detailed in my volume India’s Private Health Care Delivery (Kelkar, 2021). The next was both the inaction and the cynicism for not implementing the only weapon we had-detect, isolate and treat as much as one can under



equitable terms in anticipatory action was complete. The protocols were ready quite early. There was an enormous amount of data available on how things would worsen in terms of numbers and complexity, how these should be managed and how things would improve. The public health capacities ran out because this information was not translated into action. There were four stages among those isolated: (a) Symptomatic but tested negative: Initially their quarantine was to end after the second and third tests were negative. Later it was found that one negative test is enough for discharge (Gangakhedkar RR, May 18, 2020). Home quarantine for 14 days where possible in an effective manner as a sound option surfaced to keep more beds free but it was not used effectively, thereby increasing the shortages. (b) Symptomatic and tested positive: These were the cases that needed the Covid Centers most. These could worsen in some cases but most patients would be able to go home. (c) Tested positive and condition worsened and needed Covid Hospitals with oxygen-supported beds only: It is much easier to construct or procure these beds and reduce the congestion in ICUs. Over the weeks the medical community learnt that beds with oxygen support and various non-invasive methods of supplying oxygen were needed in much larger numbers, and were more effective than treatment with a ventilator as found later. (d) Critically ill: These patients went on ventilators with much lower numbers surviving than those in the earlier three stages. Those who survived were not moved back to a less intensive setup as quickly as should have been done, thereby reducing the number of ICU or High Dependency Unit (HDU) beds available. For a long time there was no dashboard in Mumbai to indicate to people where the beds were available, in contrast to Haryana and Kerala where this was well managed (see below). The back and forth movement in these four stages was not managed efficiently, nor was the availability translated to the dashboard, adding to people’s plight.



Health Care Infrastructure at the Periphery and Covid-19 Oxygen-supported beds are also manageable in public health care delivery in more remote places. Hypothetically, if migrants cause a much larger number of fresh cases to develop that require active hospital management, how many such oxygen-supported beds do we have at the sub-district, sub-taluka level? Practically, it will be insignificant or nil because these are the places where no work goes on. It would be a miracle if the 25,000 primary health centers had full and finctioning 500 such beds. The 5300 community health centers also placed in remoter locales do not have ICUs or HDUs. It would similarly be a wonder if these centers even had oxygen-­ supported beds. Covid-19 may not necessitate these arrangements but local endemics often do. For this the structural modifications given in great detail in this volume will give astonishing results, one more validation of the changes prescribed. If all such things were  occurring in Mumbai, the prime Indian city, things might be expected to be worse elsewhere but this does not seem to be the case. Looking at this situation, it would not be considered farfetched given the antecedents of those governing Maharashtra  state for one to draw the conclusion that the people manning the ministries had no interest in discharging this responsibility because there was no ‘gain’ for them. Another reasonable conclusion is that the ministers may not understand what to do, but indeed the bureaucracy may not either. Alternatively, however, all that the bureaucracy does or did was to manipulate their bosses, or make fools of them, and remain unbothered about what happens to citizens. This is generally the character of the IAS-type bureaucrats in independent India, and hence this is not at all surprising. When the Governments Function Well and People Cooperate In contrast to this scenario, the Haryana Covid-19 record of 21 deaths as of 6 June  and 2083 till December 20  in 2020 is a model in pandemic management. As expected, the Kerala model was praised but Haryana’s was ignored. Kerala, however, saw a second resurgence but this was also managed well. The success of both of these states is based on the same reasons. Both states 1. Conducted a large number of tests approximately 5167 tests per million population, substantially higher than the India average of 3831 tests per million.



2. Undertook early testing of those entering the state from Indonesia, Nepal, Thailand, Bangladesh and the Maldives, among others and their efficient contacts tracing. 3. Excellent use of the three-layer health infrastructure Covid care centres (CCCs) for patients with mild or very mild symptoms, Covid health centres for patients with moderate clinical symptoms and Covid hospitals for treating patients with a severe or critical manifestation of the disease preferably in medical colleges. 4. A clear pathway for the back and forward movement of Covid-19 patients through various categories of Covid health facilities, streamlining the management of resources, initiate efficient and timely treatment. 5. Strong monitoring mechanisms at the state and district levels with a dashboard providing a comprehensive, district-level overview of the latest status of Covid-19 cases. 6. Emphasis on the management of containment and buffer zones, restricting the entry and exit through the effective deployment of the police, frontline health workers like ASHAs and auxiliary nurse midwives. 7. Testing all patients for Covid-19 who contact health system for unrelated surgeries and screening their high-risk contacts of patients, with TrueNat test, to save time and reduce the burden on the state laboratory. 8. Extensive use of print and electronic media the community radio for creating awareness and dispelling myths and misconceptions and stigma about Covid 19. (Urvashi Prasad, June 8, 2020, 11:25 am, blog site Swarajya) Kerala’s success lies in its extraordinary alertness in preparing for the pandemic in minute detail early in January and being aware that Malayalis would be coming back from Wuhan and would potentially be bringing the virus with them. The health system in Kerala has always been a cut above the rest of India. The public and private sectors have many reputable institutes and when it comes to health, all appear to cooperate. Ready lists of such institutes and medical and human resources seem to be their specialty. Even though the numbers returning to the state were high, as were the death rates, they were alert for second and third waves as people continued to enter the state. Kerala has undertaken the standard Covid-19 drill so thoroughly and sincerely. It received full-page stories in major



newspapers and media whereas Haryana did not (The Indian Express, Saturday, June 13, 2020). There was a substantial resurgence in Kerala after initial containment but the state government cannot be blamed for insincerity and insensitivity like Maharashtra’s can. Inept Handling of Data There are indications that the AAP government initially underreported deaths; there were accusations of the crematorium and burial ground data being grossly in excess of the reported cases. Now AAP is projecting 5.5 million people likely to test positive and 80,000 required beds required. Both of these claims are ridiculous. Even then in the five worst affected states—Delhi, Tamil Nadu, Gujarat, Maharashtra and Uttar Pradesh—the first will fall seriously short of ICUs and other facilities. Who is the AAP government trying to fool? Are they trying to cover up their incompetence with these figures? Their much touted Mohalla Clinics simply have not worked—another indication that public health delivery in cities is inappropriate for the urban poor as well as non-poor. Three states appear to be guilty of this inept handling: Maharashtra, Delhi and West Bengal. On June 6, 2020, 428 unreported deaths surfaced in Maharashtra outside Mumbai. Mumbai’s Covid-19 death toll surged by more than 900, and Maharashtra’s tally surged by 1409 with only 81 of the deaths reported as of June 2, taking its total toll to 5537, following a data reconciliation process. Many other examples have been quoted in this report (Barnagarwala Tabassum & Shaikh Zeeshan, June 16, 2020). West Bengal claimed a 9.75% mortality rate when the center’s figure for the state stood at 13.2%. It set up the first death audit committee, which was accused of being set up for the purpose of underreporting and incorrectly reporting Covid-19 deaths through semantics of labeling the cause of death. West Bengal blamed the center for not providing kits, which was challenged from within Bengal. The inter-ministerial group was blocked from visiting Bengal for assessment to avoid incompetence surfacing (Bhattachrya Ravik and Mitra Atri, May 10, 2020). The Challenge of Urban Prevalence One glaring aspect of this pandemic is urban prevalence in large congregations of people living in hutments and slums like Dharavi in Mumbai, which initially gave rise to high numbers of people affected. The numbers



were still growing even while a report, unconfirmed by any other agency, states that Dharavi’s cases have now been contained (Sanjana Bhalerao May 21, 2020). This has been challenged by the reality that 75% of Dharavi’s population fled from Mumbai, making the situation more manageable. At least three voluntary agencies and public-spirited doctors have played a major role, which has been suppressed, and the Maharashtra government has attempted to take the credit. Another reason stated for lower numbers being reported from Muslim-dominant communities is on account of the reluctance and fear of the inhabitants regarding getting tested. The high numbers even otherwise are seen also because it is easier for the testing machinery to reach them as compared to the remote villages; city dwellers, even if they are poor, are more alert and there is more communication in cities. Clearly the urban public health care delivery system is unfit to handle this challenge. This will be discussed in the appendix on the urban poor.  he Illegitimate Scare of Rising Covid-19 Numbers T The pandemic initially alarmed everyone, as the death tolls in Italy, Spain, the USA and later the UK and then Brazil and Russia started rising extremely quickly. Over the next two months the Indian figures rose substantially to increase the scare, resulting in a great deal of action. As we completed the third month of the lockdown on June 25 many more observations surfaced and certainly quite a few of these were reassuring. Unfortunately, in the interest of TRPs, the media, with the honorable exception of DD India, has managed to increase the fear factor. This may have helped to make people behave a little more sensibly, but as on June 15, 2020 the media was not positive in its coverage of newer information. Some examples of this are given in the volume India’s Private Health Care Delivery and this will be discussed below and in other places in this volume as well. As on June 19 the total number of people infected who have tested positive was 2, 54,708, of which 1, 94, 324 were discharged. The total deaths so far were 12,237 (, COVID-19 Dashboard, as on: June 18, 2020, 08:00 IST (GMT+5:30). As on December 20, 2020 the total number of Corona positive cases has crossed 10 millions. The percentage of those who died was at 4.8%, and has been consistently low compared to many Western nations where it was 10% or higher. It stands at 1.4% on December 20, 2020. The proportion of those who were laboratory tested for symptoms and found positive was a mere 6.8%. Since the third week of May the number of tests has increased to 100,000 per day



or at least 75,000 for a cautious estimate. As more tests are performed the numbers will rise. This is common in medicine. But what do the numbers consist of? The recovery rate has already touched 95% as predicted by Dr. Randeep Guleria of AIIMS (Guleria Dr. Randeep, May 18, 2020). This means that of the 10 cases 5.2 will need or will not go beyond isolation facilities, and if home quarantine is feasible for a patient the risks of cross infections will be reduced along with the numbers. In that case 4.8% will require advanced care and may die, assuming that there are no recoveries. With over 900,000 tests per day since August 18, 2020, totaling over 150 millions on December 20, 2020 the positivity rate is still low—5.8 to 6.1%. Another way of looking at the statistics is through extrapolation. Ten years ago a similar scare was noted about the infection mortality rate and with regard to swine flu. The actual number of deaths was comparatively low, at 0.02% of all those infected as reported by WHO. The actual number of Covid-infected patients is much greater than the 400,000 and counting; rather it is approximately 10 million, extrapolated from a survey of 70 districts and 28,000 specimens. Of these, only 0.73% have been detected as positive. If the deaths reported are divided by this number the actual mortality is just 0.1% of all those infected. This means that 99.9% of those infected will not only be cured but also become immune to the disease, constituting a major part of herd immunity. The quoted survey will continue and should reveal even more encouraging statistics (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai). The Good Statistics 1. The statistics can be understood simply in percentages. If 100 cases are detected in a day with or without symptoms, 50% will not even know that they have been infected (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai). 2. Eighty percent will recover without any active treatment in 14 days. Dr. Randeep Guleria, Director AIIMS, also stated that ultimately the recovery rate will be more than 90%. (Guleria, May 18, 2020). Of the remaining patients, 3 to 4% will die and 17% will have serious enough symptoms to require hospital care and will eventually recover. Instead of bringing this encouraging statistics out, the focus remained on rising numbers actually detected, which as shown does not pose great problems in majority (Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai).



3. In medicine, sensationalism always wins at least temporarily over science, hands down. 4. Another interesting statistic presented by Dr. Gangakhedkar was about  the ability to infect another contact. It is 1.5 persons for Covid-19 and 13  in measles. But there was no positive reporting about this reassuring news either,  from other media channels (Gangakhedkar RR, May 18, 2020). 5. The scaremongering continued and had at least one major effect on migrants (more about this as a health issue is discussed below).

The Covid-19 and Public Health Measures As mentioned above, the formal system of public health care from sub-­ centers to sub-divisional hospitals has not been used to cover the bulk of the rural population. The measures taken outside this system, however, have done a good job (see below). This is partly so because the bulk of the cases were found in the dense population pockets in the cities and not in rural areas. 6. From the district hospitals to government medical colleges, due to the admissions for isolation and treatment of more severe cases of Covid-19, the capacity was exhausted, leaving a great deal of urban misery unanswered. The governments have done a poor job of enlisting the cooperation of the private sector, shown in detail in the volume India’s Private Health Care Delivery (Kelkar, 2021). Despite all this, however, the Covid-19 statistics and the data that kept surfacing over in Ocotber to December 2020 have many positives, described below. 7. The initial rapid doubling rate of a few days which by June 14 had increased to about 14 days despite high rising numbers of Covid-19 cases is something of a miracle. 8. Without doubt, the rapid decrease in the doubling rates is due to the closure of airlines and railways, the largely observed lockdown, and the system of red, orange and green zones later converted to containment and non-containment zones. These measures were outside the health measures cutting at the root of the problem. The police and other forces actually are not health agencies but have



done a remarkable job in maintaining containment zones, which has also led to reduction of these, if not to their disappearance. 9. Most red zones and later containment zones have been Muslim communities due to their initial refusal to obey the rules about social distancing and congregations. Assaults on police and the meeting of the Tablighi Jamaat that occurred right under the nose of the Central government escalated the problem. 10. This situation has resulted in distrust between the police, the government and the Muslim communities, leading to lower rates of testing and refusal of symptomatic people to seek treatment through the regular channels. Despite this, the number of cases detected in these red zones was much higher than in the general population (Ghosh Sohini, Sharma Ritu, May 10, 2020). 11. Such issues are not only community related. These are the differentials which teach lessons for public health management. 12. A big thank you must be extended to the Muslim religious leaders for emphasizing the importance of this in a straightforward and authoritarian manner to make these communities compliant. Muslim Trusts such as the Haj House in Ahmadabad offered isolation facilities. The Muslim community also needs to be saluted for this more than it has been so far.

Migrant Workers as a Health Issue This will be dealt with at some length vis a vis the public health care of the states. In simple terms it means carrying the Covid-19 virus from high-­ prevalence areas to low-prevalence areas with much less dense population segments. I did not think that there would be high infection rates in villages, that it was likely to remain low. The reason was that those who were allowed to migrate had not been shown to have any symptoms, not even temperature rise at the railway stations before they boarded the trains. Even if this was elementary testing, it was remarkable in detecting those residing  in high-incidence cities. There is some evidence that the habit (or scare) of social distancing, isolation and so on has permeated to the village level, which would result in much lower than expected fresh incidences. Three or four weeks after migration started, data on new incidences at the district level surfaced, which has vindicated my judgment.



How Serious Was the Spread After Migration? By June 22, 2020, 5,12,000 migrants had already returned to Jharkhand. On May 31, 610 was the number of positives which grew to 2140 over one month, which is meager. Of the migrants, 1325 became positive but only 205 among the locals (Saran Bedanti, June 24, 2020, Hindustan Times Ranchi). As on December 2020, a total of 1,12,606 cases were reported out of a population of 40 million with 1008 deaths. The state had a capacity of fewer than 2000 tests daily. One write-up has projected this as a serious scenario and raised a futile alarm (Abhishek Angad, May 21, 2020). By June end Covid-19 hit 174 out of 300 districts which had no cases, mostly in Bihar and Uttar Pradesh, with an average of 23 cases in each district. One hundred and fifty districts with 10–50 cases on April 22 had an average of 100 cases. The 30 districts that had between 50 and 100 cases had an average of 220 cases. The migrant load, it was logically concluded, had spread over many more districts compared to high numbers in few districts in severely hit states. This migration was  being termed the ‘first phase of the pandemic’ for the states (Mehrotra Karishma May 21, 2020). It is an incorrect and unnecessarily alarmist statement. An average district has a population of 1 million in these provinces. An average of 23 is too low even if it spreads because those infected are few. The migrant distribution is over a large number of villages. Hence this will not represent a second wave or the first phase of a village pandemic. This is a health issue which can be contained. Migrant Labor—Whose Failure Is It? The migrant issue, however, has been taken up for criticism as a failure of the Central government. At the least, it is unfortunate. The migration started at least four weeks after the lockdown. The center had appealed to the migrants to stay where they were and they did. It was elementary for them to see that going back was not an answer, and it proved to be so, shortly after, as the reverse exodus began within 15 days. The center had seen to it that some money supply to crores of people was efficiently managed, another non-health measure. An appeal not to cut wages or ask for rent had gone out. The cities, and the police force in particular, the voluntary agencies and the public distribution system were helping them in



every way to sustain themselves fairly well—miraculously almost without corruption. All these were non-health measures too.  ailure of Employers and House Owners F Employers with short-sighted selfishness denied people wages and house owners asked for rents. The center had seen to it that money stayed in the hands of all the people, including employers, for at least three months in their first announcement. This was of no significance to those who deal with money and employ people for long periods. The same employers are now wooing them back at higher salaries.  as It Failure of the Central Government? W Another accusation leveled at the Central government is that the Shramik trains should have been started earlier. This is pure nonsense. When the migration finally started the Indian railways did a magnificent job of ferrying workers back to their homes. The dismal coordination of arranging migration in the state, particularly in Mumbai, is not criticized by those who comment. Another nonsensical criticism is that time should have been provided to send them home before the lockdown; this was never the idea. Moreover, lockdown would then never have effectively happened, making it a health issue of mammoth, unmanageable and serious dimensions. Assisted migration in itself is a foolish idea as has now been proven with reverse migration. Engineered Migrations For some reason several instances took place at the New Delhi, Noida and Ghaziabad borders where migrants were collected as a result of instigation or rumors. Was this an attempt to get rid of them as soon as possible, defying all logic, or was it done with a clear idea of disrupting the lockdown and bringing discredit to the states and Center. It was reversed for some time, efficiently managed by Uttar Pradesh and badly by Maharashtra, as seen in the Bandra area first in rumors and later as lack of coordination in Mumbai. But the idea had spread and the physically tough laborers started walking back. One major reason for this is also the herd mentality without any forethought. It may seem harsh but it is true. Every media channel reported that lakhs of laborers were walking back, which was highly suspicious reporting. Continuous screening of the media images in those early days of migration reveals that a few and the same pictures were being shown for days on end. Obviously the media persons



had not gone farther than the first couple of kilometers and still reported millions walking back. The numbers are therefore likely to be not as high as reported. Thus, even before this became a big issue the Indian Railways responded speedily only to face refusals to allow trains back, lack of coordination and accusations, as in Bengal and for some days in Bihar. The railways have not stated officially how much it has spent so far on these services, but officials have indicated that the national transporter spent around Rs 80 lakh per service (PTI, May 06, 2020).  eaths During Migration D The second falsity was about migrant deaths on their way back. In all, four or five road and railway accidents were reported. The people in villages staying along the highways seem to have taken care of these migrant workers as they walked back. A large number of local voluntary agencies did their part in a heroic manner. This is not unusual; villagers do this often. In 1990, 800,000 agitators coming from all over the country were thus cared for, sheltered and sneaked to their destination by these poor villagers in Uttar Pradesh. On May 25, 2020, I traveled by road for 800 kilometers from Nagpur to Pune with special permission without seeing a single villager going back, but provisions made by people for those who might be walking back were in place at different points. (See below also.) There are many ‘heart rending’ tales reported in popular media, including prestigious newspapers. One such article distorted the concept of herd immunity by stating that the poor get infected to develop herd immunity. The rich acquire it without being infected, thereby making a mockery of lockdown when imposed and when lifted. Herd immunity is discussed below for better undersgtanding. People sitting at Harvard and high-class Delhi individuals wrote these spiteful stories with the purpose of maligning the achievements made (Ashok, Indian Express, June 12, 2020, Delhi Edition). These are not worth responding to but need to be condemned. Every issue discussed here has health aspects and logistical considerations yet it is a job well done overall. Uttar Pradesh and Madhya Pradesh have employed 700,000 and 1125, 893 people under Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). One hundred and sixteen other districts with the help of Garib Kalyan Yojana (Welfare Scheme for the Poor) and MNREGA had employed 1,985,166 by the end of April, many getting employment every day in the states (https://economictimes.indiatimes. com/­a nd-­ nation/state-­govts-­prepare-­job-­opportunities/articleshow/75585654.



cms?utm_source=contentofinterest&utm_medium=text&utm_ campaign=cppst). Herd Immunity Herd immunity is an old but valid biological concept even today, and has many aspects. Covid-19 belongs to the SARS family, to which the world has already been exposed. As such, the versatility of the human immune system can cross-react and produce immunity to Covid-19 in many people, even in India (see above also). Had this been not so, detection of 6.8% of all those with symptoms tested, a predicted 90% recovery rate, low mortality and detection across all strata of the society cannot be explained without a rapidly developing immunity among hundreds of thousands of people. Every major pandemic including the Mumbai and Pune plagues in the early twentieth century killed not all but a significant proportion of the population. Every pandemic then peters out, with or without care. No pandemic has recurred or recurs. This is because herd immunity continues to increase. The only exceptions to an epidemic recurring were cholera coming to Bengal and India in the 1960s yearly from East Pakistan, or the limited endemics of leptospirosis and jaundice in Mumbai in the 1980s. The first of these ended long ago. In widespread infections herd immunity develops itself; one cannot create or gift herd immunity. Hence when the migrants go back or come back, people are discharged from hospitals and others are asymptomatically affected, and lockdown is relaxed with people mixing freely, herd immunity will develop as a natural phenomenon. The lockdowns are said to have pushed the second wave spread by 74 days. Over this time the infectivity or virulence of an agent also goes down. Hence the fear concerning rising numbers can be said to be baseless and firm action should continue. A Good Measure to Meet the High Covid-19 Patient Load One good step was the development of a three-stage structure of fever or Covid Clinics where elementary testing for fever, symptoms and swabbing for the samples was undertaken. The second was to isolate symptomatic patients until the report came back negative and then discharge, and isolate them if the report came back positive at the Covid Care Centers for 14 days. If the patients came with severe symptoms they were to be shifted to Covid Care Hospitals. This measure incidentally did not use the existing public



health care structures within urban areas or these structures could not be utilized for some reason or the other, once again underlining the penchant for duplication, or confirming the ill-conceived formats of the urban public outfits. These aspects will be discussed in the chapter on urban poor and health care delivery in this volume.  on-Health Care Decisions and Actions N China informed WHO about the virus on December 31, 2019, and WHO declared Covid-19 a global emergency on February 1, 2020. India undertook the first airlift of its citizens from China on February 2, 2020. India also started to test, screen and quarantine those returning from abroad, reaching 1.97 lakh screenings by February 11, 2020. On the global level 46 countries stopped air services to China. As those affected by Covid-19-­ like symptoms started appearing in the general population, the most major, most difficult and most daring as well as unprecedented decision of stopping both domestic and international air services was taken, with railways and public transport shut down. The next most astonishing feat was to convert 5000 railway coaches into isolation beds to be stationed at 215 stations near power house facilities, which the states could ask for. The most welcome and somewhat astonishing aspect was the huge support people gave to the lockdown despite the initial disrespect for it in many quarters, which was dealt with using a strong hand. Fear was not the only key. Credibility of a person leading the battle from the highest position  was working. Social distancing and sanitization became norms and translated into people’s behavior. Successive lockdowns started from March 25, 2020 and lasted until May 31 and June 8 saw some easing of the same. Essential supplies were transported all over the country. Ration cards were made portable, with the Public Distribution system responding gallantly with hardly any corruption during this time. Crores of rupees were transferred in crores of Jan Dhan accounts and many simultaneous announcements were made to the effect that whatever money people had would stay with them for three months to follow. There is no need to go into the pedantic discussions over the five-day marathon addresses by the Finance Minister—the sum and substance of these is mentioned above.  he Heroes of the Struggle T From the beginning the heroes were the police, the medical and paramedical services and the cleaning services. Without doubt, the voluntary agencies have played a yeoman’s part in feeding people and caring for



them. People rising to the occasion have no longer remained a rarity lately. Two recent examples are the devastating floods in Kolhapur in Maharashtra and Belagavi in Karnataka in 2019, which were responded to by actions more by people than by the government, and this has been repeated during Covid-19 times. Digitization has also helped greatly in the development of apps to disseminate information. The early appreciation they received helped people to behave properly and carry out the lockdown. Pertaining to this volume, the role played by the junior and resident doctors as well as the nurses is the most important. They have worked throughout public health care at all levels beginning from the large institutes and medical colleges to public hospitals, and wherever else they were summoned. Their greatest requirement was in critical care. The senior doctors seem to have stayed out of this. Sassoon, the largest public hospital in Pune, had none. A group of private anesthetists volunteered on a one-week assignment. The greatest of their astonishing findings was a terrible lack of elementary as well as higher-level gadgetry. The care without any formal system was dismal to say the least. The junior residents worked but had no training and no guidance. But they stuck to it. When the system was built they responded to it and care improved. These doctors faced all the ordeals of Personal Protection Equipment for hours on end in a day and for days on end to the limit of exhaustion but they did not complain.  own Side of Dealing with Doctors and Paramedics D From various quarters what surfaced was that many medics and paramedics were not paid their salaries for three months. As is well known, their living conditions are far below ordinary expectations. The pandemic has once again underlined the need for better treatment and emoluments of these doctors (and nurses also), the need for better training and so on. The emoluments, living conditions and lack of effective training have all come under discussion in this volume. The first two have been chronically attributable to low funding for health care as a whole. The third is attributable to the structural havoc in medical colleges. The severe paucity of doctors and consultants across the public health care structure is another factor. No government seems to have any answers as to how these matters can be improved. There are scores and scores of measures I have suggested in this volume about how to improve all these conditions as well as the quality of health care without any strain on the budgets. I hope a note is taken and action initiated by those in power.



The AYUSH Ministry Contribution The AYUSH Ministry issued a long advisory on which drugs would be useful from among Ayurveda, Unani, Homeopathy and Siddha in prevention and treatment with a long list of references attached. From Ayurveda there was a recommendation of two drugs, Siddha one, Unani one which mixed two ingredients and five from Homeopathy, each with details of consumption and in a few preparation of the medicine as well. The effects claimed were antioxidant, immuno-modulatory, anti-allergic, smooth muscle relaxation and anti-influenza activity for the Unani preparation. The research base expounded surpassed all expectations. Arsenicum album 30 was credited with affecting the HT 29 cells and human macrophages, showed NF-KB hyperactivity, reduced expression of reporter gene GFP in transfected HT29 cells, and showed TNF-alpha release in macrophages. It is a common prescription for respiratory infections in day-to-day practice (Secretary, Ministry of Ayurveda, Unani, Siddha, Sowa-Rigpa and Homeopathy, March 16, 2020). The AYUSH Ministry supported the use of these medicines quoting WHO. During the Ebola outbreak in 2014 an expert group of WHO had recommended that “it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention,” keeping in view no vaccine or antivirals were available (Secretary, Ministry of Ayurveda, Unani, Siddha, Sowa-Rigpa and Homeopathy, March 16, 2020). The most remarkable and laudable part of this exercise was the way these medicines were studied carefully and in detail while reporting the findings in the modern language of allopathy. In this volume an appendix is dedicated to the controversies surrounding the AYUSH system of medicine. In the volume on India’s private care the last chapter is on integration of medical systems. This advisory has brought about many discussions and these two chapters will provide an understanding in great detail and with strong relevance to these discussions, making both the volumes pertinent in this unusual Covid-19 time. Before I return to the original Introduction of the volume a few small points need to be answered. In the wake of Covid-19 some voices called for nationalization of all hospitals, more by habit I suppose, without even realizing the utterly irrelevant nature of such suggestions. This is another form of Universal Basic Services for which there are always some proponents. Suffice it to say here that these are dangerous suggestions which will fatally harm the economic strength India has built over years, and hence should be cremated on the altar of rationality.



A small observation on the disaster management capabilities of India shows how well these have developed, admirably and greatly in the last six or seven years. The Ministry of Health and related functionaries could take a leaf from their book in handling pandemics and responding more effectively. Kerala has set an example this time. Now I will go back to the original volume. Irrespective of whether it is the private or public health field, it is the government that is central. It plans, sanctions, restricts or frees the system, gives legal backing, and is finally responsible for the outcomes. Every word of this volume is primarily and finally to help the governments to think about what happened with earlier policies and what policies need to be adopted. It is written mainly for the ministers and public policy maker bureaucracy in Ministries of Health and Family Welfare, high-level officers from Departments of Health Services and Medical Education, chief officers of their numerous directorates, in the state and union territory governments, and the officers of the NITI Ayog and National Institute of Public Finance Policy, Health Activists, Health Organizations and Health Economists. The Deans and Heads of Departments of the 260-odd government medical colleges are addressed to facilitate a relook in their respective domains and for them to think about action for betterment. This requires fresh, bold thinking, in new paradigms backed by political will, bringing all the stakeholders on board for consensus. This is an area where all the responsible and experienced persons mentioned above have to come together to understand, analyze, and ponder the merits of the idea, the feasibility of implementing it or better ways of doing the same. A new policy solution can then be found. Health care professionals working in any of the health sectors–preventive-primary, curative governmental-­ private-­voluntary sectors, those in non-clinical fields, administrators, policy makers, regulatory professionals and those working in industry–are also important contributors. The more professionals from diverse fields ponder these issues, the better the models presented can be made. Half of the book is devoted to policies needed in manpower production and its deployment in the public health care delivery system. This is an as yet unsolved problem. More or less an equally substantial part deals with the structure and function of primary health care. The real and perceived health needs over vast tracts of land, the varying and changing economic state of people located in more than half a million settlements with varying densities, their ways of prioritizing health issues,



and socio-cultural beliefs and practices is one set of variables. The other is the perception of those who are finally responsible for providing health care and the structures and functions in which it is provided. These two could be at variance, even in conflict with each other. The third set of variables is the way modern medicine is expanding and changing, the complexities that have been introduced in health care delivery, and the effects and changes these may cause in the thinking of the population across the board. In the globalized world, countries are also bound by the fourth factor of transnational world body agreements and compulsions. It is ‘wisdom forced upon’ which cannot always be ignored. On the other hand, in the early 1980s, a radical thought process emerged from the left of center and the Christian groups which had their own ideological basis for thinking about health care and poor people. It remained confined mainly to primary care. It led these scholars to consider only those ideas, instruments and the structure as the far more effective solution, a panacea for better health care especially among the deprived classes of rural Indian society. The issues were discussed in in-depth scholarship, thought over and tested by experimentation, as was every idea/ model/agency that was on offer over decades from the policy makers on primary care. The statistics were there, as was the description of the rather lamentable situation of the health sector. These were undoubtedly worthy efforts. However, these groups did not think of newer or different models for health outside the primary care skeleton that proliferated in the public health realm. The primacy and emphasis on primary care created discernible limits to the solutions these groups tried to provide. The need for quality curative services was forgotten. I will discuss four more ideas indicating why this could have happened. These concepts became Conventional Wisdom, leading to Observance of Etiquette, to being Politically Correct and using Statistics as the proof of all one wants to prove. These are always a safe haven, if you are speaking the same language. The criticism will lose its edge. One can carefully continue to prescribe more quasi-conventional ideas that may look newer. More often than not, these four elements have served as an able deterrent to break out and chalk out different paths and think differently. These four elements are also a part of a code, simultaneously making it an evaluation instrument. If one is outside any one of the four, then one’s ideas are not acceptable. They will be judged by the above code, to prove that the proposers of the new ideas are guilty. This is a verdict they should



accept, disowning their thinking. Those who play this game do some disservice by preventing people from seeing the shortcoming of the existing situation in full measure. The travel to truth becomes confusing or misleading. These players are engaged with subtlety in a game that perpetuates the problems rather than solving them. But it makes them indispensable to the debates. In simple terms, there is a planned obstructionism to realistic solutions. The goal here is to reach the truth and heart of the matter to improve the health situation. All that matters to me is the functional ability of an existing structure to solve the problem in the local situation and the country as a whole, the way it needs to be solved. If it is unable to do so an alternative must be sought. The arguments, facts, propositions and objections argued for the older ideas will be respectfully considered in great detail here. The volume is reflective and compares the ground realities, analyzed with my views on what should be done, in a reasoned manner. This will help in revealing a clear picture, replete with operational details. This will place the remedies I have suggested, the reasons behind them and the feasibility of employing these ideas under further scrutiny. Only then will a fair, detailed and productive debate ensue. Such a debate is needed. Each area requires scrutiny to discover how to harness its potential and weed out what is unrealistic and/or counterproductive for the welfare of those who need it. I do not dwell ad nauseam on problems: more than half of the book talks about solutions. The final test of all endeavors here is justice for all people. There is no use shying away from the failures of planning, and displaying a blithe complacency with an undertone that matters are well thought out and everything is working should be cast aside. I have been studying health literature and policy documents for decades now. The thinking in the health literature has a dual nature. One is the theoretical or cerebral understanding and the second is the quality and duration of, or the lack of, actual field experience among the pundits and activists over many years. In the absence of this, instead of a total, a fragmented and differentially weighted view presents itself. A certain dogmatism develops, which halts the cross-fertilization of ideas. There are five primary considerations with regard to health care: accessibility, affordability, quality, equity and justice. Accessibility was partial and differential. Affordability in the free system was marred by corruption. Quality was not reached in public health care delivery due to the lack of competent professionals. The first three having failed, the question of



equity and justice for the population was never achieved. This pushed the people, even the disadvantaged, to increasingly resort to the private health sector. What affordability people had turned into a huge and inevitable debt trap. The exploitative nature of the private sector marred the fruits of the quality that people encountered. And justice was the first casualty everywhere. This book is about government or public health care delivery in India. I hope to present a new workable and efficient policy framework to restructure it, for it to deliver much better results. In the latter half of the 1990s Indian society started changing significantly. Unfortunately, the contemporary and futuristic appraisal of those changes did not appear in the ‘reflections and debates’ of the policy makers and other health theorists. A detailed picture was needed of these changes arising out of the ‘debates’ affecting ideas about health. This would be a proper foundation on which to base our thinking about how health issues should be looked at hereafter. The achievements and the unfulfilled promises, the strengths and the lacunae, the newer needs and solutions, would then come into perspective. The next  chapter, ‘Philosophical and Social Basis of Reorganization’ draws this picture and lays the foundation for the rest of the book. What were the ideas about public health care delivery in post-­ independent India to start with? How did more ideas emerge and how has the medical care delivered in India for decades evolved? What are the place, relationship and contributions of each activity to the others, in the total context of health? How have political leaders hurt the system? How many reasonable and relevant solutions have the system and those people responsible for it given to solve the health issues? How many challenges has it addressed efficiently or how many new challenges has it created for good or for bad? What damage has it caused to health care as a whole? And finally what should and can be done to make it better? This is the general sequence followed by the chapters in this volume. Each chapter gives as complete a picture as possible of a large domain in the above context. I have, however, also tried to understand its links with other domains as well, and how these interact with and affect each other. This is followed by discussion of the improvement, regulation or scrapping of what exists in a dysfunctional state and replacements if any. The services and structure provided at any one time and their actual taking off from the ground come with a time lag. The evaluation of changes, the imperative of changing the profile of the service—structure



duo, needs a system that is agile and adaptable for rapid alterations. This is an expectation met only with exceptions, whether it is government or non-government organizations, movements, experiments or ideologies. Be it developmental issues or modifications or restructuring of any field, several ‘Ms’ are needed: Men, Money, Material, Methods, Machines and a Mind for it. The Men come from a system which the mind creates. The initial part of this book deals with this system, the government medical colleges. The present condition of the medical colleges, the question of whether we need more doctors or medical colleges to meet the challenge, and the externalities that are needed to support the purpose of education is one part. In this is also included the state of the teachers’ availability, the various functions they have carried out in the past, and new ones they could carry out in a new structure. Then the book discusses methods which prepare the Men who finally come out as a product of this system of medical education. A detailed analysis of the structure, content and methods of delivery of the historically prevalent medical education, the sequential subject learning, a structure in fact disconnected from learning the art of clinical medicine, is presented. Unacceptable modifications provided over time in the curricula and the learning of basic subjects follows. Medical education historically and fundamentally is a biological science and it is supposed to develop a sound clinician with a solid foundation in the basic sciences. New and important trends—whether the science should also be coupled with the knowledge and understanding of the social realities in which it is inevitably embedded or should remain as science— require elaborate consideration. The need that the new thinking seems to indicate is that the medical education should create leaders to do the job on all fronts. The chapter next describes the search for alternative ways of learning which will meet the demands that will be placed on the medicos. Problem Based Learning (PBL) seems to be the only alternative on which various nations are converging. The chapter then details the various aspects and experiences of these countries and the massive experiments that have been conducted in this methodology of learning in India and its success stories. It argues for development of the teaching curriculum in the Problem Based Mode over a decade by dedicated agencies and replacing the structure on which it has been run for decades.



The next chapter describes where the manpower should be placed in the public health care system, the reasons for it and the structural changes that precede or arise out of it. A large spectrum of what needs to be done to make it effective, leaving behind all the conventional and outdated thinking, has been presented here. It shows a comprehensively detailed, respectful, logical and strong reasoning about the changes suggested here to improve the situation. The reader is requested to read this chapter along with those on the structure and function of community health centers which follow this one. Manpower deployment in public health care delivery has remained a serious lacuna. The issues connected with it are the qualities of  those deployed  against the requirement of the remoter  communities and the level at which they are proposed to be placed. The views of the National Rural and Urban Health Mission and the Indian Public Health Standards (IPHS) are rigorously scrutinized here. The second issue is adequacy in numbers. The third is why these attempts have resulted in the failure of deployment in the structural units in which manpower was to be placed. This key chapter argues strongly for new ways of thinking in the deployment of manpower and links methods of improving manpower quality clinically and for postgraduate preparations. Then comes the matter of what Machines and Materials we need for them to deploy with the Men, in a system that has specific functions. Both must come from government resources. The government health care system then comes under scrutiny in the five chapters that follow. The first of these carries out a clinical dissection of the most sacrosanct idea of public health: community health work and primary care. I have analyzed a volume on Health Care for All in 2000, (1981), National Rural and Urban Health Mission (NRHM and NUHM) document of 2005, revised in 2012, followed by the Indian Public Health Standards (IPHS) in great detail. The most peripheral and deep in the rural communities is the sub-­ center and the Community Health Workers. The primary health centers (PHCs) at the level of populations of 50,000 with a Medical Officer is the first contact for people who are sick and require medical attention. The sub-center and the PHC are the mainstays of primary care. And primary care is considered the mainstay of health care. It continues to receive the maximum focus to date. The idea consists of health education for people, concepts of hygiene, prevention of the occurrence of the disease and immediate corrective measures if it develops, to prevent



complications from arising. More important is the idea that the illness is treated at home without higher intervention. Sub-centers and the PHCs suffer from dysfunction. This has mainly arisen from the conceptual framework. Every effort to make them work has unfortunately been met with more of the same incremental ideas over and over again for decades. These add-ons were more of the same nature under different names, minor solutions which were bound to fail. It was more tinkering rather than in-depth review of whatever was happening and the possible reasons behind it. These two structures continued to be loaded further and more people were recruited to the sub-centers. The addition of work force in PHCs was inadequate and many measures were of an offhand nature, and often unrealistic. Above all it lacked a total view of the system. The next two layers function roughly at the level of populations of 200,000 and 900,000 called the community health center (CHC) and the sub-divisional hospitals. The CHCs are expected to cover the five basic specialties of medicine, surgery, gynecology and obstetrics, pediatrics and anesthesia to treat the majority of the curative issues arising at their population level, as near to people’s homes as possible. The sub-divisional hospitals are planned to have these five as well as many other specialties and instrumentation for higher-level care. The curative services concentrated particularly in the CHCs needed much more attention but did not receive it, either from the governments or from scholars. They ignored the gross deficiencies of the curative services, gratis or otherwise, for a long time and did not talk about correcting the same. The scholarship did not go toward stitching together the whole fabric of health care delivery, a ‘corporate whole,’ and remained lopsided. For the curative needs, scheme after scheme was floated by the states and the Central government. There are some achievements but many more were left out. Yet on the ground the discernible changes were lackadaisical. The schemes ran and continue to run into difficulties. CHC as a model has failed more dismally than the PHC and the sub-­ center. There was no originality or in-depth dissection of what was not working and why. The greatest failure was the inability to provide the five basic specialists in most CHCs. The case in sub-divisional hospitals is no different. Without the men, the provision of materials and machines was of no consequence. To put it in another way, the ‘unchanging’ poverty of large numbers and their suffering was being overrepresented, with primary care as the



only solution. It was as if there was no need for other aspects of higher-­ level care. It was a humanist but inadequate and unrealistic stance. It missed the needs for curative services that could respond to the challenge when primary care fails, which it does frequently enough. In addition, free health care became a tenet of faith, which continues even today. Other than the free government health system, anything else was considered tarnished. The major planning defect that surfaces from all the government literature is wasteful duplications of ineffective services. Imagination is used to merely add poorly conceived structural layers and unproductive people within the failing public health care delivery system. At times mere unrealistic ideas fraught with likely misuse are thrown in. This has created and cultivated multilateralism, multiple authorities and multiple institutions. It has made the decision process extremely difficult—nearly impossible. And over years they have all failed miserably. Working and reworking the non-­ working systems has only showed that the governments have never really been in touch with the ground realities which are so different from the theory. The thrust of these chapters is against the current thinking, especially of the governments. One trend being rapidly operationalized is to shift (curative) health care to the private sector under the idea of fee for service. This principle will never adequately cover the vast tracts of land and people. It will not be able to fully serve those most disadvantaged in their dire and urgent needs. It will also not be able to control the exploitative private sector in full measure. Based on observations of past experience it will soon be an economic disaster. And it will once and for all halt the essential development of a benevolent and beneficial counterforce we must have in the public health care system. The book argues that a much sleeker, flat and horizontal, as well as decentralized, system must be built in order to keep matters in balance. The breadth and depth of the maladies make it imperative that any solution for health issues should have a minimum common factor of services, and how these will be provided. It should also be feasible. Some prior understanding as to whether it will achieve what is intended to be achieved is necessary. This may help to shift gears if it meets with dismal failure. These are dynamic issues which keep changing over time. One must remember that betterment in health may take place more often than not due to other socio-economic measures. In conclusion, considerable improvement in all the spheres of public health care delivery is possible.



Private health care has received critical analysis and changes required to make it better in the second volume India’s Private Health Care Delivery: Critique and Remedies published with this one. The reader will find it referred every now and then for topics which also relate to public health care delivery here discussed more in detail. To cover public health care delivery in a single volume has been a difficult job for me over the last five years I have worked on these volumes, incorporating as much as possible with the latest developments. A total solution to the overall and dynamically changing health situation was the challenge. The solutions or the ideas proposed had to have the intrinsic ability to respond to these changes by developing a flexible, lean and efficient system. The many different career choices I have made during the last 40 years gave me an experiential insight into almost all the aspects of health realities in different spheres. A desire to attempt a synthesis of all such ideas has led to the compilation of this and my other volume. The context of this volume and the details therein is that of India since I know the system quite intimately. However, these solutions can easily be adopted in any part of the world where the issues of health are not satisfactorily answered. The least of my wishes is that it be read with open mind. My hope is that it helps India to move forward for better health care in the country and wherever else needed.

References Kelkar Sanjeev, 2021, India’s Private Health Care Delivery, Critique and Recommendations, Palgrave Macmillan, India. https://www.facebook. com/107242304256980/posts/142804354034108. Phadke Anant, June 21, 2020, Loksatta Daily, Mumbai. Ghosh Sohini, Sharma Ritu, May 10, 2020, Sunday Express, Supplement Indian Express. Rajput Abhinav, June 16, 2020, Indian Express, New Delhi Edition. Prasad Urvashi,—Jun 08, 2020, 11:25 am, blog site Swarajya. Express News Serive, Indian Express, Saturday, June13, 2020. Barnagarwala Tabassum & Shaikh Zeeshan, June 16, 2020 the Indian Express, Mumbai edition. Bhattachrya Ravik and Mitra Atri, Sunday Express, May 10, 2020. Bhalerao Sanjana, May 21, 2020 Dharavi gets 18 mobile dispensaries to up screening of patients, The Indian Express, Mumbai Edition., COVID-19 Dashboard, as on : 18 June 2020, 08:00 IST (GMT+5:30).



Angad Abhishek, May 21, 2020, Ranchi, in Indian Express Mumbai. Mehrotra Karishma May 21, 2020, the Indian Express, New Delhi Edition, com/news/politics-­and-­nation/state-­govts-­prepare-­job-­opportunities/articleshow/75585654.cms?utm_source=contentofinterest&utm_medium= text&utm_campaign=cppst. Guleria Randeep Dr, May 18, 2020, DD News. Interview on DD News with Dr RR Gangakhedkar of ICMR, 18 May, 2020. Secretary, Ministry of Ayurved, Unani, Siddha, Sowa-Rigpa and Homeopathy 16 March 2020, D. O. NO. S.16030/18/2019-NAM. PTI, Last Updated: May 06, 2020, 12.53 PM IST. Ashok, Indian Express, June 12, 2020, Delhi Edition. Saran Bedanti, June 24, 2020, Hindustan Times Ranchi.


Philosophical and Social Basis of Reorganization

Background Changes over Last 30 Years Globalization, privatization and liberalization (GPL) were forced upon us. We had to pledge and physically transfer 48 tonnes of our gold to the UK, and the exchequer was spent on subsidies and welfare schemes; we were not even creditworthy in the international markets (Govilkar Vinayak 2018). But it helped us get rid of the Nehruvian model and the avid attraction or the welfare state idea. The rate of change and betterment increased tremendously with GPL, visible since the early twenty-first century (Govilkar Ibid.). It has also brought considerable prosperity in large sections of the population. The money has gone to the bottom of the pyramid. Vajpayee government wisely built upon what Dr Manmohan Singh and Narasimha Rao had begun. United Progressive Alliance I, UPA I, did good work and the progress occurred at a satisfactory speed. Many more changes are now afoot since May 2014. But our thinking about the public health care delivery has not changed much. Modi government seems to have an understanding of the public health issues with many blind spots at places. Health Thinking: 70 Years Sans New Ideas The first 70 years after independence is a classic example of lack of critical assessment of how things are working. There was a lack of imagination © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




and original thinking on part of the government sticking to the ancient and repeatedly failing ideas that were operative since 1945. In all these years, it was small, incremental and more of the same solutions the government has been offering till date as will be shown repeatedly in chapters to come. The thinking of the health theorists was also trapped in a few fundamental and dominant beliefs. India is a poor country, and the poor must get free health services; primary care is the panacea and should be maintained, improved and made workable and efficient, even if the primary care public health structure is functionally inadequate to the challenges of better health. The other dominant idea was that the private sector and the multinational drug industry are a bunch of dacoits who prey upon all the poor; hence, public health care is the only remedy. Hope was that miracles will happen. These unchanging ideas supported the mere incremental ideas and tinkered with the system here and there ineffectually. Some Philosophical Considerations: The Hegelian Idea The Hegelian idea is of a thesis, antithesis and synthesis, which in turn becomes a thesis. Simply put, at any one point of time, say in 1950, the prevailing health situation is a thesis for which we apply a solution which is an antithesis. These two act and react with each other, and synthesis occurs. The synthesis is a different situation becoming a thesis again for which an antithesis will generate itself over time or will have to be created. This dynamic concept is applicable to any inherently changing process. Health care delivery system in our country has been changing over years now. Many changes are not planned, many are, some are highly undesirable, some are good, but not all fructify as expected but do so variably. The thesis antitheses are first the Organization and then Reorganization, its Orientation and Reorientation, Rebuilding or Replacing leading to a Hegelian thesis over and over again. The need for the above-mentioned four Rs is perpetual in health care. The process has been tardy and inadequate, the main reasons for writing this volume. It need not startle anyone, however huge the magnitude and varied or intricate or iconoclastic such a concept may appear. It should be an ongoing process in a steady working system. The situation of societies and communities does not remain same, and at times the changes are so striking, sudden and transforming that many models, structures and policies suddenly become obsolete and irrelevant.



How Humans Deal with Obsolescence in General Many of us might have been brought face to face with how people deal with obsolescence and irrelevance. They may check the observations made below on how people deal with it. The one conclusion I have drawn is that defense of obsolescence is a favourite pastime of Indian people. A large number of people do not even recognize that obsolescence for a long time has already set in the policies and its organization. Even if it is recognized, it will not be allowed to surface, unconsciously denying its existence. The most pitiable is the fourth stage where every facetious or illogical argument is brought in, in the defense of obsolescence and preserving it. The reasons for this are eloquently simple. The more painful is the fact that their fond and firm beliefs do not seem to work; even more painful is to substantially modify or even abandon them. It is, in actuality, abandoning their identity that has been built and projected for years, the most difficult and painful part. Abandoning or substantially modifying obsolescence to a new more relevant remedy calls for an intellectually strenuous process of rethinking. This is intolerable because it may involve renewing or rediscovering or reinventing themselves in the face of having to abandon those very ideas they are known for. The conventional wisdom accepted by everyone so far comes under challenge and no one wants to look foolish about it by wanting to question it. The zone of comfort and the reflex circuitous reasoning which comes easily and automatically needs to be cut away if obsolescence is to be recognized and removed. That is not easy either. This has happened to the sociopolitical, economic and religious thoughts of every hue and kind. It has happened in the health care delivery field as well. This obsolescence of thinking health became noticeable in early 1980s and striking at least to me, a decade after the collapse of the Communism in 1989–91. A model of governance half the world was enamoured with for long, proved irrelevant and obsolete within a few years. Limitations within Health Thinking It is sad that the health theorists, activists and others who had thought out things so well in the 1980s could not manage to tilt their sails to accommodate these new realities in thinking and newer propositions did not emerge. The watchdog and the critique functions they voluntarily took on themselves remained in a particular perimeter; they neither expanded nor



accommodated newer ideas. It did not come anywhere near Reorganization or need to Reorient, or Rebuild or Replace. It remained a thinking of incremental changes for improvement, allegiance to a sacrosanct model of the public health services tweaking it here and there. The dynamism of thinking lagged and defense of the theories and policies showed signs of irrelevance, becoming obsolete, and irremediable impossibilities to improve state of function were thrust upon us. Of course, one is always wiser in the hindsight! Some of us saw this irrelevance way back in 1987 and later, but we did not get a platform to voice our thoughts.  onsequent Failure of Primary Care C The failure of primary health care is blatant. In October 2018, in a summit in Kazakhstan all the nations which were signatory to the Alma Ata Declaration gathered. These nations signed the Astana Declaration, which recorded that in the 40 years since Alma Ata there was little to show by way of achievements of primary care. The honesty is admirable (Banjot Kaur, Nov 2018). Even then, this conference ended with ‘try and strengthen Primary Health Care’. There could have been many causes for failure in those 40 years, be it ethnic wars, corrupt governments in Africa or health care not delivering itself, poverty, illiteracy and unsuitable enforcements by IMF.  The last  one, the IMF, is history now (Stieglitz 2002). There is no in-depth thinking about why the failure continues.  eed for a Philosophical Basis for Reorganization N Public health care structure badly needs a reorientation. There is virtually no discussion about structuring the curative health care or its intimate need to support the primary care to succeed, no introspection about medical education, no concern about severe deficiencies of manpower in the curative sector in over 40 years. There are no better ideas about reorganizing even the primary health care structure. All that we heard and read was that things should improve and that these measures are not working, but not how to do it. The purpose of this volume and the other one, India’s Private Health Care Delivery: Critique and Remedies, is to present detailed, fully structured health care delivery system from the top most level to the bottom most level (Kelkar, 2021). The structure proposed is based on all the experiences of all levels of care, of my own experience of 40 years, and the experiments and models developed by many others with whom I have studied or worked, in many of the health areas, and on the assessment of these for successes or failures.



The Health Theorists and the Indian Scenario The health theorists came essentially from five different camps—the Socialists, the ultra-left, the Communists, the Sarvodayee Gandhians and the Christian Groups. The right-wing thinkers had no idea about health whatsoever and were nowhere near the fine arguments and the refined logic these five groups had. One reason why the emphasis of these five groups on the public structure model lingered was the deeply rooted Socialist or other Egalitarian ideas like pro-poor, the Sarvahara, the one who has lost everything, the one exploited or the last man who needs to be uplifted by the government in particular. These tenets were to lead them to the inevitable strident opposition to the globalization, privatization and liberalization process. Paradoxically, even the right wing was also opposing it and stood with them. Either this oppositional commitment did not allow them to accept especially the economic gains of the new policies or they were forced by their fondness of obsolescence not to acknowledge the same. Their ideas were deeply ingrained. The Nehruvian welfare state model adopted by India with some elements of the mixed economy was a solid asset for them. Their belief was the widening Americanism or the globalization, privatization and liberalization, all were monstrosities which would never deliver a decent solution to the poor. It should be self-evident to all and accepted by them. On the other side was the deep-rooted dream/appeal that the Sarvahara and the bourgeoisie, or the feudal lords of the exploiting society, will come into a violent class conflict leading to a bloody revolution which and which alone will lead to the solution of the problems through change of polity. This was never an overt declaration, but was basic to their psyche. It could not have remained hidden to the discerning. The appeal of the class conflict is such that one would expect such idealists to constantly block the solutions for upliftment so that the class conflict intensifies and becomes inevitable. It is however to the great credit of these idealists that they have strived, toiled hard, year after year, within the democratic constitutional mandate and system. The high-decibel activism maintained could have hidden the ideas of class conflicts particularly after 1989. The balance between non-violent agitation and constructive as well as piercing criticism was maintained. Some of the theorists had welfare model at the heart of their thinking. They emphasized the ideas of primary health care, universal free health care, health education, prevention and positive health and so on as a whole



but pertaining mainly to the disadvantageous situation of the rural folks. The Gandhians had a deep attraction to the ideas of Gram Swarajya (common ownership and freedom at the level of villages), cooperative existence without conflict and competition, appropriate, medium or simpler technology for means of production, and many such ideas. Even the right-­ wing thinkers had an affinity for the same. These people did not realize that their ideology has run its entire life cycle and has become or is becoming rapidly inapplicable, incapable of solving any issues, particularly after globalization, hence irrelevant. The third numerically high-numbered group which worked closely with the above-mentioned two was the Christian service tradition, with the Vellorites graduating from the famous Christian Medical College Vellore. Their composite model of delivering the secondary along with the primary care efforts was far more important. Conscious recognition and discussion over it has hardly taken place. This structure was also not taken up by anyone else nor studied seriously as a key to the solution of rural health. This should have been replicated particularly by the Hindu idealists.1 Hindu Idealists were naive about such matters. The curative services of the Christian Mission Hospitals, both small and big, are gratefully recognized by India. Thousands of them are strewn across the country, with majority of them being in difficult, rural, tribal and neglected hilly tracts. The art the Southern Indian Christians perfected was that of primary health care. Using the hospitals as their nodal agency, they went to and worked for them within the community, and in case of higher need brought them to their base hospital. Thus, there was a two-way flow. They were there when the people came to them at the time of their need for cure. The Mission hospital workers went to them as primary health workers. These outfits actually developed the lingo and the concept of the primary health care. With it they mastered the art of project writing for primary and/or some such other services, tweaking and tuning them in a manner that would suit the grants available under different projects with 1  In the year 1989, I had delivered a lecture to a select group of right-wing activists in Nanjangud taluka, Karnataka, to explain the dynamics of this Christian work. It became well known and used to be called the Nanjangud Lecture. They understood the lecture well enough but did not get time or could not translate the vision in action in the myriad small time projects they carried out in Karnataka. The farthest that they went, from 1977 till today, was to attempt and create a socially conscious doctor who has the predominant idea of serving the people through medicine. In terms of numbers of such egalitarian converts who devoted their life for such ideas, they are a disappointing failure.



the state as well as the central government. However, these people did not come out with any comprehensive thinking about health care delivery for the country as a whole. The right wingers were not an activist cadre. By habit these people looked to building a nationwide organization, consisting of such likeminded doctors from among those who passed out from the modern medicine system. Endowed with certain attributes they would by and by work out the solutions for the health issues. A considerable effort went through in establishing a channel of committed doctors, leading to the areas of dire need like Assam tribal and hill areas, to work in. Holding free, scattered, periodic and curative medical camps annually, in different places by rotation and holding annual conferences were not the correct prototypes to experiment with, since these could not be developed into replicable models. A few other models I presented to them also did not succeed to convince them to establish such a channel of replicable models. The right wingers wanted to work as a deterrent to the Christian proselytizing work carried under the guise of health work. But the kind of organized multi-men health care projects they should have built remained limited to a few individuals, courageous but single doctors in North Eastern India and Odisha. Majority of those vociferous about something or the other in the health care never worked in the field of the high tension curative medicine in disadvantageous areas which I suppose is of the greatest importance, to know the ground realities. Not many went to build projects by themselves in the hinterland. Hence, their understanding was cerebral. Stagnation and sterility of solutions after a point was inevitable and most noticeable in the realm of rural health care in all these groups in spite of India progressing and changing so much. Sticking to the decades-old ideas and elements was a waste. In these two volumes I have suggested many actions to be undertaken and my claim is that it will work. The basis for it is the experience of 22 years of this kind of field work in hard situations. The present system is not capable of fulfilling our health needs in the still-changing scenario. Where exactly lies the gap between the reality and the concept? How did it develop in the thinking which did not gauge the solutions, the real needs of the society demanded? Why the need for a different comprehensive solution that covers the entire spectrum of health care—primary for poor, and cure for both rural and urban poor and various social classes—was not attempted? In short, a Reorganized or



Reoriented or Rebuilt ‘complete model of health care’ is needed in the existing one. There are many issues that I need to discuss before we go over to the modifications or new creations that we need to make in what is available to us. For that a little elaboration is needed about the four Rs! The social context as evolved today and changes therein should also be discussed. It will be followed by creating a comprehensive and decidedly doable model.  eorganization: What It Does and Does Not Mean? R To some it may mean a dominantly primary and minimally secondary, or vice versa, model, but neither is true. To some it may mean going beyond the present structure, demolish all that we have, but this does not seem to work and ‘think anew’ for a solution. It may be considered as the wholesale replacement of the government by the private system or vice versa, which it is not. It is not replacing the modern system with traditional medicine. To a bourgeoisie section of the society, it may still result in expectation of getting rid of this poisonous Western model and replace it by the age-old holistic model, the science of health that developed in the hoary traditions. But this is not the idea either. However, far more importantly, the proposed model gives a far more useful place, a significant contributory function to these traditional sciences and their practitioner for the general good of people and for the Western medicine also. The four ‘Rs’ merely mean that some demolition and new creation with changed ideas and altered structural components are necessary. Such measures should achieve some immediate and some long-term goals. The solutions will have to be appropriate and suitable to our present scenario. It will have to be an Indian solution for Indian situation. It needs a total consideration of each and every part and the system of health, not working, not having given the desired results or is not capable of coping up with new situations. Criteria for the Four Rs The criteria for these four Rs are simple. It should do justice to all, serve the poor in particular, should be workable and preferably have been experimented earlier and adequately with success. It should have accessibility and affordability, and should lead to equity and justice. ‘Reorganization’, term representing hereafter for all Rs, will have to be a fairly drastic but eminently possible process. It should not cause any disturbance to what is



presently available for service, of whatever merit, but will be replaced seamlessly. If we accept obsolescence and discard it, the huge cumulative experience India has so far from the contribution of these people mentioned above and others can easily give such solutions to achieve much more, far more quickly than what has been done so far or would be expected. Privatization need not be an anathema. However it is absolutely necessary to reign in this monster by constitutional means. Different modalities have been described in detail in India’s Private Health Care Delivery: Critique and Remedies, the second volume published with this one (Kelkar, 2021). Total governmentalization would not be reorganization; it would be neither pragmatic nor progressive. It will be a huge failure leaving tremendous disturbances in the society, and the health of the poor will suffer even more. Structural Reforms and the Four Rs We have to affect certain structural reforms within the public health as the most essential first step that can be an answer to many maladies. These reforms have been described in four later chapters. To achieve the five goals of care—accessibility, affordability, quality with justice and equity— we need to improve our resources, especially human, by a system which helps rather than delays the utilization of them at different health care levels. Given the poor budgetary allocations for health, it should be a solution not burdening the exchequer but reducing it. The reorganization will be based on certain emerging principles, priorities and practices that are likely to enable us to forge ahead. Establishing a context of what has changed in India in last three decades is necessary to understand the propositions and is given below.

The Social Basis of the Context of Reorganization The Population Shifts There is an inexorable, irreversible, uncheckable exodus from the villages to the towns, from towns to cities, and from cities to metropolises since mid-1980s, many of which are threatening to become megalopolises, bursting at their seams. The only countercheck of not much magnitude or power is the pressures of populations from within the cities. We, thus have



a large devastated countryside in many states, with nothing to look for in it, barren and desolate. Unless we are able to reverse this exodus and create a better countryside, any discussions on urban–rural imbalances, Western high-cost models, the real needs of villages and so on, are just meaningless, as is the health care and its reorganization. In this context, the health care delivery apparatus, public as well as private, organized properly can become an employer and employment generator in the hinterland that may slow down the speed of the people going to the cities and towns. Instead, they may want to be with their parents or ancestral places. The health care will be able to then reduce the pressure on the land by generating jobs for at least one in the family. This happens in today’s health care structure and delivery also but the low level of engagement and the money tied with it can be boosted considerably. What jobs are there to create? Are there ways to reach people in the remote areas to be employed or become employable? The answer to these questions is a resounding yes, and it can be done easily enough as will be shown in the later chapters. In the pandemic of Covid 19, a partly temporary migration of unskilled labour back to the villages has already taken place to the tune of 10 million people at its least due to the falling economic activity which will eventually resolve over a period of a couple of years at the most. Even then, some livelihood for these people will have to be found since their return migration will not be equal to the exodus, and will be in intermittent tranches stretched over a couple of years. As is argued in this volume, a restructured health care system can to an extent be an employment generator somewhat mitigating the issue. Another exodus that has continued since 1980 is from India to the Middle East, and to other European and many other countries, which with the US, because of their declining economic activities, are now threatening to send back the Indians, from the highest of professionals to the unskilled labour and others. This could be anywhere up to 10 or 15 million or more. The professionals, with a large number of doctors and nurses, may come back and struggle for existence. These people are likely to burden the already-supersaturated urban scenario which has been described in detail in my other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). The structural reforms suggested in extensor here may not be able to absorb each one but a fair number, not predictable at this juncture. A silver lining is that many such professionals have contributed from a distance to the rural health scenario



for years as a service to their brethren. It would both be a challenge and opportunity to harness their desires by developing the voluntary sector, a necessity in health care about the lamentable decline of which is written in a separate chapter, ‘Health Institutes and Voluntary Health Work’.  ill Smart City Idea Help? W Will the idea of “Smart Cities” be a solution for this population shift back? Will the conceptualization of these cities cause a partial halt and then reversal of urban migrants by opportunities improving their financial conditions? Not much data is available on this directly but it is possible that it is happening. As far as health status is concerned, improved economics is helpful in reducing the critical-level illnesses, even if such illnesses develop the remedies and help is likely to be available in these smart cities. Such reverse shifts are likely to reduce the huge pressures of extreme illnesses generating at the periphery and reaching the traditional tertiary centres. A detailed description of how such a phenomenon operates will be found in the main body text of this volume. These effects however will surface after a few years. There is a strong likelihood in the wake of Covid 19 that business, education and many such activities are likely to be conducted in different modalities, and health care will not be an exception. The one offshoot which at this stage is poor in its outreach, efficiency and usage is the telemedicine. The real challenge to it is the availability of the doctors and specialists much more freely and easily. The greater challenge is the availability of getting investigations done or drug procurement, if advised, as close to the place as possible if calls from the distant areas have to be entertained and followed up during treatment. In today’s situation, one strong remedy to overcome this difficulty is the structural reforms and strengthening of the community health centres for which as many as four chapters have been devoted. The details about how CHCs will help not only in telemedicine will be discussed across these chapters. There is a constant inflow of people from distant places to cities whose medical issues were remaining unsolved becoming incrementally serious. Private sector is the primary source for health solutions. It continues till date. The reasons are not far to seek. The medical colleges have deteriorated as a care centre for the poor as well as the centres for quality manpower productions, leaving a lot of rural and urban-middle- and lower-middle class without an affordable, accessible and competent curative health care model. For decades now, a daily exodus and return from



the hinterland to large cities should be considered in the reorganization and stopped. Are there other exact mechanisms by which these problems in the hinterland with or without the migrants can be reduced considerably, smart cities or no smart cities? Are there any agencies we have neglected or have not empowered which would help in this regard? How will we create checks in the functional aspects so that people get what is rightfully theirs as near their houses? The remaining volume deals with these and many other related matters. Pervasive, Iniquitous Modern Medicine: Will it Help? Accepting that we have an ill-developed, lopsided, costly, Western, technologically based and disease-oriented model, still it must be understood that it can neither be wished away nor be washed away. Building fast enough in its place, for better care of individuals, even if we disallow that model from existing, is not possible. No one has been able to or can work out enough ideas or details culled from any other sensible sources. A large variety of treatment options for increasingly complex thousands of disease situations in quasi-standardized ways to really replace this Western model are simply impossible, negate the progress and finally kill millions. These spectacular Western models have created glamour and dependency. The best use of it for our people should be accomplished. High-­ quality, high-cost equipment and systems are a part of the Western model, and they cannot be wished away either. At the same time, it does not mean that it cannot be regulated, cannot be made to serve the poor with serious disease, in a situation that both the parties win. As will be discussed, at many places harnessing the strengths of this model at the distant peripheral population segments, lessening expenses of patients and avoiding the ill effects of it are eminently possible. If a somewhat potent tool even for Covid 19 is to come, it will essentially come from this system.  ill the Public–Private Partnership (PPP) Help? W Through the ideas of public–private partnership (PPP) or the schemes like Ayushman Bharat and other hitherto operative state insurance schemes, optimization of Western model usage is being attempted. However, there are serious lacunae in the thinking about its full application in practice for to achieve success. These ideas are discussed in the chapter ‘Health Insurance, National Health Protection Scheme, Public Private Partnership’



in the second volume India’s Private Health Care Delivery: Critique and Remedies, published with this one (Kelkar, ibid.). The corporate hospitals have every undesirable element of the system that goes counter to the five principles of health and works against poor. It is not easy to control them to make it friendly to the common man. The only issue about all the solution is the political will to take the decisions. The solutions by themselves are simple in nature. Dealing with Ancient Systems of Medicine A suitable adaptation of certain life-preserving principles, variously arising from the ancient wisdom in the Western medicine, is necessary. It has been extensively discussed in the chapter ‘Integration of Medical Systems—A Theoretical Perspective and Practical Blue Print’ in my volume India’s Private Health Care Delivery: Critique and Remedies (Kelkar, ibid.). In the reorganizational contexts, it needs to be seen if a further or greater synthesis of the two is possible, especially in clinical care, an issue discussed in the volume, mentioned above, published with this one. The manpower trained in ancient systems should be used advantageously to serve both the system and the men. It will need a well thought-­ out process in the reorganization. This issue has become so controversial that it has been separately discussed in the Appendix 2 of this volume. The New Psyche In the post-independence era, the society is torn between scores of self-­ seeking, cynical vested interests. Their need and greed for more and more money has become the only security of life which leads them to unscrupulously employ ugly means to get it. The self-centred attitude, broken nuclear families, selfishness and unwillingness to help not even their own have become the norm or the base. Nowadays we have rights and rules for what one need not do, rules and procedures to say I will not do it, and it is not possible or it is not my duty. Adding to it is the labour union mentality which has got deeply ingrained. We are amply familiar with it and seen the devastation it has caused time and again. In other words, there is not a single familial, social system which would take care of people in a much more natural minimally expensive way. Everything that the doctors do seems to be done not for the person who is the purpose of their business, their existence and the cause of it.



They do it for money. They do not find an assurance in future in the goodwill and credit they would get without much effort from their patients even if they do a wee bit more. Patients are a means from which to earn, not the one to serve first. Both situations must change. This is discussed in detail in my volume India’s Private Health Care Delivery: Critique and Remedies in many different contexts (Kelkar, ibid). Transactional and Litigious Mindset The superimposition of the holy constitution on the Indian people has caused a certain legal and executive process to permeate life. It has changed the method, work style and the process of setting goals. It is possible that intellectual reflexes and patterns of thinking have got inextricably mixed up in these new executive/legal process and procedures. The legalized minds have become, paranoid and obstructive. The doctors today are the epitomes of such psyche and that of transactional way of functioning going to a level of inhuman, distrustful and paranoid interaction with the sick. It is a day-to-day reality, a changed social context compared to past. An old belief that help is extended to the sick to become an intact integrated person again is lost. Many more details about this context have been given in the chapter on corporate hospitals in the second volume, India’s Private Health Care Delivery: Critique and Remedies published, with this one. Some measures have been outlined in it to change this. To adequately disassociate from these ways of thinking as a nation and people may not be easy. For that to happen, more suitable alternatives should be attempted. The only answer for that is the strong public health care system. Why Matters Deteriorate in Public Health Care? Why is it that the doctors in public health system are never or hardly ever found there? Why are the specialists not found in community health centres? Why are the drugs not available in the public hospitals? Why are laboratories closed, and why don’t X ray machines function? What are the reasons that the mortality and morbidity indices do not come down in spite of a truly huge health army well spread across the country? Are there or are there not some structural conceptual deficiencies behind these failures? These are not examples of deteriorating morality, but have different roots. These are issues which should now take the centre stage.



To overcome these situations even in a small field of health care is beset with enormous difficulty. On this background, offering new solutions which will work may seem to be a faraway and an unattainable ideal, however attractive it may look. People have been shouting hoarse for decades and demanding action from the government, saying all the time that this model must work. Are we, including the government, riding a dead horse?2 Curative or Preventive Medicine? The next major divide with their proponents and dissuaders of the primary care as the panacea is that of curative medicine and preventive medicine. The latter has already become an unglamorous proposition for doctors to opt for. The pattern of community health work undertaken by a large number of committed dedicated workers is rooted in education, empowerment, knowledge and demystification to prevent disease from getting out of hand. These ideas have stagnated, and, exhausted of new subjects and insights, have become staid and repetitive. These efforts have not solved the problem. Could we do some entirely different new thinking about primary care and good-quality secondary-level curative care, both made available in the hinterland? These two volumes precisely do that. Crowding at the Primary Care Level The village is now the centre of all planning under Panchayati Raj. Has it not become too small an entity for such planning? Is that the reason why the issues do not get sorted out or the health indices do not change? Any issue gets micronized. Each of such issues must coalesce with the similar issues in the neighbouring villages not far from each other and continue to go to higher levels of organization. That does not seem to happen. At best there will be two factions in the village (in fact many more) which do not work together. That makes the decision-making process at the village difficult. In addition to it, there are so many agencies from the Panchayati Raj Institutions which bear down upon the health issues in the small village. For the last 30  years or more, we are still stuck with our idea of one 2  A government with a dead horse, instead of getting off and taking a new horse, will buy a stronger whip, change the rider, set up a committee, visit other countries, change rules of accommodation, provide extra funding, and, finally, promote the dead horse.



community health worker (CHW) each, male and female, for a population of 1000. It may cover one or more villages. If there is one place where the government planning has gone awry, then it is at the community level. Restructuring and rationalizing it has become necessary and is discussed extensively in Chap. 6, ‘Primary Care, Government Planning and National Rural Health Mission’, in this volume. NGOs and the Health Work The Church Then there are Christian NGOs working over 100 years in India in the hinterlands as well as towns. A detailed discussion of these and the non-­ Christian essentially Indian NGOs will be found in Chap. 11 on ‘Health Institutes and Voluntary Health Work’ in this volume. There are certain indicators which make cohesive picture of ubiquitous Christian NGOs which work at the farthest and deepest in the village system of India at the grass-roots level in the name of health. The activities of the church in North Eastern India in the decades of late 1970s to late 1980s have proved detrimental to the integrity and sovereignity of the Indian Nation (Pachpore 2001). The Christian NGOs in North East in particular continuously derogate the ancient traditions of the tribals and the upper caste-Hindus and Dalits. In the last four decades, they have made strange bedfellows by expressing Marxist ideas through Christian theology. To that they have added the Dalits from various parts of the country and tribals from all the tribal belts in India, North East in particular. Thus, there is an unholy alliance of Christian Indians, Dalits, whom they call Dalit Christians and ask for reservation for them, and Christian tribals with Marxist Ideology. There are various communist and Naxalite groups who have joined them in other states. In short it is against Hindus, against the integrity of our nation with a clear idea to balkanize this country and in effect against the right wing thought of this country. The Western and American Powers supply huge amounts of money despite the Marxist bedfellows to fuel these efforts (Pachpore, ibid.). In addition, there is a report written by the ex-director of Enforcement Department N. T. Ravindranath, ‘India on the Brink’, which gives many more details. Some more discussion about it will take place later.



 anchayati Raj and the NGOs P Till the time Rajiv Gandhi became the prime minister, no government had any interest in Panchayati Raj. It was his ill-understood enthusiasm to draft the Panchayat Raj Bill in 1984 (Ravindranath n.d.). Panchayats (Extension to Scheduled Areas) Act (PESA), 1996, granted extension of the idea of local self-governance to tribal regions. The provisions of PESA have not only extended development, planning and audit functions of the Gram Sabhas (village Governing Bodies) but also endowed it with powers for management and control of natural resources and adjudication of justice in accordance with local traditions and customs (http://en.wikipedia. org/wiki/Panchayats_(Extension_to_Scheduled_Areas)_Act_1996). This has not bode well for developmental activities where most needed, obstructed by the NGOs of dubious intentions. The NGO activists have been strongly advocating the need for strengthening the Panchayat Raj system and empowering the village Panchayat in the country, since last two decades. In 2006, another NGO-sponsored bill, called ‘The Scheduled Tribes and Other Traditional Forest Dwellers (Recognition of Forests Rights) Act, 2006’, was passed by the Parliament, extending the right of ownership of land and control over minor forest produce and natural resources to the inhabitants of the tribal areas. In May 2010, the UPA II decided to remove Joint Forest Management Committees (JFMCs) from the control of the district forest officer and instead bring them under the control of the Gram Sabhas and forest Panchayat. Thus, the staff of the Forest Department, whose primary duty is to protect the forest from forest dwellers and outsiders, would now work under the Gram Sabha or Forest Panchayat, taking orders from them. All the forestry-related funds also would be controlled by the Gram Sabha (­paper/tp-­national/tp-­ tamilnadu/forest-­management-­panels-­to-­come-­under-­gram-­sabha/article862402.ece). It led to a situation with states having virtually no or little power anywhere in the hinterland villages and the veto now lies with Gram Sabhas. Christian groups influence Gram Sabha to sabotage what will lead to their economic good and that of the country in tribal areas, and keep the people in a distressed position to make conversion and secessionist activities more fruitful.



Matters Relating to the Community Health Workers Can we improve the capacities of these workers covering a larger area, giving them tools to use like cell phones (which incidentally are quite ubiquitous) internet connections and software? With digital India already growing speedily, it should be possible and welcome. Their staid work in staid fashion can be made more interesting. The arrangements for mainstay of primary care for the community workers on too many counts are not satisfactory, do not deliver as much as expected and have many issues which need resolution as a part of Reorganization. The effective resolution of these issues is discussed in detail in Chap. 6, Primary Care, Government Planning and National Rural Health Mission, in this volume of which the mobile is a substantial part. The primary care approach through disease prevention alone will not result in health and through it economic betterment of the populations. There is no effective mechanism to support these workers when serious illnesses result which will ruin these people for generations financially. We need far-flung and far more powerful problem-solving units of curative medicine outfits in the hinterland. PHCs are of no help. The description of such workable models which also support the CHWs, and better, is described in Chaps. 7 to 10. Predicament of National Programmes An important component of the public health care delivery system has been of national health programmes. The responsibility of carrying them out finally is of the PHC, and the CHWs fall back on the PHCs, the last post. There are many issues and reasons why the national programmes do not achieve what is expected. Yearly 430,000 people dying of tuberculosis is the symbol of this failure, which is most appalling (ET Health Bureau, October 2018), painful and yet an inescapable proof of the failure of all the structure, hence the function of all these arrangements. The enormously important social context needs better solutions which are described in Chap. 10, ‘Structure and Function—4—The Final Picture’, in this volume.



Predominance of Non-Communicable Diseases Today, the non-communicable diseases are prevalent almost like an epidemic in continuously escalating proportion, spearheaded by the diabetes epidemic, accompanied by every conceivable complication. More people die because of it than communicable diseases as was the case before 2007. The kind of trained manpower needed to treat it effectively at the periphery is in short supply. The curricula of medical colleges and education imparted therein do not in any way train the doctors in this sphere. Reorientation of the mindset of the doctors to chronic disease care and improving the knowledge, practising methods and support systems are the true answers. Some capacity can be built in the public health care also but a concentrated effort carried on by multiple agencies is the necessity. These issues have been described in my two volumes, at different places. The plight of these patients in such a situation at the periphery can be easily understood. Decline of Voluntary Sector The decline of voluntary agencies is only a partial answer to the overall service quality decline. Only a meagre, miniscule number of doctors have come together to start voluntary hospital centres, urban or rural, which were excellent, far more cost effective, humane and competent where ethical care was given. Many more attempts have been undertaken by the voluntary sector in primary health care activities in remote areas compared to curative outfits. Both would look for and serve year over year, the more marginalized populace which does not want to go to the government hospitals but cannot afford the costly nursing homes either. The answer the voluntary agencies have given is that it is extremely difficult to fill this gap. The idea of multiple specialists at more peripheral levels in a single unit did not grow far and wide in voluntary sector. It remained at its best emanating from an incredible and courageous sacrifice of an individual to start a project and ended in his failure in making it a multi-men project to pack a lot more power and effectivity. Thinking bigger, acting bigger, developing an institutional mind could not be brought about in such sacrificial effort. In any discussion on reorganization, the issue of how to rebalance the presence of the voluntary agencies in health care needs a full review, which has been undertaken in Chap.  11  on ‘Health Institutes and Voluntary Health Work’ in this volume.



Incompatibility of Government and Private Sector, Including the Voluntary Organizations It is unfortunate that the governments exclude both the private and the voluntary sector while planning. This non-reciprocating behaviour, that is, reluctance to partner private/non-governmental organization sector or to draw and give help, has made the two sectors watertight compartments. More unfortunate is the dislike of the government system of the voluntary sector. The commitment, the idealism, the willingness of the NGOs to suffer hardship for masses, notwithstanding their shoestring budgets, never resulted in spontaneous government action for help. The bureaucratic attitudes are an exact opposite to what voluntary sector is. It does not want itself to be juxtaposed with the voluntary agencies and get exposed in front of the society in poor light. This attitude continues. It is a bit unfortunate but not surprising that the idea of PPP did not meet with a wholehearted approval of those who think that the governmentalization of health services is the only way. The best ways of collaboration will be discussed in the chapter titled ‘Health Insurance, National Health Protection Scheme, Public Private Partnership’ in the other volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one (Kelkar, 2021). Unionism, Welfare Model and Its Consequences The government is almost always at the root of how problems which are solvable are not or cannot be solved. In the welfare state model India adopted, the government developed the ego of a doer, and the only doer. It reduced people to mere recipients, without ever invoking their own power to participate in the efforts to solve their problems. It pampered and taught them only to demand, and not to do the legit work for which they were paid, but create obstacles to the enterprises under unionism. Unions also gripped at throat of the private sector and rendered it an impotent powerless entity. This has been the greatest sacrilege the governments have perpetrated on human capabilities, initiatives, egalitarianism and ability to think of higher ideals, as well as empathy and all such attributes. It has caused the degeneration of work culture. The health care delivery has suffered greatly under this. There is already a hue and cry that the privileged labour position is being undermined. The pitiable condition of West Bengal, Tripura



and Kerala with a spoiled work culture affects the health care delivery also. The central government has taken a significant step by collapsing the 44 labour codes and laws into just four acts, weeding out contradictions and irrelevance. The criticism has not been all that strident as would have been expected. Long tracts on how to improve work culture will be found in several chapters in this volume. Quackery, Anti-Science Occultism at the Periphery After the disappearance of the registered medical practitioners (RMPs), the Licentiate of College of Physicians and Surgeons (LCPS) and their compounders, a new breed called officially as quacks has come up. These ‘genuine’ quacks, untrained, unlicensed practitioners in the country outnumber qualified medical doctors by at least 10:1 (Barua et  al. 2009). Urban areas too are witnessing increasing numbers of these untrained practitioners as we see in the report (Barua, ibid.). These are pure money-­ mongers and cheaters and should be ruthlessly eliminated. The quacks practising allopathic pharmacology found in ultra-rural areas need to be considered differently compared to those in cities and town. The rural category should be helped with interaction with a higher-­ level treatment centre, thereby converting them into an asset in distant places. Their social context is large and consideration for them is due. This process is described in detail in a later chapter on community health centres. The next remotest grass-roots element is that of occultists, many of whom cut at the roots of better sciences. The rural patients have had more faith in these people than in the modern men of medicine. We need to work with them and use the faith people have on them for our purposes of the betterment of health of the rural people in the reorganization schemes. This process also has been described in a later chapter. The deal is simple. Let them do what the rural folks believe is worth their money. Ask them to pass on the messages for the continuance of the treatments of the bada (the big) doctor from the cities when it comes to tuberculosis, vaccination, continuing the treatments for chronic non-communicable diseases and so on.



The Moribund, Incompetent and Unjust Referral System This is one of the most major ills of the public health care delivery system. The pathway of referral is from the sub-centre to PHC to a community health centre, or the sub-divisional to the district hospital (DH) or a medical college. The level of competence for many reasons does not change till the DH or even the medical college is reached, not always. By the time the patient reaches there, he or she is either extremely serious, or dead or moribund. In addition, there is whimsical behaviour of the patients and/or their relatives about going to a tertiary centre, particularly private centre, and their distrust in it. This leads to ambivalence of decisions, hesitancy of actions, delays and further deterioration of the case; this leads to escalated costs and disappointing outcomes, giving rise to acrimony and fights till the matters go out of hand, which is common. In spite of authentic tie-up between the government and private care centres, the cases are not referred unless a deal is reached between the individual doctor and the private centre. The answer to this social anomaly is CHC and is the purpose of my two volumes mentioned in these pages. The Hilly, Remote Tribals of the Jungle This is a human conglomeration on small scale, not easily accessible to anyone to and from where it is situated. Some of them will change their geographical location from time to time without notice. Or they may reside in the deep jungles. At best they will form 10 to 15% of the total population of India.  xclusion from the Main Tree of Health Care Delivery: A Necessity E These people should be included only under special services and provisioning for them excluded from the ‘general planning’ of health services for the remaining 80 to 90% of the rural folks. Including them will be enormously costly; quality of delivery and utilization will be extremely poor. Unless we do this distinction, our planning will get skewed, get dragged unequally, get distorted and will appear more hopeless for the remaining large and more accessible village populations. These people need mobile health services mainly. Some of the 1253 mobile units under governments could be deployed exclusively for them. It has long been recognized that in difficult areas the population and distance criterion for establishing



stable medical centres for health-related and other activities are far more difficult to carry out.  obile Health Services, the Answer M As far as the health issues are concerned and providing modern and/or other health systems are used, these are a few essential ingredients: 1. Such a health care delivery will have to depend on mobile health units only, which should have different functions combined in one. 2. The second prerequisite would be good commutable railway or roads. This incidentally is also a political necessity since many of the tribal groups are on the borders of India, adjacent to every kind of risky foreign terrain. 3. Once such services are established, there will be an inevitable inroad of modern civilization for good or for bad but the isolation and its dangers faced by these population segments will substantially end. 4. Difficult areas in North East will have to be treated like Siachen, where quicker rotation of medical people might help, especially with far greater incentives for the future career. 5. Disease-specific and focused small mass campaigns should be arranged consistently and in well-chosen areas where more people are likely to come or can be brought to easily. It is possible. It may solve many health issues without establishing a stable facility within these areas. I have conducted huge experiments in such hilly areas which are a testimony that these ideas work. Some of the experiences will be discussed later. 6. Telemedicine is not an answer here for health care delivery as a whole and in more complicated health conditions. S ome Crucial Considerations Aside of this there are a few more crucial considerations. Those who have worked with tribals are familiar with them but cannot claim they have the answers. 1. Do we wish to keep them where they are and with the lifestyle they have?



2. Is it possible to give them relevant education and improve their financial status without arousing a desire within them to migrate to semi-­urban or urban places, abondoning their places and culture? 3. This would mean improvement in their agricultural practices, and in related enterprises, so that they can have more money in their pockets and more amenities while they continue to stay where they are. 4. If we bring modern health to them, then how do we also preserve their own culture-specific health practices and study them in other contexts and in laboratories? This is briefly alluded to in the Appendix on Controversies Surrounding AYUSH in this volume. 5. If we bring modern health to them, the rest of the civilization will follow. 6. Or we decide to bring them out into the larger civilization and think of their present and the past as of no consequences. 7. Or we simply leave it to the way it is going on. In that case there are dangers involved which have serious political and cultural implications to the sovereignity and integrity of our country. (See above.) 8. Using a standard model of the sub-centre worker will not work because of the distances and geographical hardships involved in travelling.

A Brief History of how the Structure and Function of Public Health Care Evolved The evolution of the public health care system can be better understood from villages up. Those are human conglomerates without a medical professional of whichever denomination, catered to by community health workers and their supervisors. The gamut of primary health services has truly evolved by yeoman’s effort by the state and central governments as well as visionary medical social workers over the last 45 years or more.  volution of the Primary Health Care Ideas: Community E Health Workers This section is written since most clinicians are not well aware of these aspects of health care. It will help them to follow the future arguments given in this volume. The challenge is to reach the small villages and address their health issues, a primary duty of the state. It has been recognized since early times that most illnesses start small; many of them are



self-limiting, if minor care is instituted. The agencies evolved for transfer of the elementary knowledge of how a disease develops and that it can and should be prevented by changing our manners, like keeping the cooked food closed and so on; this knowledge was conveyed by the community health workers, a generic title I have used everywhere in this writing. The concept was to select and train community health workers, from within a community, give them a small compensation, to engage with the health issues. This then became the mainstay of primary care. This process has undergone many difficulties and vicissitudes but has gained wide acceptance and has succeeded in many places. Dai or Village Midwife: For Safe Labour and Related Matters The traditional dais conducting deliveries in villages with compensation from the family were provided with kits and training in safe uninfected deliveries preventing neonatal and perinatal tetanus. Later, they were trained to recognize difficult labour early and bring the pregnant mother to a health centre or a hospital, without making it a prestige issue. A simultaneous thrust on family planning and increasing time between the pregnancies was brought in. The large prevalence of antenatal anemia was sorted out through these human agencies by a rational combination of iron and folic acid tablets, with calcium added later.  nipurpose and Multipurpose Health Workers U Detection of malaria, leprosy, tuberculosis, polio and the poxes, to start with, as early as 1953, was then taken up under the Unipurpose Health Workers, which met with fair success. India hosted 75 million malaria cases then. Presence of many Unipurpose workers led to segmentation and fragmentation, with little work to each hand, rigidity of attitude and refusal to work for any other field which is typical of Indian mentality. This idea was later abandoned or converted into a multipurpose worker looking after many areas of such illnesses. Vaccinations were added, and over the years various national health programmes have been made a part of their portfolio. One thing leading to another, more jobs including coordination with other agencies like sanitation, water purification and such others were added. Mitanins and ASHAs Two more models or upgraded versions of these community health workers were introduced. One called Mitanin was from Chhattisgarh state.



ASHA, or the Accredited Social Health Activist, came along with the famous National Rural Health Mission of 2005 by Dr Manmohan Singh. Today the work of all the peripheral workers has evolved in a highly complex pattern. Free care for poor communities has been one of the most dominating arguments of these protagonists of primary health care. Supervisory Hierarchy A supervisory hierarchy was set up, that continued through the PHC, community health centres, Tehsil and the sub-divisional hospitals, district hospitals and then medical colleges to the very last level of state health administration.  rimary Health Centre and the Lone Medical Officer P Like the community health workers whose number of tasks evolved into a complex fabric of dozens of functions, the lone MBBS PHC doctor with a vehicle became responsible for myriad functions. The rationale of primary care was like a repetitive prayer people sing—a litany. After a couple of decades, a locally backed referable  centers, more than  5000 second-­ level care units across the hinterland supporting five PHCs, called community health center were developed over years. It was expected to cater to a population of up to 250,000, with four basic specialties and instrumentation were conceptualized.  These  community health centres, were also called cottage hospitals or rural hospitals. Sadly this model has not delivered as much as was expected and needs a drastic reorganization. What Reality Do We Have in Front of Us? Absence of will to do good to the people within the bureaucracy and its legendary inertia still remains the most crucial reality in reorganization of health care delivery. It is a mute question if a government, whichever the denomination, is politically strong willed and is willing to cast aside clichés, obsolete jargon, slogan and conventional wisdom. But the two equally mute questions are: Can the ministers bend the bureaucracy to get the work done? And whether we as a nation possess any strong political will, intelligence and fortitude, to save ourselves and rise above our petty considerations that are bound to result in self-annihilation? Till June 2014, any discussion on the political will to do or not to do things had become almost irrelevant due to corruption and policy



paralysis. We see a new government at the centre with a robust majority and many state governments under the same party. Their work in health will be described, critiqued and appreciated where relevant in the narrative to follow. The courage of conviction, dialogue and political will are needed to make the health better. The present and rising  population level is no longer an asset. It has already become the single most important problem, devouring and outstripping all our resources, ideas and systems. This is a big area of control without which economic and social upgradation is extremely difficult. Some Ideas to Work with: It Is the Quest for Alternatives 1. Effective and efficient decentralization should be the fundamental principle in devising health care structure. 2. Modern ideas like patient as a partner in care and cure, attainment and maintenance of positive health, no drug or less drug, rational therapeutics, would be important. 3. Fostering the tendency to view the patient as a man against his entire background, ability to recognize him as the individual representation of a larger social issue, especially when it comes to metabolic disorders, to understand him as a psyche and not merely as a conglomeration of deranged chemistry, could be the bright beginning of holism. Changes in medical education will play a good part as shown later. 4. We have become a fast-developing nation. Fortunes of large tracts of land and men residing in them have changed for better. Irrigation, railways and roads have seen great improvement. Land fertility and minerals have changed people’s circumstances for better. Technology has shot forward. Highly intelligent manpower, developed in the scientific tradition of the West, is available in large number. All of it needs to be understood in the total context and put to good use. However gigantic the problems may be, the solutions are simple, as has been argued repeatedly in the pages to follow.



References Govilkar Vinayak, Modinomics, Perfect Paperback India—2018. Banjot Kaur, in Health Nov 2018, Stieglitz, Joseph, June 2002, Discontent of Globalization, W.W.  Norton & Company, USA. Kelkar Sanjeev, 2021, India’s Private Health Care Delivery, Critique and Recommendations, Palgrave Macmillan, India. https://www.facebook. com/107242304256980/posts/142804354034108. Pachpore, Virag, ‘The Indian Church?’ 2001, Bhaurao Deoras Human Resource, Research & Development Institute, Nagpur. Ravindranath N T, India on the Brink, n. d. Retired Intelligence Bureau officer, presently working as Director, (Research), Institute of Defense and Strategic Studies, Vidya Prasarak Mandal, VPM Complex, Chendani, Thane, Maharashtra. Act_1996­paper/tp-­national/tp-­tamilnadu/ forest-­management-­panels-­to-­come-­under-­gram-­sabha/article862402.ece Barua, N, Seeberg J, Pandav C S, 2009, Health of the urban poor and role of private practitioners: The case of a slum in Delhi –Centre for Community Medicine, AIIMS in collaboration with ICCIDD, New Delhi. ET Health Bureau, October 2018.

Additional Reading India on the Brink by Ravindranath N T available on internet.


Shortage of Doctors and Government Medical Colleges

Preamble There is a long-standing argument that India is short of doctors; hence, the health care is not optimal. This is a colossal myth. Shortage is primarily due to skewed concentration of doctors in cities and their absence in non-­ city areas, not because of inadequacy of numbers. It is also related even more importantly to the kind of doctors required at different population levels and their absence there. The ‘shortages’ should thus be viewed differentially. It also leads to the question of how to build our public health systems in such a way as to deliver most health solutions within the hinterland with the available yearly numbers of graduates and postgraduates. This is eminently possible. These change elements described in the rest of the volume should result in the complete overhaul of the idea of shortages as well as its proper deployment. The old demand for more doctors is rooted in the illogical, ill-founded misleading desire to open more private medical colleges and make huge money. Proper development of our manpower is the first step. It rests on education methods and the arraying the externalities needed for that. This chapter concentrates on the latter aspect after first exposing the myth of shortage of doctors. The educational methods are discussed in the next chapter.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




The Colossal Deliberately Misconceived Myth of Doctors’ Shortage The population to doctor ratios conventionally decides the shortage. The WHO ratio of the basic doctor to population ratio of 1:1000 has already exceeded in several states in India. Delhi, Karnataka, Kerala, Tamil Nadu, Punjab and Goa are the six states that have more Doctors than the WHO norm. The ratio in these 6 states averages to 1: 400. The calculation is done after deducting 20% from the number of enrolled doctors to account for the retirees, dead and those who have gone abroad. (Nagarajan Rema 2018)

The doctor-to-population ratio in Kerala is about to reach 1:700 and within a few years, will go beyond 1:500, which is equal to that of developed countries. This happens at a time when the developed countries are struggling to bring down the number of medical education institutions to ensure a healthier standard in medical education and excellence in human resources. This hyper saturation is the breeder of malpractices, due to overproduction and failure of deployment where needed. The Kerala government has been told to stop allowing newer medical colleges and close those which are poor quality. The intake should be determined by the job opportunities and vacancies in the state. Yet, States like Bihar or Uttar Pradesh suffer from an acute shortage for rural public health system. (Nagarajan Rema 2018)

Generalization of Ratios and International Bodies The ratio to decide shortage of doctors in such a generalized manner is faulty. Neither the issue nor the way out of it can be understood with it. ‘Shortage’ is a relative and differential term. The shortages must be viewed against the different dominant needs of any substantial segment of population especially in the hinterland. These needs will determine which kind of basic doctor or specialist is required and where against their availability. This is a differential not addressed till date in India in its specifics. It creates a huge and distinctive disadvantage for planning at grass-roots level. We have for a long time swallowed such recommendations of international bodies hook, line and sinker and made policies. Our needs and dire necessities in areas where we do not have the variety of doctors we need should be the criterion for measuring shortages.



The High-Level Expert Group (HLEG) for Universal Health Coverage used the original idea of the Joint Learning Initiative (JLI) adopted by WHO later. Coverage of measles immunization and births conducted by skilled attendant were the two needs (Deo 2013). These two needs are low-level medical skills of paramedics and not doctors. At least I cannot see the logic of this to decide shortages.  ne Basic Doctor in a Population Segment O The overall agreed doctor-to-population ratio in India is 1:1800. Large tracts do not have even this much of a ratio, it is much higher. Assuming this doctor works privately for 300 days a year and should see 20 patients a day to make a good living, each of the 1800 persons will have to become sick enough to go and see him at least 3.5 times a year. This frequency is certainly at odds with common sense especially if there is a payment attached for consultation services, or of investigations, medicines, travels cost to reach the doctor with consequent loss of earning for the day and so on. The only service the doctor can render in such situation is on an outpatient basis. A considerable number from among these patients every now and then will require more competent specialist consultation, or somewhat more sophisticated indoor care which this one doctor in the 1800 people cannot provide. The ratio hides this ground reality. The statistics of gynaecology work in Coorg, Karnataka, aided by diagnostics and infrastructure on OPD basis regularly found disorders in high orders the average practitioner cannot address. About 10% of women suffering from gynaecological disorders had surgical problems. This is an indicator of need for higher skilled doctor population (Dandavate and Kelkar 1989–90). The doctor here has either no competence or no infrastructural, paramedical and equipment support for solving such problems. If he is working in a PHC, the situation is no different; in fact, it is much worse. The one PHC medical officer with all the disadvantages is expected to cater to 50,000 people. A huge list of common but serious-­ enough problems can be given but is not necessary. These types of unsolved cases will reflect in the sad and large prevalence of health indices which are dismal. Nearly 80% of all such problems will lie in one of the five specialties of medicine, surgery, gynaecology, obstetrics and paediatrics, rising higher if the critical care component is included.



S ome More Myths of Statistics and Doctor-to-Population Ratios The statistics is believed to give a better idea of the ground realities, but it is not true. Those arguing for shortages are so avidly attached to statistics that they are forgetting that a qualitative description of the largely prevalent ground realities will give an actual picture. Statistics ignores these differentiated ground realities. Quoting statistics has many limitations, especially the way it is presented. It cannot be accepted as the only indicator. Each quoted unit of statistic when presented needs a limited context and variables within it which are not described, thereby making the statistic misleading. For example, the doctor-to-patient ratio is clearly in excess in the Metropolitan or the capital or the A or B or C type of cities. Each branch and/or specialty will have a different statistic. If we add to it the variables of five basic specialties, there will be 50 statistical units we have to measure. For that dozens of background realities and explanations will be required. The stark reality is that there are just too many of them in some places and less than 20%, as will be shown shortly, in other. The majority of their patients come from the hinterland due to shortages of specialists, to bigger cities. If the city doctors have to treat only the city residents, in absence of this inflow they will starve to penury. Then what kind of doctor-­ to-­patient ratio is being calculated? Any non-A or non-B district place today will either have a medical college in it or in a nearby district. Or the people will have at least some basic specialties in the private sector that will come with costs but whose competence levels are tolerable or acceptable, if not optimal. Part of the non-­ optimal skills of the doctors is the situational and the infrastructural backing they need but do not have. This point will recur at many places through the volume. In these relatively smaller places, even the medical colleges do not have the adequate facilities functioning optimally with quality. These are short of infrastructure and staff they need. One more important cause for these shortages is rampant absenteeism of teachers/specialists. For example, in a recent survey of a hilly district in Southern India in June 2018, the newly given medical college could not fill the bed capacity to more than 20% and most specialists on a working day were just not there. On weekends, their presence is not even an exception (Kelkar, 2018). But in the statistical sense there is no shortage in the grossest, single-digit doctor–population ratio. The patients thus and therefore still have to come to the private sector in larger cities.



 edical Seats Available as of 2014 to 2015 M These figures are retained purposefully since many central government decisions since 2016 will alter the statistics significantly by 2020 and the data status is fluid. The rise in the number of apex institutes, considerable decline in the admission rates in the private medical college intake because of NEET, the National Entrance cum Eligibility Test, and a boost to develop more medical colleges in the states are the main reasons for data fluidity. It will hopefully settle down to a lower number. This will be argued further in various chapters to follow. The need for certain corrections in these actions will be amplified later. With approvals for new seats, disapproval for some of the existing seats or for renewal of permission, the count on 15 July 2014–15 is 46,508 (Harsh Vardhan 2014). The NEET is discussed extensively in the chapter ‘Regulators and Regulations in Health Care’ in my other volume, India’s Private Health Care Delivery: Critique and Remedies, which was recently published (Kelkar, 2021).  ontinued Myth and the Concern of Shortages at High Levels C Large-scale actions to derecognize and/or stop admissions in substandard medical colleges were laudable steps, taken within a month and a half of the Modi government assuming power in 2014 June. These decisions were challenged in the Supreme Court. A bench of justices, A. R. Dave, Vikramajit Sen and U. U. Lalit, remarked that ‘this action has resulted in loss of MBBS seats available. It not only causes loss of opportunity to the student community but at the same time causes loss to society in terms of less number of doctors being available in academic year 2014–15’. With due respect, the government effort, to maintain required quality in medical education, should have found an appreciative place in the directive. Instead, the Supreme Court issued many directions about ‘what to do when a medical college applies for renewal’. The bench asked the Medical Council of India (MCI) and the central government to show ‘due diligence’ right from the day when the applications are received (PTI | 23 August 2015). All in all, the issue of shortages needs better understanding at all levels. The propagandists of more medical colleges covertly demand more private medical colleges in view of the ‘shortages,’ thinking that people are so naïve or foolish that they will not see the less noble motive of making huge money. The propagandists try to conceal it using other authorities and high faulting statistics. It is another matter that not one of them talks about the menace of Capitation Fee Colleges.



Population Size, Level, Needs and Shortages: A Statistical/ Theoretical Argument To make an assessment of the shortages, one should have some experience-­ based ideas and knowledge of the optimal size of a community with definite needs. This can help to decide doctor/specialist numbers corresponding to needs in an economically viable manner, such that doctors/specialists will have adequate work and can save people. Health should be delivered with quality, affordability, accessibility  and  equity, which does justice. It requires adequate infrastructure and paramedic support also. In such arrangements, the benefit-to-cost ratio is high even within public health care delivery. The community size should be large enough but compact enough so that those in need of higher level of care can travel to the facility with relative ease and provide enough work. What then is a reasonably sized community in the hinterland at or below the Taluka level?  dministrative Block and CHC, the Best Levels A Administratively, the block level is conceived at a population level of 100,000 and is considered manageable. In actuality it could be as high as 150,000 or more. A primary health centre (PHC) has a stipulated population of 50,000 at its maximum to look after in plains and 30,000 in hilly areas. The first feasible level for deployment of specialists the government has considered is the community health centre (CHC) as a backup for four PHCs, where every fifth PHC will be converted to a CHC. The population coverage thus will be between 250,000 minimum or more in plains and 150,000 in hilly areas. The experience so far is that these are adequate population concentrations to deploy five specialists anywhere in the country. This is a wise choice. However, the same area (for ease of travel) will usually contain much larger population than mentioned above which adds to more work and satisfaction for both the caregivers and the population. This population size will also fulfil all the requirements of economic measures needed to create facilities; a lot more will be discussed in the chapters to follow about it. This therefore is the best level to calculate shortages. It is at this level that the shortages of specialist manpower are at its peak. National average of shortage is 50% or more in one, two, three or all the five basic specialty branches, including residents and general duty doctors and/or doctors trained in skills like anesthesia. Then there is a serious issue of the necessary numerous functions in health and grossly



inadequate manpower to carry these in both PHCs and the CHCs as of now. This dysfunctional status needs correction for our health system as a whole, which will be provided in this volume.  est Levels for Specialty Professionals B Within specialty services, there are smaller branches with lesser numerical output of specialists. The patient numbers also would be smaller in such specialties. Such specialties can be still made available in public health care. If we consider taking a group of adjacent five CHCs, (described in detail in chapters to follow), these services can be provided at every alternate or third or in one out of five CHCs. This will take care of factors of work load, infrastructure and economic support needed without affecting the population needs. The population size of 250,000 can indicate prevalence of related disorders and number needed to be deployed or policy changes made to regulate the output. Since the public–private partnership (PPP) is an accepted principle of today’s health policy, such services can be shared. The reader is requested to keep this matter in mind as it will form the basis of the major ideas in chapters to follow.  evels Irrelevant for Calculation of Shortages L For calculation of shortages all other levels, up from CHC to the metropolises, will be utterly useless; hence, all such populations should be excluded from this calculations. This will be necessary to modify the higher levels of treatment centres like sub-divisional and district hospitals as direct fallout of the reorganization of the public system below them. This will also be discussed in detail. The other reasons for abandoning the shortage calculations are that each state will differ in its healthcare delivery capabilities from the other and in different regions even within the state. The following four  questions naturally arise. First, does the government system have the capacity to match the needs thus surfacing? The answer is, yes. Second, are there ways to achieve it with ease? Again the answer is, yes. Third, how will it be possible is the subject of the five chapters to follow on reorganizing the pubic healthcare., Fourth, are there any ways of supplementing it, and how and from where in case of short fall? Again the answer is, yes, there are enough resources. It is discussed in detail over several chapters to follow in this volume. At levels higher than the CHC, there is an abundance of non-state doctors resulting in excess numbers to population. There are ways to disgorge



the superabundance, which is one of the major thrusts of these two volumes (Kelkar, 2021), especially the one on private health care delivery. Worthless Alternate Ideas for Making Up the Shortage of Doctors in the Periphery The idea of a rural doctor has spanned across decades with a fatal infatuation and the colossal nonsense it represented among policymakers and activists. The central government in 2013 batted strongly for a course, ‘Bachelor of Rural Health Care’, with the usual rhetoric of to strengthen rural health services, woefully short of professionals, to create mid-level health professionals with three-year training with necessary public health and ambulatory care competencies to be primarily deployed at sub-­centres. A Parliamentary Standing Committee rejected this. It was renamed Bachelor of Science (Community Health). The curriculum of the course was redrafted, and was to be accredited by the National Board of Examination (NBE), since MCI refused to notify it because ‘it had no competence since it was not a medical course’ (Dhar Aarti, May 2013). The proposal did not go through and the central government changed. Similar ideas were floated by Dr. Pramila Tople, the then health minister of Maharashtra in the Janata Wave in 1977. Luckily that did not go through either. This foolishness of half-baked solution creating half-baked people with no mechanism to ensure that they go to the rural areas must stop once for all! The idea suffers from every defect of the government planning. Callousness, multilayering, unimaginative approach, pandering to populism for political mileage, complete neglect of the huge resources we already have and we are not utilizing, absolute indifference to the quality of the product, no idea of properly utilizing the same, reasons going ad infinitum. Such minuscule training is blatantly and shamelessly misused by Indians to promote themselves big with harmful consequences. This idea would have achieved the same. To conclude: the real shortages thus begin at sub-taluka level in terms of the postgraduate degree holders in basic specialties. One must also remember that several nations have achieved much better health indices even when doctor population ratio is higher, as in Sri Lanka with just five medical colleges against Kerala a comparable province, which has 17 colleges (Shanthi, Dr., Personal communication, November 2018, Director Provincial Community Service Kandy Province, Sri Lanka).



Public Health Care Structure in India At the remotest periphery are five or six community health workers of various names and descriptions in a sub-centre (SC) for health. Together they serve a population of about 5000. The first qualified medical officer appears at the primary health centre, covering six such sub-centres, nearly 30 community workers and a population level that varies from 30,000 to 50,000. There are more than 25,000 PHCs. This is the most coveted idea of all the health thinkers. Next, a community health centre is to be created from one of the five primary health centres, covering thus a population of 100,000 in theory but nearly 172,000 to 250,000 in practice (Rural Health Statistics 2012). The number for these ‘new’ CHCs is more than 5000. Serious issues connected with it are about the already-existing 5300 CHCs with considerable infrastructure which will be discussed later  in great detail (Rural Health Statistics 2012, 2014). Above these come the sub-divisional and then the district hospitals. Various directorates for national programmes are situated at the district levels. Often a medical college will also be found there. In the capital of each state, various directorates looking after the national programmes and other functions with many more medical colleges, corporate hospitals and private nursing homes will be found. The next question is, from where can we make up for the lack of doctors, especially the specialist doctors, who are in extremely short supply in the periphery? That leads us directly to the production centres in medical colleges, and how we could do it. Government Medical Colleges: The Key Factor Large numbers of our medical colleges are not in a position to produce a good general medicine doctor or a medical specialist who is suitable to work in the public healthcare system. That necessitates examination of the techniques, technology of education and its contents we are teaching. The quality of medical education needs more attention to produce the right kind of graduate and postgraduate doctors. We will essentially discuss the government medical colleges and what we could do about solving the health needs of the hinterland, and leave medical education to another chapter. The major issues to be dealt with respect to an average medical college are as follows:



1. The infrastructural issues and the upkeep 2. Externalities to be improved to complement the admission criteria 3. The structural components of the teaching methods 4. Procurement of good teachers 5. How to hitch the technological development to human development, a breach so blatantly obvious in today’s world, so that the graduates, as they man our health care delivery, will serve the populace better 6. How to use the manpower equitably, justly and honourably for the benefit of doctors and patients in the public health system 7. Establish coordination between the health services and the medical education departments of states  ovt Medical Colleges and the Infrastructure G Once teaching of non-clinical subjects is over, the clinical medicine and investigative phase begins. For that, functioning and quality infrastructure of basic to advanced diagnostic modalities is needed. It must be available in adequate measure and quantum. After this the therapeutic modalities and follow-up start, which completes the learning cycle. Almost always all the three essentialities are found to be in a pathetic condition. The reasons for this is not far to search. 1. There is a horrifying apathy of the handlers of the equipment and all others concerned, no thought to patient suffering, no one getting punished even if the equipment is dysfunctional or damaged. 2. The machines are deliberately kept in a non-functional state to avoid working routinely, or in emergencies or nights; technicians have enough knowledge to fool the doctors and to keep the machines idle. 3. The technicians and even doctors are given informal payments by private sector to keep them so, and to get references; all the three parties thereby making money over the misery of poor, forcing them out of public health services and towards bankruptcy. 4. The good habits of using therapeutics develop in undergraduate years in medical colleges and this is hampered by non-availability of diagnostics and drugs. 5. Pharmaceutical industry visiting residents and postgraduates cultivate money-earning culture; the origin of all the deplorable deterioration, which we see in practice today, lies here.



6. Huge numbers of patients outstrip the diagnostic and therapeutic armamentarium within government sector leading to further exploitation of the patients. Issues mentioned in points 5 and 6 are discussed in my volume Private Sector Health Care Delivery: Critique and Remedies, published with this one (Kelkar, 2021). Work Culture 1. The work culture is deplorable, including going to great pains to avoid work and being unwilling to even think of making a situation better for others; it is neither worship nor a civic norm; it never was. Dishonest to the core, it is indifferent towards grief of others; 2. Lack of civic values of cleanliness, orderliness, disciplined behavior and elementary decencies for the person opposite; being self-centred and egoistic with no bars is what we are. 3. The labour unions have played a big role in creating this dysfunctional unit of medical colleges and elsewhere in this country. I doubt if there is a single example where unions have uplifted the enterprise. This aspect is mentioned in the preface of this volume also. 4. The nuisance value, self-aggrandizement to assuage the feeling of inferiority, or the pleasure of destroying a well-functioning service and inconveniencing the people by hundreds is all that these factors do. Sloth, Dirt and Corruption in Medical Colleges 1. The medical colleges so often are dirty, slothful, poorly lighted with darkened walls, painted red with spittoons of pan and tobacco, with corners with spiderwebs, rusting waste, and items with fungus strewn everywhere. 2. The beds, the bedsheets, the pillow covers, the cots, the bed pans and the bathrooms are dirty. From where will the impetus for the doctors to stay and work in the wards and learn come? 3. For a large volume of this kind, it may look ridiculous to write all this rather than suggest some high-faulting remedies. We may do well to remember that we have a prime minister who declares from the Red Fort in his very first speech, which the world listens to, that



toilets are more important than temples and actually launches a Swachha Bharat Mission. Improvement in medical colleges should begin with correcting these simple things first. The politicians and administrators may note that the costs of these contracts and purchases will be thousand times more than the one-time purchase of sophisticated gadgetry they are fond of purchasing, which for obvious reasons gather dust. Let the place get well lighted, and well painted, let there be descent stuff for the people to lie on. Let each person who enters it stops at least for a second before thinking of spoiling it. Enforce the work culture by whichever means one wants to but this is where the reforms begin. The medical college upgradation is thought of typically in the bureaucratic ministerial response—to equip the college with high-cost gadgetry like a CT scan or some other high-value equipment. This is on account of the hype in the media they get. Such purchases do not serve the health needs of the poor to which repeated reference will be made in this volume in different contexts.  Laudable Improvement Initiative A The central government has taken laudable initiative to upgrade about 54 medical colleges starting from the bottom as discussed above. The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was announced in 2003. The objectives were correcting regional imbalances in the availability of affordable/reliable tertiary health care services; also to augment facilities for quality medical education in the country ( 2003–06). But the real boost it got was since 2015 under the new central government. The outlay is INR 150 crores per institution, with INR 125 crores as the share of central government. Upgradation of ten colleges is complete. In Phase II, six institutions have also been included for upgradation under PMSSY.  Considering the large number of requests from elected public representatives and state governments for upgradation of their medical colleges, this ministry has revised the proposal to take up 38 medical college institutions in Phase III of PMSSY, to provide adequate health care facilities to cope with the increasing number of critical care cases in many states including North Eastern states. The details of what is included in the upgradation are not at hand but let us hope some of the ideas listed above are included in it.



The Selection Process of Medical Admissions Marks obtained in entrance examinations as the sole, the most important, or the inviolable criterion for selection, is inadequate and unacceptable. At the national level, newer ideas should be institutionalized in the selection process. Admission process should be able to select those endowed with the culture, attitude and aptitude, consideration for the human suffering and human development, for admission in the government medical colleges. The knowledge assessed in the entrance test would thus be an additional, not the main  criterion. Counseling has become a part of the admission process, which is good. This exercise, however, as I understand, is post selection. It is not clear if the result or the impression of the counselor, if adverse, leads to admissions getting canceled. The place of counseling needs a shift to pre-selection and given weightage. Today in corporate culture, any person employing another human being is concerned more about the right attitude for the job than even the knowledge of the function, for which training mechanisms have been instituted in corporate culture. The Examination System for Admission Entrance tests by the 29 states, the dozens of deemed universities and premier institutes like AIIMS, and the central common entrance tests were an inhuman way of admitting young ones in medical colleges. During the enforcement period of National Eligibility and Entrance Test (NEET), many agencies convulsed and screamed in high decibels for cancellation of NEET. NEET has however survived and has in the process uncovered number of shortcomings, which have been discussed in my volume India’s Private Health Delivery: Critique and Recommendations, in the chapter ‘Regulators and Regulations in Health Care’ (Kelkar, 2021). A few more decisions of the central government will deeply influence the hitherto undesirable and faulty admission process. They will be discussed at various other places. A single examination of NEET for the entire country is one of the best decisions taken by the central government and supported by the Apex Court this time. By 2018 end, three such examinations had been carried out. The picture that has emerged is as described below: 1. All government, private colleges and deemed universities have been subjected to ONLY one National Eligibility Entrance Test,



2. 3.

4. 5.

6. 7.


NEET, from academic year 2017. The Apex Court has redeemed itself in reversing the degrading 2012 judgement that the status of the NEET is voluntary and all the types of common entrance tests prevailing will continue as it is. The central government wisely permitted in pure pragmatism the multiple tests from states and so on for one more session after NEET. Since then only NEET holds. NEET created a common standard for the country, first time in the last nearly 70 years. No words of congratulations are enough. After banning the combination drugs, this is the second equally great decision by the central government. This will pave the way for a curriculum for Indian needs in times to come. The central government has indicated as much. The bill also stipulates to hold NEET in regional major languages of India. Creating instruments of examinations in several regional languages is not as simplistic. The entire orientation of learning medicine is in English. How useful will it be to give these examinations in regional languages and then go learn medicine in English? This will be taxing, making student nervous over a difficult task. It will take time to develop quality medical textbooks and curricula in regional languages helping the task finally, of learning medicine in one’s own mother tongue through the postgraduate level also. It will take a decade or more. However, the present arrangement will go easy on those who have the requisite intelligence and aptitude but have fewer skills in English when they enter the medical college. When the regional language examinations come up, a far-reaching effect will occur on localizing a large number of students to that particular state. This is beneficial because such students could be taken care of better by their own state and the teachers with common language. Students less endowed with inadequate supporting means like family economy will benefit from regional language examination, not having to travel and reside for five years outside the state. There is a flip side to this also. Historically, over five decades now, insistence on teaching in regional languages has continued under the misconceived sub-nationalism or perverted provincial parochialism. It was done in support of the proposition that foreign language destroys the development of the students. It ignored that it



is restricting opportunities in life over the national scale in large measure to a state. Nationwide opportunities were denied. 9. It has harmed at least two states, Bengal and Tamil Nadu, badly. One lingo was golden, the other ‘more ancient’ than any other. In the Sonar (Golden) language, the percentage of students passing the tenth with science subjects is miniscule. Speaking in English in both states, even among the educated, is a struggle. This is the state generally obtained in other provinces as well but few others are accusable of this parochial tendency. 10. One of the main pleas of states like Maharashtra to oppose the single entrance test was that the state board curricula are less stringent than the Central Board of Secondary Education (CBSE) or Indian Certificate of Secondary Education (ICSE), an examination conducted by the Indian Council for School Certificate Examination, a private board of school education in India. This, the state argued, gave a distinct disadvantage to the students at the national level. 11. In the last many years gone by, the Maharashtra government has successively lowered the standards of the state board so that more students pass. There were years when examinations were not held for classes till ninth standard so that everyone would go in the next level, with no one failing. This in the long run has led to the destruction of generations of students, especially from hinterlands and sub-taluka situations compared to the cities where alternative means to bolster one’s education level and general exposure is better. Education is to elevate standards of students, not lower its own. 12. The states were driven to strident protests, review petitions to the Apex Courts and pressure on the centre, which got them a relief only for one year. That hopefully pushes them in action to make curricula more stringent and of higher standards, and demand that students work harder to get better colleges for admissions. The extent of toughness of the standard can always be set to any desired level in few successive phases of couple of years starting from the bottom or in a wholesale manner which is better. In particular, there will have to be changes in the schools still teaching in the state languages. 13. A mechanism to command English needs to be put in the vernacular schools. The point being that this was never attempted. I doubt whether there was any attempt to convert more suitable schools to



CBSE courses. I believe it was left for the parents to decide the school, based on the affordability which also came into consideration. 14. Nothing is lost even if the supremacy of English reigns at national level because medicine in India is still learnt in English. Development of the medical curricula in regional languages will lessen dominance of English. I do not see this happening for at least a few more decades. Whether we should do it at all or not is a large issue worth a national debate and out of purview of this volume. 15. The pragmatism, logistical consideration, the psychology of students being delicate at these times and the other issues the states grapple with did not find much place in the sweeping judgement of the Supreme Court. It enforced NEET on students at a notice of 15 days and then for 45 days. My take on this is that the Supreme Court was aware of the controversies that will erupt which it desired and left it to the government to take suitable action. The government did a good job of the responsibility. 16. The NEET idea was extended to the single national postgraduate examinations under the same conditions as NEET, named as National Licentiate Examination. It is still an idea since the National Medical Commission has not  started its functioning in full force after replacing MCI. It is extensively discussed in the second volume of private health care in the chapter on Regulators and Regulations in Health Care. 17. The discussion on the content of any examination type one adopts has been left out here. It will be discussed in the chapter on medical education.  ptitude Tests before Admitting a Student: The World View A In Japan, philosophy is a subject taught to everyone. There could not be a more imaginative solution to the development of certain attitudes. The kind of philosophy, the contents and the success of the method are not known. It is clearly an attempt to develop ethical commitment of the person. The University of Newcastle Health Division Australia considers it important that the ethical elements of the thinking be nurtured (Henry et al. 1997).



I did an extensive search for a structured procedure and content of these newer elements in many reputed universities of advanced nations. I hardly came across a system we could employ. The MCI has made some curricular changes to achieve some of these elements. A serious appraisal and disapproval of all such measures will be found in the chapter on Medical Education in this volume. Hence, we will have to develop our own system of pre admission evaluation. This is required to help those students who were forced into medicine by their parents. These wards do not have the aptitude and willingness even if they are merit holder students. There are examples galore that show that many of these students do not reach the competence of their parents and are miserable all their life. If we achieve this end we will free a large talent pool for other areas which are also in need of intelligence. The details of the format for testing these matters require a participation of people of different disciplines. Once this principle is accepted, the rest will follow.  he Bond System T The Bond while admitting a student should be scrapped. It binds the students to serve in the rural areas for two years after graduation. In Tripura, the bond is for five years (Sinha 2015). Following can be considered as a representative sample for all India status of the bond system. The graduates find this scheme not so effective, due to lack of support from government. It lacks a system to guide the freshers, which they need badly, while working in periphery than in medical college as the situations are totally different. The other living facilities are with poor or non-existent infrastructure in rural areas; hence, the bond system should be withdrawn and the one-year rural service should be implemented with continued medical education (Sinha 2015). This suggestion is further modified in Chaps. 7, 8, 9, and 10 here. The bond money is as high as INR 1 million, and generally it is not possible to buy it off. After passing MBBS, it is incumbent upon the graduate to inform the respective state government that he/she has passed! Then, it is the government’s responsibility to give him/her a job in the rural areas. At least in Maharashtra this is how it happens. If the government fails to do so for two years, then the student is not bound anymore by the bond and is free. If the government gives a job but the student is already in some postgraduate course, the bond is not executed. How the



bond conditions deal with the fugitives who have left the country is not known (Savarkar 2015). These arrangements do not gel well for practicalities. The bond delays the admissions in postgraduate courses. Hence, there is a wholesale resentment of it in freshers and medics fraternity. There is no learning, nor does it improve the rural situation repeatedly shown in this volume. Three years of human resources at their best theoretical understanding of medicine compulsorily wasted is at the very least bad planning. It should be eliminated across the country. The alternatives to man the services once the bond is scrapped will be discussed extensively later in the chapter ‘The De Novo Manpower Deployment Processes’, in this volume.

The Externalities Needed for a Good Education Process The Administrative Failure The administrative failure in the undergraduate teaching process is the proof that we cannot run our institutes well with the seriousness Europe or the US has done in the past. In India, there is every good rule and relevant criterion present in the working details of our institutions for teaching, the bedside clinics, ward rounds, lectures or special activities like the faculty research and active conference participation that must run routinely and spontaneously. None is implemented properly due to administrative failure. Everything is tip-top on paper. Administration does not bother or those responsible will not listen to the administration. Simple considerations like the following need attention: tightly overlapping lecture or clinic schedules should be avoided and adequate time is needed for the mass movement of students through the vertical or horizontal distances in reaching from one place to another. Hence, nothing can start on time and ends hastily. These are time-consuming elements. Student Teacher Relationships Today Confining myself to the medical college scenarios in Mumbai, I must say that we and some later generations were fortunate in this regard. The professors were not terrors. The driving element was learning, to be with them as much as we could. Every word, every gesture and everything that



they did was about learning on a minute-to-minute continuous basis. We were friendly with each other. Let me emphasize that this type of learning is still the best. A lifetime of experience is teaching you. I have dealt with this again in later chapters. There was no fear of any repercussions on their role in passing the graduate or postgraduate students, and no scare of displeasing them by asking questions. The best of it is described by Dr Ravi Bapat, ex HOD Surgery KEM Hospital, Mumbai. Their sports-loving teachers encouraged the students by attending their matches, often cancelling the practicals. For compensation they would take extra classes for sportsmen without any fees on Sundays or odd days or at odd times. They would take the unit students to fine places for dining or call them home for the same (Bapat 2011). There is no meaningful relationship between the teachers and the students today in any and every form of education from the primary to the postgraduate degree. The continued agitation of parents against the primary schools in New Delhi in April and May 2017 is an example that is valid across the board. See the contrast. Today neither wants the other to spend time with each other as shown elsewhere in this volume. There is no interest in teaching and quality learning today. Medical College Teachers Medical college teachers for long have had a dominant mindset towards the undergraduates and even more so for postgraduates. The students must be not only in awe of them but also scared, and better if they are terrified of them. They are the high and mighty in the knowledge of medicine. They look down upon these creatures from their high pedestals. These two are supposed to be unequal warring factions. This is an image they have built about themselves. In addition to it: 1. The teachers do not take effort to upgrade them. New insights do not reflect in the teaching process. In an ever-changing subject like medicine, substantial changes which cannot be ignored occur every three to four years. The teachers need to exert/work on their teaching. 2. The sad fact is that they are just not interested in teaching, and have no interest in creating excitement in the learners either. All that the teachers want is to be paid for all that they are not doing as expected.



3. The same teacher will enthusiastically teach outside the college at medical tuitions classes, which galore. It is high treason that teachers open classes and charge exorbitantly from the same students who have paid their dues elsewhere. 4. There are classes and tutorials that help you get admission in the medical colleges by clearing the medical entrance tests, and classes after getting into medical colleges for them to pass. This construct thrives since the teaching in colleges is poor in all respects. 5. The doctors from my generation can never think of this; we abhor and consider it unacceptable and insulting to us as well as the colleges we passed from and to our teachers. 6. The teacher invites students of his caste to come to these classes to give additional help to pass aside of teaching. There would be a threat of dire consequences by the same non-teaching teacher to students of other castes if they do not (pay) and attend his classes. 7. The omnipresent age-old system of caste-dependent hierarchical differentiators continues with vengeance even today. Teachers proactively bring up students of their caste, often at the cost of others not ‘belonging’, by obstructing theses students wherever possible. There is no shame associated with such acts. It is done gleefully, proudly and vengefully. This is not fiction. 8. Caste hatreds are native to Indian mind; each one wants to fight an imaginary battle either to survive or to wreak vengeance for the sins of the past or the effects on present. 9. If a good teacher retires, he/she goes to the capitation fee colleges to teach. A more poignant and an emotionally evocative appeal is that he/she cannot remain happy without teaching. The motivation of earning money while they do what they like, and are good at, also prevails. 10. The most basic objection however does not lie in what is described above. It lies in that medicine cannot be and should not be taught or learnt in classrooms. Classroom teaching is passive and hence useless. It should be a post hoc well-thought-out matter as it is in problem-­based learning discussed in detail in the next chapter. Medicine is learnt in the wards, learnt while working with the seniors caring for the patients and by continuously following patients and what the teachers are saying  to or doing for  the patients all the time. That is where the wisdom is flowing through for the students to catch, learn and remember to practice.



11. Knowledge of the human body and disease, its diagnosis and its cure should no longer be our only focus of teaching. This idea should have been applied to our lives at least 25 years prior and is still relevant. In context of this chapter, the focus should be on teaching with a view to deploy him/her for the health of people as a whole, and care is taken to make the ill person whole and integrated again after disease is controlled. 12. Unfortunately the medical education and public health have gone away from each other to their separate ways. That is why we have not been able to achieve the planned development of our doctors. This will also come under further discussion later.

Improving Teaching in Medical Colleges The externalities and supports or some basic needs which are independent of day-to-day or year-to-year teaching process are discussed below. 1. Reorienting our medical curricula has been under discussions for over four decades. Some ideas and literature, however sketchy, also may be available. An appeal to all to contribute to the process is needed. No single person or a group of people have so far applied their minds to decide the full scope of its contents. This however has to be started at the topmost level. The top brass may have remained unwilling for many reasons—the long duration and hard work involved in it, or being uncertain about its fructification, and whether anybody will have the political will to implement it. The need is certainly there. The potential to change the entire paradigm of medicine to what is relevant to India, and quality of doctors coming out will undergo is huge. I have to however add that further discussion on the content of such reorientation is beyond the scope of the present volume. 2. We have to get our good teaching faculty back from the capitation fee colleges or classes they run. Extending their age of retirement or work can achieve this easily. This will be a special cadre within the government medical colleges. The younger faculty, the administrative hierarchy, its promotions and transfers and so on remain intact. Other rules can easily be made to optimize the work of the younger cadre and the experienced teachers as shown below:



a. The load of acute and chronic patient care should be left to the younger faculty in regular service and teaching is left to these greats in general without obstructing any help that both can extend to each other in need. b. It is not just a matter of a good and teaching teacher. This teacher has to have a strong background for educational theory behind him as expected in the foreign countries (Bapat, ibid.). Education theory itself is becoming an integral part of postgraduate medical training. Formal qualifications in education are also becoming the norm for medical school educators, who are increasingly accountable for the students (Bapat, Ibid.). c. This will be even more necessary if we decide to change our technology of medical teaching as argued for in the next chapter of this volume. d. There was a time-honored practice of honoraries described above and the culture prevailing then (Bapat, ibid.). They were great teachers, interested in students. Can we bring back this culture? e. Above was probably the earliest example of the PPP model in healthcare and medical education. Coming from a different type of practice of people from different strata of the society, the variety of health issues would be different than the medical college patients. That brought in a different perspective. With a maximum of three to five years in any one medical college, their lectures and/or bedside clinics would be a great boost to knowledge acquisition. f. The regular faculty of any college has four difficulties in teaching. Their time is bound up in clinical services they have to offer to the patients, or bound up in official meetings and related matters. These  are two legitimate excuses. Their unwillingness to stay in the hospital beyond a specified hour and leave even before that for private practice is not acceptable. Fourth is their actual dislike or unwillingness to teach. These two are not legitimate. g. There should a complete ban of private practice for those who are in full-time government service and particularly in medical colleges. Much of these ills will disappear if the private practice is banned. h. In Sri Lanka, the regular timing of all public health institutes is from 8 AM to 4 PM. After that the consultants are allowed pri-



vate practice. However, they are provided accommodation within the peripheral hospital campus and must attend emergencies round the clock. Both the watchful public health care system and the Sri Lankan culture do not dilute their attention and devotion to the public health. Private practice is not the focus (Wanigatunge, C Prof, December 2018). In India, expecting this is not realistic. i. For reasons stated above, we need a supplementary cadre of superannuated teachers or the retired ones to teach. j. Revision of the teaching schedules is important. Even when the content reorganization to suit Indian conditions may not be achieved in the short run as pointed above, the college authorities could constantly reshape the same. By prioritizing and emphasizing different subjects in the teaching schedules relevant to today’s prevalent health conditions, it can be achieved. No approvals are needed from the University Academic Councils or Accreditation bodies or MCI, since it is within the present curricular content and knowledge. k. Given the unwillingness of teachers to update and work on their teaching, we suspect that such an exercise may not be carried in the colleges for years. It could be considered unwanted, or as extra work or a result of pure inertia. l. The cases discussed in the side-room clinics in the ward should be followed through and completed till the last. It is a must. The time management mentioned above as well as far too fewer clinics and the patient discussed half or quarter way or getting discharged before the follow up clinic  are the reasons it does not happen m. Problem-based learning is best suited for the non-availability of patients which we discuss in the next chapter in great detail. n. Within the teaching spectrum, much more focus and stringency should be applied in postgraduate teaching. Some lapse for credible reasons could be allowed at undergraduate teaching but not at postgraduate level of teaching. o. The caste of faculty presently employed in medical colleges is a sensitive issue in private conversations among teachers. This faculty in fair percentage comes from the backward-class category today, through the reservation process. Some of them have gone to postgraduate courses, obtained a degree and joined the cadre. Given the native, strong and deep-rooted perception the upper-



caste faculty has, they cannot see anything good in this backward-class faculty. That they are not good teachers, and are not interested in teaching, is an opinion expressed far too frequently. p. Traditionally, Brahmins have taught as they have done since time immemorial and even in medical colleges. They have lost a considerable percentage of their jobs to the backward class today, a strong bone of contention leading to resentment and hatred. q. The backward-class faculty is in a gleeful mood since it is ruling over the Brahmins today. They would like to teach a lesson to the Brahmins every now and then to take revenge for all the atrocities they have suffered at the hands of Brahimns  for centuries. r. This war is coming in way of good teasching, and deciding who the good teachers are. The only answer is for the backward-class teachers to perform par excellence and win the students (and even the upper-class faculty) over. The historical vendettas and superiority feeling, have no place in medical colleges. 3. The Central Government Cabinet on 15 June 2016 raised the superannuation of doctors in Central Health Services across the board, in various ministries and departments, Indian Railways, AYUSH and Central Universities to 65 years to tackle shortage of doctors. Low joining and high attrition rate in central services are the main causes behind this good decision. Senior Central government doctors above 62 years working in all its entities are going to be relocated for medical education and clinical-patient care services and to carry on national public health programmes (IANS | June 28, 2018, 10:09 IST). 4. There are many other foci not discussed here. For example, the development of a doctor is a graded phenomenon. To produce one good doctor, we need a dozen years. At each stage of their career, we should be able to provide them a working environment which can improve their knowledge, skills and attitudes, and foster their chances to go to the next higher level of development. Its relevance here is about the availability and various functions of the real teachers during the medical college years. The greater development will have to continue beyond the medical years as well. This will be the subject of Chaps. 7, 8, 9, and 10 in this volume. centres.could not delete centers. 



5. Following are a few  ideas about the work for the superannuated teachers:

a. One of course is to teach, as discussed above. b. The state of dissertations and thesis is awful, shameful and horrible all over the country and needs to improve. The supervision of the postgraduate dissertations and MD thesis is only slightly better. Helping students to write better-quality ones are an important job that needs more time. c. These dissertations serve a useful purpose; answer clearly defined questions in a clear-cut manner. It teaches the students to  ask significant clinical questions or doubts where no information is immediately available. Dissertations and MD thesis are extremely important lessons for students in systematic thinking and painstaking attention to details, which is needed for research. There will be improvement in clinical research and outlook towards it if the superannuated teachers take a hand in it. Much more can be written about it. d. The superannuated faculty having no official clinical load could start research, independent of dissertation, involving the students. Liking a research project to work is a sure-shot formula of academic excellence. These teachers had had no time in their tenure for all this. They could now put plenty of work in it. e. Indian Council of Medical Research (ICMR) and Department of Science and Technology (DST) do their research often by employing medical graduates and also fund it. It is highly desirable that ICMR throws in its ideas to this older medical college faculty, to take up relevant research activities, by roping the postgraduate students in and expose them to the research methodology in the long run. This will reduce the absolutely and utterly downgraded quality of the so-called thesis, postgraduates ‘create and supply’ to complete the formalities. In my volume India’s Private Health Care Delivery: Critique and Remedies, in the chapter ‘Integration of Medical Systems—A Theoretical Perspective and Practical Blue Print’, many ideas about research in the AYUSH systems of medicine have been put forward emphasizing that graduate and postgraduate students should be involved since these research areas are simply vast but necessary.



f. The key difficulty when three institutions of medical colleges, ICMR and/or AYUSH Ministry have to work with each other is the unwillingness. Working together as a habit has not developed in Indians who do not work together well mainly due to ego issues, bureaucratic attitudes and inertia. g. Nature abhors vacuum. If the faculty is short in numbers, then alternatives will have to be devised to attract and retain other people. Liquidating the capitation fee, colleges will solve this paucity issue to a considerable extent and quickly. h. To achieve all this, the bureaucratic attitude should be done away with. Adopting the rules in a reasonable manner (filling up the faculty differently if quotas are lying vacant) will help greatly. i. All blinkers will have to be removed to have a courageous look as to which of the administrative barriers, rules and laws need to be scrapped within the health field for achieving the goals we are setting for ourselves—a proper staged development of a doctor by providing the appropriate atmosphere over years to learn, work well and mature. j. None of these actions need new laws and bills and so on. Most of these are simple administrative decisions, and administrative strictness is all that is required to see that people execute it. k. Faculty induction could be done for each and every paramedical course run by a medical college using same principles and methods described so far.

6. Scrap the deemed (medical) university status of all including some government colleges having the status and the state health universities. a. Several justifications are given below about this necessary step. Operationally speaking, no university has exerted to either improve medical colleges or provide adequate manpower to regulate the curricula or to retain quality or improving the admission processes or the employment or induction of teachers. None have taken any notable initiative to work with other universities for developing an Indian curriculum for the Indian doctors to effectively deal with Indian health scenario better. Nothing can be expected from these hotbeds of corruption. The discussion below applies to both the undergraduate and the postgraduate education. b. When the right to conduct the pre-MBBS tests for admission has been removed by NEET, one of the two mainstays of being a university or being a deemed one, that is, conducting examina-



tions and the right of assessment in passing students, has been nullified. c. This betterment should hopefully come about in near future when the qualifying examination for MBBS registration across the country to practice will be by passing the National Licentiate Examination, a strong element introduced by the National Medical Commission. It comes with the same exceptions as those institutes like AIIMS which were specially created by an act of Parliament. A detailed discussion of National Medical Commission is presented in the volume India’s Private Health Care Delivery: Critique and Remedies, in the chapter ‘Regulators and Regulations in Health  Care’, published with this one. Thus, no justification for a medical college as or under a deemed university will remain. d. Generally, these deemed universities have many different varieties of colleges run by a particular group of politically powerful people and get the status of deemed university for a prestige that does not exist since it cannot be backed by quality of anything whatever. Such Indian deemed universities are subjected to ridicule, de-recognition and disqualification across the globe. The issue is discussed in detail in my second volume on private health care delivery in the chapter ‘Capitation Fee Medical Colleges’, also published with this one. The present pattern is not a wholesome one since the quality of the product is in doubt. e. There are contradictions among the regular and the deemed universities. In the states where there are medical health universities, there are capitation fee medical colleges with the status of a deemed university. All government colleges are not, but a few are, deemed universities, and not all capitation fee colleges, but few are, deemed universities. This is absurd and the whole structure will have to be demolished. There is no question of compromise in this situation. f. Removal of the deemed status done piecemeal will make all the non-­ deemed colleges orphans. Or else all these non-deemed colleges will have to be made deemed universities. This would be the height of absurdity. g. This denotification of the deemed university status will be complete when all the branches of higher education apply the same measures as attempted by the health ministry by NEET and NLE. In the last



four years there is not even a hint that the ministry of education and human resources is even considering this. h. The much older idea of having a health university for every state or a group of smaller states geographically adjacent was a brilliant one. That should have presupposed the affiliation of all the government and private medical colleges to it. It did not. Now these health universities should be dismantled after NEET and NLE for reasons given above. It will reduce the clutter of multilateralism and multiple authorities guarding their own turf and doing nothing meaningful. These today have no locus standi.  The New Education Policy,  2020, has gone in the opposite direction with respect to these suggestions, discussed elsewhere.  i. Many other paramedical branches with both the public and private colleges should also have come under the health university. With the plethora of deemed universities, these slipped away from it. Getting the paramedical branches under the pattern of NEET and NLE has as yet not been seen on the horizon. j. AYUSH medical colleges will also be following the same system once the NMC bill becomes  fully functional. (See Appendix B Controversies over the AYUSH system of medicine in this volume.) k. The government is already foaming at the mouth with the other massive reforms, beleaguered by the high decibel protests from all around. Hence, it may be said that such complete overhaul that could not be taken up by the government in the last term should now be taken up as it has more won handsomely in 2019 general elections.

The Results of Medical Education Today The final result can be easily seen in clinical practice today. Fundamental to medical profession is the diagnosis. It is as great an art as is the science behind it. It is no longer taught in the classical way where we use all the five sensory organs, work organs and the brain to come to a diagnostic conclusion. The most important benefit is the dialogue it facilitates between the patient and the doctor, which is as required today as it was 50 years ago when diagnostic facilities were much less (Bapat, ibid.). One of the serious consequences is that no one really examines the patients today. There is nothing as important as that for various reasons. A detailed picture of practice of clinical medicine today is drawn in the chapter on corporate hospitals in my volume India’s Private Health Care



Delivery: Critique and Remedies, which has become pervasive. The reader is requested to go through it with this one. In conclusion, the shortage of doctors is at the level of basic specialties, the failure  is to deploy them at the appropriate population levels with good infrastructure. The perception of shortages is red herring created to pave the way for more capitation colleges. In conclusion, we have to improve the externalities of educational processes at the medical colleges. Recruiting good teachers is a must and for that purpose a new profile of work of all medical faculties is detailed. The recommendation is to remove the deemed university statuses and particularly those colleges which have been so deemed.

References Nagarajan Rema 2018 | TNN | September 02, 2018, 08:28 IST. Deo M, 2013, Doctor Population Ratio for India—The Reality. Ind J of Med Res; 137(4):632–6325. Dandavate VR, Kelkar, SS, 1989–90; Detection Drive for Gynecological Disorders—Statistics of 1400 women 1988–89. Kelkar, Sanjeev June 2018, Survey of Medical Facilities in a Hilly District of Coorg in South India. Harsh Vardhan Dr, Union Health Minister, Government of India, 2014. PTI | 23 August 2015. Aarti Dhar, Updated: May 12, 2013 03:38 IST The Hindu,. The Sunday Story, Education—Health. Rural Health Statistics, GoI, 2012. Rural Health Statistics, GoI, 2014, 2003–06. Henry R, et  al; Imperatives in Medical Education, The Newcastle Approach, Faculty of medicine and health sciences, The University of Newcastle, NSW, Australia, 1997. Sinha, Priyanka Dr MBBS fresh graduate on bond system in Tripura 2015. Savarkar N, ex-Den Sassoon Hospitals Pune, 2015. Bapat R, 2011, Postmortem, Manovikas Prakashan, Pune. Wanigatunge, C Prof, Jayawardenepura University Sri Lanka, personal interview with the author, December 2018. ANS | June 28, 2018, 10:09 IST. Kelkar, Sanjeev, 2021, India’s Private Health Care Delivery: Critique and Remedies, Palgrave Macmillan India 


Medical Education

Preamble Medical education limited to a few years in British era is a matter of 10 to 15  years today from MBBS to specialization and superspecialization. One segment of the graduates cannot  or do not go for postgraduation. The knowledge explosion howe0ver is alluring for most to go for more specialization. How to train and educate graduates, postgraduates (PGs) and superspecialists, and the options available, will be substantially discussed in Chaps. 7, 8, 9, and 10 on community health centres. In this chapter, I will discuss the medical college–imparted education mainly for the MBBS entrants. Some general expectations should be acceptable to all. The training should lead to the ability of all graduates to earn a decent livelihood. A doctor should be able to contribute in some way to the health of the nation and people aside of treating just the diseases with which patients come to them. Any sector of the health care system should also be oriented to achieve nation’s health as a whole. The preceding chapter looked at the ground situation in government medical colleges. This chapter will discuss the system of training and what more or better can be done in it within the government medical colleges. This treatise considers the existence of capitation fee medical colleges as illegitimate in every way but the discussion applies to them so long as they exist. The chapter of manpower deployment will logically follow to explore how to achieve both these expectations—livelihood and contribution to the national health. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




The Steadily Worsening Situation of Teaching in Medical Colleges In 1975, the Srivastava Committee for medical and health education observed ‘that there is no structure to bring about the needed changes’. Further, it observed: It is therefore of the utmost importance that a suitable structure … established (for) implementing the needed reforms and of initiating and nursing the change process … (is needed) an UGC-type body for medical education and … recommendation … by the Education Commission [1964–1966] … (to be implemented.) In the absence of some such machinery … we are afraid that the quality and relevance (emphasis ours) of medical education may continue to remain as a no man’s land between the Centre and the States. (Srivastava 1975)1

This volume will go through all the developments/changes that have happened since then and the state we are in at the end of 2018.

The Original Aim of Medical Education and What Happened to It In the early twentieth century, the training for registered medical practitioners or Licentiate of the College of Physicians and Surgeons (LCPS) was intended to develop a basic doctor, with an ability to manage a lot more than what he/she can manage today as MBBS. The idea of the basic doctor became more distant especially in the last four decades as the 1  The Srivastava Committee recommends an additional University Grants Commission (UGC) -type body to look into this. UGC and MCI Medical Council existed then also, charged with maintaining the standards of medical education. Why recommend another body? Was the committee even in 1975 already disappointed/disillusioned with the ability of these two? It is a just question to ask today. The moment we create a separate body, the extent of the mandate, the follow-up and the finance requires definitions in the context of all other bodies. The same considerations apply to decide who is to accept or reject its findings? What would be their relationship with other bodies, place of the new body in the hierarchy among the existing bodies and a host of other questions come up. Once bodies come into existence, there are turf wars within all of them and the one who creates it. The bodies do not disappear if the work is over; it is never finished. Many unsavoury and unwanted issues come up when a committee or a body is born de novo. In this volume, the reader will come across criticism of creating parallel or multilateral bodies, with dubiously distributed authority, repeatedly. The above criticism must be kept in mind in all such mentions. This remains the favourite way or game or a ploy of the governments to pretend to solve any problem.



complexity of and knowledge in medicine increased. This is not a complaint. We have to advance ideas about how to accommodate knowledge to get the good quality doctor, which is what this chapter does. The questions about what the education should do to a doctor are many: Does one cease to be a basic doctor if his/her knowledge vastly expands? Or, should such body of knowledge necessarily kill the creation of a basic doctor in the process? Or, is there a change of perspective among the vastly more knowledgeable doctors that they do not want to be, or function like, a basic doctor as well? Does it cause any difficulties to them in patient care? Do we or do we not need the basic doctor and his/her skills for the national health even now? Has the explosion of knowledge affected the practice of fundamentals of medicine? How sound the fundamentals are or have remained? If not, then why not? If it is being lost, what has gone wrong in the educational process? These questions may appear to romanticize the nostalgia of those doctors in 1950s and 1960s. No. Unfortunately, these are loaded questions which should be raised across all levels of knowledge and qualifications and will be addressed every now and then in this volume as well as in my volume published with this one, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). If there was ever a time to reconsider medical education globally as well as in India, it is today. The challenge is the reconciliation of the technological advances to on-­ ground effective reduction in morbidities and mortalities of the sick people at all levels of population and diseases afflicting them, in large or even small numbers, thereby increasing their chances to do better in life. This process per force has to span through several stages. The challenge is to build the fundamental understanding of medicine in a manner solidly enough for the doctors to be able to easily manage the information overload intelligently as well as deliver excellent care. We have to understand first, rethink next and either remodel or discard the ideas so far prevalent in the world as a whole about the education systems. It may not be possible in the discussion below to keep the distinction between the undergraduate and the postgraduate medical education because the formats of teaching I propose are relatively the same. I will discuss mainly India with a brief review of the methods of medical education elsewhere and the current trends in thinking about medical education.



Rote Learning: Is It the Only Way to Learn? As prevalent in the 1960s as is today is the view that learning, teaching and practising medicine depends on the ability of a person to remember a million unconnected data about human body. It is no surprise that this trend has got strongly fortified for the last 20 years. It has destroyed generations of doctors in India. The main culprit is the multiple-choice questions (MCQ) system of examinations for an entry into the under- and postgraduate courses. Put it otherwise, it has not dawned on most students and well-qualified doctors/teachers that medicine can be thought of mathematically as we solve a theorem where the previous equation indicates the next. One may call thinking in clinical medicine as algorythmical. I prefer to call it logical, which can include something more than the mathematical and algorythmical aspects in it. The logic in medicine exists and operates at all the levels, the cellular and subcellular, organ and organ systems, and as a whole for the human body. It has not been recognized or even thought of as existing.

The Traditional Individual Subject Approach: The Preclinical Years The first subject of anatomy is at its best if the physical human body, a cadaver, is available for a group of six or eight students to dissect. At its worst, it is a mechanical remembering of numerous Latin names of the hundreds of muscles, organs and cells and all else that needs to be learnt about it. It is taught divested from the physiology and light years away from the biochemistry of the human life. The rote memory thus is the only way. It takes generally about three years after passing the first MBBS and joining a postgraduate surgical course to start developing some logic in dealing with the human anatomy. In these early years, physiology is the loser looked upon with disdain as a secondary science; anatomy dominates. The fate of biochemistry is worse. Having never perceived the organic chemistry as anything more than a humongous data-cramming subject, ignoring the fundamental logic in it, the biochemistry is at its worst perceived as unimportant and/or useless to understanding medicine. At its best, it is an unavoidable headache which has to be learnt by rote. Thus, there is no connection between these three fundamental branches of human biology and the way they are taught.



Thus, the question of relating this knowledge to pharmacology, pathology and the clinical medicine simply does not arise. It is only after the first 18 months that the student comes to the abnormal physiology also called pathology; 36 months after the admission, an in-depth teaching of clinical subjects start. By which time the student has forgotten the anatomy, remembers physiology sketchily, biochemistry not at all and pathology to a limited extent and cannot relate the drug therapy to clinical syndromes effectively either.

Learning Pharmacology, Pathology and Preventive and Social Medicine Each of the six is a separate vertical without any logical connection with the other two in the present system. Today large data is available on cellular drug interactions which should make the logic of connection easier. There is no substitute to keeping the understanding of these subjects fresh to first learn and then practise clinical medicine. Yet, the teaching continues in unimaginative ways in the age-old methods in undergraduate laboratories of physiology, pharmacology or pathology. It can be easily done in much more realistic and interesting ways in all branches. The will to do it is the great challenge. Establishing these interconnections is called the horizontalization and integration of all subjects.2 These six verticals then will not be left behind and forgotten as clinical medicine starts. Pharmacology Pharmacology is far more complex today than it was 30 years ago. The high throughput process, three-dimensional structuring of the molecules, and the interaction between them and their receptors also created in the 2  In the dialogues about how to improve medical education, we occasionally hear the word ‘integration’. I wonder whether there is a clear concept among those who talk about integration. In India’ it has another connotation. It is the integration of other Indian, non-Indian, but non-allopathy medical systems with the allopathy system. This matter has been extensively argued in my volume published with this one, India’s Private Health Care Delivery: Critique and Remedies, in the chapter ‘Integration of Medical Systems—A Theoretical Perspective and Practical Blue Print’.



three-dimensional method virtually, with the help of computer technology have increased the speed with which new drugs are added. New inputs from these aspects can easily be taught now. The quality standards of drugs and the product formulation technology have gone much higher and have advanced profoundly, which should find a reflection in the teaching methods. Pathology Learning pathology in non-rote manner can be improved. For organ pathology, the medical colleges should have sufficient museum facility. Histopathology, immuno-histochemistry with associated techniques, compulsory post-mortem room attendances and clinico-pathological correlation meetings should find a prominent place in teaching from the beginning. Unless death is taken seriously, no learning will ever occur for the students or their teachers either. The addition of the humongous details of molecular biology involved in the changes in cells, tissues and organs in pathological conditions and the way they affect the structure will fascinate the young ones today. When I deal with the graduates in the practice of medicine either in the wards or in the teaching rooms, I see a serious lack of understanding of these five subjects. Pharmacology fares a wee bit better. As a result of this, they are not in a position to understand medicine as a mathematical, but much more logical subject where cramming million items is no longer necessary. It affects their understanding of clinical problems deeply. Today the idea is to somehow pass third MBBS and then concentrate on the branch one wants to do postgraduate in by appearing for postgraduate entrances. This will never produce a good doctor and, by implication, never a good specialist. Preventive and Social Medicine The preventive and social medicine (PSM) meets the poor guy who has no interest in it, who cannot understand the logic of why it is there. Now pushed from the truncated first MBBS to the second MBBS with pathology and pharmacology, it either spreads through the rest of the course or has been shifted haphazardly (Bapat 2011). With the second MBBS curtailed to 12 months from 18, this subject will get compromised even further. It has never been taught to the students that the disease of an individual they will treat in their clinic is merely a representative of the



social malady behind it, affecting millions of people. The huge implication of it in terms of economy and poverty is neither taught nor understood. It does not create an understanding that as doctors we have to deal with that large population segment also in some way. The hinterland starting within 20 miles from his town or city where the understanding of preventive and social medicine is most needed does not in any way interest him. There is no question that knowledge of PSM becomes more and more necessary and relevant to practice to address more intelligently and sympathetically these issues, as extended parts of the practise. However, the vast landscape of the preventive and social medicine has nothing to do with the young graduate since he has already focused his sight on another postgraduate course. Epidemiology is another great sufferer. After ten years of active practice, even an MD finds himself confused about the two most basic terms, ‘prevalence’ and ‘incidence’. It is up to us to make the subject interesting and relevant to students. I wonder if these terms were correctly understood during the ongoing Covid 19 pandemic. Virtual Techniques in Procedural/Surgical Learning People who are fond of or are enamored of technology find it worthwhile to spend money on virtual learning like on mannequins who have set great hope in training doctors and nurses on mannequins for acute situations like cardiorespiratory arrests and other procedures to save lives. Medical Council of India (MCI) Vision 2015 emphasizes on tech learning, using simulators, computers and mobile phones and distance learning through computer technology (Shrivastav and Gwalani 2011). The great familiarity and ease of operating the modern gadgetry at the hands of the young generation is cited as the enabling factor. Hope is afloat that this will help students in research. Others have found it useful for private medical colleges where the number of patients is small. It is exasperating to keep referring to the pathetic situations obtained in the entire teaching scenario. These are matters of such grave importance that they need systemic efforts to correct them. While the best methods are ignored and dumped under the name of modernity and technology, such fanciful ideas will be best utilized only if the basics are set right. Fortunately, the article cited in this regard quotes a number of students who insist on the teacher and the patient being irreplaceable for learning.



The New Decisions of the MCI about the Preclinical Subjects The most disturbing decision that MCI has already taken and implemented is the reduction by six months for the study of anatomy, physiology and biochemistry, which are to be finished now in one year. It was implemented against the advice of expert committee. Assuming that the admissions take place as scheduled, it takes a couple of months for the students to settle down for the absorption of the knowledge to begin. Holidays and examinations, festivals and gatherings take away much time. Thus, it is around eight to nine months or less left for the study of these three fundamentally important subjects. In the six months that have been ‘saved’ by MCI, a whole lot of soft subjects are going to be introduced—medical ethics, behavioural science, communication skills, managerial skills, vernacular language skills and yoga not found in the traditional curriculum (Tilak 2015). MCI had put on the website a draft of new medical curriculum asking for suggestions. After a few months it was removed. Hence, no further comment about the exact changes can be made (Tilak, ibid.). Thus, at one go the MCI has done grave injustice to anatomy, physiology and biochemistry. I feel almost like an ancient fossil when I write this. The subjects of extreme and rising importance for quality practice of medicine at all levels are killed. The second MBBS is also reduced to 12 months instead of 18 months, another disaster (Tilak, ibid.). Good understanding of pharmacology for effective, logical and sensible usage of medicines, the logic of the way the drug works, a solid grounding in cellular and organ pathophysiology is a must. After the curtailed duration for the three subjects in first MBBS, the students will have no base in physiology and biochemistry. They will be hopelessly raw in their understanding of both pharmacology and pathology. They will then resort to rote learning, remembering ten million unconnected items. They will go through the graduate examinations with the help of these items stored in the brain. And once in the PG course they will have even less time to develop this base. What kind of an MBBS or an MD or an MS do we expect to come out and operate in the society, with the curtailment of basic sciences?



‘New Skills’ Added to the Medical Curriculum: Communication and Vernacular Skills One of the foremost skills introduced is communication. Undoubtedly, it is a skill of paramount importance. With all the unpleasantness between the doctors and the patients, and all the distrust between them, the greatest and the most frequent cause for the development of litigious mentality among the patients is the improper ways of communication on the part of the doctors. What does the MCI want to achieve by segregating communication and making it into a ‘virtual learning?’ What kind of methods will be used to teach the same? Lectures, problem-based sessions or role-plays to demonstrate what is right, wrong, acceptable or unacceptable! How many situations can they emulate? Who will develop all these situations? Who will create a dozen different but highly effective and proper styles of communication which the millions of physicians use in different cultures? Within India we have about a dozen major cultures which have distinctive practices and ways of communication. The tones and the gestures are different; taboos in one social culture are acceptable features in another. In reality the communication is embedded in when the student interacts with the patient. Considering all the variables mentioned above it would be best to learn to communicate. Similarly, use of different methods and different instruments of communication is not denied. Yet this is not important enough to curtail the time for the three important subjects in first year. It is totally unjustifiable, unacceptable, unnecessary and harmful. The time at which it is introduced is also totally inappropriate and too early because the students will not see a patient in this period, making communication irrelevant and baseless. Assuming that the ‘vernacular skills’ included by the MCI will be taught, I will show what the ground reality is. The Newcastle experiment detailed later in this chapter has given us a lot of insights. Having taught nearly 700 MD and MBBS students coming from 220 cities from every part of the country in an extended yearly course over five years, it is obvious to me that the difficulty of most doctors is with English. They are fluent in vernacular and reach a different mindset and unexpected high level of communication, are profuse with words to deal with patients, and convey much better. With a relatively poor base in English, not vernacular, what is this aspect going to add? Teach English?



After examining nearly 5000 recorded interactions, among these 700 doctors with 15 years of practice, we found these to be marred by jargon, with no benefit to the patients. The real need is to teach non-jargonistic, non-technical, non-judgemental, empathetic, non-condescending and non-paternalistic manner of communication that is able to demystify the disease situation and empower patients. Vernacular communication skills, however profuse they may be, will not achieve this kind of communication. It will have to be taught. Doctors do not talk to the patients. They talk at them. It leaves the patients with a sense of inferiority, that they are fools, ignoramuses and stupid. Attitudinal change and not vernacular skills are needed. The second cannot bring in the first. In short, they do not need vernacular skills. Even in the most hopeless situation, a patient needs some reasonable assurance without falsifying the truth. Hope is all they have and despair is all that they get. There are a hundred different situations for which the content and the manner of communication need to change. That cannot happen in classes for communication. That has to happen with the patients. Good doctors understand it instinctively. It can be done in different styles depending upon the specific culture in which it is used. The idea of communication is to help the patient to adhere to what needs to be done by him. It needs a lot many more imaginative inputs within the communication area for enabling him to comply. This is not achievable through separating or adding the subject as a standalone. It has to be an intimate part of the actual outpatient or ward situation. The communications today in the corporate set-ups operate on a completely different tenor and psyche. Attitude and vernacular skills do not form a sufficient base to understand that. This needs to change greatly. The Himalayan difficulty with it is that the entire culture and administrative methods and thinking will have to change. In the chapter ‘Corporate Hospitals’ in my volume published with this one, India’s Private Health Care Delivery: Critique and Remedies, I have analysed this minutely (Kelkar, 2021). MCI can have a look at that. Then there are skills of yoga and a few others. The less said the better about them. For attitudinal changes, special techniques will have to be learnt/taught while the actual patient learning is going on. These are called the problem-based learning techniques. There is no need to slash the six months of the first and the second MBBS for all this.



Medicine, Surgery and Gynaecology The level to which an MBBS rises in treating/managing an indoor patient in the three great subjects of medicine, surgery, gynaecology and obstetrics reveals what was possibly taught, not taught, what was forgotten and what was told to be unnecessary to the craft. The tale is unvarying because the learning is fragmented and unrelated as shown earlier. The years in MBBS and the year of internship certainly appear to be inadequate to develop a wholesome idea of what human life, human disease and human needs are and to learn a wholesome practice of medicine. Today the graduate doctors understand something about organs but not what the organs of the same system do with each other and the organs of the other systems affected or unaffected, as functionally linked systems.3 This is particularly apparent when they deal with symptomatic diseases. This fragmentation in the graduate years sows the seeds, which in the more erudite medical circles is described as Tubular Vision, which gets narrower at the level of specialization and superspecialization. The British Didactic Model The model of educating doctors prevalent in the world could be broadly characterized as the British didactic lecture–based one. It is practised as a knowledge-transfer method, assuming that the learner does not have any or much idea about the subject of the lecture. Thence follows a unidirectional teacher to learner monologue which tries to explain a topic and transfer the knowledge regarding the same. A slightly sinister part of this method is that the lecture programme is constructed by the faculty. Therefore, it becomes a teacher-centric model and not a learner-centred model. This by implication says that for a long time the faculty may not have taken into consideration or would have made little or no effort to find out what the learner needs are. This by 3  Isaac Newton made us understand that this universe is like a huge mechanical contraption which is bound by some immutable laws. We applied it to the human body as a conglomerate of automatically acting chemicals through their release or inhibition in the body in response to an external stimulus. This also led to the doctrine of emotional neutrality and even detachment towards the patient during treatment. Thus, diagnosis and treatment and nothing more became the prime goals for nearly a hundred years. It meant that the doctor had no responsibility towards the patient as a whole. This approach should be discarded since it is too limited in an intelligent and conscious human body.



implication also means that a lecture curriculum once done may not be getting revised within the college faculty in India at least for long years. Stagnated continuing curriculum will be a certainty if it involves getting a permission of the academic council of the university looking after the medical college curricula for the change. If such permissions have to be sought from the MCI, state or central, then it does not stand the slightest chance that the curricular changes will ever be reorganized. Lecture-Based Education: A Few Words There are several significant problems with lecture modes, foremost of which is that they are stand-alone and do not relate to what the students may be learning at that time especially in the clinical years. The situation is not much different in basic science years either. Knowledge transfer in the given time is considered as the main aim of the lecture, which it is not. (This is the first idea we need to refute.) It is passive learning with about 7% remembered. From lecture alone to a lecture based on slide presentation, the retention does not improve beyond 15 to 20% of all that is said. The lectures, it is believed, should be crammed with as many details as can be, jam-packed with slides which are run at the speed of light to complete the topic. Theoretically speaking, in the lecture mode there is scope for questions and answers and getting doubts clarified during or immediately after the lecture. Usually there will be no time available for that. But the practicality of questions and answers is also limited by the fact of the student being scared of doing so. This terrified reality has not vanished in government colleges. Not all the lecturers will welcome it, especially if the question interrupts their mugged-up lines. Time management is not a strong characteristic of Indians as shown earlier. In that case, is there any scope for lectures as a teaching method in the medical colleges or not? Is it possible to coordinate the lectures with what is happening in the clinical side? The answer to this lies in the methodology of the PBL, or the problem-based learning. The real purpose of a lecture is to build a perspective or logic so that the details could become more intelligible. A teaching programme at its least should be enjoyable; otherwise, learning will not take place. It should arouse interest and should grow with time. Else it will serve no purpose.



The Clinic-Based Approach, Grand Rounds and the Post-Mortem Rooms The next mode of teaching in the clinical years of the medical students is the ‘clinic based approach’. This is essentially teaching on a patient who is generally admitted in the wards and should traditionally have a physically demonstrable finding. It is natural and logical as well as correct that this is the place where the students flock to learn the way medicine is practised from enquiry to diagnosis and management. Whatever medicine I have learnt was in these clinics, the grand rounds a day after the emergency which used to last from morning till late evening, and in the post-mortem room. On passing MBBS, the same students avoid bedside learning abundantly shown later. On any one case chosen in any department, the clinic does not go through the full cycle of inquiry and examination improving the understanding as the case goes along, leading to a differential diagnosis, the plan of investigation and final diagnosis and the actual management of the case. Every time a case is taken up, it will end somewhere in the middle of history or examination and stop. Since the frequency of clinics becomes less and widely spaced, the patient with which it was begun in the earlier clinic could have got discharged or dead by the time the next date for clinics comes. Here the totality of the learning is lost. There are several reasons why this happens as shown below. The students may not be allocated enough time to be spent in the department, given the cases to prepare for presentation well in advance. Adequate number of faculty, senior enough with adequate time on hand to take clinics, may not be available. The time limitation of the faculty is due to either the clinical burden or official meetings. In main however, their unwillingness to spend time in the college and to concentrate on private practice, as shown in the previous chapter, is the root cause. The other reasons put forward by many a student I talk to includes the fact that the department is on emergency duty schedules which take away at least two days a week without holding any clinics. If the department has two emergency days in a week, the reduction in the clinics will be for four days. There is no efficient system to teach while running the OPD or check on admitted cases on these emergency days. It was not there during my time also. There are departments in many places which are on emergency duties on alternate days and hardly hold any clinics. But these are unacceptable excuses; hence, remedies should be found for these. Many of the remedies are already presented in the previous chapter. 



Faculty numbers of teaching staff should be determined by the number of students. Inadequacy on a regular basis is a common malady; or there are those who are available but do not teach (see above). We will see this happening in capitation fee medical colleges in my volume published with this one, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). The answer to these issues lies in the methodology of the PBL, or the problem-based learning. If we decide to teach in more intensive ways devoting much more time as will happen in problem-based learning (PBL), the number of facilitators to do the PBL sessions will go up sharply. They are generally accommodated on part-time basis, without making any department top heavy. The Real Hands-on Learning In fact the emergency should become the theatre for attending the patient load with the students assisting the seniors. In doing so, the learning will be simultaneous. The teachers teach in this hullabaloo. Even the small snippets in which the teaching occurs is lifetime learning at that stage. The next day when the tensions simmer down, there has to be an insistence on a post-emergency grand round compulsory for the interns as well as the students. Under no circumstances this tool of learning can in any way be neglected. In developing this model of teaching, there has to be an explicit, unflinching and willing agreement between the students, the college and the universities that all of them will work for long hours on emergency and post emergency day. This has to be followed by another grand round three days later when each and every meaningful case which has remained in the wards will have been completely worked out, therapy instituted and the success or the failure of the same watched, and fresh challenges that the case may throw up in diagnosis or elsewhere will be understood and solved through a reasonable process. This in fact will mean that the life of the entire medical college will revolve around the teaching. That is the purpose for which they have been instituted. The medical college hospitals relieve the human suffering as an aside or a concurrent part of the teaching process. I am aware that these ideas and the models I am advocating have existed for six decades but I am also aware that in most places it is not given the importance; hence, the time and are not practised. The simple reason is that in majority of the colleges the faculty is allowed private practice, and open coaching classes.



Any teaching or learning process has to be interesting or exciting. All learning happens only and only when the learners are enjoying the learning process. Hence, it has to be innovative also. Whatever comes in the way of proper education from whichever quarters must be ruthlessly destroyed! To achieve this we must have the culture of full time teaching faculty at base; others may be added as described in the previous chapter and in this chapter below. It should be supplemented with educational technology which will pay attention to create an additional mindset from acute short-time clinical care to care for chronic diseases across all levels of health care providers. The major components of this mindset are the patience and all the characteristics of communication described above with good knowledge base. This is one of the major challenges in health care today. A Word about the Postgraduate Education and Degree Dr Ravi Bapat ex-vice chancellor of Maharashtra University of Health Sciences writes that today no one wants to be a general practitioner. None of the parents want their ward to be just an MBBS. Their choices are not guided based upon which discipline their ward truly likes. By the third MBBS any student will start having firm understanding about the subject he or she really likes and would like to do her PG in. Stress arises if she does not get what she wants in a reasonably good institution. Then alternate decisions are taken without making a factual judgement of the financial ability of the family to support the student once he passes out and the ability of its ward to practise it well. Sometimes, the liking has to change to another subject under the parental pressure. The choice is often made even because of the influence a teacher has on students as role model (Bapat 2011). Dr Bapat writes further that today such decisions are also taken keeping in mind the financial returns. Many a times these decisions are taken without comprehensively thinking about the place that will be needed, one’s social and financial position to meet those conditions, opportunities in future, one’s own attitude and aptitude, suitability of it for a job or private practice, willingness and ability to take solid physical efforts, liking or otherwise for research or teaching and so on (Bapat, ibid.). It is common knowledge that if one or more factors have to go wrong in making the choice, unbearable mental agony and even early death (by suicides) have been witnessed frequently. In case of women, a PG course that has limited



involvement of time becomes a consideration, not the liking and inclinations (Bapat, ibid.). Indian Text Books for Indian Medical Education What should be the content of the curriculum is a vast problem. Books written by Indian doctors on different subjects is not exactly the same as books with Indian content. I doubt if any progress has been made in that direction which Indian doctors would benefit from not only in practising medicine but also in keeping them well versed with the theoretical grasp of the highly advanced and advancing medicine. To go into the curricular details will be out of place for me in this treatise. It is a subject one has to be involved with many others at multiple levels over a decade. The need for Indian [basic and advanced] textbooks for medical graduates arises out of the fact of rapidly changing health scenario. To be able to get a direction to the curricular content, we should look at the health scenario in India today as discussed below. However, the matters have developed in another direction, altogether ignoring this facet. With the expanding body of knowledge, there is over burdening of the student with the content information. In order to grapple with this problem, it is essential to define the core content which every student ‘must learn,’ things that are ‘useful to learn’ and ‘nice to learn’ but do not need the same emphasis (Bapat, ibid.). Some more disturbing realities about the state of content have been brought out by Dr Ravi Bapat, who has taught in one of the finest colleges of India, GS Medical College and KEM Hospital Mumbai, for nearly 40 years. In brief he says: Everything that has come as new knowledge has been forcibly pushed into the MBBS curriculum and textbook. In the University committees the Dean is a member who is also faculty of some specialty subject in medicine. Deans coming to the committees pushed their specialty subjects in the curriculum. That is why the MBBS curriculum has got hugely bloated by specialist subjects and technology. It has no longer remained capable to produce a good general physician or a primary care doctor. There is no need to inflate the curriculum this way. It is important to understand the process of reasoning behind this. It is pitiable but common knowledge that the MBBS is ­considered as an agent to send patients to the specialists. That is why these superspecialists are bent upon inserting their subject in MBBS. (Bapat, ibid.)



Today’s health scenario clearly shows that India is getting affected with far greater numbers of chronic, metabolic and/or non-infective acute or non-acute diseases which have already reached epidemic proportions. The Indian mindset of an average practitioner or a consultant or a sub-­specialist managing this newly emerged chronic load is still the way they manage the acute critical care load. This chronic load gets distributed across subspecialties like nephrology, ophthalmology or cardiology and other specialties. The distribution is not unique to any one subspecialty. Multiple specialties are involved in managing the same patients. These chronic diseases inexorably go into complications, becoming more and more difficult and expensive to manage as years pass. But even today, especially in the smaller places, the management of this huge burden still falls on the average health care provider, an MD or an MBBS or an Ayurvedic, Unani, Siddha or Homeopathy (AYUSH) doctor or even a quack. It is not an easy task to secondarily prevent such inexorable progress of these complications or the tertiary prevention of the complications from speeding up. It is clearly beyond these peripheral health care providers who operate in adverse conditions. Their individual and infrastructural capabilities are limited. The knowledge base is limited. There is no stimulus or environment to upgrade their competence. Among many other measures we can take for these practitioners, one important tool we can place in their hands are modest-sized Indian textbooks for dealing with health issues of epidemic proportions. This discussion will get more clarity in the next chapters on manpower deployment and the reorganization of the public health care delivery in this volume. The Examination System: On Evaluation of the Students The multiple-choice questions (MCQs) in the examinations must be removed most substantially. There may be limitations in other much older systems of examination but they are any day better than MCQs. The essays and short-answer questions test the ability to coherently write out the thoughts a student is capable of holding and expressing them in an articulate manner. It needs establishment of logic to join the dots of information. These instruments test his clinical reasoning cascade and clarity of understanding. Short and long essays also test the articulated memory power of the students. These are the additional benefits. Progressively unfolding scenario questions directly test the critical, clinical reasoning.



I would ardently support that the students are allowed to use any form of knowledge source, be it textbook or notes or online devices during the examination. If he has used these resources well to articulate the logic, carrying such sources to the examination hall will help him to do better as he will know where to look for information needed. In fact he will have to resort to them only occasionally in those few hours. If he has not articulated his stuff, no amount of resources in the hall will be of any help to him. The other issue is of continuous evaluation by the teacher against the end of the term examination. The fragmentation is further enhanced by the numerous short and small examinations conducted by the colleges as a part of curricular guideline. That takes away a lot of time of the students to think about various subjects and understand them in a wholesome manner, and do some other essential activities like games, exercises and cultural activities to develop a more rounded personality (Bapat, ibid.). As an educational technologist I am not in favour of frequent examinations. Six monthly two examinations, the results of which has no bearing on the final, would be the least and the best dose. The third six-month examination however should include all the portion of 1 ½ years. Semester system fragments the wholesome revision of all that he has learnt in that 18  months. It allows students to learn what has been taught every six months but forces them to reread the whole subject. I do not believe in or approve the semester system where what is learnt in the semester will not be asked again ever. The allocation of 12 months we have seen above is a disaster to such a system. Few examples of additional tools are given here. One could test these abilities by asking him to write a discharge letter to judge his communication abilities, or see the ability in terms of total understanding of a case. He could be judged on his abilities to listen, his compassion and his understanding of the human being in front of him while assessing his clinical method skills, diagnostic reasoning and/or the ability to argue out his diagnosis. He could be judged on his interpersonal relations and ability to go along with his peers (Hegde 2009). The examiners are in themselves an issue that needs to be solved for fairness and no other people than the examiners alone can sort that out. It is to them to keep the other helpful factors like caste considerations, partiality by teachers, favouritism and college spirit, or political pressures out, which influence the results, and to ensure that the students who pass are adequately equipped. The capitation fee colleges that grew in numbers since 1980 have introduced serious derailment in the process of examination, more so after the



status of deemed universities offered to many. The full discussion on it will be found in my volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one (Kelkar, 2021). It will not be repeated here. The State of Education of Established Practitioners, the Teaching Methods, Related Ideas and the Continuing Medical Education These CME courses are required for continued licensing to practise in most countries which vary by state and by country in its quanta. In the US, accreditation is overseen by the Accreditation Council for Continuing Medical Education (ACCME). Physicians often attend dedicated lectures, conferences, grand rounds and performance improvement activities, in order to fulfil their requirements. The last two—the grand rounds and performance improvement activities—are absent from the Indian setting. Continuing Medical Education before 2008 in India was not necessary to remain registered and to practise as a legally qualified doctor for those who passed from any recognized university and whose name had been entered into the medical register of any state or the central medical council. Thus, people who graduated decades ago never ever underwent any further updating of their old knowledge in any formal, recognizable and measurable way in India. In the last 25 odd years, upgradation has been in the hands of the pharmaceutical companies’ salespersons, in the therapeutic segment only. It is doubtful if the treatment methods of these doctors have improved substantially. Dr C. P. Thakur was the health minister in the National Democratic Alliance (NDA) government around the turn of the last century. He was the first to firmly insist upon legalizing and institutionalizing the process of continuing medical education which was later incorporated in the medical system in India. The first and the later times of renewal of license to practise medicine have since been specified. It has become a stringent requirement now to produce adequate certification of 20 hours of CMEs, conferences credited with certain hours in one year before renewal of license. Undoubtedly, this is a highly desirable and welcome step. Attending CMEs by no means indicates that their understanding of medicine and clinical acumen will/has also substantially increased. But undergoing the exercise properly is necessary. This system must remain. Sooner or later it grows better knowledge and desire for it in all. It can be



made more meaningful by a deeper examination of what is being done and what could be done better. The moment CMEs became threateningly compulsory, the acts to complete the formalities accelerated and the attendances ‘in halls’ become larger, even in a remote state like Tripura. It is a big gain. There are reasons why the exercise may still not achieve the best understanding which are discussed below.

Examining the CME Content and Methodology The process of CMEs started with gusto many years prior to its becoming mandatory. Novo Nordisk, the Danish giant, took the lead in 1992  in India. It organized at least one CME somewhere or other in India per day year after year. Their educational programmes were directed towards the knowledge needs of various stakeholders in the diabetes chain, without any undue emphasis on their insulin products. Novo Nordisk also organized major updates and conferences of world standards which are greatly appreciated. In fact, I had a substantial hand in developing their ideas after 2000 AD, which have continued to dominate at least the diabetes segment even to date. After 2003, as the pharmaceutical industry support increased, the tilt to product promotion and displays slowly became a norm.4 First, it is the way the CMEs are organized. The process recognizes accrediting different bodies and organizations holding CMEs and conferences. Either the state university or the MCI allocate the credit hours. The initial focus on academics did give the attending doctors a good deal more insight in the way they should be practising. This picture continued to become better over years. After many years, the academic focus changed and some commerce entered. Pharmaceutical companies sensed the opportunity to oblige doctors, now keen on going to CMEs and conferences. Willy-nilly the commercial content stealthily seeped in CME/conference benefitting the sale of industry products, particularly after newer molecules appeared rapidly. The clinic-based learning of medical colleges started occurring in the five-star hotels in the grand and gala conferences in the lecture-based formats.

4  The CMEs and the conferences have now, over a decade, clearly deteriorated to lavish entertainment, foreign trips, gifts and so on, which has been dealt with in the two chapters on Pharmaceutical Industry in the volume on India’s  Private Health Care Delivery mentioned in the text here.  



In the current system in India, what to teach in these CMEs is largely unimportant and is overlooked. Different organizations and/or the pharmaceutical companies carry out their CMEs independent of each other. They decide on the priorities of what their contents will be equally independently. Thus, the contents of all such CMEs taken together are always disparate, discontinuous, overlapping or repetitive. Even if the same group attends different CMEs or different groups attend the same CMEs, the learning will be patchy. The speakers are chosen from among those who write the company products maximally. They will sometimes use their own independent thought leading to their way of management of different problems. This is less likely to happen since preparing for it is really a heavy time-consuming exercise. The industry sponsoring them will give the industry content to them. The exposure to the contents and messages delivered will vary due to teacher variations, and may take different positions about the same themes. This at its worst may be confusing and the participating practitioners may draw erroneous conclusions. At its best, it will stimulate their thinking, though it will not be wholesome. In addition to the above, within a year, and year after year, the professionals attending these CMEs also will vary greatly. This would lead to the impossibility of tailoring the content for the needs of the attending doctors. It has become speaker-centred and not learner-centred industry. The nature of the CMEs is still didactic, and has all the inherent defects of it as discussed above. The only constant feature is the dosing, drowsy majority in the dark halls with slides flashing by. NRHM and the Continuing Medical Education National Rural health Mission (NRHM) has added to the perspective of continuing medical education. Page 44 of the NRHM 2012 document says: The NRHM recognizes the need for universal continuing medical education programs which are flexible and non threatening to the medical community, but which ensures that they keep abreast of medical advances, and have access to unbiased medical knowledge, and adequate opportunity to refresh and continuously upgrade existing knowledge and skills. NRHM wishes to reorient medical education to support rural health issues. (NRHM 2012)



The least it could have done, even in a policy document, was to briefly identify the agencies which will do this task. Taking upon itself the reorientation of medical education is a tall camel NRHM should not kiss. Those having something to do with education like MCI or the universities have not done much for it in the last 70 years. NRHM is neither aware of what is going on nor does it want to recognize any other agencies to do anything. This attitude will be pointed out repeatedly in pages to follow with more explanations. NRHM will not be able to rectify the defects the system. Medicine has become and is being made more complex, a situation terrifying to the patients. In addition to it, the Net-savvy people ask straight, more pointed, awkward questions and even argue about every step the doctor asks to be undertaken. The doctors have to be taught in CMEs to deal with this fast-emerging reality of practice smartly, with equanimity, respecting the level of information the patient is throwing at them and still be able to explain more than the patient knows. On top of that, the doctor has to bring home to the patient that after all the intellectual exchange has taken place, the element of how the bidirectional faith-based relation is necessary for the welfare of both. If the doctor is unable or unprepared to do this or is unwilling, such an interaction could turn in an adversarial fight, result in loss of faith, pervasive paranoia and animosity directed towards the doctors. Matters worsen to this level less frequently but equally true is the fact since a large number silently swallow whatever the doctor says.

The New Thinking about the Foundations of What to Teach It has been argued and practised for a long time that medicine should primarily be taught as a science in the biological context, in a classic reductionist manner. The new understanding of how we look at medicine is based on other principles, not the mechanistic characteristics, a diseaseand diagnosis-oriented one. The limited model hitherto missed out on a vast scenario of human suffering and had less or little human face. As the medicine advanced, various thoughts that developed started to push in a diametrically opposite view point. It is summed up by Gustavo A Quintero, from Columbia in 2014.



In the learning processes of physicians, the priority concept that should change is the way we look at the health-illness process. Do we see it simply and only as a biological process or we see it as a primarily social, cultural and psychological one into which the biological facts reside or arise from (Quintero 2014)? This way of thinking would lead to a change in the perspective of what more is required to be taught. It cannot necessarily be changed in the way a doctor treats an individual patient since it is a biological business, irrespective of any other concepts. Is there anything lacking so far, that needs to be added to the science of medicine? What is it and which mechanisms can we use to fill this aspect in? Quintero draws a fine picture of how medicine is practised and questions the process. Should it, or can it, continue with doctor being treated as a demigod, who arrived in this world to treat these sufferings, basically ignorant and undisciplined humans with not much seriousness about their disease, careless about medicines and instructions, and essentially non-­ compliant? Hence, they must be ‘told’ in a way which will make them comply with the instructions (Quintero 2014). However, to Quintero avoiding this predicament for the doctor is altogether different. He thinks that doctors should be taught to take into account a lot of sociological, emotional, behavioural and economic consideration when he practises his trade. Balancing the science goals and the human goals is the challenge (Quintero 2014). The present system discussed in great details above is not the answer to these obviously valid considerations. Fortunately, there are systems of training available, well tried and experienced which can assimilate these newer issues while retaining the focus on the biology of the science of medicine easily. The Columbian experiment will be discussed further under problem-based learning. Ideas of Education: New and the Old Thinking How much have our ideas about the kind of doctor we want to create through our institutions within the curricular structure changed? Hardly any! So far we have been looking at the difficulties of getting the science part right in the training. In that single area we have found so many difficulties and barriers to learning unchanged over decades. Now we have to accommodate the demands of the proponents that the social, the psychological and the cultural aspects of human disease and illness process should



be the primary or at its least a strong focus in education. This might be a proper place to discuss the brand new National Policy for Education as it pertains to the health or medical education.

National Education Policy 2020, Ministry of Human Resource Development, Government of India The publication of this volume got delayed as we decided to bring it up to date vis-à-vis Covid 19 and how the measures suggested herein hold in such a situation. In the last week of July 2020, the National Policy of Education was released, giving me an opportunity to analyse it and see the concordance or divergence with my ideas or its strengths and weaknesses, which are presented below as briefly as can be due to space constraints. Preamble The purpose of the educational system declared in the policy 2020  for short is to develop good human beings—capable of rational thought and action, possessing compassion and empathy, courage and resilience, scientific temper and creative imagination, with sound ethical moorings and values. It aims at producing engaged, productive and contributing citizens for building an equitable, inclusive and plural society as envisaged by our Constitution. There can be no objections to these aims, but will the policy achieve it? The policy discussed here pertains to what it gives for betterment of medical education and will achieve. It is doubtful if it will help. One Major Shift in the Thinking It talks about how to learn, use less content and more of critical thinking to solve problems. It envisages making education more experiential, integrated, inquiry-driven, learner-centred, hands-on, discussion-based and enjoyable with some emphasis on mathematics, art, culture and humanities as well. Finally, the education is for gainful, fulfilling employment, to develop ethically oriented, rational, compassionate and caring individuals. These ‘soft skills’ introduced by MCI have already been severly criticized above. 



On the Major Problems Plaguing the Higher Education System in India 1. The policy says that higher education distributed in more than 50,000 higher education institutions (HEIs), most having fewer than 100 students and  is severely fragmented. This as has been shown elsewhere also should be dismantled. HEIs are governed in a suboptimal way by a leadership lacking certain quality. The policy has more to say about this. 2. There is a lack of emphasis on learning outcomes and the development of cognitive skills, rigid separation of disciplines and excessive early specialization in narrow areas of study. The policy does not indicate a tool to correct this, but problem-based learning discussed below is one of the answer. This issue is discussed with measures to be taken in numerous ways here. 3. There is lack of quality in research and lack of research itself at most HEIs. Enough has been said about the ways research has to be done in my two volumes but is not reflected in the same way in the policy. These are the very defects pointed out in this volume. The policy has in fact made it into a complicated method which will not fetch results. (See below.) Other Structural Measures, Ideas, Obstacles and Corrections It is good to see that these aspects emphasized below have been identified by the National Education Policy, 2020, GoI also, as I have done much earlier. 1. A regulatory system not empowered to close down fake colleges is a grave matter identified here. 2. A lack of access to higher education, in socio-economically disadvantaged areas, due to there being few universities and colleges. This ‘Utopia’ says that by 2030 at least one large multidisciplinary HEI in or near every district will be developed for better access for disadvantaged groups. Such declarations make good copy but such availability is likely to be the existing situation. I also think that it is the uneven spread and poor quality which is the greater factor which if it could be corrected, will solve this issue. That is a



bit in excess of the needs given many other avenues and hierarchies of skills of learning in health care and a large number of disciplines as has happened in medical education. 3. The next is even more utopic—such colleges could evolve into research-­intensive or teaching-intensive universities if they so aspire. When the basics are so brittle, how can anything built will last at all? Note the contradictions with deemed universities above.  4. HEIs teaching in vernacular languages is also not available. I have discussed this issue at length in this volume and in my other volume, India’s Private health Care Delivery: Critique and Remedies, published in January 2021, and has its downsides also. University-Affiliated Colleges, Its Nexus, Future and the Restructuring The policy  making committee thinks that the causes of poor quality of education in large numbers of colleges affiliating with large universities are multifarious. The policy seeks a new approach where the final goal is to improve all HEIs qualitatively to such degree that each should be an autonomous unit giving its own degrees. The remedy the policy thinks is of a new regulatory system to foster culture of empowerment. It will also lead from graded to full autonomy, facilitating innovation, gradually phasing out the ‘affiliated colleges’ over 15 years. The universities will be responsible for this change and develop their capabilities, achieving adequate qualifications in academic and curricular matters, teaching and assessment, governance reforms, financial robustness, and administrative efficiency. This is an ambitious goal destined for a miserable failure. Given the pitiable state of universities in all action spheres for long years now, even a period of 15 years appears long as well as short. Long because I do not see any university or an affiliated college rising to this challenge even elementarily. Short because the time for ‘quality criteria to be achieved’ to become autonomous can and will get shortened by manipulations, tacit approvals and other means. This is what is going on for four decades and will continue. The ‘new’ idea of mentoring by the government will not happen and the corruptions will create more and more unworthy colleges to become autonomous degree-granting entities. It goes against the discussion of autonomy of HEIs, the medical colleges. 



The reader is referred to two chapters in my volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). One is on capitation fee medical colleges and the second on regulations and the regulators in health care. It is impossible to understand how such a policy could ever be thought of given the appalling conditions of both the universities and the colleges made worse by the high courts of this country described therein. The National Medical Commission Model Discarded One primary defect in this policy is that it has generalized every entity or aspects of different streams of education into a common system for all. One type is not a fit for all. The National Medical Commission has given a model for restructuring the medical education described in detail in the chapter ‘Regulations and the Regulators in Health Care’ (vide above). I have gone to the extent of saying that such a model is applicable to any system of higher learning by appropriate contraction or expansion. The issue of affiliated colleges as autonomous degree-conferring ones is scrapped there. That model has a far greater possibility that it will achieve quality and this Policy move should be opposed strongly. What happens is that a new committee is given such a task. What happens almost without exception is that no one looks at what one has, to start with, forgetting to assess or deliberately ignore or determine not to accept the merits, and is unwilling to adopt it. Every such commission wishes to show that they have discovered something extraordinarily ingenious and force it down the system’s gullet. The objection is to the extent of quality  manpower needs chronically ignored in health care planning which is also discussed at many places in these two volumes I have written. My General Observations on the Policy The entire policy document is drafted so that it should look to be aligning itself well with the sustainable developmental goals, which probably means state’s obligation or international pressures. The second is the classic trite of multidisciplinary, holistic, for the fourth industrial revolution, breaking the rigid barriers of different knowledge streams, well-rounded development, ethical values and greater choices and so on. (Please see the discussion on holism in the chapter ‘Western Models in Health Care, Disease and Health Care Delivery’ in India’s Private Health Care



Delivery—Critique and Remedies, Kelkar, 2021.) By itself it is not bad, but it will lead to a holy mess when implemented because those responsible for it on ground are far from understanding it. The third is the frequent invocation of the great Indian traditions of learning centres which unfortunately are dead for 2000 years. The last observation is on setting up multiple bodies, new bodies in a policy is acceptable but there is no mention of the dissolution of any earlier bodies engaged with education. A dozen examples can be given but are skipped due to space constraints. Issue of Deemed Universities, Individual Colleges as Deemed Universities The policy wishes to do away with present complex nomenclature of HEIs in the country; nomenclature such as ‘deemed to be university’, ‘affiliating university’, ‘affiliating technical university’ and ‘unitary university’ shall be replaced simply by ‘university’. In the chapter on capitation fee medical colleges (vide above), I have discussed the hazards caused by the deemed universities, and recommended scrapping the same; and as far as university affiliations of medical colleges go, I have recommended to scrap that as well. That is because the National Medical Commission has taken in its own hand both the responsibilities of curricular standards and the assessment for getting undergraduate and postgradute/license for practising. No note has been taken of this. This is how the policies are made in his country! Higher Education Teachers and the National Policy for Education In sum the issues listed are as follows: ( a) A lack of teacher and institutional autonomy to innovate and excel (b) Moving towards faculty and institutional autonomy (c) Reaffirming the integrity of faculty and institutional leadership positions through merit-based appointments, systematization of recruitment, and career progression based on teaching, research and service. (d) Ensure equitable representation from various groups in the hiring of faculty



(e) Inadequate mechanisms for merit-based career management and progression of faculty (f) Providing faculty with professional development opportunities None of it has worked due to low faculty motivation levels in terms of teaching, research and service in HEIs. In the preceding chapter I have shown a much larger spectrum of issues related to teachers and teaching with some solutions. The remedy mentioned by the Policy is to make each faculty member happy, enthusiastic, engaged and motivated towards advancing her/his students, institution and profession. However the policymakers have not suggested how to do it.  The general law of human behaviour and capacities is— motivated persons are often mediocre and far fewer in numbers. Those who are extremely intelligent often do not have motivational or  inspirational drive  and do not exert to achieve change. The answer lies in creating a system in which each one has got to perform or get ejected. Good intonations will not help. I will once again refer the reader to Chap. 3, ‘of Doctors and Government Medical Colleges’, in this volume, which discusses the teachers in medical colleges over scores of points to achieve these ends. Curricular Content and the National Education Policy Curricular Content Policy envisages reducing or debulking curriculum content to its core essentials to enhance essential, inquiry-based, discovery-based, discussion-­ based and analysis-based learning and develop critical thinking. The learning process fundamentally is that of perspective building  mentioned earlier, and more details are added subsequently, It is good to see these ideas recognized. Professional Education 1. Provide education in ethics, importance of public purpose, discipline and education for practice. 2. Involve critical and interdisciplinary thinking, discussion, debate, research and innovation.



3. The policy envisions stand-alone agricultural, legal, health science and technical universities, and stand-alone institutions in other fields. As pointed out earlier here the health Universities are clearly anachronistic now. 4. There are 10,000 stand-alone institutions which do not attempt teacher education but are essentially selling degrees for a price. Regulatory efforts have failed to curb the rampant systemic corruption. It has also not been able to enforce basic standards for quality. In fact it has had negative effect on curbing the growth of excellence and innovation. It needs urgent revitalization through radical action. I can only add that the entire system from government down does not have the courage and political will to achieve/restore integrity, credibility, efficacy and high quality of the teacher education system. See the teacher’s related issues in the preceding chapter. Health Care Education Health care education still is an idea in evolution. The ideas mentioned are followed by my remarks in the following points: (a) It shall be re-envisioned for duration, structure and design suitable for the roles that graduates will play. This is a pitiable statement in 2020. The examples given in the policy indicate poor imagination and understanding of this issue. (b) Regular assessment of students for their primary care skills and working in secondary hospitals. An idea of continuous assessment is also thrown in. As little as possible would be what I shall choose for assessments and lay more emphasis on curricular reorientation for the same  is  discarding  MCI recommendations and instituting Problem Based Learning. (c) The quality of nursing education will be improved; a national accreditation body for nursing and other sub-streams will be created. An extensive discussion on it will be found in Chaps. 7, 8, 9, and 10 which is far more practical with an in-built quality instead of adding another body to the melee. (d) All students of allopathic must have a basic understanding of AYUSH systems and vice versa. Here the issue is of balancing proper learning of core allopathy subjects, which is already messed



up by peripherals having been added by Medical Council of India with criminal shortening of the core subjects. To add basic learning of the AYUSH also adds to detriment of understanding these core subjects also. Intellectually, it is confusing to the young minds. How to arrange for it is discussed in great detail elsewhere also at several places in many chapters. See particularly the drug situation as described in Chap. 7 in this volume. (e) There shall also be a much greater emphasis on preventive health care and community medicine in all of health care education. To realize this will need a structure which has been extensively elaborated upon in this volume. (f) The existing system of Board and entrance examinations shall be reformed to eliminate the need for undertaking coaching classes. We wish the policymakers success but I am not able to see these two affecting the coaching business. More is said about this in the preceding chapters. (g) Board exams to be redesigned—one part of these is an objective multiple-­choice questions and the other of a descriptive type. This aspect has been dealt with under the examination system at a few more places in this volume.  Online Distant Education This is an idea in evolution. It provides a natural path to increase access to high-quality higher education, improving ODL, Online Distance Learning contents and adherence to articulated quality standards, through concerted, evidence-based efforts is how the policy sees it. ODL programmes have to be equivalent to the highest quality in-class programmes. Norms, standards, and guidelines, regulation, and accreditation of ODL will be prepared for systemic development and a framework for quality of ODL that will be recommendatory for all HEIs will be developed. I have described the state of Online Distant Education in other places  which please see.



Structural Reforms Within the Higher Education Policies Adding more bodies is a disastrous penchant of the government, as is seen here. It does not mention that the earlier ones doing the same functions should now be dissolved or not. Nor does it mention if such bodies are absent or do not have transperancy and whether should be liquidated. Creating numerous other bodies is the sine qua non of this exercise. At least a dozen new bodies are added. The accreditation system of National Accreditation Council for no logical reason is tied to NHERC.  I have discussed the need for independence of NAAC in different places. There is a new body for each issue, for example the teacher education, beleaguered with mediocrity and rampant corruption. Identifying the Ills of Regulatory System of Higher Education 1. Regulation of higher education has been too heavy-handed for decades. 2. Too much has been attempted to be regulated with too little effect. 3. Mechanistic and disempowering manner of working. 4. Heavy concentrations of power and conflict of interests within a few bodies, lack of accountability. 5. Difficulties to set up HEIs in India—the largely input-centric, land and space norms, endowment funds and their sources with centralized, outdated and rigid requirements of faculty qualifications and curriculum implementation. 6. Instead of an effective regulatory system, an inspector raj got established, which does not promote innovation or pursuit of excellence. What else have I been saying about Medical Council of India? Here again the National Medical Commission provides a way out to many of these ills but the policy has not even mentioned it in any manner. Overall these two volumes have given numerous suggestions to improve at least the heath sector.  Aptitude and Attitude Testing In principle it is accepted by the policy. Test scores would assess the science and aptitude testing could indicate a more conducive mindset to absorb and accommodate these ‘Newer Ideas’. Making such pre-­admission



assessments and give a strong or even an overpowering jurisdiction over the traditional merit obtained to get in medicine is not an easy matter. In India the merit is obtained through MCQs, a mindless process of the examination. The softer considerations like Attitude are eons away. There are other factors rejecting the attitudinal issues leading to rejection of admission like powerful and wealthy parental pressures. To work out every detail of this process—instruments devised, juxtaposing soft skills with science, percentage weight to both aspects and many more, will take long years to come to any conclusions and make it foolproof. The greatest fear is that this process could be used as a handle to weed out those students who are an obstacle to the wards of powerful people. Experience of Aptitude/Attitude Testing World Over At the entrance level of the medical school in Australia, the question of aptitude was answered substantially by emphasizing understanding the temperament, other characteristics of empathy, ethics, communicating skills and dignity of behaviour towards other human beings (Henry et al. 1997). This was not a part of the undergraduate admission process, which has now been brought in, in several Australian universities and elsewhere (Henry et al. 1997). India has to think about this. In most countries with low population, hence aspiring numbers for medicine being far too smaller than India, like in Australia, the difficulties such a system faces are minuscule. In many European countries, there is good governance, and with common culture of discipline and traditions to guard their institutions, the possibility for corruption and nepotism is little. This is not the case in India. The second aspect is about inculcating these values after getting admission into a medical school. A life and work of sacrifice or an ideology or strong social concerns are given to few getting admitted. In others also it may be present but are less intense, and doctors may not act in the manner desired, spontaneously. That does not mean they are not socially oriented or are greedy or fundamentally corrupt. They could still be just normal beings. In such a situation the only way out is to get the required work done without unnecessarily invoking high moral grounds, without causing unbearable personal pressure and anguish over it. This is achievable if the system is well laid out and is completely fair to all and deals equally



with all. To achieve this, the job of the management is to create a win-win system as described further under Chaps. 7, 8, 9, and 10. Process of Medical Admissions in India Process of medical admissions in India seems to have got fairly divided in the academic credits obtained in National Entrance cum Eligibility (NEET) and the counselling process for MBBS and will become applicable in future for AYUSH doctors as the National Medical Commission has become the law. After extensive search, the details of the counselling process that could be found world over were few. CMC Vellore seems to provide a good model of how it should be implemented. It carries out a special academic test and an interview. Apart from merit, the institution looks for communication skills and ability to be and work as a team member in  the candidate who will uphold their motto to serve the under-­ privileged and spirit to serve the needy and poor in remote parts of the country. It is a moot question whether counselling in India manages the process effectively to this end. New Considerations about What Should the Medical Education Do One consideration is about which strategies to employ, to promote the global health. A number of medical schools like the Colombian University have taken up the challenge of modifying their curricula in order to educate physicians capable of responding to the current and future trends arising from population health maintenance and the consequent changes in practice in that context. The next change is about the methodology of teaching. The British didactic model needs an alternative to replace it. These changes aim to ensure integration of basic biomedical sciences with clinical sciences by horizontalization of the unconnected verticals of preclinical and the clinical subjects as early as can be after the entry in the medical school and to reduce unnecessary knowledge overload through a new study plan for medicine. What is of interest to note is that in the various corners of the world, especially in advanced countries, a single alternate model to the British didactic one has been accepted! There appears to be little doubt that this system should be studied and its merits and demerits found; the



experience abroad and in India should be noted and then assessed to see if it is feasible to employ this in India as ‘the’ system to educate undergraduates or postgraduates or both. The alternate system is called problembased learning, discussed hereafter.

Problem-based learning, or the (PBL) This is the technology some of the nations of the world have converged on but India has not. This is the answer to the prevailing one for 100 years or more now and the difficulties we have about how to teach medicine. In normal course, the integration is supposed to occur as the successive years go by. The students renew and integrate the knowledge layer by layer from all previous strata. But we have seen in the previous pages that it does not happen. Then obviously sequential learning is not the answer. The challenge is to integrate the knowledge of these verticals with the clinical medicine that we finally go to and are interested in, as early as possible. It should convert the contextless learning in interesting and enjoyable learning. PBL is the answer. In the dialogues on medical education, sometimes the word horizontalization occurs. The meaning is generally not clear here also, and how it can be brought about is even more unclear. Accepting for the sake of discussion that this is the central dilemma of medical education, PBL has successfully answered all these questions by giving a simultaneous learning model of the clinical sciences as well as the basic sciences. PBL Is Not a Part of Existing System Do we think that PBL should be a part of the conventional or sequential learning in medical colleges? No. Or should it be constructed for the entire undergraduate curriculum with PBL as the only method? Yes. Should it be constructed for only postgraduates? No. But it was found to be particularly more effective in postgraduate learning (see below.) Is it possible to construct the PBL methodology for all postgraduate courses? Again the answer is yes. If so, should it be domain specific, or should it encompass all the learning the postgraduate must have before he or she starts working as a consultant? It need not be so. Anyone coming through the PBL method from the undergraduate to postgraduate level will have absorbed enough of basic learning before going to specialized subjects. What is the place of hands-on learning in PBL during the postgraduate years? This is implicitly present in PBL system, (see below). The answer to



all these questions is a resounding yes if we are ready to take PBL methodology in toto to teach the undergraduate and the postgraduate students as well. The construction of such a course/or courses is a methodological issue if people are convinced and are committed to implement it. There is a conscious but tentative drive to do work with PBL in a few private colleges and possibly in just few colleges run by the government in India. It is heartening. Bringing in PBL needs tremendous amount of work for developing these courses whatever may be the scope, as mentioned above. Second, the teaching faculty in medical colleges playing with this model should not get an idea that they have started or mastered the PBL. Most of what is going on and the teachers implementing it are actually at the primitive stage of PBL experimentation, a fact I have verified about the depth to which the PBL methodology has gone in a few medical colleges. At present it is rudimentary and amateurish. That is neither a complaint nor is it intended to be an insult or derogation. It is a matter of joy that it has started. Matters can always improve. Innate Qualities of PBL The awareness of PBL needs nurturing. The progress of PBL will depend upon deliberate effort by the colleges to improve it by seeking those out who can help them to make a complete undergraduate course, fully replacing the didactics and the linear sequential construction of the course as done hitherto. It is a job of a decade. Lastly, we must understand that it is alien to the nature of the teachers and the taught since they have developed for generations on end in a different system which keeps them at different hierarchical levels. In the processes of PBL these two groups get intimately mixed and  substantial changes in the  mindset come about. (See below.) PBL has one great advantage that it can take myriad forms. British didactic is a relatively rigid system. The conceptual backbone of PBL can be used to teach almost anything in any subject, not just medicine. This concept was attempted originally in Maastricht University in the branch of clinical psychology (McPherson 2002). In its first major travel, it went to the University of Newcastle about which we will see below. The scope of the subject can be made large, in which case it will serve the beginners for comprehensive basic understanding of medicine. If the scope is narrowed especially at the postgraduate-level courses, then PBL can take itself to its



great depths and fineries. At that level, people already experienced with the basics of medicine as well as PBL and have done work over years in a particular discipline can grapple with the depth of the subjects easier and better. No tools of conventional teaching methods are an anathema to PBL. What is deficient in the conventional tools is made up in significant measure and made meaningful in PBL by simply giving these tools a context of sequence to operate on. The isolated sequences in which the conventional tools are arranged suddenly become one of the most significant facilitators of learning by the context given to them. It is the construction of the sequence in which the process of knowledge acquisition happens. That is the key to PBL. It is this sequentialization which leads to a continuous relevance of every detail connected with any problem being studied. The teaching institutes in India lack this advantage. Another specialty of PBL is that it does not play with abstract, virtual or symbolic. Everything it does is to concretize the concept behind the words and is greatly hands-on. One small example is the sessions often held as ‘workshops’ in large and small conferences or in CMEs. The way they are conducted does not come anywhere near the quality of a PBL session or a PBL workshop. The PBL process can and does continue in every branch of undergraduate medicine where there are students with facilitators who can conduct the PBL methods. In other words, different students are learning different branches. Thus, the learning continues linearly for each batch in it for some time. When the batch changes the branch, it goes laterally in some other branch with a limited period of linearity. These lateral transitions keep operating till eventually all the branches get covered. The facilitator is an anchor to hold the group together so that it does not deviate from the learning issues presented to the group of students in every session and every branch as they advance in it. (See below.) Thus, the linearity of PBL is limited and always in context of that branch also focusing on basic sciences. The learning from elementary to higher knowledge of different branches continues smoothly. PBL is so adaptable that even in smaller branches of surgery where limited time is spent by the students and interns or the specialty medicine subjects where a longer time is spent, it can be compressed or stretched in well-thought-of designed problems or actual cases. These are the sessions on problem-based learning with many techniques applied to it. That brings into focus the useful fact that each and every facilitator need not be a domain expert but should have internalized the PBL session



methodology. This is an important aspect as it reduces the specialist attachment burden in PBL sessions to the college. The PBL sessions will find the gaps in the reasoning or in the knowledge. But these are not filled up by the facilitator by giving away the answer or the explanations for the gaps. The students have to go and find the answers. The facilitator should know that tact. The lectures, plenaries, highlights, hands-on workshops, debates, group deliberations over common ethical issues, non-clinical considerations like epidemiology as the courses are underway, many times throw up the answers the students are trying to find. Or the students receive directions as to where to find them, which texts and journals to refer to get the knowledge and how or where the reasoning gaps will be filled. That core knowledge is required only in these sessions. The PBL sessions are a process by which sooner than later the students find answers by their own efforts. Thus, in the given structure and faculty position of any medical college, there will be many people who could carry out different roles, including that of domain experts.

The Columbian Experiment in PBL The World Federation for Medical education has come out in support of an alternative to the present system of education anywhere in the world, a methodology which has now become well known as the problem-based learning (Quintero 2014). The Quintero paper has appeared in 2014 after the Columbians developed a problem-based learning system. The Colombians emphasize and look at it as a tool ‘about developing leadership attribute, to produce an enlightened change agent, to deal with the individual, community, national health care and to create awareness in the professional about the ideas operating at the global level’. I would like to add to what Quintero specifies in his PBL model. PBL is much more capable and much more vast, beyond what his experience so far might suggest. PBL will cover his ideas mentioned here and teach the science as well. How far they have succeeded in achieving these goals will require time to decide, since the whole process is just about seven years old. According to the assessment of Quintero: medical education is the process for training doctors, subordinate to the dominant economic and social structures in societies in which it takes place. Therefore … [it] cannot be divorced from social reality. If medical education



is a process … [it] is lifelong learning. Such learning must also seek the welfare of the society… In a globalized world it is universal. A new curriculum has been developed that addresses a ‘comprehensive instruction of the biological, biomedical, psychological, social, and cultural … aspects of medicine … (as well as) to acquire leadership, teamwork, and communication skills in order to introduce improvements into the healthcare systems where they work. (Quintero 2014)

The Colombians also look to provide opportunities for students to obtain experience in research, policymaking, education, primary care and other areas, reflecting the broad role played by physicians and the Colombian societal needs. Several of these characteristics could be described as ILAS, that is, Integrative Learning Activities by System, SPIC ES, that is, student/teacher-centred, problem-based/information gathering, an integrated/discipline-based, community-based/hospital-based, elective/ uniform and systematic/apprenticeship-based, reforms (Quintero 2014). This is an ambitious agenda. Commencing in 2013, the staff at the Rosario University School of Medicine and Health Sciences, Bogotá, Colombia, implemented an undergraduate curriculum reform in medicine. It has implicit variations based on their health care needs with curriculum content. This will be useful to improve their health care system. It further states: Teaching in an integrative way allows doctors to practice … better. The curriculum is supported on learning outcomes and its aim is “Teaching for Understanding…” It is a non-memory method for teaching and learning, to cultivate learners’ capability to think creatively, formulate and solve problems, and collaborate in generating new knowledge. (Quintero 2014) (It is a PBL variant, practically speaking.) We adopted the SPIC ES model … with learning focus in early expositions, in both hospital and community settings to benefit primary care in its conception…. [This would be a road to] Primary Health Care [system] Renewal…. [With it the Colombians have] strived for Integration of all levels of healthcare. (Quintero 2014)

The medical curriculum has five more programmes in health science which favour inter-professional education to provide skills for collaborative practice and professionalism. It is a value-centred education. Communication skills are taught under the ‘new Trivium’. Learning cognitive-linguistic



competences, research and innovation through basic/biomedical sciences and clinical sciences (translational medicine), the socio-humanistic sciences, and population health sciences (Quintero 2014). Another route refers to patient safety, which may contribute to decreasing errors and improving quality in medical practice (Quintero 2014). There is no doubt that the Colombians have set themselves with extremely ambitious goals. For the wonderful method of PBL, these are additional onerous challenges to meet.

The Japanese Evaluation of PBL The study by Nobuo Nara, intended to contribute to the innovation of the medical education system in Japan states, ‘We visited 35 medical schools and 5 institutes in 12 countries of North America, Europe, Australia and Asia in 2008–2010 and observed the education system.’ They found that even in the same country, several types of medical schools co-exist. Although the education methods are also various among medical schools, most of the medical schools have introduced tutorial system-­ based learning, or TBL, as part of PBL and simulation-based learning to create excellent medical physicians. The conclusion was that clinical training by clinical clerkship must be made more versatile to develop excellent clinical physicians, and tutorial education by PBL or TBL and simulation-­ based learning should be introduced more actively (Nara 2011).

Experience of Charité University in Berlin, Germany The Charité Universitätsmedizin Berlin is a large teaching hospital in Berlin, affiliated with both Humboldt University and Freie Universität Berlin. With numerous Collaborative Research Centres (CRCs) of the Deutsche Forschungsgemeinschaft, Charité is one of Germany’s most research intensive medical institutions. From 2012 to 2014, Charité has been ranked by Focus as the best of over 1000 hospitals in Germany. A Pilot Study Underway in Charité University This study runs a conventional education system and a PBL system of learning simultaneously, with a student number of 540  in conventional and 63 in PBL. This study is under review here. The national board examination scores at graduation are not significantly different between the two.



The reformed course students, however, mastered more clinical skills, which could not be evaluated in national board paper examination, than the regular course. Therefore, the education by the reformed curriculum was considered successful (Rüdiger 2003).

The Australian Experience of PBL The next question to be asked and answered is about the credibility, effectivity, non-inferiority or any other comparability of the PBL method with the current medical teaching, not only in India but elsewhere in the world where the British didactic model may have been used. The best and one of the earliest evidences thus has to come from Australia. From 1975 to 1982, a group of faculty of University of Newcastle, New South Wales, Australia, created the full undergraduate course of the problem-based medicine and applied it to themselves after getting permission from the Australian Medical Council. The faculty ran the course with the same idea for many years, making improvements en route (Henry et al., ibid.). The remaining 9 Australian Medical Schools and 2 from New Zealand had long considered the Newcastle approach as out of step, with skepticism and sometimes hostility. Later, all the 11 schools had to undergo an evaluation based on different criteria developed by the Australian Medical Council. Only 4 of these 11 schools got a limited accreditation for five years. It was a shocking revelation to the entire faculty from these schools that they were after all not as good as they thought. Their deficiencies in the curriculum were exposed. With it they came across good practices in other schools to which the faculty was never exposed (Henry et al., ibid.). Three of the schools decided to completely overhaul their teaching programme including changing the admission criteria by adding some non-­ academic ones. The Newcastle approach by then had enjoyed high reputation internationally for their problem-based learning approach, becoming a benchmark for various schools. Newcastle was now in a retrograde direction, gaining high-profile recognition of itself at the national level. An international conference to discuss medical education was organized by the University of Newcastle Australia, attended by 300 people. The volume Imperatives in Medical Education: Beyond Problem Based Medicine was brought out which highlighted the Newcastle approach. The title of the book also highlights and emphasizes that all the innovations do not end with problem-based learning (Henry et al., ibid.).



About the PBL Sessions, the Main Stay of PBL in General It should be noteworthy that PBL does use videos, audios, physical cases and cases on paper, or even abstract problems to be presented to the group. The objective is to bring out of these materials what it calls the learning gaps. In a group of 10 to 12 which is ideal, the students repeatedly come across a few situations where some answers are known to some partly or at least at the preliminary levels. Those students who know something will answer. Many answers will not be known to any students from the group in detail or in full. Since this fact comes through easily, no one is sheepish about not knowing, or ashamed to admit it. All the learning gaps are distributed among them, one gap to be worked on by one student. The answers are brought back by each student in multiple copies made for distribution to the entire group. This is self-learning. It is also in context. Hence, they remember what they have learnt, better. These sessions continue throughout the undergraduate level till they pass out. Intermittently, there will be hands-on training sessions which are ‘actually hands on.’ These sessions again may have patients themselves or instruments and laboratory methods or whatever that has been woven in the curriculum. These are followed by plenary or a longer lecture or short addresses, and so on. The philosophy behind these lectures is clear. It is to build the perspective or the logic or the structure of the subject being learnt. This is adequately supplied by elaborate notes at the end of the sessions. The lectures are not meant to download humongous data or details on a specific subject. That is why these lectures are carefully segmented to a small and specific area alone that is relevant to some problem. These problems under process are large or frequent enough or serious enough to merit finding answers. The selection and placement of lectures will occur after and once the problem has hit the limits of understanding or deciphering the answers. That area is presented in depth to build the perspective by medical experts with core knowledge of the subjects. It relates to the problem sessions where learning gaps were identified so that what is learnt gets reinforced. This is in stark contrast to the repetitive lectures saying more or less the same thing in any conference one may attend in India. In the undergraduate medical PBL curriculum, the students have 8 to 10 days of orientation of the medical school and departments as they join the school. After that they are placed directly in the clinical situations, in the wards where the cases are assigned to a small group of 4 to 8 people. In India, this group could be larger up to 12 or 14. Suppose a group



comes across a case of deep jaundice, the new entrants will try to understand and study what they can, knowing about jaundice as much as they can. It is a problem for them because they are much less likely to have any deeper knowledge at their high school graduation level. In the first session, the facilitator will take them through a number of steps about what information they have pertaining to the case of jaundice. What do they think is the problem here? What do they mean by certain terms say like ‘jaundice’, ‘obstructive’ and so on? What is it that gives colour to the conjunctivae and skin? As more number of questions are raised by the tutor or the facilitator, the group realizes that they know the answers of some or do not know the answers of many other questions. The questions for which the answers are not known to the entire group become the learning issues for the group. The group is advised to go to the library and try to find the answers in the books or any other source except approaching any faculty or students to get the direct answers. It is a must that they do it on their own. This process goes on for two to three days when the group reassembles and tries to understand what exactly is happening in the case here. It is easy to understand that they have had no particular anatomical and physiological knowledge of any human organs beyond the high school level they have studied. Thus, they are forced into a situation where they have to study all they need to know about jaundice simultaneously—the anatomy and physiology of liver, the biochemistry of bile formation and what happens to it, and why jaundice would develop and so on. This is the most beautiful part of PBL. Nothing from all the five basic subjects is ‘learnt’ without context. Nothing is learnt unless the group has identified what they do not know, has accepted that it is important to know about it, then make an honest search and come up with most answers. This becomes contextual learning. Thus, they find it a lot easier to remember these details of anatomy, physiology, biochemistry and pathologies of liver. Remember, this starts from the first week after they join the medical school. In the standard system of medical teaching they would have learnt the basic non-clinical subjects in a contextless manner, without a physical picture of relevance for about two years. This second session would throw up more questions. In this session, having some base about the disease there is a need for more information, be it clinical bits or lab findings about the patients to reach a reasonable problem formulation, which in conventional language is called diagnosis or differential diagnosis. To do that the group could ask for the laboratory



or imaging findings. Even this information does not come easily. The student will have to justify by some clinical reasoning as to how this information will lead him to the final diagnosis and/or the treatment/management. At this stage also many more questions will arise, and if the answers are not known, they will become the learning issues which the students will have to find on their own. They will be given one more chance to collect answers. Once these two sessions are over, there is no need for the patient to be actually present for the rest of the learning but he could still be found if the jaundice has turned out to be an obstructive jaundice and an operation has been performed. In such a case they could be made to understand the technique and the principles behind the operation. It is not necessary that for days together the group will be stuck with the same problem. It can have more than one problem on hand at the same time which may not come from the same system. Contact learning in PBL format is probably the best option. It is heavy in terms of the manpower needed. It may not be that heavy in the Indian context where the faculty is present; there are postgraduate students in a unit and there are other doctors. All of them could share the burden by taking up the PBL and spend time in useful endeavours like this. The other modalities of non-contact learning can be taken up to cut costs, inconveniences and burden on the manpower once the contact learning has skilled and enthused the students in self learning techniques, laid out the foundations clearly and set them on track. Here a doctor thus trained can be recognized as a leader capable of rising to solve the issues, at least in health within his community or clientele.

Relevance of Other Educational Methods It is becoming more common for medical education around the world to be supported by online teaching, usually within Learning Management Systems (LMSs) or Virtual Learning Environments (VLEs). To the credit of some organizations like the Research Society for Studies in Diabetes in India (RSSDI) are the online learning resources they have developed. But there is little information on the users, usage, utility, change in level of comprehension and so on. Mannequins are costly, not easy to be taken around easily. Virtual images to learn operative methods are also quite away in timescale. In India there is a lot of talk about telemedicine and involvement of Indian Space Research Organization (ISRO) but on ground there is still very little to show. What is going on is of primary-level



communication. To the extent it serves, it serves. Telemedicine still is far too remote an option for medical education. However, once the ‘all accommodating’ PBL becomes the core of the construction of the undergraduate teaching programme, supplementing it with not just the virtual learning methods, but every other audiovisual, real time and any such aids should be consciously developed and deployed. The essential point I would still like to make is about the basic contact learning programmes in PBL and other conventional modalities. There are no substitutes to contact learning in laying proper foundations. The duration for which it may have to be continued would be group dependent. The PBL program must be robust and well set in the matrix of a well-rounded medical education curriculum. If  it is  not well set, then building the rest of the structure on LMSs or VLEs will have a foundation of sand. Then all these fancy ideas are not going to be in anyway helpful, barring of course the interest of the policymakers as new avenues for spending money. One more emphasis is needed. The base of all learning is not always a live physical patient for  each and every problem of the PBL which the faculty takes the students through. There are many other ways to emulate the clinical processes by which the need for a physical patient is fulfilled. Within a medical college, however, a patient should be available in majority of the cases.

The Indian Experience with PBL  A huge experiment has been done in India using this methodology over five years from 2001 to 2005 end with more than satisfactory results. It was conducted by the Novo Nordisk Education Foundation, Bengaluru, with the University of Newcastle, New South Wales, Australia. Under this, five yearly courses in a space of about ten months in a calendar year in the above-mentioned years were conducted. Each course had a 5 two-day module structure with a gap of six to eight weeks between the modules. Each year these 5 modules were conducted in three to four cities in India in tandem. In the different cities, different groups participated. However, in each city the same group of doctors attended them successively. The modules were designed as contact learning. Each year, 17 clinical problems relating to diabetes were discussed in 44 problem-based Sessions. Workshops and debates were held among the participating doctors, plenary and short lectures were delivered by the 39 facilitators each year and



41 outside consultants to deliver superspecialty lectures in these five years. A total of 119 two days contact learning modules were conducted. There was rigorous work in the intermodular period for the doctors who took this course. The essence of this work was in two segments. One was the 17 practice tasks which had to be done by interacting with 5 patients having a particular condition relating to diabetes. The practice tasks from each one were scrutinized and detailed feedback was given to the student doctor in the next module written on the tasks. The second task was to find answers on their own for the learning gaps that the doctors came across during the 44 problem-based sessions. On an average, there were 10 to 15 learning issues in each of the 17 problems in each group of 10, they had to work on. That was roughly 1 to 1.5 learning issues per student per problem per session and had to bring the information for all the other group members. Most learning issues if not all were common to most groups. This number decreased progressively. We had a collection of nearly 100 learning issues from one 5-module course in three batches. This to an extent guided tweaking our courses over five years to add different/new subjects for lectures. In addition, there was learning issue material supplied by the University of Newcastle at the end of each module on important topics, carefully selected. The students found these extremely relevant and useful. Later, CDs containing the learning issues and presentations in each module in all centres in one year were given to all students. At the end of the fifth module, an examination was conducted with a few serially unfolding clinical problems and a few short essay questions. These were examined with the seriousness of a true university examination, and many doctors were failed and did not receive the completion certificates unless they cleared the examination. Among those who failed, some enrolled in the course again and then passed. Among those who failed were doctors who had high-profile clientele in their practice. The reasons for the failures will be apparent in the discussions below. On an average, 136 doctors per year have participated in this learning process. A total of 698 doctors were admitted to the first course (basic, short course in diabetes care); they came from 220 cities and small towns of India. Of these, roughly 60% were postgraduate-degree holders with an average postgraduate practice of 10 to 14  years. The MBBS graduate degree holders who constituted 40% of all students had also spent a similar period of time in practice after their graduation. Out of 698, 638 completed the contact learning programme of 5 two-day modules. The



attrition rate was less than 7% if serious illnesses, floods, pregnancies and untimely deaths are taken out. This is a remarkable retention for a course which had no formal recognition by any authoritative bodies like MCI and UGC or from any international bodies like WHO or other such bodies working in the field of diabetes in India or abroad. The retention was remarkable for so rigorous a course, where a practising doctor lost more than three weeks of his practice in ten months of a year just to attend the course. He had to travel long distances to attend, often face floods or crowded trains and heat. He had to do a lot of intermodular work which actually caused his time for both the practice and the family further curtailed to a significant quantum. The course fee was remarkably low, Rs 17,500, which the practitioners could have just let go and stop attending but did not (Novo Nordisk Education Foundation, Bangalore, 2000 to 2006). The Initial Shocks in Indian PBL Experiment Once the course started, the participants had a completely different and somewhat shocking experience than they expected. The deeply ingrained British didactic teaching was nowhere visible. The mute and drowsy majority and the monologue of a teacher in a dark hall with beautiful slides flashing one after another were absent. Instead, there was a clinical problem presented to them on paper in a group of 9 to 11 with a senior man sitting back, asking them to sort out among themselves what they thought were the issues necessary to look into. All of a sudden, each one found that they had to express themselves and there was no escape! Within the first two problem sessions of the first module of the first ever course, the reservations were gone. This was witnessed in all the five 10-month courses. All participants, long in practice, had so much to say about what they thought was right or needed to know about. The common desire was to share and learn, which then burst into great interactions. In no conference or CME they were ever asked what they thought about anything at all. We asked them precisely that. And then they wanted to talk! The pent up energy, experiences, doubts, questions and even uncompromising opinions came loose and lo and behold! The problem sessions became the most important ones.



Important Achievements of PBL in India 1. The participants put themselves into the student mould and it was university campus during the five contact learning modules. 2. They openly acknowledged the gaps in the knowledge in the groups. 3. They enthusiastically wrote down what they did not know and accepted that it was important that they needed to learn it ‘on their own’. 4. On the end of the second day, in the very first module they were presented with a considerable back-up material for learning during the intermodular period; they knew that they had hard work to do and rose to the challenge. 5. By the end of second module, all the participants became enthused by the process, developed strong group and facilitator affinity, expressed without reservation, to teach, learn and help. 6. As the modules progressed, the groups became more adept at solving problems, needed less time allocations for sessions. 7. The change in attitude and the confidence levels achieved by the participants were thrilling. 8. The discussions, especially the debates in open forums were extremely focused and precise. The heat often rose to shrill opposite views. 9. In TUNNDA, acronym for ‘The University of Newcastle Novo Nordisk Diabetes Academy’, as it is popularly called in India boldly experimented with conducting workshops differently. We decided to force everybody do things by themselves than showing how to do it. This was welcomed with enthusiastic and smiling participation. The workshops often would look like a streaming and churning melee. 10. Almost everything that was attempted went the right way. The problem scenarios were considered relevant, as in real life. The discussion, confusions and the knowledge gaps identified during problem sessions found the right answers in the plenary and highlight the quasi-­didactic part. 11. We owe the success to all our 80 facilitators and external experts for the great job they did during these sessions. 12. Both the participants, facilitators and external experts with the students have enjoyed every bit of this learning experience greatly. They expressed that this is the best they have come across about learning and nothing like this anywhere else.



Verification of the Measures of Success of the Indian PBL Courses The verification has come from two sources. Ninety per cent of all responders rated each module and the course as a whole at the end as very good or excellent. This lasted through all the five yearly courses. The university faculty, the veterans of PBL, found the process reaching unexpected levels and pitch, in a transcultural setting. The quantum change in the skills, knowledge and competencies as evidenced by the overall course evaluation before and after the course indicated a substantial change. The manifold feedback over years now indicates that most have built upon what they learnt in their focused practices, many developing large centres and a few hospitals dedicated to diabetes. We made a questionnaire survey two years after the first batch of 122 students completed the five modules. The paper which endorsed many of the successes mentioned above was accepted for oral presentation in International Diabetes Federation 2003 held in Paris. On all counts, except there was hard work, the course was rated as excellent (Kelkar 2003). Why Did PBL Succeed in India? The few cardinal principles or assumptions on which the course was based have led to the success. It was the landmark observation of the team that over years a clinician loses the ability to critically clinically think in an articulate manner while dealing with patients. It happens particularly if the medical graduate is working solo, without contact with the larger treating centres, where high-level complex medicine is practised, or if the solo doctor is not involved in regular teaching and learning activity, or is remotely placed with no back-up in his immediate surroundings. This leads to introduction of an element of imprecise and incomplete enquiry, the relatively more frequent possibilities are often overlooked, the vision becomes fuzzy, and treatment suffers from loss of focus and precision. Thus, they lose out on basic anatomy, physiology, pathology and also structure in practice. High profile doctors who failed could not internalize this process.  The failure to first articulate the clinical critical reasoning in their brain was followed by inability to articulate the same by vocalization. This deterioration was going on for years. Over years, it had resulted in their loss of ability to articulate the thoughts clearly to self and/or to the patient in clear cut terms. This incidentally represents the huge majority of the



Indian health care provider. When the articulate reasoning and its expression is lost, there would not be any systematic approach towards history taking, physical examination, and the process of differential diagnosis investigation and proper management, in the entire context of the patient and the illness. During the training, it took a solid effort to drive down the fact that reaching a diagnosis is not really the purpose here but to use critical thinking to reach it. It will help keeping one ready to go over one’s reasoning again if things do not turn out as one thought. The course invited them precisely to achieve articulated expression through articulate reasoning. And over a period they started doing this! To achieve that and as is implicit in the PBL process, the speed of the process of asking, collecting the information on history, physical examination followed by investigations and differential as well as the final diagnosis was slowed down. It was intended to shape the enquiry with the right sequence of questions in each of the aspect of clinical reasoning. The tendencies to jump from the staged approach to differential diagnosis or suddenly ask for investigations breaking the classical mould of approach to the case were so frequently visible. That is precisely the way in which the practitioners practise. Much time had to be spent in the PBL sessions to instill and force upon them the sequence and the sessions brought back on earlier tracks. In the initial phases, we least realized a simultaneous process change of the attitude towards the patients itself was going on in their minds. There was introspection about what have they been doing for so long and that they need to change it to something else. It was one of the foundational ideas to emphasize during training. The success and the impact of it were generally visible at the end of the third module. We believed that any subspecialty is best practised if it is solidly grounded in internal medicine. The course we designed was a broad-based course in internal medicine, touching on many other specialties, with a strong focus on diabetes. We believe this has worked. It also therefore has become a model adoptable to any subspecialty of medicine. The role that Novo Nordisk Education Foundation (NNEF) the full-­ time facilitators and external experts have played is very substantial. It has taken NNEF considerable effort to build upon the understanding of the process, to make it work in so many diverse groups coming together. The participants with different cultures from different provinces in India coming to a nearby centre were the most variegated group to deal with effectively. The facilitators even after familiarization with the technique of PBL



had their own individual styles in dealing with their groups. The external experts were more uniform. The ways of interacting of University of Newcastle faculty culturally, attitudinally and in terms of expectations was different. It adjusted itself remarkably with this cultural melee of India, liked its food, took painstaking journeys over thousands of miles every six weeks, went through thousands of tasks diligently evaluating them, and derived pleasure and satisfaction of conducting this extraordinary experiment.5 With due pride I submit that I was the central figure from the Indian side responsible for the construction, conduction of the course and the success of this experiment with invaluable support from the University of Newcastle faculty, which regularly came to all the 119 two day modules we held over five years. The common expression among all participants is, ‘You changed our thinking, you changed our mind set and you have actually changed us.’6 Another expression across the board was,‘We have learnt to ask the right and precise questions on what we do not know. We have learnt to identify and work on what we do not know ourselves, the development of the self learner’s attitude.’ Those who understand something of research will know the enormity of the change the students are voicing. These doctors were well-settled medical generalist consultant practitioners, who thought of getting some specialized training in diabetes. PBL was till then a teaching technique applied to undergraduate programme to pass a degree in Australia but was not used to teach postgraduate-level student practitioners. The success of this methodology and the experiment can be gauged or further emphasized by the fact that a remarkable 144 of the 638 who completed the short course on diabetes care opted for the next 5  In the year 2004, NNEF and the university got an award instituted jointly by Australian government and the Australian industry under the aegis of AusInd for the best foreign collaboration, which I received on behalf of NNEF, India, with the university faculty in Sydney, November 2004. As mentioned in the nomination for this award—Dr Sanjeev Kelkar, Medical Director, NNEF, who plays a significant academic role in both the delivery and organization of the short course and the clinical attachment subject in the graduate diploma. 6  We have exposed a number of such teachers outside the University of Newcastle courses to the role of a facilitator in a PBL setting to make the students think in an informal roundtable session, strictly prohibiting them from teaching or giving answers but being friendly to the students to explore the problem at hand, usually paper-based cases. We have seen teachers change in their attitudes in a span of one day, leaving their students agog with what exactly had gone wrong with their teachers that day? Most of the teachers we exposed it to have found this approach fantastic. Many were driven to tears on realizing what they were doing to their patients after this transformation of theirs.



qualification of graduate diploma (University of Newcastle records). This was a costly affair requiring an additional two to three years of intensive work, as unrecognized as the earlier one by any official body. Of these, 15 undertook master’s, which had all these factors on an escalated level. The Indian doctors place a great weight on the recognition in India of a course they have attended,  especially by such statutory bodies. They strongly desire to display these certificates as their authentic skills which they advertise and benefit from. This experiment defied all these conventions. Development of the PBL Course for India In the simplest terms, the technology of the PBL was brought to the table by the University of Newcastle, NSW, Australia. I designed and developed the contents of the short course choosing the most pertinent themes an average practitioner comes across frequently, as  suitable for the general aim of the course. That it should help an average health care provider in treating diabetes much better was a clear goal we set for ourselves. The contents were fitted into the PBL technology to learn diabetes, in all its forms it presents to the clinician. The understanding and management of metabolism was made fundamentally important not making the course teaching a mechanistic way of practice of diabetes. The principles of management and the rationale behind it were emphasized strongly. In addition, the problems were designed to make the doctors learn about epidemiology, proper communication and the ethicality of their practice, including dealing with other professionals. Tools of gathering reliable information were also taught to them so that they can handle information properly. The first design was created after 12 days of daily discussions in February 2000. It took me another 11  months to identify the external speakers, workshop demonstrators and the facilitators to hold the PBL sessions. I spent hours in creating the modus operand of how to conduct each and every small item included in the short course. Hours were spent with the speakers to convey them the idea of how the same lecture becomes highly contextual in PBL method. The toughest work was to convince them to narrow the focus of their lectures, build an in-depth perspective rather than the humongous details. While conducting the touring schedule of three or four cities in tandem, carrying the documentation and its distribution were tasks I could not have completed without the help of my secretary Mrs Anandhi Singh and MV Prasad, my librarian.



The social milieu and learning culture of the University of Newcastle NSW, Australia, was completely different than the Indian teaching, learning and social culture. To state more elaborately this was a transcontinental, transcultural adaptation of an undergraduate system of learning and teaching medicine  in Indian situation. It was used for the postgraduate level with a focus on a limited specific disease spectrum of diabetes. This was unique and to the best of my knowledge has not been tried on so successful and massive scale since or before. Lastly, the understanding we reached was that this undergraduate tool works far better in a postgraduate setting, a landmark observation by the university faculty and the progenitor of PBL, Dr Jean McPherson. Net Social Change from the Indian PBL The situation with respect to metabolic disorders in the country from 1996 till 2000 had already assumed epidemic proportions and continues to grow bigger. The efforts of the prime movers of education in diabetes was limited to getting the city and the metropolitan doctors who had an MD in medicine, interested in specially taking up cause of diabetes in practice on a large scale. It remained (as was desired) a class practice by class doctors  which could not be handled by lesser providers. There was rising evidence that the people of smaller cities, larger towns, in the hinterland were also facing the burden of metabolic diseases in large number to manage. I was clear in my mind that the burden ultimately lies with the small town practitioner, whichever the disease spectrum is. They need to be empowered through education or any other means to take better care of this new face of medicine. But metabolic diseases, particularly diabetes was considered to be beyond the capacity of an average practitioner as pointed out earlier. This idea was strong and came from professionals of the elite circles, sometimes as a caution, sometimes as a warning to us in NNEF as well as Novo Nordisk and stern action. Inclusion of 40% MBBS in the course described above was the most contentious issue. We faced a lot of trial, opposition, court cases and general anger in the elite circle against this idea. Today those trained herein lift the burden of diabetes and metabolic diseases, without causing any harm to anyone else’s practice, in 220 cities and towns for the people in India. Not more than 13% of these people come from metropolises and capital cities of states. The effort clearly demonstrated that a mass disease can be befittingly given a mass answer ending the classicist game. It must be noted that all stalwarts of the country finally



appreciated the effort and participated in it as speakers increasing the value of the courses greatly. None of these student practitioners have since looked back, and represent the largest body of doctors which was intensively trained in a particular methodology in a specific area in India. Today, a large number of them, anonymous, faceless practitioners earlier, have their own big diabetes centres even in C towns or in lesser places. They are considered by the pharmaceutical industry as distinguished. They are the office bearers to all diabetes-related national and/or provincial/specialist organizations today. All of them came from conventional medical college backgrounds. The PBL technology reached their core and made some fundamental changes in the manner they worked or thought. It strongly stimulated self-­learning, unprecedented in their life, and the life of medicos in India in general. This course changed their self-perception, communication methods, empathy, own emphasis on education, empowerment and demystification of the patient and disease, which this volume emphasizes again and again, in their subsequent practice across 19 years now. This is a signal example of how the mindset of doctors can be made different, by using different technology of education a task that will be far easier during the medical college years. There is a sense of camaraderie among those who learnt in PBL, ever so often coming from the same cities, knowing full well that they would be practising in that limited disease spectrum more intensively with or without giving up their original profile of practice. At the end of the course, their understanding was that the burden is huge; why only we few, many more would be needed to deal with this issue, the sense of competition, disbelief, paranoia and one-upmanship was so completely absent. They believed the population segments under their care were a joint responsibility of all of them. This attitude directly leads to the adherence to ethical practices. This was one of the unexpected bonuses which the conductors of the course had not imagined. While the medical colleges which introduce a few items of PBL in the conventional Long Vertical Model should be encouraged, they should not be allowed to taut their method as PBL and declare this as their unique sales proposition. The second prerequisite is the validation of the items that the medical colleges coming together to design PBL will create. At this point it is necessary to say that creating committees and working groups and drafting a schedule for their meetings is not the solution to create a quality PBL.  It has to be a few dedicated ones in a group for



different domains of knowledge working full time on a daily basis with a time limit of whatever feasible duration. This will be a national creation, held largely in common. The final argument and conclusion of this chapter in this respect is to adopt PBL technology first in those colleges where teaching standards are better and or the teacher mentality is receptive to new experiments, then extending it to all colleges as time goes by. Alternatively, it could be developed and deployed in postgraduate courses first, even when the doctors in PG residencies will have been trained in the old didactic system.

References Srivastav Committee, appointed by Central Indian Government, Report in 1975. Bapat R, 2011, Postmortem, Manovikas Prakashan Pune. Shrivastav Snehalata and Gwalani Payal, Times News Network, Sunday Times of India, Nagpur, February 20, 2011. Tilak Prof M, of Pharmacology, in personal conversations 2015. Hegde, BM, What Doctors Don’t Get To Study In Medical School 1st edition Paras Medical Publishers 2009. National Rural health Mission (NRHM) document, 2012. Quintero, Gustavo A, BMC Medicine 2014, 12:213. s12916-­014-­0213-­3.­7015/12/213, Published: 12 November 2014. Henry R, et al, Imperatives in Medical Education, Looking Beyond PBL, 1997 University of Newcastle, New South Wales, Australia. McPherson, Dr Jean, Hematologist, University of Newcastle, to the author, 2002. Nara, N, J Med Dent Sci 2011, 58: 79–83. Rüdiger M 2003 Records of Novo Nordisk Education Foundation, Bangalore, 2000 to 2006. Kelkar Sanjeev, Paper presented in International Diabetes Federation, Paris, 2003. Kelkar Sanjeev, 2021, India’s Private Health Care Delivery: Critique and Remedies, Palgrave Macmillan India. University of Newcastle, New South Wales, Australia records.


The De Novo Manpower Deployment Processes

Manpower Deployment: The Greatest Government Failure The measures taken so far in deployment of government college graduates and postgraduates in public health care delivery have been sketchy, unimaginative, not equitable and not just for the doctors but with meager benefit to the people. Non-availability of doctors in the main and inadequate infrastructure led to the ineffective public health care delivery and poor quality in the hinterland. It has no capacity to deal with more difficult situations. This has been amply demonstrated in the pages to follow. Primarily the failure is the total absence of coordination action between directorates of medical services and of medical education across the states. They have always been at loggerheads. As a result, internship was treated with ineffectual and counterproductive manner with bond system added, associated with waste of manpower and no tangible benefits. The governments have not made any special efforts to see that the graduates/postgraduates at the cost of the exchequer should initially join the public health care. The options of doing postgraduation, joining the medical college faculty or going abroad, or joining the public health service were simply left to the doctors (as in a truly capitalist system.) ‘Each system has certain powers which it does not want to surrender or amalgamate with another. These powers help them deal with various situations by using discretions leading to further benefits’ (Bapat 2011). In © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




contrast, in Sri Lanka there is a single authority of health services at the top level under which the medical education and state health services including the community health services are placed with five other services (Wanigatunge Chandanie Prof, December 2018). The professor was surprised when we talked that it is not so in India. Key Questions About the Deployment Failure at PHC and CHC What makes the patient come a long way to the district places or cities? Is a greater number of primary health centres (PHCs) or a higher number of doctors in the PHCs the answer? The governments manage to get one doctor for PHCs but not the second in type B PHCs (which means heavier work.) Why does that happen? Is there something the PHCs are lacking across the board? Are the PHC officers equipped, after training, to discharge their PHC duties? Or is there anything fundamentally incorrect in our ideas of PHCs which we are not ready to acknowledge, worse have not understood. What are the reasons behind our inability to populate the hinterland with specialist doctors? Is it only the reluctance of the doctors? Or is it something else of much more relevance? Is the idea and conception of the community health centres (CHCs) correct or faulty? Why the CHCs have 80% vacancies for specialist positions? Is it possible to give basic specialty care near to the homes of the patients? How close can it be given? Is the state of instrumentation, infrastructure and human help available adequately conceived and provided? What is the actual status of backups? Why have the critical indices of health not improved over last six decades satisfactorily enough? These and many other questions need answers and analysis to think of effective alternatives which can still be provided.  hy the PHCs Do Not Deliver? W The range of functions expected from the PHC medical officer is so vast that even a chief executive officer of a smart company cannot do it. Hence, most functions will somehow get dubiously reported. On the one hand, it falsifies the government statistics. On the other, it will lead to wrong policy decisions about public health care. In addition, provisions for PHCs in last four decades cannot take the responsibility of health issues of higher complexities. PHC structure and facilities provided are so inadequate that specialist positioning in PHC has been near impossible. The PHCs will be discussed in much greater detail in chapters to follow.



I s CHC the Best Level of Deployment? The pragmatic question then is to ask how the next level of public health care, CHC, was conceived, providing higher functional capabilities PHC was not able to handle and referred to. Four to five PHCs refer to CHCs (in the older system). The same obtains in the newer system with a flaw which also will be discussed. CHC is thus the farthest from the medical college as a competent centre and nearest to the population where in theory the basic specialists are located and expected to take care of the referral from below.1  ossibilities of Many Failures and Occasional Successes in CHC P Right from its conception till date, CHC has remained a failure and remained deplorable till now for many reasons which will be discussed below and in detail later. It was in glaringly faulty manpower allocation initially, with dire neglect of the infrastructure for living for the staff and doctors, then instrumentation, hospital supplies and such other factors following. That led to the chronic and severe shortage of manpower of every variety. The ill-equipped state of the basic diagnostic and management inputs needed for the specialists to take on the complex problems hampered the process of specialists voluntarily going there. The state of affairs did not attract them to work there. It got caught in a vicious cycle. In government thinking, anybody coming in must be permanently there. That one will be coerced to remain there all the time was another fear with the specialists. Even then my proposition is that reorganizing the CHC is the best solution to our people’s health in the hinterland where even now 66% of India lives and where more than 80% of health issues related to the health indices arise. The most logical would be to ask, will this also not turn out to be a failure like the PHC model? We do not think so since there is adequately strong evidence available now to indicate that this is the right model. Suffice it to say here that some ideas intrinsic to the government planning of CHC are strong. Its augmentation is needed as provided in this volume that will result in sea change in the rural health scenario in India. The emphasis of this chapter on CHC should therefore be understood against these strengths.

1  We have already demonstrated that the population size under a CHC ensures that there will be adequate work for the specialists.



Preparing the Manpower Purposefully In the preceding chapter, we have discussed the techniques, technology of education and its contents in preparing the manpower. More attention should now be paid to the deployment of the graduate and postgraduate doctors in the CHC and how to do it so that the maturation of the knowledge acquired so far at different levels of learning continues. Other ancillary measures of infrastructure and instrumentation will be discussed in this volume at different places in chapters to follow. The quantum, type and the hierarchy of the manpower allocated at the periphery to the taluka/tehsil level up to the sub-divisional hospitals (SDHs) is given below to start with. Public Health Care: Manpower Structure There are 25,000 + PHCs with at least one medical officer. Then there are 5000+ CHCs with a stipulated strength of five specialists making it a total of another 25,000. The specialist places filled in the CHCs are anywhere between 25 to 50% at any time. (See Rakesh Prakash below.) In actuality it is around 20%. I must re-emphasize that the paucity is not proof of inadequate number of graduate and postgraduate doctors produced. Specialists from medicine, surgery, gynaecology and obstetrics, pediatrics and anesthesia are expected to take care of most problems that arise in the rural communities. The population level at which a CHC is situated, to remind, is anywhere between 172,000 to about 250,000. Then there are 1006 sub-divisional hospitals (SDHs) roughly at the taluka or the tehsil level with 15 to 17 specialists of many varieties and general doctors, at least in its conceptual idea. The vacancies here also are uncomfortably high. Roughly there are 7000 + tehsils or talukas.2 This excludes the metropolitan and capital as well as A and B type of cities. The SDHs are not that far away from the CHCs and much closer to the much larger district headquarter hospitals and the cities. But the doctors would like to be in the district hospitals than in SDH. These factors finally lead to dysfunctional units all along the hierarchy. When a supposedly better unit co-exists nearby, the lesser units will shake them off from treating and push the patient  load to the better  unit. This adds to the agony of the people. 2

 The way it can be calculated will be shown later in detail.



The district hospitals and the 261-odd government medical colleges are additionally populated by specialists and general doctors. The numbers of these two are not our concern just now. The thesis to be advanced therefore is that particular combination of the specialists in CHCs is all that is needed. Both the sub-divisional hospitals and PHCs will not find any place in this thesis. Procuring Manpower to Correct Shortage: The Barriers At any point in time, there are not more than 35,000 doctors actually serving in the public service (Rural health Statistics). The requirement as per planning is roughly 100,000 doctors, from the SDH to the periphery. Procuring these numbers certainly is a formidable task. There are more reasons which make it even more difficult and are discussed below. It may also lead to a logical correction of these factors and help solve the issue. About 80% doctors after the internship opt for postgraduation. Their allocation to CHC is thus blocked for a variable time. The experience of the interns at the PHC leads to a resolve never to return to it. Infrastructural facilities and instrumentation being pathetic, the specialists do not seem to find the options of the CHC attractive. The location away from the cities adds to it. These and other factors create dysfunctional units in a system.  dditional Factors in Creating Dysfunctional Units A The work profiles are planned without providing adequate manpower to discharge it. This is classic government thinking in the health sector. If the government cannot source the manpower, the imbalance in the function-­ to-­manpower ratio becomes extremely skewed. Correcting it by reducing the number of functions has not been done at any time in India in the history of public health care. In fact it has continuously increased the functions successively with sketchy increases in the manpower inadequate for carrying out the functions.  rowded Hierarchy of Similar Units: PHCs, CHCs, SDH and DH C A crowded hierarchy of similar units, in close proximity with each other, results in dysfunction. I have called it multilayering in this volume. In this arrangement, sparsely available manpower  and its  placement becomes a circus. Should somebody be at a higher level, or a lower distal one? If one is placed distally, there will be political pressures to shift him near a city or



large town. If it cannot be done due to higher political pressures the absenteeism will be connived at. This holds for all cadres, not just the doctors. The idea that prevails in creating multilevel structures is to make all variety of doctors available for the people at all levels, as near as possible. No one has bothered about the impracticable foolishness and the lacunae it creates. If the units are of similar competency, the patient will be tossed back and forth. If the competency gap is wider, the lower units will pass off the loads to the ‘higher’ centre. This has been my impression prima facie about these factors in other developing countries as well, though I have to refrain from mentioning the names. The most serious handicap of this multilayered planning is the minimal incremental changes as planned by the government in the competence level of units, as one goes through the hierarchy. From the remote villages through the community health workers (CHWs) hereafter, to the PHC and then through the CHC and the SDH, there is little change in the competencies, mainly due to absenteeism or vacant positions, infrastructural issues or more often both. From there to the district hospital or a medical college could be a journey of 20 to 100 kilometres, particularly hazardous for an already-sick patient needing higher competent care. The proof of this will be amply illustrated in Chaps. 7, 8, 9, and 10. Whenever a unit becomes dysfunctional, it also locks and blocks considerable manpower, which serves no purpose. Making these large numbers of dysfunctional units, PHCs, CHCs and SDHs functional, or rearranging them with deletions, is the challenge here.  ive Undelivered Health Care Vectors with Such Health Structure F What is it not delivered in such a system? The five major guiding principles—accessibility, quality, affordability, equity and justice—are not. Throughout the discussions, the shortcomings or defective thinking or inappropriate conception of health care delivery system will come under criticism if it does not serve one or more or all five principles. Any suggestions or policy decisions to be made will be based on achieving the five principles and how it will be done. Let us also examine the performance of the PHCs on the basis of these five principles. It is documented that the PHCs mainly serves people residing in 3 to 5 kilometre radius (Rural health Statistics 2012). Certainly the bulk of 50,000 populations it is supposed to cover does not reside in this radius. Hence, the accessibility is a myth and there is no equity either. In the technically free of cost government PHC service, corruption is



legendary, and this affects the affordability. Quality is something no one has ever claimed for the services rendered at the PHC. Poor state of laboratory, unavailable drugs, poor motivation of the staff and an overworked medical officer are the well-known causes of it. The range of functions at the PHC level is unwieldy. (See Appendix A for its truth.) The manpower to discharge these is grossly insufficient. There is no service. Hence, the questions of quality, equity and justice are not served. Attempts have been made to increase the numbers or categories of the CHWs. That has not improved delivery of functions either, and has additionally created its own problems and handicaps.  ismantle Superfluity, Restructure D The only way is to restructure the health care by dismantling the dysfunctional units and concentrating their manpower at a level of CHC to put it to better use. If this is acceptable, then it needs a detailed description of how each person to be brought to CHC will function, what or whether it will accrue any benefit for such a person, which in turn can benefit the care structure. The proposal is to dismantle PHCs and the SDH systematically in a phased manner and the manpower available there (at least at the conceptual level initially) be brought to CHC. How it should be done will come under detailed discussion in chapters to follow. Interns hitherto posted in PHCs will be our first consideration in all its aspects. After that we discuss the PHC personnel in CHC. The twin purpose for which it is suggested is to fill the gap in manpower shortage and to facilitate learning. We believe that getting MBBS or a postgraduate degree is the beginning of maturation of a professional which needs three to five years to produce a competent doctor. In the present system, this process is operative only in some medical colleges. This needs to be expanded at a few other levels while serving the population with all the five principles. Hence, the rest of the chapter will mainly focus on how learning will take place at CHC. The structural changes will be discussed in later chapters.

Continued Learning of the Medical Graduates It is discussed in consecutive stages during inernship, in medical colleges, during the rural posting and in CHCs.



Learning in Internship in Medical College It is pathetic. There is a rotating schedule for interns to follow but not a program for learning for interns. Traditionally, in departments with longer postings, the intern gets the most unappetizing, unfamiliar work, running around to collect reports which the arrogant ‘ten to five’ departments would not send proactively to help the units on day and night emergencies often longer than 36 to 44 hours at a stretch. The interns do not find time or a proper place in the clinical rounds taken by the multiple faculty levels or Honoraries. The rounds are supposed to be teaching rounds and not just for treatment of patients. Rounds are sketchy and may not have much academic content. If a professor is interested in teaching on long post-emergency rounds (which was and is rare), the interns would get left out. In smaller surgically oriented departments, the honorary staff rarely has interest enough to teach, the concentration being on operating the patients. Or they may leave it to the registrars who would have spent a couple of years in those departments because of their interest in doing postgraduation in that particular specialty. Learning in Internship in the Three/Six Months in the Rural Areas The three/six months’ rural PHC posting is also similarly useless for learning or helping run village health care and/or to learn how to do it. No intern stays there, no one works there. No one can. The living conditions are generally quite unacceptable to anyone who is brought up in a city. Even if the intern stays there for extended number of weeks, there will be no difference to the situation or for him. The PHC officer does not want them there. He looks at them as a pestilence or an intrusion on his business of looting the PHCs. He does not want this to come to the knowledge of the interns and then the administration. The administration probably knows this but is least bothered about it. For them a PHC officer in place is all they look for. The PHC officer makes a deal with the interns which could be as simple as a whisky bottle of some good quality at the beginning and end of the term. The PHC officer signs their attendance. Administratively speaking no one has tried to rectify the situation. We suggest that the futile internship in its present structure be scrapped completely. The three-year bond system as shown earlier adds to the agonies of the fresh graduate and must also be abolished.



The System Proposed for Interns in CHCs Briefly, the system detailed below is to equip CHCs with fresh interns as well as the postgraduate doctors, for two to three years only, overcoming the fear of doctors to be incarcerated in it for long or forever.

1. No bond system will exist for the reasons already mentioned in the chapter in this volume on government medical colleges. 2. The rural internship in the PHCs should be scrapped for reasons already mentioned. 3. That one year should be spent compulsorily in CHC. Two more years should be added to it after internship but no more. The Sri Lankan system places these graduates in different levels of peripheral hospitals for one year under which they improve (Wanigatunge Chandanie Prof, 2018). 4. The intern would be eligible to apply for a postgraduate seat only after completing two years in the CHC. The reasons for this are given below. 5. The specialists should mostly be posted in CHCs. Then without doubt MBBS graduates working under specialists will learn and work more enthusiastically for these years. 6. This will also need some change in the terms of their working detailed below. 7. The main paradox, an MBBS not willing to go rural because he does not learn, does not gain in any way to become better equipped for postgraduate entrance examination will thus vanish. 8. This will be a compulsory general tenure for a maximum three years, beginning with the internship. 9. These placements should be non-transferable.3 At the beginning, there may be scope for exchange of a placement or even a choice of a placement. Once decided the placement should be non-transferable. 10. The entire placement period should be residential with no leniency about leaving the place on every weekly holiday. In general anyone

3  When a government voluntarily suspends the right of the politicians to transfer bureaucrats, the corruption in the government precipitously falls. We have seen the central government do it as soon as it came to power in 2014, and the rights of reshuffling left to the Prime Ministerial Office (PMO). There have been daring dismissals of high officers within hours but no transfers. The pattern has been adapted from the Government of Gujarat. It can work in health also.



should be available 85% of their time in CHC unless on sanctioned leave. It is a 24 × 7 job. The details will be discussed later below. 11. The entire ruin of the public health system at all levels including medical colleges is on account of this tendency of not sticking to the post and going back to one’s place in an unreasonable and uncoordinated manner. 12. This can be easily prevented by placement being done where overnight or shorter travel is not possible on the night preceding the holiday. 13. This arrangement for availability  will expose the graduate to the basics of whichever branch he wants to follow by working in the five major branches and also invaluably in the critical care. 14. The MBBS doctors in a short while after passing, or even before, make a decision about which specialty is to their intense liking. In CHCs, they may be given preferential time allocation for it.

Posting in CHC and Issues of Postgraduate Qualification for Interns

1. They should be allowed to take postgraduate entrance examinations after completing first two years. 2. Assuming that at least 50% of our graduates want to specialize, assuming that they have got selected for the higher learning in the third year, their time left to be spent in the CHCs in the third year can simply be waved off. 3. If he does not get a postgraduate course, he is free to go out of the government system after the third year with additional attempts. 4. These two are the years devoted to learning medicine where it should be learnt, that is, in wards, and see the specialists work and learn from them, which will prepare them to become better postgraduates. 5. This has been the big lacuna in the internship years in rural PHCs since there was no higher learning, which will be thus removed now. 6. All of them should be given a substantial salary and other provisions be made for such a person to feel comfortable even in the semiurban locations. The abominable conditions of both the PHCs and even the medical colleges where these people have to live are compounded by the fact of poor monetary compensation. The yearly strikes of resident doctors in metros and other places and the shame-



ful plea of the government that it has no money and that it has already spent a lot of money are simply unacceptable. (See below.) The ways to solve that issue are mainly economical and will be discussed in the restructuring of the CHCs where ways of making huge savings in the budgetary allocations is argued, from which more money can be provided. 7. In addition to the postgraduate course, he will be eligible for the other useful special training courses like public health diplomas offered by Public Health Foundation of India, or any other accredited non-­ governmental agencies about which more is written elsewhere.  bjections to These Suggestions O The immediate and vociferous argument against the plan detailed above will be about the compulsory tenure for three years in a semi-urban location. The Trichy Doctors Association for Social Equality has already called for the abolition of the one-year mandatory rural service for the MBBS students because it prevents them from appearing for PG examination (TNN | June 11, 2018, 12:29 IST), quoting Dr Ravindranath, general secretary of the association. This is now  a meaningless objection after  the National Medical Commission has started operating with demise of MCI. It provides for a common single nationwide National Licentiate Examination, the performance in which will be treated as postgraduate entrance in a college according to their ranking. The only stipulation we will add to the NMC Act is to provide for post graduate seat applications only after two years for the MBBS batch passing out under NLE scores. Another objection that the one-year compulsory service in rural hospitals postpones the permanent government appointment. About 31,000 students are thus affected in India (TNN | June 11, 2018, 12:29 IST). If the argument was about the poor working and learning facilities, one can support the abolition of rural service. That however is not the case. The CHC placement in fact is expected to fill this lacuna more than satisfactorily as will be shown with respect to post graduate admissions. There are several considerations all the doctors’ associations should understand and agree to as explained below.

1. The internship year is already agreed upon as the integral part of the education. Placement in CHCs the rural service will be far more satisfying for learning.



2. If at all there is abrogation of freedom to join the postgraduate entrance, it would be for only one-year post internship. How this ‘abrogated’ year is normally spent must be told. (a) A large number of MBBS anyway do not get postgraduation in the year of internship and have to spend at least one more year for it even otherwise in today’s situation. The objection therefore has no basis. (b) One of the reasons for many of them failing to get a postgraduate registration not only in internship but in the years to follow even after many attempts is their lack of clinical exposure and good grounding in it in internship. (c) They could very well spend two years in the CHC to acquire the sound clinical base and get a PG registration with expanded knowledge. This was not the system. It is unfortunate that sound knowledge has no longer remained a value, replaced by a PG degree. (d) Those interns who do not get the PG registration would any way spend at least a few more years in a corporate hospital or some other large hospital to earn and prepare once again for the postgraduation. (e) As will be shown below, the manner in which they spend time presently in such hospitals to study does in no way help them in their goal of passing PG entrance examination well enough in order to get the specialty they genuinely like and a good institute they want. (f) If they do not get the branch they genuinely want—and the cause for that would be a weak clinical base—then another compromise sets in, wherein they have to accept a branch that is to their utter dislike; this could turn into a lifelong pain for them as they would have to practise the same for the rest of their life. (g) Thus, there is no significant loss but a lot more to gain by way of bedside learning and direct exposure to clinical medicine in this one extra year, one for admission and two for better learning in their post graduate branch. (h) This arrangement will make the completely wasteful internship year into a fruitful year. They gain a lot more experience of what medicine actually is in the second year. They will understand their textbooks better. (i) Against this imaginary loss, these fresh graduates are going to get the following in the scheme unfolded here: a decent salary, a



good place to stay, work under specialists and learn, and at the very least comfortable living conditions while getting enough time to study. (j) Among the statists or the governmentalists, the compulsory two to three years (including internship) may be a heartening proposal. The argument they will have in favor of such arrangements would be that the state has spent a large amount of money on them and is therefore entitled for their time (although with good ­compensation and good living conditions for a reasonable duration). The argument is old. The trouble with it was the utter uselessness to which the time was put to and wasted in the preservation of the internship format. 3. The sceptics and the government planners will be up in arms while opposing better remuneration: from where will the money come from and that we do not have the money and no resources to find it in. Such utopian system can be written by anyone who knows something about the health care delivery structure or is a grandiose schizophrenic, which have no practical implementable possibility and so on. My first answer is: it is high time the resident doctors be paid enough to make them think twice before they go on strike, an occurrence we have seen dime a dozen times. With Goods and Services Tax (GST) revenue now averaging in pre-Covid 19 months, INR 93 trillion, and average share of 42% of this going to the states, there should be no insurmountable difficulty to find this money. There are ways, outside GST and other fiscal measures to raise the money discussed in detail later in this volume which will make it eminently possible to foot the remuneration bill. Another point is the failure of many governments to pay these young doctors for a period of at least three months or more who were actually fighting the Covid 19 menace, with whatever competence they had. Instead of paying them, the governments have threatened them to snatch the degrees, disqualification and removal of service if they refuse Covid duty. But they stayed there unflinchingly while the seniors conveniently self-distanced from it. The private doctors avoided it as long as they could as shown in my volume India’s Private Health Care Delivery: Critique and Remedies, published with this one (Kelkar, 2021). It is barely few months since economic activity has stopped. Yet the doctors have come under victimization. Wreaking vengeance for reasons unfathomable, Maharashtra



and Telangana governments have threatened to cancel the registration license of the hospitals which overcharge the patients instead of fining them or paying the patients back (the Quint, 25 July 2020, with inputs from PTI). Thousands of irregularities have gone without action in the years gone by. At a time when all sectors must cooperate, these are insane measures to seek it.  bjections by the Interns/Doctors Themselves O Their objection could be about being on 24 × 7 duties. It is a great misconception of doctors to consider this as ‘bonded labor’. The money given to them is not to a function of the hours they put in, one of the fatal practices in Labor Union raj. The issue today is to create so much clinical work for them that long hours become a by-product, a yielding bounty beyond measure. This situation can be created in the CHCs as will unfold throughout the volume. It is not possible to do so in the PHCs where they are being posted routinely for years. There is no relenting on that for various reasons I will continue to discuss. This is the only time in their life when no one is going to ask them why they are working for long hours. If sound judgement is the key to a satisfactory career, this is the only way. The Internship Format: Should It Be Preserved or Changed? Preserving the format serves the procedure and requirement other countries make, to allow doctors to apply for jobs after internship. The name can remain but the content or the format may change without causing any heartburn or becoming an obstacle for further studies abroad. This entire circus described above (and will be discussed below as well) is necessary to prepare the graduate for a satisfactory developmental path. Direct to the ward!! That is the slogan. The following discussion is to see if it is possible to achieve. I may add that the ideas discussed below go way beyond the thinking in this respect so far.

MBBS as Under Trainee After Internship It was utterly ridiculous that a hospital set-up like CHC, with 30 beds and 5 specialists, did not have any place for a junior cadre of resident medical officers (RMOs) in the government planning till 2012. The Indian Public Health Standards (IPHS) changed it. The reasons the government planners may have given before would be that whatever the workload, each of



the specialists should be able to manage easily without the RMOs. It is not so on ground. The specialists do need the help. More importantly, it also serves the dictum that at every stage of the health care delivery, the just passed-out MBBS must be on the scene and operative. That is the only way to learn the craft of medicine. The new MBBS rookie will work under proper supervision of those postgraduates and still enjoy some liberty within it. In Case of No Postgraduate Registration The MBBS doctor has to continue in CHC for a total of three years. Once he goes out after that, we will inadvertently be filling a long-felt vacancy of a good family physician in the communities far and wide (Bapat 2011). Having come from a place dealing essentially in complicated situations, he will have a much better grasp of which of his cases need a specialist opinion and where to send them, especially the rural or semi-urban people, to get it treated and get a guideline on how to continue to manage his patients. This return feedback from higher centres will expose him to a greater understanding of the treatment given, how to follow the patient up and how long to treat before another referral is necessary. It is a day-to-day reality that more remotely placed doctors do not understand the prescriptions coming from specialist. If the specialists develop a culture either to write back to these practitioners about what they have done, what to expect in future and what could be done at that primary level, the level of health care delivery will go up without doubt in those areas. It is sad that such a culture does not exist. The next best substitute is a detailed and well-written discharge card for cases which get admitted. These cards are far away from achieving a quality level unless, or even after, the specialist has put in extra efforts.

Postgraduate Consultants/Specialists in CHCs Only 19% specialist doctors are working in India’s community health centres across the country, 4186 against the current requirement of 22,040 (Rakesh Prakash | February 05, 2017). The proposed model implicitly has it that there always will be successive batches of these five basic specialist categories working in the CHC system at any one time having one, two or three years of experience after specialization. The answers about how to manage the paucity of the specialists is to place the fresh postgraduates



passing out from the medical colleges in the CHCs for three years, a drastic move which requires a convincing explanation, which is given below. Maturation of a Specialist Degree Holder in a Consultant Having a postgraduate degree is a license to practise as a consultant or specialist but it is not a guaranty of maturity. In fact, getting the degree is the beginning of the process of maturity for specialists. As discussed and proposed below in some detail, by working with little more experienced specialists in semi-urban and full-time cultural settings of their own branch and other branches in a CHC-like setting, where the contact is frequent and exchange of help sought and given, they will mature faster. I have by now seen enough number of the generations of postgraduates in various settings—in projects, in urban practice and in rural locale. I have come to the conclusion that it is absolutely necessary that they be run-in, in CHCs. These long-standing beliefs of mine found an unexpected and strong support from the health system of Sri Lanka. It consists of deploying postgraduate degree holders within the government system at the higher-level teaching hospital under a consultant for a variable period of 2 to 2½ years, which is remarkable. He is then sent abroad to the UK, New Zealand or Australia to further train under specialists/consultants. When he returns, he is then allowed to work as a specialist consultant in the government system as well as outside it (Dissanayake Prof Upul, November 2018; Rathnayake Dr, November 2018). This is a good recipe for the maturation of a specialist. Specialists in CHCs In this arrangement, within a couple of years the majority CHCs will have specialists who have two or three years of experience in their specialty. The fresh postgraduate recruit will have to go and work with those who have already experienced the profile of illness in the area and will be more learned. Profile of illness differs in different locations. Only portions of it are identical but almost all other aspects differ. Here his performance, acumen, attitude, aptitude, concern about patients and so on will be directly observed by the seniors. The quantum, the extent and the level of independent responsibility that can be given will be judged. He will mature most effortlessly in such a system, doing work on his own and still supported by the other seniors, and quickly



become a ‘tough guy’. His ‘hands on’ experience may increase much more in CHC than the hierarchical self-saving system in the medical college, which will stifle much of what he may want to do by taking more initiative. Inter-CHC Movement and the Superspeciality Training The specialists in one centre under this arrangement may be shifted to other CHCs, and will be need based, for short durations and they will be exposed to more locales in these three years. Going through this mill is necessary because it will make them understand the different situations, and their constraints, and learn to improvise or create means to get things better, for example teaching the staff. It will also break bones of their ego. That alone will make them competent and safe for the population. Unfortunately, we lack this after postgraduate system. It is because, as I have repeated ad nauseam, we do not have projects in our system that can do this work for them. And we have not used our imagination! The movement of the postgraduates irrespective of the merit, caste, domicile, place of preference will be in the dynamical process of managing well the health care as a whole, over a district or geographically linked parts of the state or the state as a whole. It begins from the CHC posting. The directions it will take are as follow.

1. Some may have to be called back to their medical colleges, dictated by their merits, and their inclination and ability to teach. The last will or should have the greatest weight in such shifts. 2. Some may be required in the district hospitals. 3. Any postgraduate who has spent more than a year in CHC should be eligible for reallocation in the district hospitals, dictated by their merits and the need of the different places. 4. They will not be allowed to do private practice in these three years. 5. If anybody is found to do so, he should be dispatched to a remoter CHC for the remaining three years. The postgraduate may have ideas about going for postdoctoral degrees. Like the interns the enrolment of the postdoctoral course should be allowed after two years are finished in his/her basic specialty in a CHC after his postgraduate degree. There are several and strong reasons for this delay:



1. The foremost reasons are to allow time to get the fundamentals of their basic specialties firmed up in this arena. Those of my generation are worried and concerned about the absence of the sound basics among the superspecialty practitioners. It results in the fragmentation of the health care. There is today an unwillingness to attempt an integrated care in one hand. 2. The second reason for the two-year delay is the simple fact that there always exists an enormous load of health issues which fall in the ambit of these basic specialties at the level of CHC. The number of issues requiring superspecialty become fewer and fewer as we go up the pyramid. There is therefore no hurry to send them there early. 3. Unfortunately, within the government system there is no conception, idea, concern, awareness or a sense of at least a partial responsibility to answer the curative issues within the basic specialties of the vast tracts of people in hinterland as near to their homes as can be. 4. The two-year delay will answer these unmet numerically high needs more than substantially when a whole lot of patients get relieved of their significant illnesses close to the homes. More will be said about this many a times. 5. As explained later in more detail, it will reduce the senseless load of the higher centres. 6. Facing such high loads day in, day out will foster his strength, as well as his skills and ability to manage complications arising from the work or presenting from the community as complex disorders. 7. The next, additional and important reason for devoting these two years to his basic specialty is the responsibility of training the MBBS to deal with the higher forms of illnesses falling in the basic specialty purview. More will be written about its nitty-gritty below. 8. Sooner or later these MBBS will also be going to do their postgraduate degrees in basic specialty of their liking. What can serve that end better than these young specialists to teach them the craft? It can happen only if they stay compulsorily for two years in CHC system on a 24 × 7 residential system. 9. Assuming that our specialist in CHC does not get a superspecialty, we still will get a sound MD/MS as a generalist whether he continues in the public health system or goes out after losing his chances for a superspecialty degree in the compulsory three years. 10. Today the MD/MS feel inferior to the superspecialists. I have gone through this severe existential crisis. I was saved from it and given



a proper view of what I could do by my professor, Dr. P S Bidwai. MDs are the common sense in the mayhem of the superspecialty bazaar. At the community level, the well-trained MD/MS, with the common sense can take some burden off the superspecialties as well. 11. If there is entry in postdoctoral degree, then after two years this person is free to leave the service, to join the postdoctoral course. 12. Otherwise, he is welcome to stay at CHC for a full three years. In addition, he may be given an extension of one to two years but no more. He himself may think so or the others may advise him. 13. After five years, if he so wishes to continue, he could then be shifted back to the district hospital or even the medical college level, become a faculty and continue to contribute for years to come. This will contribute to his continued betterment as a specialist. In one stroke, we will have solved the shortage of specialists at the CHC level.

Full-Time Culture in CHCs One must grasp two aspects of this CHC deployment. There is an insistence in this model on staying in it for more than 85% of the time, be it MBBS, specialists or AYUSH doctors or even the paramedics who will be discussed later. There is also the need to run our medical colleges, specialized institutes and different services in the format of a full-timer culture with no possibility of practice elsewhere and no desire as well about it. This is the single most causal factor which has singularly ruined the public health system at all levels—the freedom to practice privately. There are examples even in reputed nongovernmental institutes, which have, for reasons unknown but fathomable, allowed the private practice and ruined their mettle and caliber. A reputed, highly awarded doctor from one such institute was later caught in a tax evasion case involving billions of rupees. We have shunned that full-time model resulting in serious consequences. Enforcing it, but for a limited justifiable years, will result in equity for contributing to the public good and individual freedom. Given adequate incentives and making appropriate demands on discharging special duties, it is eminently possible to revive this culture.



Surrender or Indifference to Public Good Policymakers or the theorists have surrendered to the idea that the positions of required cadre will not be filled particularly with (quality) teachers and there will be chaos if the private practice is disallowed in medical college faculty which will resign. The three major teaching college hospitals of Mumbai Corporation largely run on the full-time system since my time in 1971 till date. AIIMS, PGI Chandigarh, and JIPMER Pondicherry run on full-time teachers. Nature abhors vacuum. The rules of engagement with people to join medical colleges as a faculty are rigid and their scope is narrow. For example, I served in the University of Newcastle Australia as a conjoint faculty for nearly six years. I taught nearly 700 postgraduate and postgraduate doctors in that period. This will not give me a post in any medical college in India even if I want to teach and think that I am good at it. This is an aspect discussed later in greater details while dealing with the institutional paradigm of medical practice, in my volume India’s Private Health Care Delivery: Critique and Remedies, published with this, in the chapter on Health Institutes and Voluntary Agencies. (Kelkar, 2021). More About the CHC Scenario and the Manpower Solutions The model which will unfold progressively in Chaps. 7, 8, 9, and 10 is a CHC-­centric model. The strengthening of the CHC above all other structures is the real solution to the health issues of rural India. In this volume, these centres are devised to grow far more than the government conception. It may not be apparent at this stage of discussion. Therefore, additional or rising manpower needs and from where to get it will continue to be an issue till it is made clear how to meet this challenge, in the succeeding chapters. We have discussed dysfunctional health care structures above. The largest manpower is locked and blocked by the PHCs. PHC functioning is not just up to the mark, it is dismal. The 25,000+ PHCs are too widely scattered, and maintaining them logistically is extremely difficult. Improving upon them is impossible since it is a narrow structure not capable of expansion. It was not designed for growth. Hence, one of the two major sources of getting the manpower to equip the CHCs is the PHCs. The other is from medical colleges, which has been discussed above in extensor.



Defence of Obsolescence PHCs are deeply ingrained in the psyche of the government planners and the activist thinkers. Therefore, this statement will evoke strong and widespread criticism, to the extent that people may refuse to read this volume further. The paradox till today is that the activists and thinkers keep on raising voice about the failure of the primary care and in the same breath come out with more of the same idea with the PHCs. It is particularly the insistence on community health workers being the axis with emphasis on strengthening the arrangement. National and international bodies do studies but do not go beyond more of the same and/or incremental ideas to solve the issue. I will argue this out in a later section and Chaps. 6, 7, 8, 9, and 10 on health care delivery system in this volume fully. Present issues of deployment, specifically with reference to doctors’ non-availability or shortages, are the basic arguments of this chapter. How it could be overcome by PHC closure will be shown later.4 In the 25,000+ PHCs, the majority have one medical officer present there and working. Technically the number is filled. IPHS stipulated the presence of one more in larger PHCs. But the PHC portfolio is so vast even in the smaller PHCs that the range of functions cannot be supplied by one more MBBS also. Appendix A will give the picture about this workload more clearly. I propose to liquidate the PHCs in phased manner and shift these medical officers with new interns and MBBS graduates to CHCs to man these properly and fully. There is no point in letting them continue where due to the sheer adversity of the work–time ratio and the poor infrastructure they are not able to deliver anything satisfactorily.

4  The problems of non availability of the doctors of different qualifications and experience in the required number are present in the corporate set-ups as well. To solve them is a far more difficult proposition, since that will require a complete and dramatic transformation of the corporate psyche, the vested interests, the unhealthy goals they are committed to, directly linked to the pay packets as well as the continuity of their services and so on. The corporate sector is dissected in great detail in my second volume published with this. It is far easier to do so as we suggest here in the CHC system and concept.



National Rural Health Mission, NRHM, and Indian Public Health Standards, IPHS: New Thinking About the PHC and CHC The NRHM and IPHS and the rest of the government thinking is to convert every fifth PHC out of 25,000 into a CHC with five specialists. This is the right thinking, however with few serious misgivings about the method, discussed below. This idea technically frees 5000 PHC officers from their duties as the PHC officers. The four medical officers of those PHCs not converted to CHC are to continue even when the new CHCs start operations after getting built. The 5000 PHC officers in the converted CHCs either have no place or should go to other PHCs till it is functional. In the 5000 + CHCs, there had been no provision for General Duty Medical Officers (GDMO) hitherto. NRHM/IPHS recognize the need now. I have argued that there should be more GDMOs than IPHS sanctions. Hence, the CHC-converted PHC officer would be the first such GDMO. Bane of Continuation of Erstwhile PHCs Under NRHM/IPHS NRHM/IPHS incidentally does not talk about wherefrom the five specialists are going to come either. There already are more than 5000 CHCs existing in deplorable condition, which should be first developed over years. To that the NRHM/IPHS planning is going to add another 5000 and then develop them, decisively neglecting the existing one. This in its turn will mean 25,000 more specialist positions to be filled in when the existing CHCs have more than 80% vacancies. The government has no idea or planning about where to get the extra 25,000 specialists from. This is the duplication and redundancy that follow the classic government thinking. While proposing this one out of five PHC conversions, no thought was given to the existing CHCs. Yet, both the NRHM and IPHS wish to continue PHCs. That is not the solution. It is ineffective wasteful multilayering. See the discussion on crowding of dysfunctional units above. NRHM/IPHS as in case of specialists do not talk about from where the GDMOs are going to come either. NRHM/IPHS do not specifically state as to what is going to happen to the PHC officers in the converted CHCs. In such a scenario, why should we then hesitate to put all these PHC officers, in the CHCs? Without them the number of GDMOs added per CHC will be just one. NRHM/IPHS specifies as many as four GDMOs per PHC with some



specialist training (discussed later and elsewhere) without specifying wherefrom they are going to come. The only way to achieve this is to abolish the other four PHCs below the newly developing CHCs which solves the issue of four GDMOs. If it is done, there is no surplus of the PHC officer cadre to man any other services. (See below.) This cadre has experience, however patchy, of ground reality. The wisdom of appointing GDMOs dawned in 2012, seven years after the NRHM document first came into existence in 2005. More details are given later in the volume. This is another incidental collateral reason for dismantling PHCs as I find it, notwithstanding many other a priori ones already existing. Much Greater Need for GDMOs In addition to 5000 CHCs, we have more than 700+ district hospitals which, in the scheme of things proposed here, must remain but need improvement in all aspects. We need the cadre of GDMOs in much larger number there as well. To that add 1066 SDHs in need of GDMOs. Once we decide to close PHCs according to a plan given in the chapter on PHCs (and closure of SDHs in a later chapter), no surplus PHC officers now remain to man district hospitals. And there is a need in district hospitals for them. For the solution of this issue, we need to do some mathematical modelling as to how all this graduate, postgraduate and intern output could be channelized in the public health services for the next three years for the initial priming once the PHC closure process begins. An additional source of manpower is the graduate of the AYUSH system for this gigantic task of fortifying the public health services. It will be discussed later. Compelling Factors to Shift the PHC Officers to CHC There are other necessities why these PHC officers need to be placed in centres of higher complexity like CHC or the district hospital. Any medical graduate in the absence of contact with continuing medical education at higher levels will deteriorate in his clinical skills and at times even in human attributes. Longer the years in PHCs, the greater is the deterioration. We should prevent that from happening. Another reason for this shift is the lack of diagnostic as well as the treating facilities at the command of such a PHC officer. All experience so far has confirmed hundreds of times over that the situation with respect to



these two is dismal, gets outstripped within a short period or is siphoned off. Whatever the reason, we have created a system where we are allowing a deteriorated service provider to continue to ‘serve’ the people. There is no chance of getting any better service. This is an unjust situation which should be eliminated. The overall ability of getting trained and retrained in these officers is unlikely to be optimal if they continue in PHCs. Be it for the poor or rich the effort of the system, again government or private, is to make every effort to continue to improve the services. All these issues can and will be solved if we think of the centrality of the CHC model as proposed herein and by placing all the PHC officers in CHC. Needless to say that the PHC officers will get all these academic benefits mentioned above just like the new MBBS joining CHC, irrespective of the years these doctors have served in PHCs. Their pay scale will not change. After one compulsory year, these PHC officers in CHC can then enrol for attending the NLE  entrance examinations for post graduate training and to help them catch up with knowledge. Under the National Medical Commission (NMC) the National Licentiate Examination (NLE) will come in. Should these PHC officers undergo the NLE before being declared as eligible? This can be a matter of debate and decision. Should NLE be compulsory if they want to enrol in PG courses? My take would be that they should. The modalities to shift them to the institutes for higher learning can be easily worked out. In any case there will never be a shortage of at least resident and general duty doctors in the system. On a positive note, if there are more hands at work, the CHC can be helpful in many other ways detailed later in the chapter of CHC. The First Proper Place for the AYUSH Graduates The graduates of alternative medicine should be given an honourable place to work in the public health care system. The defense for it will be found in the Appendix B, where all controversies related to AYUSH have been consolidated. We request the reader to refer to the appendix for all the details.



The Bedrock for Success of This Model: Teaching I am a believer that the solutions are always simple, however monumental the problem may be. Given little interest and a little sensibility, the arrangements mentioned above are eminently possible even in a large government set-up. For that we have to take care of all the measures mentioned above which as a fallout will help adopt this teaching model. The bedrock of the success of this model is the full-time 24-hour system of availability of general duty and specialist doctors and the paramedics. The role of the last cadre will be discussed much later in chapters to follow. Factors which go counter to teaching are discussed below. The Shortcoming: Time with Patients Today the entire shortcoming of the idea of the duty doctors has arisen out of the arrangement that they will not work for more than six to eight hours a day. This in real terms reduces meaningful care to zero. Residential CHC posting prescribes that they will be available 24 hours in their allocated departments and will have to be on the scene before a consultant is called. Below is a picture of how the care is delivered by the residents as a generic term. Prevailing Mode of Work The prevailing mode of working particularly in private corporate set-ups is of a protocolized working in wards for a few hours in which no knowledge of patients can be obtained well. It has developed into a transmitting device. The nurse to the GDMOs or the interns, the GDMOs or interns to the consultant, they keep transmitting any new information that comes in on any patients, however trivial it could be and could wait for the evening rounds. The phones are constantly ringing. This is followed by the instructions from the consultants back in the reverse order. There is no initiative left in any other hand to take any decisions on their own, reducing the presence particularly of the GDMOs and the interns to a mechanistic, disrespectful and demeaning status. If such decisions are taken by the residents, the management as well the consultants will loosen a barrage of angry words on all three cadres. There is no respite from this for any of these parties. No one can do any meaningful work like reading in a continuous manner or attending the clinical meetings for even an hour.



Rift Between the Specialists and the Residents The GDMOs or the interns are perpetually holed up in the duty room trying to learn the MCQ jungle. This is the reason why these two cadres, residents and the consultants do not wish to be in the wards for more than eight hours at best. Hence, the liberty and encouragement by the consultants to the resident cadre to take independent action and managing/ monitoring the more critical situations is possible only in a 24 × 7 system. Seeking help of seniors only at certain points of deterioration of the patient while routine care as prescribed continues is implicit in the arrangement. It is possible only when some liberty is encouraged among the residents or GDMOs. It is not given. These are the ways of training which alone will give us better-quality non-specialist consultants tomorrow. The surgical branches will never ask these two doctoral cadres, interns and residents to assist in surgery during routine or emergency hours. These doctors are also not willing to ask to assist because their duty time will overshoot. The intensivist may not assist them to do more skillful work like putting a central line or intubating a patient or take at least one round for teaching while managing. Training Without Strain and Its Benefits The training of these freshers (if undertaken) will continue without any strain on anybody once they are in continuous care of the patients of one or a more specialties for a couple of months in wards and intensive-care units (ICUs). Such continuous training in a discipline could substitute for the specialists if the latter are absent for a few hours or a couple of days. Every few months there will be rotation among them to another department. An MBBS or an AYUSH in charge of the patients for 24 hours, staying in the campus, will lead to the relief of the specialists and of their tensions and strains. This will give them time to dialogue and teach the residents about the why and how of the diagnosis and care. This will lead to less number of errors. The ward work will not remain a mechanistic transmission device but will be live and light. The quality of the judgement and competence will improve. It will increase the capacity of the consultants to do more work, conduct academic activities without getting exhausted. This will be touched upon later also.



When such a subordinate cadre is operative for long enough in a community, it also gains confidence of the community; not all problems need to be referred to higher centres, if a consultant is absent for a short while and initial management can always be carried out to stabilize and buy time to decide what to do next. The communities will accept that. It leads to the development, confidence and self-respect, improved self-image, of juniors. It is a great stand-alone gain. This will also break the bad habits and foul attitudes of the patients to create ruckus, baying for the consultant all the time and making everyone’s life miserable. Today there is no full-time system. That is why the model that has firmly developed today is of the consultant centred care. It is without delegation. This mould has to be broken ruthlessly by using full-time culture across the care givers. Making CHC a Vibrant Place to Work in In making this arrangement far more viable and vibrant, following are some points not covered so far:

1. There should be duly structured incentives, increments and change of grade the government generally is good at doing. But governments tend to pay poorly for all the three categories—MBBS, postgraduates and AYUSH—and the paramedics as well. Put otherwise the payment should be substantial for the doctors of each category to have some money in hand when they step out of this system to try their luck in the free market or the private system. 2. The pet and quick objection as to where the money for all this is given partly above and more answers will be given in extensor, in Chaps. 6, 7, 8, 9, and 10. 3. There could be a huge debate about whether the payment for MBBS and AYUSH should be at par or otherwise. I do not wish to opine on it at such a premature state of thinking where their very coexistence is being opposed. Once that becomes operative something can be decided; it should be honourable and not demeaning. 4. Consideration for placement should be extended much more scrupulously to women, young girls, recently graduated as MBBS or a ­graduate of alternative systems of medicine, who would like to work, earn and learn.



5. Gujarat has an exemplary record in this matter (Doctors from Gujarat in 2016 personal communication). Irrespective of whether people are trying to get in postgraduate courses or trying some other openings, each new graduate gets a letter of appointment at some specific place under standard conditions within days from the Government of Gujarat. This is going on for last several years. This is a system which the country could follow.5 6. There should be a well-illustrated career path during or after the compulsory general tenure if the doctors have preference for working in particular specialties. This will expose the graduate to the basics of whichever branch he wants to follow by working in the four major branches and also invaluably in critical care. Having the required number of anesthetists and/or people trained or well exposed to critical care in every CHC will be crucial to the reduction of Health Care Indices, or the Millennium or Sustainable Goals or what other esoteric goals and high-sounding declaration India will continue to be a part of. The other advantages of these arrangements are described below. The detailed reconstruction of the CHCs is given later in Chaps. 7, 8, 9, and 10 in this volume. 7. There should be a mechanism to guide the graduates in their career paths with the help and opinion of the consultants under whom they work. The individual inclinations of the graduates must be considered. 8. Unless there are able structures in the periphery, there is little chance that majority of the new ideas about care distribution and quality will work. This will receive elaborate description of details later. 9. The last but not the least is to understand that the load of complications that reaches the higher centres in government outfits arises at the periphery or the sub-taluka level, not so much in bigger towns or cities. The situation about the treatment and results in such cases at higher centres is hopeless and pathetic, mainly because there is a senseless load on them, the manpower is inadequate, there is no one to ask or to tell, professionals at every level do what they want to do, if they do something at all, or can do, till their golden hour of departure to their ­private practice comes. The only way to cut this load down is the powerful development of the CHCs described above. 5  In the same year, Maharashtra Health Department IAS officers sat on the appointment letters of a few hundred doctors, waiting for them to appear, pay and get the letter. The then minister issued these letters bypassing the IAS officers and appointed them directly.



The State of Teaching and Learning Ideas about this, today, are vastly different and sickening. There are two parties—the learner and the ‘facilitator’ (a much better term I would like to use than the term ‘teacher’)—that are responsible for what is going on. Thinking of the Entire New Generation of Doctors The entire generation of new graduates does not think the following: 1. The real learning is on the patients. They think that it is in solving MCQs or reading guides and notes but not necessarily the text books. 2. That it is so because such learning does not support their immediate and, for them, fundamentally important goal of qualifying for the postgraduate entrance and pass it.6 This is patently false. 3. That staying in wards longer, observing patients, seeing them as many more times as possible is not learning but is actually taking away their time to read in the duty rooms. 4. That this generation also thinks that in government system there is absolutely no learning once you graduate, which is not completely true. 5. It is fruitless to teach them, because they will never put it into appropriate use and in any case leave abruptly. 6. In addition it must be noted that the private set-ups for every conceivable and undesirable factor and reason have the protocolized working systems (mentioned above) in which there is no learning, something which has been discussed further in the second volume of the author, India’s Private Health Care Delivery: Critique and Remedies, published with this in the chapter on Corporate Hospitals (Kelkar, 2021). 7. Learning instruments like clinical meetings and so on are not useful. 8. There is no time to attend them without getting boxed from all sides for being absent in the wards (for works that could wait for a ­millennium, are trivial, hierarchically based, could be done by anyone else but strictly forbidden and so on, making learning impossible). 6  The all India NEET for medical entry has already drastically cut down the numerous and dubious examinations to a few. This will be reduced further from PG entrance test once the NMC makes the NLE a compulsion. The NLE content hopefully will not be based on memory power but on logical reasoning.



What the Facilitators/Consultants/Teachers Do and Think The seniors and consultants have no respect for or trust in the juniors, are unwilling to give any initiative for management to them, express severe displeasure all the time when they are on rounds for something being not done well or not understood or as having caused problems. But there is absolutely no teaching, which is the one thing to prevent such happenings. However, the consultants have no time for teaching. The consultants today as a species are mutated. Of all the abnormalities, one of the most damaging is that every psychic connection to teaching, every consideration for teaching, even the understanding that this is something they must do for the future, without getting paid for that, has been lost. The reasons are many. Consultants think that the junior staff is not interested in working, and that they come here to bide time, are unwilling to learn, are stupid, and are incapable of learning and it is completely wasteful to teach them. But I read the following in the above-mentioned lines:

1. I want to spend the least amount of time either in wards or with the juniors, utterly oblivious that they are paid for this time also. The idea that wards (or operation theaters or labor rooms are) their principal places of working is a knocked-out gene now. 2. The management systems are such that to stay here the least, just to ensure that their patient does not get into problems, is all that they will do. 3. This way I can look into secondary jobs (which give me some extra bit of money). 4. Or I will spend time with my family. I do not want any social circles, no bondage, and no obligations and others have no right on my time or effort or help, including teaching. This is a pervasive attitude not only in medicine but in the general psyche of our people. 5. Hence, the one legitimate place they could spend time in teaching, they will avoid and create facetious arguments mentioned above. 6. Most consultants, in their years of maturity or in their prime, also tend to think that parting with their tricks of the trade is to their own detriment; the recipient will move ahead or the consultant will become redundant. To mask that fear, they will unleash a tirade against the juniors in the wards and avoid teaching.



7. No one realizes that the system has raw fresh graduates who have by now become just a little familiar to the human body in health and disease. They are at their best possible theoretical knowledge. They need further facilitation. They have come to us from some other place, where they have not been taught. That is why they have remained ‘useless’. If I do not teach them, they may go to the next place in a short time. The next batch of consultants under whom they will work will say the same thing as we are saying now—these are useless doctors. The consultants are going to say: from wherever these graduates have come, they have learnt nothing, have been taught nothing, are stupid and are uninterested. 8. The graduates will get their postgraduate seats in a year or two. Since they have not been taught, they will be immature to learn the postgraduate subject. This is a generation which needs to be moulded, and those who have by now consolidated their learning must prepare them. You have to begin teaching irrespective of where you are. Everyone must teach wherever he or she is. 9. The hospital administrators, a part of the facilitators’ team (although they do not think so and are in perpetual warfare with the consultants) do not believe in facilitating teaching. On a deeper level, they have no conception of such matters, the pure ethical responsibility about these aspects. 10. They do not understand the highly significant impact the training/ teaching will have on the quality of care in the short run and  a longer period. Even when the administrators desire that it happens, especially in the corporate set-ups, but they do and can do precious little, actively, about that because they are mired in their own system of protocolized working. 11. Instead, the systems are run by vultures, the administrators that are looking for something which is not done according to the stupid protocols they have set up, be it private or government outfit. The hospital administrator is borrowed from today’s business schools, without realizing that treating consultants  do  things on a level much higher than that of the admin. 12. Many of these factors are operative also out of the fear that if something goes wrong, I should be able to get out of it and blame and frame someone else for that. Here the hospital administration and the consultants are playing the cat and mouse game or the snakes and ladders, and are looking for scapegoats.



In short, the medical profession has developed a complaining or whining tendency to incessantly comment on deficiencies and do nothing about it if a solution is offered. Teaching should be a part of the culture. Mere inclusion in the duty list will not help. The most important of teaching process is at the bed side and some other measures I will not go in to the details of.

When and How Do the Medicos Earn? Till such time that the system is moulding them, they should be paid adequately well for their sustenance and even nourishment on government salaries. It is a state responsibility. In the second volume on private health care delivery, published with this, I have stressed all along that medical education should be a state subject. It will now become clear why? It is when a graduate is being prepared at the cost of ‘state exchequer’, then only the state has a moral right to ask him to work, to partially pay back through his abilities to fulfil the needs of the state as well. By paying him well, the state acknowledges the value it gives to the education given, the value such a person brings to the welfare of the society through a highly specialized training in medicine. And as again repeated ‘ad nauseam, he must be provided with a proper environment, which will then solve the problem of our masses. It is inevitable today to know that the character desired in a medico will be available with few. Ability to do the work will be found in many. Developing the required human attributes by acculturation methods has failed throughout the human history. The only way we can get both is to put everyone in a system that has strength to mould the doctors as well as the paramedics. Will this compulsory route through CHCs after the internship as well as after the postgraduate degree serve as an obstruction to or disincentive for joining medical colleges? It may. Is it by itself a bad thing? No. Why not? There are several reasons. But then how are we to address that issue? The Anticipated Cycle: From the Entry to Exit Once it is well known that after 4 and 1/2 years the graduate will start earning adequately or even substantially for the next 2 to 6 years in the proposed public health centres, with or without entering postgraduation, it is a great reassurance, hence will not be a deterrent to join medicine at all. He may alternatively go for postgraduate studies for three years and then will have to continue to work under the mandatory three years, once



again in the CHCs. Thus, he will be in a closed system for up to nine and a half years, which is the situation today also, without any guaranties of quality living conditions  or a good pay but a certainty  for the two. Of these years, the doctor will be earning well for five years at the least during the CHC and the postgraduation period. Those who need huge money too early will know that this avenue will not pay for their greed for a time period longer than they would accept. They will drop out if there are no alternative capitation fee channels, which any way should be closed. It is a question whether the same system could be applied to those graduating and postgraduating from the capitation fee medical colleges. Once this system is established, those who really want to practise medicine with avidity will remain and come forward to join this route. The selection method NEET, now adopted, has already shown that it is capable of weeding out plain incompetents, physically, intellectually, temperamentally and emotionally ill fitted to the medical profession from entering medical colleges.7 It will relieve the system (as presently operating) from the load of cynics, schizophrenics, depressed and frustrated medicos. We must have competent but psychologically sound and good doctors as well. There is another category of doctors that we need in larger numbers and may not be easily available in the model that will continue to unfold in the chapters to follow—the community medicine officers and the persons of integrity—to move the skeleton of administrative side of the health care system. The answers about how it could be done will be given in Chaps. 7, 8, 9, and 10. In conclusion, CHC should be the central pillar of medical care in the public health and dysfunctional units should be dismantled to create a lean and efficient system. There are numerous other aspects related to these two ideas which will be the focus of discussion of the next five chapters.

7  One of the reasons the Sri Lankan system has produced remarkable health care is because 40% of them are selected purely on merit irrespective of the place they come from. The next 55% come from district quotas and such other avenues but the criterion is still merit. In bulk of the medical entrants in capitation fee colleges in India, money is the only merit. With NEET we are certain to achieve the baseline quality of doctors. The evidence for this is so convincing. It is elaborated upon in my second volume on private health care delivery, published with this one, in the chapter ‘Regulations and the Regulators’.



References Bapat Dr RD, Postmortem, Manovikas Publication, Pune, 2011. Wanigatunge, Chandanie, Clinical Pharmacology, University of Jayawadhanepura, Sri Lanka in a personal interview with the author December 2018. Rural health Statistics, 2014–2015. Rural health Statistics, 2012. TNN | June 11, 2018, 12:29 IST quoting Dr Ravindranath, general secretary of the association. Rakesh Prakash | TNN | Updated: February 05, 2017. Dissanayake Prof Uppul, National Hospital, Colombo, Sri Lanka, in a personal interview with the author November 2018. Dr. Rathnayake, Director Kandy teaching hospital, Sri Lanka in a personal interview with the author November 2018. Doctors from Gujarat in 2016 in a conference of National Medicos Organization in New Delhi, personal communication. The Quint, 25th July 2020, with inputs from PTI. Kelkar Sanjeev, 2021, India’s Private Health Care Delivery: Critique and Remedies, Palgrave Macmillan.


Primary Care, Government Planning and National Rural Health Mission

Preamble We have discussed the most major theorem of this volume, namely the de novo manpower deployment in the public health care system. This chapter and the subsequent four chapters will now describe and explain all the changes that ensue once the centrality of the CHC is accepted. It will be discussed from the bottom-up, most peripheral to the central agencies. This chapter will consider the major policy-related documents from 1945 till date. Particularly relevant will be the National Rural Health Mission (NRHM), the Indian Public Health Standards (IPHS) and Rural Health Statistics, 2012 and 2014.

Statistics and Functional Issues of Indian Public Health Care The statistics typifies the characteristics of the thinking of earlier governments as baseline. The new central government since mid-2014 is trying out many new ideas, particularly the newly declared Ayushman Bharat, the National Health Protection Scheme (NHPS), National Health Policy 2017, National Drug Policy 2017 and the controversial National Medical Commission yet to become fully functional. The quantum change that may take place and its statistics after these measures will take time to surface. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




The Sub-Centres: The Existing Structure There were 148,361 sub-centres (SCs) or primary health units (PHUs) in the earlier terminology, 25,020 primary health centres (PHCs), and 5396 community health centres (CHCs) (Rural Health Statistics 2014). The sub-centre is the most peripheral and first contact point between the health care system and the community (NRHM document 2012). The Sub-Centres: Manpower and Distances Sub-centre is required to be manned by at least one auxiliary nurse midwife (ANM)/female health worker and one male health worker (Park 2015). The concept of multipurpose health workers (MPHWs, male and female) was introduced in 1974 for the delivery of preventive and promotive health care services to the community at the level of SCs. Since 2012–13, the Accredited Social Health Activist (ASHA) and the Anganwadi workers have been formally included (NRHM, ibid.). SCs cover an average of 5615 population in plains and 3000 population in hilly/tribal/difficult areas. Average rural area covered by sub-centre is 21.02 square kilometres with an average radial distance of 2.59 kilometres and four villages. It would mean that each village has a population of about 1250. This in actuality is not so. There will always be remoter hamlets of 100 to 500 people scattered and a village or two which may be larger than 1000 inhabitants and may be nearer (Rural Health Statistics 2014). These villages need not be in a neat circle, and the distances may vary considerably which in rural terms could be large, due to communication and safety issues. In smaller hamlets, the number of functions to be carried out may be fewer since all health issues listed in the functions (see Appendix A for details of the functions) may not occur together. Whether it is one work or more, it could take as much time to travel to smaller hamlets. It would take more time if more functions have to be carried out. In a dense population that is nearer, the overall time could be much less. The distance-to-­ population equation is closely related to the work–time ratios with multiple functions. This may put a strain especially on the lady cadre of SCs. In such cases it is possible that remoter places may be deprived of attention and go unreported or falsely reported. Thus, distance to be covered is an important consideration in planning.



Sub-Centres: Multipurpose Health Worker (Male) The non-availability of multipurpose health worker (male) as the grass-­ roots health functionary is worrisome. There are so many national programmes for communicable diseases, with environmental sanitation, sudden disease outbreaks and their control, health education, and more than 40 other activities, all of which will be adversely affected by the absence of male MPHWs. During the past two decades, the number of male MPHWs has dwindled considerably. This is a long and in-depth course. Young men are likely to feel that their compensation does not commensurate with their training or are already making a beeline for the larger towns and cities. Many states have stopped this course due to poor enrolment and declaring the male MPWH as a dying cadre. Of all the posts available in 146,036 SCs for MPHW (male), the latest figure of the shortfall is 96,734 (Rural Health Statistics 2014).  easures Suggested by the Government of India M Government of India’s 100% financial support to appoint 9655 contractual MPHWs (male) in 16 states, with 200 high-endemic districts for Malaria and Kala Ajar, led Karnataka to start the course again with notable success in Assam and West Bengal also. Government of India promised to finance one contractual ANM for every MPHW it could appoint, as if this was the cause of MPHW non-­ availability. Most of the states could not fill up the vacant posts of MPHW (male). The male MPHWs are better suited for certain functions. Many more national disease control programmes were initiated in the 12th five-year plan. Their absence overburdened the available lady CHWs. Both male and female health workers especially at the sub-centres (SCs) in the tribal and other underserved areas are not available. Most of the National Health Programmes have limited success, which could be also due to non-­ availability of male health workers at SCs. To top it all, the relentless increase in the number of functions at the SCs continued. (See Appendix A.) The situation of any woman worker in any field, in the villages, hinterland, towns and semi-urban areas, is vulnerable. Absence of male workers will force us to find some other ways of keeping the health work on and keep the women safe at the same time. Few substantial ideas are discussed below and later in this volume.



Financial Maintenance of the Sub-Centres The Union Ministry of Health and Family Welfare is providing 100% assistance to all the sub-centres in the country since April 2002. There is a contingency fund provided @ Rs 3200 yearly. The expenses for drugs for minor ailments and equipment kits which are at the heart of functioning of the sub-centre cadre are borne by the centre with various other arrangements. A little thought will make two things apparent. All these arrangements are sketchy. These are constrained by the human resource availability and are primarily financial in nature. Financing has not solved the issue of manpower shortage as seen above. From 2017 onwards, under the Goods and Services Tax (GST) Act, the central government passes 42% of the collection to the states. This may help in bringing in alternative arrangements, for which further discussion here is not necessary. The IPHS-2007 also stipulated the availability of one MPHW (male) for public health programmes and two ANMs for maternal and child health care, respectively (IPHS-2007/2012, Rural Health Statistics 2012). The persistent efforts since then have led to increased number of ANMs in all the states as more ANM schools have opened; from 271 in 2007–08 the number of ANM schools jumped to 662 in 2009–10. Since 2012, ASHA has added a really significant number to the sub-centres (NRHM document 2012). Within that area, the Anganwadi workers had already been introduced to carry on some of the health activities. This is the model that is going on for the last 60 years with incremental changes or more of the same type of changes as the constant characteristic. Judged on the single criterion of unsatisfactory health indices, it is still not working optimally, much below it. Can this working environment be rationalized, or should something more effective/drastic be done to improve matters? In the sections to follow, I have elaborated on them to get a clear picture of what needs to be mended. The issues related only to the community health workers, a generic name for all the categories, are discussed. After that I will discuss in detail the NRHM, and have a discussion about the sub-centres to see how many of them are addressed in the NRHM, and about new things proposed to make the system better and its merits.



Work–Time Ratio and the Multiplicity of Community Health Workers Multiple people and/or agencies doing more or less the same job in the same areas is a common solution the government seems to offer, at least in the field of health. This is emphatically illustrated in tabulated form in Appendix A, which the reader is requested to peruse while reading this chapter. I call it multilateralism and multilayering. I was curious about the reason why it is done and asked a brilliant IAS officer, who is a doctor by qualification, to explain. This is what he said: Initially when a person has to be given work, a job profile will be drawn. It is complex. The government knows it cannot be achieved. But it keeps people engaged for some time. Since some member gets a job in a family, some equilibrium is reached. When the inability to deliver this work is discovered and agitated upon, the government adds some more people with more or less of the same profile of work in the same areas. That keeps more people engaged and peace and equilibrium returns. The peace and equilibrium are more important than whether the job is getting done or not. The Government does not bother about the overlaps, proper division of work for efficiency. Quarrels are bound to arise as to who should be doing which work especially if it is tied with incentives.

The following is the outcome of multilateralism, multiple agencies and authorities: the moment two or more agencies co-exist, the meetings, coordination and thinking time become exponentially scarce and continue to be so with each addition. There are then quarrels and skirmishes about who should be doing the task at hand and why every agency would like the other agency to do it. More people within the administration feel that they have a larger turf to guard, action or inaction does not matter. The number of agencies added in the scheme are many which I have not listed here. Community Health Workers and Primary Care The sub-centre-level arrangement of the community health workers, a generic name for all the varieties, is a classic example of what the IAS officer says in the aforementioned quote. This tendency has led to appointing additional workers at the periphery. Its justification can be and has been easily reasoned by the activists, who have supported such moves with the following logic: high mortality, morbidity in all segments of population, and developmental or deficiency indices need to be lowered. It is the



villages from where all the indices arise. Therefore, strengthening the village services by as many people or agencies as possible should solve these problems. Some of the examples of additions to ANMs, lady and male health workers as well as the village maternity attendants (in the past, now replaced by an emphasis on hospital deliveries) are Anganwadi workers, and occasionally an idea that teachers at the grass-roots levels and the self-­ help groups should be involved. ASHA, the Accredited Social Health Activist, has now been added. Individually, in any one village or a sizable close community the absolute figures of illnesses of these indices are relatively small. The absolute number of these indices will go up if we include as many villages as exist within a radius of 15 to 20 kilometres. This comes close to the radius of influence of CHCs. The next logical issue was, what if the early detection and treatment or prevention by CHWs in villages failed? The convenient answer the government and the activists have given and accepted is the PHC. This is and should be the maximum distance the poor people can and should need to travel to get the complication treated. PHCs, for reasons explored later, stand a failed model because it could not most of times fulfill this expectation. The subsequent chain of referral was no answer either and the indices continued to rise or refused to come down. This is the dilemma this volume primarily wants to solve. A Profile of How the Work Gets Done in the Sub-Centre Area The work–time equation and the demands from above are so skewed that the community workers have no time for the most important work they are supposed to do, that is consistent and persistent spread of relevant information at different levels on different subjects and instituting primary care. Hence, the performance despite several categories of community health workers does not improve. This issue is explored below.  eporting of the Work Done R As far as recording the field work in the daily diary there is no problem. After that the community health worker has to make different reports from the same data, for different and many sub-sections. Then they have to be sent online to all these departments. As many as 12 health workers share one computer, which may not be workable, or the electricity  or online connection may not be available, or the computer may hang  or would be very slow. The days for working on the computer are divided



among the workers. Sending all these reports is thus unnerving; the task takes away the time from the field (Kelkar P. 2013). More constraints on the working time are due to the weekly visits of lady health visitor (LHV) and the male health visitor from the PHC. The ANM has to somehow keep the records ready since weekly reporting is the norm. That reduces the working hours further. Then there is a surfeit of training and retraining, and supervisory work. After all this is done, or achieved there is no enthusiasm left for the work in the field (Kelkar P. 2013).  dverse Factors Affecting the Ground Work A There is a competition and fierce battles among the five or more different categories of community health workers for working or not working where the schemes are monetarily incentivized. There is some discrimination as to who has to finally do the task. All of them will want to get the benefit accorded, most of which lays in the family planning and safe delivery services. It also leads to uneven provision of other services. These situations, even if unclear at this point will be explained in much detail below. The suggestion from P Kelkar, a community health worker himself, is to make the whole range of tasks and reporting them a joint responsibility of CHWs and to give credit to all. Incentive for each successful task can then be divided equally. Even then the argument over who should preferably do the task will not settle. Except for financial credit no other credit will work. For further solutions, the reader is referred to the next two chapters. Target achievement has remained the criterion for the better part of post-independent India. It causes tremendous pressure at the lowest and other lower levels as the real work is done there. The results shown on paper are not the ones achieved, leading to undependable statistics and its fallouts. Target achievement and proper work are opposite to each other. Targets refuse to accept that geographical and seasonal variations as well as other pressing situations necessitate that some target works will have to be kept away for a while, which could result in lower-than-target performance. In case of lapses, these workers are publicly and badly insulted in meetings. The situation worsens when many other directorates order their work done on priority, especially in crisis situation, thereby setting aside the routine work. How do we remove this out of the system (Kelkar P., ibid.)? This situation has happened during the ongoing Covid 19, that is,



work taking priority over work related to tuberculosis, and even more so in universal immunization activities. This happenstance is also routinely observed in priority allocation to different national programmes as well, as will be shown later. This is a planning defect, not a shortcoming of the workers and certainly a skewed work–time ratio–related matter to which no attention has ever been given.  oo Many Unproductive Supervisory Levels T Lady and male  Health visitors are the immediate supervisors.  In Indian culture, supervisor is not a facilitator. The basic belief that develops in no time among the supervisors is that people are cheats and do not do their work properly or are incompetents, hence need upbraiding and filing of report against them; this kind of fear should be instilled. The supervisors teach or assist less but criticize far more. Most importantly, this attitude does not add to the actual working hands, and those who are supervised detest their supervisors. There is no trust between the two. Two such persons immediately above the CHWs are the weekly lady or the male health visitors. How these supervisory visits affect the actual working time is of both instructive as well as remediable for better work. As per WHO surveys: the LHV … spends 40% of her designated time in travel, 40% in giving medical care, 5% for paperwork and only 5% for what is her real work that is assisting the lady community health workers for better ante natal, post natal care, deciding on the one likely to need higher facilities and any other help she may need. (Park 2015)

The LHV will collect from the five or six CHWs statistics reported by them and give it to the PHC officer. The PHC officer may/may not read it but will send it to the CHC another supervisory, (read unproductive layer). From there through the sub-divisional hospital, it will reach the district health officer and from then on to the various concerned state directorates. Whether they will carefully collate the reports and read it properly is anybody’s guess. Hence, the reports that are finally submitted to governments are a mystery, to understand which some exploration would be useful.  igher Levels of Redundant Supervision H The health inspectors, the PHC officers and the officers from different health directorates also fall in this non-contributory supervisory cadre. Directorates represent the National Control Programmes. Over years the



number of such programmes has increased, and each has brought its own supervisory and urgencies. The higher supervisory cadre continues to grow with each layer. Their remunerations are higher. Irrespective of the number of national programmes that are added, they have to be finally and actually executed at the sub-centre level. The numbers and variety of CHWs has increased but the work distribution, the work–time ratio, is still skewed.  iscrepant Views: On Ground and at the Top D On the one side there are urgent local needs. What the PHC sees and the view the sub-centre workers have on ground and what the district and the state is viewing from a higher, helicopter view, are obviously many different visions of one reality. The same number of CHWs have to struggle with other large-scale disturbances in the community health like floods, draughts, small epidemics or earthquakes along with the routine work. The state may think that there are changing situations and urgencies where more pressure needs to be put for these works. One frequent reason for such orders, which the CHWs do not understand, is that it arises from the necessity of answering a question in state assemblies. The supervisory levels do not work side by side with them to do the actual work despite such a huge rise in the workload in such conditions  but just continue to supervise. These factors were outlined, and suggestions that doing away with as many supervisory cadres as an absolute must were made in an essay I wrote on Tuberculosis Control Program in India 26 years ago. The issue is that chronic (Kelkar Sanjeev, 1994). The Work Profiles at the Sub-Centre Level: Too Many Questions Need to Be Asked While the work  portfolio looks reasonable for a group of five to seven persons handling an average of 3000/5000 population in four villages, it is not such a simple matter. The actual list of the responsibilities is much longer and has further increased by about ten more additions since 2012 with advent of NRHM and IPHS, which we will discuss in a later chapter. Part of the reason, at least in Maharashtra, as to why the community workers have no time (left) is (probably) the vacant posts of district extension officers. The reason is a court case going on for 16 years over this issue (Kelkar P., ibid.). It is quoted to show that in different provinces there



could be plethora of court cases or some other situations  which may be hampering the achievements of CHWs or other incomprehensible reasons. The Long Arm of the State The state through the district directorates have to issue orders to the multilayered health structures below them. Can these be conveyed effectively and without trivialization, without losing the speed, thereby not losing the relevance? Certainly not! How speedily are the orders conveyed, or will the information demanding some new action reach each sub-centre? More pertinent to ask is if the information reaches after the relevance of that job is over. It is more than probable that this will happen. Reasonably speaking this is likely. How can then a new priority be juxtaposed while doing some of the more important routine jobs like the antenatal services, or DOTS and so on? Under such urgent directives, how will the PHC officer decide which out of all the programmes, different directorates are pressing for action and information, should the taken up in specific territories in his jurisdiction? Can the supervisory cadre balance between the two opposite pressures, routine and emergency by taking it upon himself a substantial part and helping the CHWs? Are they equipped for this mentally or intellectually? Can the PHC medical officer have the time and the wherewithal to understand and act upon such rapidly changing situations? Will PHC medical officer have the courage (time and willingness) to brush aside all the pressures, get down to the field and do only what the demand of the situation in crisis times locally is? The answer to all these important questions in the present structure is a clear-cut no, or that it cannot be done. Such situations are typically the plight of national programmes. Removing supervisory levels is a partial but a necessary action. It is time to recognize that a different structural arrangement is necessary, which is detailed in Chap. 10  of CHCs and the community health officer to be stationed at a group of CHCs covering a population segment of about 200,000.1

1  This is an averaged figure. Administratively, a block level is 100,000, but has exceeded now and may vary from 172,000 to 200,000 at the CHC levels as may be found in the later chapters.



The Random, Inequitable Remuneration System for CHWs The payment structures for the different categories of the CHWs are random, decided from time to time for the new schemes and workers. It seems to have never taken in consideration the payment structure of earlier workers. For taking a pregnant woman to a hospital for delivery, the transport cost to be reimbursed is not less than Rs 250, and for assisting the delivery it is Rs 200. The money is to be delivered to the worker after a post-natal visit, and after the child has been given BCG. She is given Rs 250 for a caesarian section after 42 days and completing the five compulsory visits after coming home, Rs 50 if a sick child gets well in a Special Neonatal Care Unit, and Rs 50 per monthly follow-up visit to an underweight child. A village health guide, admittedly less trained, but is needed for national programmes is paid Rs 600 for training and Rs 50 per month and a drug kit worth Rs 600 per year. The traditional birth attendant is given Rs 300 during training (Park 2015). Voluntary worker to keep the sub-centre clean and assisting ANM is paid by the ANM from her contingency fund @ Rs 100 per month (Rural Health Statistics 2012). Such questionable variance was added to with more  discriminations when the ASHA cadre was introduced. The ANM hitherto was to accompany the pregnant woman to the hospital for delivery, with an incentive tag attached to it. It was part of her job. Now it is expected that ASHA will do it and get an incentive. An ANM may also do it. The earnings of ASHA will come out of the incentives for doing this as well as other works for which there is no remuneration. ASHAs do not seem to get more than Rs 1000 per month (Ashtekar 2015). In the same area, a lady health worker is paid Rs 50 and an annual drug kit worth Rs 600 and a village volunteer a mere 100. ASHA has a performance-based package. ASHA’s work tends to be that of counseling, and is expected to be more articulate but so will all others’ work be. But the others are considered more of fieldworkers with a full portfolio than the counselors. Causes of Discrepancy Discrepancies occur because each new scheme is launched on the backdrop of a segment of social dynamic which has come in priority, often when a foreign fund gets interested. And while doing so, it does not/has not taken into reconsideration the existing payment structure in the different cadre of the health army. These decisions have been and are made ad hoc. For example an Anganwadi worker under another a scheme receives



Rs 1500 per month as pay (Park 2015). It is certainly grossly disproportionate to the others’ payments, which are quite low. On top of it, Anganwadi work is done for a sub-segment of a population which in general terms gets covered by the other cadre. A contracted nurse gets around Rs 10,000 at the most in Maharashtra, whereas a nurse who comes from the regular service cadre gets Rs 30,000, a discrepancy too unjust to be ignored (Ashtekar 2015). The serious wage disparity between all the categories of the CHWs should be ruthlessly removed and made equitable. There is no further statistical information of any payment/remuneration/award system. For ANMs, LHVs, health assistants and so on and MPWs I could not find any reference about payment. There could be a counter-argument that these inequities are more acceptable than not employing any. This is cruel. The peripheral workers do not think in the same manner. The important issue is the coordination of work, attitude towards each other, cohesion and avoiding the resultant fights and displeasure. There should be some limit to and concern about the arbitrary ways of handling sensitive issues like disbursement of money. In governments the right hand sometimes does not know what the left is doing. Schemes multiply, workers multiply, and discrepancies and disgruntled feelings mount causing heart burn. It is so well brought out by Ritu Priya in a massive volume talking about the dais in villages (Duggal R, et al. 2005). Such discrepancies have continued since none of the planners ever gets down to the reality of rural India to know what is happening there. These wounds caused by the planners fester but when the system becomes fully dysfunctional and gangrenous, no one knows where the original sore was and why did it develop. Since we are discussing the working of the sub-centres and its CHWs, it will be appropriate to discuss ASHA cadre in detail as she is the symbol of NRHM. We will then go to NRHM in relation to the sub-centre.

ASHA and the NRHM The idea of ASHAs was discussed within the health activist circles with great enthusiasm and mostly welcomed, as has usually been the case when a new idea comes from the government, even when some shortcomings were pointed out. The following dissection of the ASHA idea may look too cutting and unjust, may even be termed ‘wisdom’ in hindsight. Yet it asks some fundamental questions about the planning.



ASHA, the latest confounding factor now added, has as complex a work profile as the other CHWs. What exactly is the idea behind the addition of ASHA? Did she do anything that the hitherto CHWs and/or their supervisors, PHCs, were not doing or could not do? In the following text, I have isolated the NRHM ideas about ASHAs in discreet units and commented on them. Imaginative, Ingenious or Faulty Conceptualization? NRHM: Every village/large habitation will have a female Accredited Social Health Activist (ASHA). ASHA was chosen by and was accountable to the Panchayat—to act as the interface between the community and the public health system. If this is the case, then were all the other CHWs functioning without an approval tacit or otherwise, or knowledge, of the Panchayat? Were they or were they not the interface between communities and the public health system? These CHWs were accountable to PHCs. Why should ASHA be accountable to Panchayat and not PHC? NRHM: ASHA is supposed to promote access to improved health care at household level. What exactly prompted the idea? That the lady CHWs were not up to their jobs, hence needed an agency to promote the access? If so, were the causes for that explored and addressed? Did it still require an additional hand? Or was there recognition that the lady CHWs have so much to do that an additional hand was considered desirable? If it was additional help, then has the above work description shared the responsibility to lighten the work? Not really. Suffice it to say that ASHA was not conceived as help and share work but as another functionary but with a slightly superior profile which reduced the first-level older workers to a few more degrees lower in competence, and added one more partial supervisor or coordinator. We will see the answers below in bits and pieces which will help us to synthesize the picture. The final picture which will emerge in the table comparing the functions of each given in Appendix A will be revealing. NRHM: ASHA will be an honorary volunteer, receiving performance-­ based compensation for promoting universal immunization. The lady and the male community health workers also do this job. But ASHA will get the performance-based remuneration. Then why should these two worker cadres do the job since there was no such incentive but it was a part of the work? Why another agency is required, that too in such



a small microcosm? Is the logic defensible? In fact it introduced newer strains, strife and fierce quarrels in the erstwhile functioning cadre (Kelkar P., ibid.). The least is to acknowledge the error of its logic or oversight, or the piecemeal thinking. One cannot but get a sensation of offhand or indifferent way of making plan documents without looking back.  RHM: Referral and Escort Services for RCH by ASHA N The questions repeat: Was the lady community health worker and the dai also getting the incentive for taking the women to the hospitals for delivery? Yes. Then why add one more worker to share the money? Or was it the Janani Suraksha Yojana (JSY) the protection of (pregnant  mother) that found the dais or ANMs or lady community health workers not doing this referral and escort services properly? Was it because there was much less incentive and that ASHA should do it at a higher one? If incentive was the cause for inefficiency or sub-optimal performance, why was the erstwhile LHW not given it? Why introduce strife?  RHM: ASHA to Look After the Construction of the Household Toilets N This job was given in 2012, three years before the Swachha Bharat Abhiyan (Clean India Mission) gathered speed. The question then and now (but has never been raised in the health literature) is, whose job it is to construct toilets and coordinate the activities of doing it? I suppose it is the Public Works Department (PWD) or the Public Health Engineering (PHE) which is to do it. Why should ASHA run after them? Is it that easy to convince the village women first and then run to the PWD? No representative of either body is likely to be present in that particular village, but located somewhere else. Should she then run after them? Least of all does the idea and the logistics involved justify the addition of this worker for this new job? This need not be considered as such a unique function given to ASHA since the matters related to defecation and hygiene around it have been there in CHWs profile for decades. Toilets as a symbol of that is a recent happenstance. How was this tiny little girl to overcome the resistance of even the educated or well-off people, even more so the women who would consider open defecation as a social free mixing in the villages just three years ago? Earlier there was not even a whimper about this item of work. Today, since



August 2014, it has become a sine qua non of hygiene with a tremendous virtual backing to ASHA, who is getting defined by this work at this point. Granting that this was a unique idea, one wonders why the government before 2014 did not back her as is being done now. NRHM: Other Health Care Delivery Programmes to Be Looked After by ASHA ASHA is also doing the same thing as the others in this sphere. The issue of what has been achieved by adding ASHA will run through all the comments below and elsewhere. And what are the works? This is a prodigiously long list of over 40 functions, many of which are common with existing CHWs in the microcosm. These have been listed out and tabulated for different community health workers in Appendix A. We will discuss the more pertinent ones. It will thereby argue that  adding people will not solve the problems of implementation. The PHE and PWD, or the Programmes of Midday Meals, have designated people. There is no need to bring it in the arena of health and thrust them upon these simple workers in the name of inter-sectoral coordination. Nor is it necessary to bring the Anganwadi workers under the health department. Disparity of wages also does not justify anything about such forced mixing. (See above.) School health in curative terms is a function arising at the level of the PHC officer. Imparting education and looking after people’s immunization are common to all CHWs. National programmes, which are in shambles, are again a common responsibility of CHWs and ASHA. Similarly, the teachers from time to time are drawn in health care. Teachers are known to perform their main tasks badly and complaint galore. There are always quality and qualification issues about these teachers.2 Let them do their ordained work well enough. It is not a sound idea to continue prying on a failed group to show people that it is new 2  In Tripura, the norm of appointments for years was the unconditional allegiance to the ruling CPM. In states like Bihar and Uttar Pradesh, qualification was never the primary condition for appointments. In 2017, the chief ministers of both UP and Bihar removed a large number of these teachers. See the brand new National Policy for Education as well in Chap. 4 in this volume.



thinking. Health is not the only issue at periphery. Education also is. There is no realism in such ideas. NRHM: ASHA will be trained on the pedagogy of public health developed and mentored through a Standing Mentoring Group at National Level incorporating best practices and implementing through active involvement of community health resource organizations. NRHM has an amazing capacity to lump things together and making things incomprehensible in the first reading. Let me break it down. Unexpected danger signals start coming in from this statement onwards. NRHM: She will be trained on a newly developed Pedagogy of Public Health, What is new about it? Have not the CHWs been trained in this pedagogy for the education and the prevention of disease for years? Is education not the most attractive and sound principle of primary care? What was the justification in creating a new nationwide cadre? When the public health issues, work profile and the methods of addressing those do not change, what kind of new content is expected to emerge? This exercise of new pedagogy and adding new cadre under it is unjustified. NRHM: Mentored Through a Standing Mentoring Group. Thus is born another body in the milieu of multilateral, multilayered and multiple bodies supposedly doing a coordinated job!! It is a deception. I have already described the nonsense of more bodies being actuated; this will be more abundantly shown later. NRHM: Standing Mentoring Group Works at national level. Thus, in due course there will be State Standing Mentoring Groups, that is, more bodies at the state levels, and the above-mentioned objections will not go away. There is another administrative complication that arises here. When a large number of ASHAs have to be trained year after year and then mentored, through another agency at the national level, it cuts across so many administrative systems. The moment somebody is going to be mentored nationally, the states will call it good riddance. If the states are asked to do something like this, there will be no interest, since it is not the states’ idea; then there will be demand for funds if it has to be done by the states. What is so special for ASHA? Why should the other classes which have served the population for so long, and are also legitimate beneficiaries of this mentoring, not get opportunity to learn the ‘New Content’? In December 2018, ASHA was more than five years old. We have not come across any assessments of whether this cadre has made any difference



at all so far. Going by the mortality indices, the change is marginal. Having started, all that the government has to do after five years is to say that this has not worked fully satisfactorily, hence we are bringing in new measures, that is to say new cadre. NRHM: Incorporating best practices Mere words, the now-trite modern business language! The governments have tried to inculcate examples of best practices found in 50 years of primary care. The erstwhile CHWs try and incorporate them as best as they can or are at least aware of them. The measures required are different. Instead, NRHM goes in for some new ideas, represent the functional profiles not much different or bring in more structures which in turn are an opportunity for many more who can be assigned to work. NRHM: (Best practices) implemented through active involvement of community health resource organizations or as said elsewhere in NRHM document, actively worked through them: The absurdity and danger signals now begin. Community health resource organizations have not been defined clearly in the NRHM document. Just look at the number of committees in a small village which the NRHM wants to work together: vigilance, health, planning, sanitation, water supply, mahila mandalis (women’s conclaves), community health resource organizations; anything to be done, a committee! Most of these are not the community health resource organizations the NRHM has in mind. These are in addition to the many which I have described below. But people generally try to get their work done through a Gram Sabha (village gathering for work). The stark reality is that the Gram Sabhas are generally poorly attended (PRIA 2006). Or people have to get work done by some other means. There is relatively little expertise available at such micro level about the issues. The resources to address them are concentrated somewhere else, like PHEs or the PWDs. How much do we expect to be accomplished from the conglomeration of the committees in resource poor micro communities? Then at last, when nothing seems to be achieved, it all comes to the really functional and effective units, that too of women—the self-help groups, or SHGs—which are drawn in. They are non-government. They achieve, they deliver. They do not look at the face of government but manage their own finance. Are we going to learn to leave them alone in their success, or by dragging them in our failing work, spoil their achievements and still fail in ours? I certainly and do mean that SHGs should neither be drawn in nor be involved in solving the health issues. Whether they can or



cannot do it is not the argument. The betterment they bring to their families will help them to improve the health of their families more than any other health measures can. NRHM: ASHA will facilitate preparation and implementation of the village health plan, along with Anganwadi worker, ANM, functionaries of other departments, and self-help group members, under the leadership of the village health committee of the Panchayat. I do not think the utter absurdity and futility of this exercise needs any emphasis. Each constituent group will have a baggage—complaints against Anganwadi workers, midday meal problems of food poisoning, SHGs busy with their own, or the people who do the village health plan having their own difficulties about making one. How will such disparate or dysfunctional groups come together, or how can we expect that the little girl whose training period was just 23 days (NRHM document 2012) will be able to bring them together to make any plans at all? In the name of democracy we have merely given rise to certain sacrosanct ideas like involving the last man or in the name of primary care at the lowest level and the Panchayati Raj. Criticizing them is politically incorrect, indecent. And yet they do not seem to achieve what they are supposed to. I will deal with Panchayati Raj at a few other places in this volume. NRHM: ASHA will be promoted all over the country, with special emphasis on the 18 high-focus states. The Government of India will bear the cost of training, incentives and medical kits. The remaining components will be funded under Financial Envelope given to the states under the programme. The acronym ASHA seems to have fascinated those who drew up the NRHM document, the Sanskrit/vernacular word/name conveys a sense of hope. The earlier cadre did not have such a name. Then the sketchy performance of the older cadre which had not improved beyond a point needed some idea to infuse the enthusiasm. Once this was accepted, the vigorous promotion followed. However, the final work profile that emerged was not in any significant way different compared to the CHW cadre. This has resulted in injustice to the older cadre which has worked in the system for 30 years or even more, as pointed out earlier. It never got this kind of boost that ASHA, just about five years old, did. This needs correction. As regards the financial envelop, we will see below the uncertainty of transactions under the Panchayati Raj institutes. One suggestion is to convert the various cadre names in one common name—ASHA; remove the wage disparities and make the work profiles



identical with a common financial incentive system to the whole group working in a community. NRHM: ASHA will be given a drug kit containing generic Ayurveda, Unani, Siddha and Homeopathy (AYUSH) and allopathic formulations for common ailments. The drug kit would be replenished from time to time. Those who thought of it either do not know that it is an old idea and what happens with it or think that by including AYUSH drugs they will be hailed as the path-breakers! Adding AYUSH formulations need not be viewed as touching the people’s faith and adding an effective arrow to the armamentarium. It has many inherent risks which are described in detail in the chapter on PHC next. This idea should be abandoned fully. There is a monumental allopathy drug supply chain that has to go from the state or medical colleges down to the sub-centre, totalling to thousands of entities nationally with variable requirements. The logistics includes availability, procurement, and timely and wide distribution of hundreds of thousands of products to thousands of ASHAs and CHWs, and replenishing them every week. The status of this chain is highly sub-­ optimal. It will be the same with AYUSH drugs with many more dysfunctional features added. Reorganizing it will be discussed in detail in this volume. NRHM: Induction training of ASHA is to be of 23 days in all, spread over 12 months. On the job training would continue throughout the year. The structure, content, language and techniques or the names of training methods have now fairly evolved from the days of CHWs in 1970s. The need is for some common content of moderate duration for all cadres in SCs. The training quantum or the number of days and so on should be applicable to all peripheral sub-centre workers. NRHM: Cascade model of training was proposed through training of trainers including contact plus distance learning model. Whatever the method, the trivialization of the content as it travels peripherally is a reality. The question of discrimination will arise again if the training method and content is claimed to be new. The same questions will repeat. Would it then be available to the older cadres of the community health workers? NRHM document mentions nothing about it. Or is it that everything is only for ASHA and no other cadre? The description of how ASHAs will be trained is demanding and gives rise to two small apprehensions. The machinery for training already exists.



We hoped that newer machinery and more bodies with it will not be created. The hope is dashed (see below.) Does the government know that the training of an MPWH (male) is over 18 long months and is much more intensive/extensive? And that his place in the hierarchy of payment structure and career path does not justify compared to his training!! NRHM: Training would require partnership with non-governmental organizations (NGOs)/Integrated Child Development Scheme (ICDS) training centres and state health institutes. The latter two alternatives do make sense as these already exist in the system. The one of NGOs does not. The NGOs span from the international to national to the lowest levels. Throughout the NRHM document, we find repeated reference to involvement of NGOs. Most of the NGOs that can teach will be found among Christian health care chain. Bringing Christian influences in has been the characteristic of UPA I and II under Sonia Gandhi. The health work of Christians is exemplary but the conversions, encouraging secessionist tendencies, violence and creating rift in the social groups through it, disrespect and contempt for native traditions are too dangerous to be allowed in health also, particularly at the lowest level, under plea that not many others are capable of this. There is no need for such an act since there are enough and more resources within the government set-up which can do the job easily. The only likelihood is that these could be pretty dysfunctional and improving them in a proactive behaviour is all that is needed and is eminently possible. The issue is discussed much more in detail in the chapter on voluntary agencies and health work in second volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one, which the reader is requested to refer (Kelkar, 2021). The NRHM document 2012 covers a much wider range of subjects, actions and ideas not only about the sub-centres, PHCs and the CHCs. The latter two are subject of the chapters to follow. The other ideas about the sub-centre working will now be taken up for discussions.

More on Financial Arrangements for Sub Centers Under NRHM NRHM: It is to fulfil the government commitment to increase public spending on health from 0.9% of GDP to 2–3% of GDP over years to follow.



For years after the first declaration of NRHM in 2005, there was no budgetary provision. That had come under criticism. In 2012, the government was nearly bankrupt due to corruption. From where would it have provided funds? Compared to that, the Ayushman Bharat reaches out further than NRHM did and continues to do so efficiently. It is also discussed in my second volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one, which the reader is requested to refer. NRHM: Each sub-centre will have an Untied Fund for local action @ Rs 10,000 per  annum to be deposited in a joint Bank Account of the ANM and Sarpanch and operated by the ANM, in consultation with the village health committee. Again multiple players! In addition, it meant a bank transfer to 146,000 sub-centres. The government could not launch a mass-scale opening of the bank accounts, of which the successfull Jan Dhan Yojana was a new avatar. How could this be achieved and who could believe this? What if the ANM or the other parties change? What if the ANM is bullied into signing by the Sarpanch? Will such untied funds poured in a non-­ performing system solve our problems or will they prove to be a siphon? NRHM: Strengthening the sub-centres through an untied fund to enable local planning and action and more MPHWs. Is this the second channel to siphon? In the same breath NRHM says that it could be utilized for (employing?) more multipurpose workers (males). But they are simply not available. NRHM: Integration of vertical health and family welfare programmes. There is a terminological confusion here. Health and family welfare programmes is one unit related to family planning, and related activities. By concession we could add all the different nomenclatures of Mother and Child Health Programme, Reproductive & Child Health (RCH) I and II, the Janani Suraksha Yojana and the Pradhan Mantri (Prime Minister’s) Safe Motherhood Scheme to it. Integration of all this will be mere words but they will run as separately as they do now. Such multiple schemes in the same area have been added for minor additions/deletions, a populism gimmick. True integration can happen when all such similar schemes are merged under a single name, single cadre, single protocol and single common higher functionary that is the community health office, as suggested in this volume later. The proposed integration needs decentralization and horizontalization cutting the long vertical arm of the delivery chain. If there are no structural changes in the exceedingly long vertical arm of health



care, then these are words meant to fool. Within NRHM there was no clear indication of how it was to be achieved. (See later.) The reason why so many schemes operate is because each one carries a tag attached with something which they would like to preserve for posterity; hence, true integration will never happen. These concepts should be applied to the National Control Programmes in particular without which good results will not be obtained. It is also one of the major arguments of this volume. How to do that will be discussed in Chaps. 7, 8, 9, and 10. NRHM: It seeks decentralization of programmes for district management of health and to address the interstate and inter-district disparities, especially among the 18 high-focus states. There is no mention about how this decentralization will occur. In the present form, it serves mostly supervisory or conduit functions and corruption. This is a complex issue for which the new model proposed herein will be the solution. NRHM: Sanction of new sub-centres as per 2001 population norm (are there new norms after the 2011 census? is not answered in 2014 Rural Health Statistics) and upgrading existing sub-centres, including buildings for sub-centres functioning in rented premises will be considered. Since we cannot run the existing sub-centres well, we have no right to promise new sub-centres. NRHM talks of upgrading existing sub-centres or transferring the sub-centres running in rented places into their own buildings as be wiser and will save enormous money. The latter in particular, including buildings for sub-centres functioning from rented premises, means creating assets in an ultra-rural reality which are quite useless. NRHM has proposed 56,000 buildings for that purpose. The woes of the sub-centres are different as pointed above. They want a solution for that. New buildings are not the solution they are asking for. If at all one has to create the assets, money should be spent on CHCs as the central pillar of the health care. For asset development, PHC is not a good candidate either and certainly not the sub-centre for the four or five villages. The sub-centre and the PHC operate more or less like a day working centre. There are no treating facilities for a patient who becomes ‘sick’ enough to need admission. The many more reasons of PHC failure will be discussed in the next chapters.



NRHM and Its Thinking About ANMs NRHM: ANMs at the sub-centres are to be strengthened/established to provide service guarantees, in 175,000 places. The situation of ANMs and staff nurses vis-à-vis the NRHM proposal is as follows. The sub-centres already existing are more than 143,000 which have to be increased to 175,000. Presently, SCs have 11,191 vacancies (Rural Health Statistics 2012). To this total of vacancies 32,000 more will get added, and if just one ANM, and not the other four or five CHWs, is to be present in each sub-­ centre, what is being attempted to be achieved? . The current central government, from 2014 onward has picked up this idea under the Ayushman Bharat or the National Health Protection scheme by declaring that there will be well-functioning 175,000 wellness centres under it. This is old wine in a new (that too a little leaky) bottle. Ayushman Bharat is discussed in detail in my second volume on private health care in the chapter ‘Health Insurance, National Health Protection Scheme, Public Private Partnership’, published with this (Kelkar, 2021). As mentioned above, there is one more ANM post to be conditionally filled by the states agreeing to appoint her on contract basis as part of a block (level) cadre. That will push the number up by 44,000.  If the additional ANM is to be a part of the block-level cadre, some questions arise: Will she work at the block level or will she also work in the many sub-centres a block has? Who will decide where she should work and will it lead to frequent location changes? Once accustomed to work at block level, the ANM may find it difficult to relocate her in sub-centres. NRHM and the logistics or details adequate enough for any idea proposed  do not go together. NRHM has also made this ANM appointment conditional to the state by appointing one MPHW (male). This cadre is already in serious short supply due to falling interest. Then how will this deployment occur in numbers needed at the periphery? All in all, this looks to be a faulty design. NRHM: The ANM remuneration will be extended up to a ceiling of Rs 7000 per month. NRHM wants it to be controlled by the District Health Mission (DHM). This will add further to the wage disparity detailed above. It will further affect the working of the many different cadre at the most peripheral levels. Even if as a policy matter NRHM was to say that the CHWs will be upgraded into a single ANM cadre over time, there was substance to this idea. It must also be noted that the ANMs have a rather restricted portfolio compared to the CHWs (a term generically used here). These functions



are also predominantly carried out by the CHWs. Since the emphasis now for some years is on the institutional deliveries, one part of the training of ANMs, home deliveries is taken out. There will be more duplication and redundancies and crowding of health workers with all the other factors and ill will discussed above. If such was the idea and the salaries government is ready to offer for the additional ANM, it would have created enthusiasm in the last of the CHW cadre to become ANMs. It would bring more money to remote and peripheral regions. As would be obvious, the government would open a new avenue to get these CHWs to become ANMs, which in plain terms means wholesale corruption at the time of appointment. This idea would finally be quashed by the bureaucracy by saying that this addition being conditional to the appointment of one MPHW (male), it cannot be done.  And the MPHWs are nowhere in sight.  This DHM is another new entity that NRHM seems wanting to form or rope in if it exists. (See later.) Given the overall picture, matters do not seem to merge with each other seamlessly to give a composite idea. Issues in Recruiting ANMs The private and government nursing and ANM schools produce annually over 197,000 “trained” people. Karnataka has a 25% share and a small Union Territory of Puducherry has 7% share while Bihar has a 0.4% share. These figures are indicative of severe discrepancies between the population to general nurse/ANM output. It also reflects the status of women by the Bihar figures. It also means that we have enough ANMs who have been certified by various agencies,  the  quality of which  is something we will never know in adequate detail. The question for consideration is about the not-so-good ones. The preponderance of these schools in south does not indicate that the output is 100% of the South Indian girls and boys. North including Jharkhand and North Eastern states like Tripura and Manipur is substantially represented in the ANM and the General Nursing schools largely in Hyderabad. NRHM is hopefully aware of these sources for ANMs and graduate nurse midwives (GNMs)  training. These ANMs  thus may not belong to states where there are shortages. That is one difficulty. One of the reasons for failure of recruitment of ANMs or GNMs mainly in the government trained  from any source is the demand to complete certain ‘informal arrangements’ with the recruiting officers which many households may not be able to afford. This is amply testified to me by a number of nurses/ANMs from Manipur. How is the NRHM going to manage it in state by state vacancies sub-centres upwards?



NRHM must be seized of the situation of a large numbers of sub-­ standard schools, deficient with respect to attached hospitals, deficient of patients to learn on, poor infrastructural and academic facilities, and generally poor standards. Is NRHM banking on this output also to fill the vacancies? It is not safe to employ these people on the basis of certifications alone. It would be a good work if the NRHM strongly mentions other bodies under the ministry which are supposed to deal with ANM training. These agencies must take steps to improve the quality of the output irrespective of whether they are run by the government or the private agencies. It should have the power to close highly sub-standard schools beyond redemption, if found. I did not find any steps for quality control or closure of such schools outlined in the NRHM document. In the New Policy for Education, the quality aspect is considered seriously; how much can be delivered and obtained in this regards needs to be seen (National Policy for Education 2020, GoI). Filling the vacancies is one aspect, getting quality worker is another. Except a mention of skill development at half a dozen places in NRHM, there is no other suggestion as to how quality is going to be achieved—no mechanism at least in NRHM’s conceptual kernel. There are certain key issues about the whole idea of the skill development which need to be addressed. They are discussed elsewhere. NRHM says that the ministry has already initiated the process for the upgradation of ANMs into skilled birth attendants (SBA). See how the piecemeal, paradoxical and self-contradicting the thinking is. For so long, what were the ANMs, if not better skilled birth attendants, compared to traditional dais at least in terms of training? The traditional village woman, the dai, was trained and upgraded to become a skilled birth attendant. How do we understand this contradiction? How far can it go? Applying forceps or vacuum extractor? Are they expected to remove placenta stuck inside after the delivery, which even the medical officers will not so easily dare to do. Or is it an admission that the present state of training of at least a substantial segment of ANMs is highly inadequate and that the upgradation is needed in the most basic function the ANMs have been expected to fulfil? What follows in the next statement is a height of contradiction and grandiose stupidity.



NRHM, ANMs and the Nurse Practitioner: A Colossal Misconception NRHM document mentions, on page 63, upgradation of ANMs to nurse practitioner. Upgradation has any meaning if the basic learning is sound. The real task is to first make the basics better. With bad ANM schools we cannot achieve that. NRHM document further states that short-term programmes are needed to upgrade skills of nurses and ANMs. The aim is to train them as nurse practitioners for those centres/regions which potentially have adequate nurses, but have a chronic shortage of doctors over at least two decades so that they could take over some of the functions of the doctors. The main question will be, has the NRHM found that there are two distinct classes of ANMs, that the first class is so poor that it needs to be trained as skilled birth attendants and ward work first, and the second class is of the really good ones. Which one or both will go for learning higher functions to substitute for doctors? Adding programmes when the basics are (likely) to be just too inadequate or not right is difficult to understand. The faulty logic is elaborated below. NRHM mentions the places where there are adequate nurses but not doctors. The implication is that the ANMs will be trained to become nurse practitioner bypassing the registered nursing cadre. Doesn’t the government understand that the nurses are far more equipped to be trained for nurse practitioner than ANMs? With absurdity the idea is also unjust for the registered nurses. This speedy journey from ANM to nurse practitioner is highly questionable. As it is the ANM skills are limited, particularly in the wards. The priority area should have been to improve these standards. Further skills will come much later. If ANM has to enhance her skills from her present level, the correct manner to do it is to first go through general nursing and midwifery (GNM) training or getting a BSc Nursing degree. After a few more years of working as GNM or BSc Nurse in the wards, they should then be getting exposed to ICUs, trauma units and operation theatres if they are found to be really good. She could then be selected, if found really well trained and experienced for the nurse practitioner training. These steps are totally bypassed here. Such speedy decisions will prove costly in the long run. We may be defending and legitimizing not only their doubtful qualification but also the innate ability they may not have, to undergo the subsequent intellectual challenges of becoming nurse practitioners. Moreover, a person trained to such levels will refuse to go to a place where doctors are



deficient. Such a place without doctors anyway will not have any worthwhile work either. In the entire pubic health care system, there is no concept of even a high-dependency unit, a concept elaborately discussed in the next few chapters. What work will develop there for this practitioner? Such a well trained nurse will have such high demands for the complex work for ICUs and trauma units in cities that she will never be able to go to areas without doctors. I have also discussed elsewhere the absurdity that goes by the name of a basic or a short-term doctor. This is another form of it. Psychologically, a GNM is accustomed to working, even boldly, on her own in presence of the doctors. On her own she will find it scaring. Unfortunately, the media and the pundits have lauded this idea. It has probably been borrowed from the enticing picture of ICUs in the US or such other developed countries where these nurse practitioners practically look after the ICUs. That in plain terms is to reduce the cost of more doctors in such developed countries, nothing more. The unacceptability of such proposals lies mainly in the vast training differences between India and the developed world and not costs. The problem we are stuck with, first and foremost, is how to relocate the doctors and not producing the nurse practitioner. Even the governments are enthused by this idea. An officer on special duty for the education minister of a state enthusiastically spoke to me saying that his minister is also excited by the idea. When the above logic was presented, he became reflective. Without wanting to be uncharitable to NRHM, the least that can be said is that there appears to be some fundamental conceptual confusion of these two versions of ANMs going in opposite directions. I will write below extensively and later about the way reorganization of the ANM training should be done as the first step.

NRHM: Effective Integration of Various Agencies NRHM: Effective integration, preparation and implementation of an Inter-sectoral District Health Plan prepared by the District Health Mission, (DHM)  including safe drinking water, sanitation, and hygiene and nutrition: First of all, why a new District Health Mission should be formed at all, or roped in if it is already there? Why multiply multilateral authorities? Why not use an agency already existing in the health ministry or other concerned departments in each state? We have been hearing about this famous inter-sectoral planning since 1985–86 as wisdom coming from the WHO. It arose first in the famous



1978 Alma Ata Conference. Alma Ata was not particularly focused on health as many may believe. Health was a small part of the agenda. Drinking water, sanitation, and hygiene and nutrition already have separate mechanisms to address the issues. As seen above, there is no need to place the poor health worker at the centre of coordination with all the other departments. Why should we make these departments responsive to ASHA or her to the departments? Why should they not be doing their work effectively and on their own? Why should the state and the department under which these services  are, not compelling them do it? The above arrangement will provide these departments excuses not to do the work and stay away from their general responsibilities. Will they be so kind as to listen to this puny health worker and do a better job? No. Such involvements are like three-­legged races, where no one can move with one’s own speed and no common speed can emerge either. It also makes the decision process unnecessarily lengthy and complicated as shown above with zero outcomes. What probably would be more justifiable is the coordination between the water and sanitation people with those laying cables for digital India or electrical cable workers with the Rural Electrification catching up, so that the same road and places are not dug often. Such an undertaking will also delay the implementations of each department to some extent but may also reduce the contract costs and once started will be finished much faster in one digging. In today’s digital world, such coordination is simplified and speeded up if one does not mind the reduction it causes in the contract costs.3 The fascination of the inter-sectoral cooperation through the health workers for health should be given up, once for all and in toto. NRHM: To help the states achieve inter-sectoral convergence, appropriate guidelines would be issued to the districts. Inter-sectoral convergence should be removed from all health thinking as shown above. Issuing guidelines year after year as is common in health does not serve much good purpose. It only makes people feel guilty and terrified if they cannot follow these. The zero is being invented again to give more work to some more people. That is all it will achieve. This is just spinning word webs to appear as evincing the new wisdom. It does not address the main maladies.



NRHM: Developing Capacities for Preventive Health Care If one could be blunt and ask, what has the huge capacity of primary care apparatus and its workers been doing for so long, if not to improve the habits of the people, which nowadays is called the lifestyle? This is just sidelining the fundamental unsolved problems which we will continue to see in this volume. And from where can more capacities be brought? There is no answer to this. NRHM wants to develop and deploy preventive health care at all levels of health care and promoting healthy lifestyles. Tobacco and alcohol are the major issues. I will discuss its relevance at the sub-centre level only. These ideas add to the pressures, impossible to cope with at the sub-centre level. It will not meet with an enthusiastic attitude to do more about it at any level of public (or even private health). Here the concern is about the gross health indices, mortality figures and the faulty health care delivery system as our prime problems. Let us do that well.  RHM: Reduction in Consumption of Tobacco and Alcohol N Admittedly, the oral cancers are a painful and disfiguring problem. Before we start its detection among the poorer people at community level, we must ensure that every possible treatment modality can be made available in public health to treat them. This is the case with any common malady with or without lifestyle issues. This precisely is absent. Hence, more work to CHWs should not be added.  Instead of pushing it in CHW work, it might be better to develop a consensus among many of the cancer societies to think through the problem of early detection. A lot of preventive and educational activities are done by cancer societies in different parts of the country. No coordination with them is mentioned here. As far as I know, this side has not been explored. What is needed is to make the life of the community workers easier by all means and not adding to it more work.

NRHM and the Panchayati Raj Institutions in Health at Sub Centers NRHM: The Panchayati Raj Institutions (PRIs), right from the village to the district level, would have to be given ownership of the public health delivery system in their respective jurisdictions. Community action is the



only guarantee for right to health care—putting community pressure on health system. I have a lot of reservations on this idea of handing everything over to the Panchayati Raj Institutions. The process of village health plan at the village level under NRHM is characterized by too many people representing these bodies (as shown above) getting involved in it for doing what they least know about. Health care delivery during a health problem is all that the village people know and ask for. None will have an adequate idea as to how it gets delivered. Nor will they know why it cannot be delivered with the existing apparatus. The unauthorized people and quacks do not have power to set right the big deficiencies— namely, medical manpower, infrastructure, equipment, paramedical availability, medicines, competence, burden of excessive work, referral system defects and so on. Nor can handing over matters to Panchayati Raj Institutions achieve anything as these are also beset with the same difficulties. If the Panchayati Raj Institutions (PRIs) get power to dominate and demand health care which the available medical men cannot deliver, the cascade of events will not remain in the roads of legitimacy of demands and cooperation. This would be particularly true at the sub-centre and the PHC level and the consequences will not be savory and become gorier at the CHC levels. The spate of attacks on the doctors even at the level of medical colleges and at other places since May–June 2017 is a testimony of this possibility. Panchayati Raj: An Evaluation The elected representatives may have a little better knowledge of their situation but may have uncertain ability to plan for their villages. They may not have aptitude or understanding about coalescing village level plans to higher and higher levels. The bureaucracy has to do it because it is used to doing it. Even at the Zillah, or the district, and the state level the seamless integration of the plans at higher levels is a technocratic mission. The secretaries to the Zillah Parishads paid by the government are not enthusiastic about working under PRIs, unwilling to locate themselves in places other than their own. Whenever a parallel body is created to do what an earlier body was doing, one of them has to become defunct and/or disinterested. This multilaterality, multi-authority or multi-­coordinating parallel hierarchies are detestable. What will we achieve by transferring health care to a body which cannot look after itself and does not have the human resources within or is bereft



of the expertise which resides with those who hitherto managed the health care? The National Finance Commission (NFC) and the District Planning Committees (DPCs) are the principal regulators of funds for Panchayati Raj Institutions. These will or have probably changed or dismantled after the planning commission has been replaced by the National Institution for Transforming India (NITI Ayog). The District Planning Committees (DPCs) are ineffective or disinterested. Therefore, whatever integration has to be done is finally done by the state government to be sent to the central government. Till Rajiv Gandhi pushed it, no government was interested in Panchayati raj. His motivation behind this will be made clear at different places. PRI was the commitment made in the constitution years ago. Now it has become a nuisance and menace. It has politicized the society to the farthest of its reaches and to the deepest of its levels of human co-existence. If medicalization of the society is bad, then this politicization of the society is even worse. If we have created it as a constitutional commitment, then what are we supposed to do with it? Abolish them? It is reasonable to ask this question. This is a highly constitutional question which I have to leave to the experts. There is hardly anything of financial resources left at the state or the district level, due to PRIs to which most of it has gone. Only the state administrative hierarchy has remained, a system of PRIs fully parallel to the state invariably multiplying the authority has emerged. And as it is, without getting transferred to the PRIs what great benefit has the health care delivery system achieved on its own for years? From Mr Amartya Sen to a lay media person anyone has talked lamentably about the high mortality indices even when the PRIs were not dabbling with the health care delivery system. Therefore, to my mind PRIs owning and controlling health resources looks absurd. Five community health workers look after a total population of 5000 distributed in four to five villages of unequal population size. With today’s communication and IT capabilities, the village may become too small an entity for planning where the problems and issues get micronized and lose the larger perspective. I think we may be able to give these matters a better perspective if the unit of planning is at a higher level like a CHC instead of handing it over to the three-tier Panchayat system from village to district levels.



NRHM and Its Ideas of Infrastructure NRHM talks about as many as 59,226 buildings to be constructed for the sub-centre and PHCs alone. This was proposed on account of the recommendations of the IPHS in many cases. It would have been better if NRHM had desisted from such massive construction suggestions for several reasons. Firstly, newly built buildings given to the sub-centres are simply not necessary for those few workers who spend their times in the field and have homes to stay. Secondly, provision of an office would result in its becoming a barrier for those going to the fields. Thirdly, the paperwork (as suggested later) will become more digital and should be so. This removes any further justification for the sub-centre buildings. The supplies, whether weekly or monthly, are not voluminous and diminishing all the time, leading to lessening the need for a building. For the CHWs to hold them has not been complained about so far. Construction projects, especially on a grand scale, are viewed with suspicion. There should have been a more substantial justification for that. NRHM seems to have a lot of money and does not seem to know what to do with it. The issue of buildings for PHCs, equally unnecessary, will be discussed in the next chapter. NRHM and the New Thinking on Sub-Centre Restructuring The failure of the PHC as well as CHCs to support the SCs for more than ordinary or serious cases will be dealt with in more detail in the next two chapters. Many other changes in these two structures will also be discussed in chapters to follow. Some of the changes in PHCs and CHCs will have to be mentioned here in dealing with sub-centres since they are integral to it. NRHM and IPHS have laid down that every fifth PHC will be converted in a CHC.  The CHC will thus have CHWs from five PHCs, each  PHC  having four to six CHWs, totalling  24 to 30 numbers. The slipshod planning does not state explicitly the fate of existing 5000 + CHCs, its infrastructure and whatever manpower it has. I am pretty sure that this factor has either been deliberately ignored or has slipped from attention of the planners. (I would call them document writers rather.) This means additional building work on the fifth PHC  and then the CHCs in addition to the 59,226 buildings for the sub-centres mentioned



above and so on without reference to what already exists. This is how the waste gets built up. I can vouch for these already existing 5300 CHCs as having enough structure and instrumentaion, some manpower most of which is lying waste. The sub-centre, if located in a rented/owned facility, should actually be immediately liquidated. The building in which the centre works can either be sold, or rented to some other government agency for which they can find numerous uses; for example, it could be a silo for Food Corporation of India. I have proposed liquidation of as many PHCs as possible by a process and criteria; the ones which come under the new CHC being the first. It frees the supervisory staff first and the sub-centres from the supervisors and the medical, nursing and the paramedic staff next. All of them should become part of the CHC in addition to what exists now as an automatic fallout of closure of PHCs described more in detail in the next chapter. Under this process, the further  changes that will/should take place about the SC community health workers are described below. The link between the sub-centre CHWs should now be direct to the CHO, the community health officer (in the old or the new CHCs), and the PHC should be bypassed. To find out ways to numerically increase the ground force of CHWs within  the dismantling processes described above, instead of locking them there. All the drugs, testing equipment, report formats, record sheets and proformas and any other property needed will have to come from the CHO in CHC and not the lady health visitor and four PHCs under it. The new arrangements will be on a monthly and not weekly basis: 1. Providing a handheld device to CHWs to do all the work-related entries; 2. Since the number of entries are many, the handheld devices come as a part of parity of wages discussed earlier. It means that there will be substantial increase in the money placed in the hand from which 50% of the cost of the handheld device will be recovered; 3. Clearer delineation of the boundaries and functional distribution to reduce distances and increasing safety; 4. Reduction in the number of functions to be described later; 5. Once the handheld devices start working, the stationary will be done away with, the inadequacies of which are being chronically borne under disgruntlement (Duggal R,  et  al. 2005) and is logistically difficult:



(a) All entries will be in a single format. Multiple formatting for different directorates will be stopped. These entries will be transmitted to the CHC which controls the four PHC areas. (b) The sub-centre workers will transmit only one data set of records from which different authorities may draw their conclusions, collate and see if it leads to any action. (c) The sub-centre workers will not transmit the same data for different agencies in different formats. It will be done at the CHC or with the help of IDSP.  The job of reporting on the same data to a dozen different agencies should either be rationalized or simplified at the CHC level. (d) They will also send the entries of all the drugs they have used, vaccines used, slides made directly to the community health officer (CHO) in CHC since the entire PHC will be closed; (e) This bypasses data check, data re-entry and consolidation, with which come all the human errors built into it, saves time since there is nothing that needs to be written any more but merely incorporated in the bigger data at higher levels. (f) The reporting for the shortages of drugs and equipment, weekly in the present stage, may continue, but after six months the average monthly requirement can be worked out. (g) These supplies can be carried by CHWs when they arrive for their monthly meeting at the CHC and not at the PHC. Weekly meetings should be abolished since it is a colossal waste of time, energy and money. (h) The handheld device will have automatic pop out for what they need in the next few days at the end of each monthly cycle; in case, some items from the monthly quota are likely to finish much earlier, the pop out will set the process for supply of these items bypassing the monthly routine. (i) This in itself could be a warning for the monitor at the CHC that some abnormal activity is happening in a specific locale since the medicines are exhausted much faster. (j) The other statistical reporting should be done monthly. This provides ample time for these workers to truly pay attention to each of the item of their work portfolio. They can do it at a later time if urgent tasks take their time away, such as in outbreaks and so on. This will result in more accurate entries and much better statistics.



(k) Presently, among all the jobs these far-flung peripheral workers do, jobs pertaining to the area PHE or PWD will be specifically removed from the hands of all these people. (l) They will remain a part of all the village communities but will not be responsible for bringing about the famous inter-sectoral coordination between health and sanitation and all such works. (m) There could be prizes for best report transmission, best maintenance and best proactive improved behaviour post–handheld device introduction and so on.

 lternate Mechanisms of Doing Field Jobs A There are many ways of doing the field jobs. If all the four or five categories of CHWs decide to work in the same geographical area covering their population of 5000, then there should be a clear segregation of duties. The male workers will not do anything related to pregnancy, neonates, female contraception, family planning (non-surgical works) and immunization and so on. They should concentrate on national programmes more. In case of their non-availability, the burden will fall on the remaining. Each category of lady CHWs should demarcate their 1000 population and should do all the jobs that they have. Or alternatively. Each category works in the entire population of 5000 but segregates their work so that no category will do a work or a job on a population segment which is being done by somebody else. This option is retrogressive in the sense that it goes back to the unipurpose category of workers, hence is not encouraged. The second objection to it is that each lady worker will have to travel a larger and more remote area, which is not desirable. The villagers also will find it funny that different people are intruding upon their work and time for different reasons and for different purposes. The Anganwadi worker should no longer be a part of the health army; she is paid many times more than all others for a job much less in its extent, easier because it is rooted to a school premise for a population much smaller in extent. This has arisen because Integrated Child Development Scheme (ICDS) was thought of and funded by different ideas. Such funding cannot go on, and sooner or later ICDS or any other schemes have to run on our own money. Hence, the Anganwadi worker’s pay should also become commensurate with other peripheral workers in the short run.



Hence, the only option valid is the one that eliminates duplication of work. As a corollary it follows that even if these three categories of women workers belong more or less to the same locality, they will have to choose their territory among themselves and work. All the peripheral workers should be encouraged to buy a transport for themselves, like bicycles so that the issue of their travel allowance will be permanently settled. Suggestions for Efficiency Improvement of the CHWs 1. Reduce the excessive time spent in surveys and trainings to a minimum of one training programme in one year. 2. Institute awards for the best health workers at the district and state levels, as is the practice in many categories, like teachers. 3. Sometimes in specific or urgent situations it is the simple relevance and prioritization of the various works that take precedence for short term. After that the community workers should be enabled to return to and restore the work rhythm back. Giving the workers extra time for the work not done during such specific periods is a necessity at that level. 4. Besides being considerate, it will reduce the falsehood in statistics when things have to be processed against short deadlines. 5. Organizing the work of CHWs is the work the CHO in the CHC.  uture of CHWs: The Career Path F As far as the dynamics goes, there always are brighter CHWs who would want to be trained as ANMs or even nurses and would like to come to hospital bases. Governing laws of continuously upgrading the organizational functioning should inevitably cause the brighter ones to be pushed up. We should make some paper rules for the CHCs to be able to relocate the bright ones first in ANM and then, if found  even more  capable, in GNM training programmes. Such trends should be encouraged. The ANM training, as will be repeated elsewhere, should be at the CHC. The better-trained ANM can be located in the area from where she comes. Thus, it will serve second principle of decentralized training of equal quality and localization of people back to their own environment from which they are picked up. It reduces the frequency of leaves; they are happier being near their household and familiar community. People who



find someone of their own has become more qualified and has come back will have greater faith and respect for them and in these new CHC structures. Localization could cut through the bane of control of the centralized government machinery on services, namely the transfers in which the corrupt or incompetents are unjustly thrust on innocent populations for no fault of theirs. It will also help people to go up the ladder if better functioning and heavily worked CHCs can be given a nursing school again serving the principle of decentralization for enrolment. If they wish to stay at the same level for various reasons, such as helping to manage their other needs like agriculture or some other home industry is not uncommon, there should not be an objection. These people in their turn could rise in the hierarchy and some could later become doctors to return to their locales. We are talking of health as one paradigm. It is for education, industry and others to use these ideas for their own needs. New Roles for the Supervisory Cadre, Now Defunct The supervisory visits of the lady health visitor and her male counterpart will stop in the arrangements above. This gives us a free and somewhat more talented workforce, theoretically of 50,000, assuming that all the 25,000-odd PHCs have these two workers. With this we are saving all the expenses related to these visits, including the stationeries and so on. We will give them their new roles once we reach the CHC level in the chapters to follow. In conclusion, we have exposed the serious inconsistencies in the government planning and we have also drawn a lean picture of how the sub-­ centres and the CHWs working can be improved. We have tried to connect it sketchily with the higher levels with which the work should integrate. These need to be explained in more detail, which will be the subject of the next chapters.

References Rural Health Statistics 2014, Statistics division, Ministry of Health and family Welfare, Government of India. NRHM document, 2012 Framework for Implementation, 2005–2012, Ministry of Health and Family Welfare Government of India, Nirman Bhawan, New Delhi-110001 No.L.19017/1/2008-. Park K, Textbook of preventive and social medicine, 23rd Edition 2015.



IPHS-2007/2012, Rural Health Statistics 2012 and Indian Public Health Standards (IPHS), Guidelines for Primary Health Centers, Revised 2012, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India. Rural Health Statistics 2012, Statistics division, Ministry of Health and Family Welfare, Government of India. Kelkar P, A Gramsevak or village health guide from Nashik, Maharashtra on his experiences, 2013  in Dawandi, Pragat Maharashtrachy Arogyaseva Dubalya, Sathi, Pune. Kelkar, Sanjeev, Tuberculosis control in India, submitted to lite for life foundation 1994. Ashtekar, Sham, 2015, Chikitsa Arogya Sevanchi, (analysis of the health services) Manovikas publications, Pune. Duggal Ravi, Gangolli Leena, ed 2005, Review of Health Care, Cehat, Mumbai,  PRIA Continuing education, certificate in Panchayati raj institutions in India 2006. Kelkar, Sanjeev, 2021, India’s private health care delivery: Critique and remedies, Palgrave Macmillan, India. National Policy for Education, 2020, Ministry of Human Resource Development Government of India.


Structure and Function I: The Primary Health Centres

Preamble The next three chapters with this one will discuss the five all-important vectors of health care delivery at its centre place—accessibility, affordability, quality, equity and justice vis-à-vis how effective the public health care so far from the lowest to the highest level in delivering them. It has remained unsuccessful. When the present cannot teach what one should do for future, or does not give a clue as to what and why things seem to have gone wrong, one way is to look back to the history and evolution where an answer may then be found for both the dysfunctional status and its remedies. Similarly a difficulty that arises at the present level of thinking and technology, it is possible that a different technology or a thinking paradigm on a higher level only will help solve the issue. The issues related to improving the government medical colleges for better functioning, the externalities required to be provided for sound development of the medical graduates and postgraduates as the chief source for manpower needed for the public health care have been addressed. The educational technologies to develop an appropriate doctor for the public health are then discussed. The ideas for the maturation of both types of graduates and how this could be done in the public health machinery, in Chap. 5 are also discussed. The many ways by which it will benefit the public health system and the people at large are also detailed. This chapter will discuss primary health care and sub-centres, the claim © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




that these are the mainstay and indispensable machinery for preventive/ primary health care, the people working for the same, and the government planning.

History of the Primary Health Care Ideas in India The evolution of the ideas about how to provide health care needs a short mention to understand the arguments both in favor and in opposition, or the modifications suggested. Till 1973, there was nothing much by way of a health policy. The feedback from public at large was requested for the first time at the turn of the millennium. It was the world of Planning Commission then. Several five-year plans came and went. There was the Mudaliar and then the Srivastava Committee, then the emphasis on ‘Health for All by 2000’, an ICMR–ICSSR report and so on. The Bhore Committee recommendations (1945) were already ignored. They were the ones which are statistically sound even today in 2020. Bhore Committee had correctly grasped the situation (Duggal R et al, Review of Health Care 2005). It has elements similar to the model I wish to put forward. Bhore Committee and Primary Health Care: Less Known Facts The original Bhore Committee suggestion of 62.3 doctors and 150.8 nurses for every unit of 100,000 populations was the most realistic mix. At the population level of 10,000 to 20,000, Bhore Committee had recommended 6 doctors, whereas today in public health care we have only 1 for much larger population coverage of 50,000. Bhore recommendation today also would be realistic since the idea of curative medicine and non-­ curative aspects of health care have to be taken up by the same agency.  ssessment of Bhore Recommendations A In today’s parlance, the Bhore model was a heavily curative-oriented model, which was top heavy, an idea no one likes. Yet one has to admit that J. Bhore had a clear vision that this body has to deliver preventive, promotive and educational care as well. J. Bhore understood that the curative load however is going to be large and curing people satisfactorily is the gateway to primary care. The chances that people who listen to primary care concept are more likely to adhere to it (or even pay attention to) if they have undergone a disease cure process themselves. Not necessarily  the other way



round. And naturally it would be the word of the doctor, supported by the treating nurse who will produce results, may be a little tardily.  ifficulties in Implementation of Bhore Committee D If this model was not implanted in immediate post-independent India, there were obvious reasons. In pre-independent, undivided India, in a population of 300 million, there were 47,524 registered medical practitioners, of which 29,870 were licentiates. Of all these, only 13,000 were in the government service and rest in private practice. There was roughly 1 hakim or vaid for a population of 4200+. By a simple calculation we would have required 225,000 qualified doctors in government service at that time to implement the model against the 13,000 that we had. Since, or if, the complainants want the Bhore model implemented, opening more medical colleges of modern medicine will have to be considered (Duggal R et al, ibid). Opening medical colleges to make up the now-increased numbers however has been a disastrous step for the last four decades as shown in the chapter on capitation fee medical colleges, in my volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). Curiously in these recommendations, the medical and paramedical professional level to which Bhore makes a reference, the concept of community health workers and all its nomenclatures is absent. For Justice Mr Bhore, the auxiliary are pharmacists, nurses and dentists  were to do it. (Duggal R et al, ibid).  he Paradoxical Activist View about Bhore Recommendations T The left’s grievance, and rightly so, with the centre was that the Bhore recommendations were not implemented by the government of independent India. But the activists in the same breath accuse the Government of India to have gone for opening more medical colleges, thereby promoting and glorifying the curative medicine, of a Westernized, hence ill-­affordable, skewed and disease-oriented model and so on. The contradiction here is easy to see in view of the discussion above. The other complaint is that in doing so the government has neglected the primary health care and the concept. There is a deeper contradiction here. Since late 1970s, the Bhore Committee model has been presented as the harbinger of primary health care, whereas in its statements Bhore Committee talks of comprehensive care and not primary care. The term



‘primary health care’ was born in Alma Ata USSR in 1978. Until then it was known as comprehensive care or basic health care.

Evolution of Primary Health Care J. Bhore was the starting point of the discussions in all the discourses of health care from late 1970s through the turn of the millennium and later. One by one the various components of the primary care evolved over the 1980s, and the structure became well established with due credit going overwhelmingly to the activists and partly to the government. However, it took us long to know what exactly are our problems, how grave and where did they lay. The West may have given us some solutions, some models which benefitted the West in terms of money. It would be curious to see if it has benefitted us. Primary Health Care Structure and the Activists The design as evolved till date no doubt has remained high in numbers but too feeble in function. The expectations that it will deliver on health were too high. Everybody accepts that. The expectations continued to increase on the inadequately powered, hence beleaguered, structure of the PHC. There have been studious activists who have found many other reasons for the failure of the PHC concept. Below is a discussion about the views that are more than acceptable, but some are not. For example, there is reference to scarce funds for the PHC design. A curious comment in this connection was that ‘the government did not see any (monetary) benefit, in the preventive health care, initially’ (Reddy Prof K Shrinath 2005). This could have been one more cause for the neglect of the primary care. Returning to the debate of activists and their opposition to Western medicine vis-à-vis the primary care, the constant contention was that the value of the preventive aspect was neglected. More importance was given to curative medicine, allegedly done through deliberate opening of the medical colleges and emphasizing high standards of medical education. This, in its due and logical turns, went on to develop basic specialties and post-1980 superspecialty. The widespread prevalent belief, especially after 1990, in the government and the general milieu was that we need more allopathic doctors, more specialized services which are more relevant. These were the acts of commission by the successive governments. I would



consider these contentions as an error of perception and/or error in knowledge or reasoning at the government level without attaching any deliberate intentions or motives to that and the consequent neglect of the preventive side, if it was there. That there was deliberate promotion of the private sector by the central and state governments is another perception this group has. This was done by providing incentives, subsidies and so on to the private sector, blamed as an act of commission leading to the neglect of the model for primary care. There is need to make a distinction with a watershed years of 1981 and 1983 here. Till then the governments did not in any particular way foster private health care. Simultaneously opening as many government medical colleges as they could may certainly not be called promotion of the idea of private sector. Equally unacceptable, at least in today’s situation, is the elitist idea that more doctors will sort the problem out. From 1981 onwards, the successive state and central governments have been responsible for the blatant facilitation of capitation fee colleges. This has led to the excessive and prolific production of private sector doctors, who would never be and possibly cannot be made available for the public health. As a result they started forming and then populating the inevitably exploitative private sector; they opened nursing homes, and, subsequently, the first of the five-star, or corporate hospitals came into existence in 1983. It happened in a natural and progressively escalating manner. The politicians would not have had a foresight to see that all this will happen after 25 years. They cannot see beyond five years. They are certainly blames worthy for all the ills of corruption and many other violations of law, morality and constitutional mandates. But the charge that they did it to systematically degrade the public health will probably not hold. The anatomy and functioning of these colleges and the ill effects produced by them have been thoroughly discussed in my volume India’s Private Health Care Delivery: Critique and Remedies, published with this one. (Kelkar, 2021). No one can really call India a true market economy even after 1991. A few years after 1991, the first fruits of the shift in the economic policies became visible somewhere around 1997. Till then it was a protectionist, more socialistic and mixed economy. Hence, to charge the governments till then and ascribe motives of capitalism of it would be unfair. As Duggal et al. make it extremely clear, it is the lack of vision in the then Indian ruling class. It is the post-1981 health scenario which was allowed legally,



fostered brazenly and connived at and which did enormous injustice to the people. It is a sin that those who indulged in it have never really paid for it. That has introduced tremendous distortions in the health care, and primary care is just one of the sufferers. Duggal et al. have pointed out one significant lapse of the Bhore committee, which is that they recommended the abolition of the three-year licentiate course to become a medical practitioner. It is both a lapse and an elitist approach. The Registered Medical Practitioners (RMPs) and the Licentiates of College of Physicians, (LCPs) were useful people, served as good, clinically oriented diagnosticians, were like the most required family physicians today and would have reduced the burden of producing more doctors through the costly exercise of running medical colleges through the exchequer. But what is done is done. As pointed out elsewhere ‘Rural Doctor’ is not the solution. Then there was comparative neglect of the practitioners of Ayurved, Homeopathy, Siddha and Unani, as pointed out at many places in this and the other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). The status of their training and teaching institutes is highly unsatisfactory. The scholarly activism of examining the prevailing health care situation started in 1980 and was voiced through more than 170 Medico Friend Circle Bulletins, and other forums. Till 1990 there was not much mention about the practitioners of Ayurved, Homeopathy, Siddha and Unani. In spite of the charges that primary care has been neglected, the most discussed topic in planning for health is the primary care. The latest was the Astana declaration from Kazakhstan in October 2018. It emphasized two things: ‘forty years after Alma Ata we have very little to show by way of success of Primary Care … (yet) we must find ways to strengthen the same’ (Banjot Kaur, October 2018). From 2005 on, NRHM was the biggest document largely devoted to primary care. We have seen that it has not helped greatly at the sub-centre level. From 1980 the same activists have kept the clarion call for primary care alive, thinking about it, experimenting with it and supporting it. Since the advent of National Rural Health Mission (NRHM) in 2005 and then its 2012 revised document, these activists have also analysed it in detail. It may be better to say that it was not the neglect but the partial/substantial structural failure of primary care  which should have been recognized. Meager budgets and curative care dominating the scene became the scapegoat needed to justify the failures of primary care.



Here the discussion about the sub-centre-level primary care should be left behind and important issues connected with the primary care and PHCs should be turned to. Now a critical evaluation of the next public health care structure, its function and its reorganization—the PHC—is necessary. Primary Health Centres: Thin and Ineffectively Spread The main argument will be that this system is thinly and extensively spread in the name of accessibility and of equity losing the power to deliver quality service and achieve justice. In addition, the multilayering of various structures in close proximity without much changes in the capabilities is discussed sketchily before. It is also further discussed here. The causes for this will be discussed in greater detail in the chapters following. A review of the extensive health literature will also be taken to clarify the issue, with an insistence that the dysfunctional units be closed outright.1 The real and primary guaranty of the quality is the way we develop our graduates and postgraduates, and our paramedics, as well as the opportunity we give and the sustenance we provide to them to get their contribution for the public health needs. This aspect also needs further elaboration and attention than has been given so far. With this background, we will go into the changes required on the structural side of the public health care delivery in this and the next few chapters. These changes will lead to the functional improvement to the desired/required level. It is my belief that a detailed and comprehensive picture can be drawn which will solve majority of the difficulties. It will fulfil the criteria laid out by the five vectors mentioned above. Government Conception of Referral System It lies hitherto at the root of the problems of delivering quality curative health in the main. Unless we understand the follies of it, the subsequent discussions cannot be understood in its full.  The rationale behind closing dysfunctional structures came for me from Mr. D. R. Pendsey, the then advisor of the TATA Group in 1984. He had a clear message which I have not forgotten till date. ‘The governments should be lean. Then only they can be agile. Then and then only it can become highly effective.’ Two practices interfere with this attempt. One is the multilaterality and the multi-authority that the government, or more precisely the IAS cadre, builds deliberately. The second philosophical issue is to spread everything widely in the name of equity and justice which it does not deliver. Then large-scale restructuring with newer forms with abilities to deliver is imperative and should be able to show the power and effectivity to deliver durable results, which can then build confidence among the people. 1



The hierarchy in the Government Referral System is as follows: 1. The sub-centre is situated at a population level of 5000 in plains and 3000 in hilly areas. 2. PHC is situated at a population level of 20,000 to 50,000 population. 3. CHC caters to the  population level of 100,000 which in actuality could go up to 172,000 to 250,000. 4. Sub-divisional hospitals are to serve at a population level of roughly 700,000 to 1.25 million. 5. District hospital is the pre final fall back at the population level of three to five million. 6. Medical colleges—government is the final fall back for a much large level of population.  7. Apex institutes like All India Institute of Medical Sciences (AIIMS); Post Graduate Institute, Chandigarh; or Sanjay Gandhi Post Graduate Institute SGPGI, Lucknow utilized by surrounding states and by people who may be far away from them as well.  8. Both the  State and the central government machineries exist because health is a concurrent subject. This is a top-heavy bureaucratic arrangement with an extraordinarily long vertical arm passing through multilateral authority at the centre as well as the state and its districts before it reaches the frontier workers. Governing at the state level are the

State-Level Health Structure It consists of state health and family welfare ministries, state-level directorates for various national programmes and the two broad divisions of medical services and medical education. This structure gets more or less replicated at the district level in every state. Below that it is supposed to co-exist, support, and work for the Panchayati Raj Institutes. These long vertical (and multiple) arms have never been shortened. PHCs Under the States The PHCs are established and maintained by the state governments under the Minimum Needs Programme (MNP)/Basic Minimum Services



(BMS) programme. primary health centres (PHCs) are the first contact point between village community and the medical doctor. The PHCs were envisaged to provide an integrated, curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. The medical officer in charge, has to deliver and supervise both the primary and promotive health care and curative services also. (NRHM Document 2005–12). Functional Profile of PHCs and the Planning  During the study of the system of primary care over long years beginning in 1984 till date, my one consistent observation has been the excessive number of functions assigned to each person in the sub-centre and to the PHC officer. This was unacceptable from the point of view of ergonomics, work–time ratio, distances involved and the larger prevalence of women in the sub-centre-level workers. There were internal contradictions in the way the functions overlapped, and time allocation and many other factors, discussed in the previous chapter, were an issue. More disturbing were the additions in the functions as more and more national programmes were relentlessly introduced, which enhanced these concerns for which no justification could be found. I started reading the health literature in 1984. Since then, till date, it did not seem to be concerned with any of the issues mentioned above. The activists debated a lot about the additions, finally defending it and expecting that it will work. Reducing or eliminating some or many of the functions in particular was not considered and did not reflect in their long and incisive deliberations. All of them are learned people, devoted to the public cause and certainly had much more experience and more years devoted to these causes than I was. For long I did not have the self-­ confidence to say that I do not agree. Yet, I had arrived at the view that some rationalization and reduction of functions and people was needed. Concurrently, every now and then reports keep surfacing that the PHCs are dysfunctional, not able to deliver what is expected of them, the paucity or, more blatantly, the non-availability of patient care items due to both supply chain inefficiency and the corruption at the PHC level. Yet, there was little doubt in the minds of these scholars that this is the model and it must be made to work. Debates continued. The idea of primary care through prevention, education and immediate measures, that too by the community health workers from within the communities, trained many a



times over in tackling different morbidities, thereby reducing the number of almost all conditions leaving a few which would require higher care, were still the dominating ones. It was so alluring an idea and turned out to be the winner! The successes of these attempts often were too few, and were outside the government system, which was not taken on board. It was difficult to dissociate from it, take a few steps back and view it more distantly and see the ground realities. Non-functioning PHCs were one such reality. The unsatisfactory lowering of the mortality indices in maternal and child care, deaths during delivery, infant mortality rates and the still-continuing deaths to the tune of 600,000 in 1994 to 480,000 in 2015 yearly from tuberculosis were other realities. This was caused due to weak curative structure capabilities. These figures have featured in health literature again and again. What it meant to the avid supporters was that undoubtedly additional support was required at the preventive level. Not everything is related to diarrhoeas, chest infections or anemia in pregnancy. And several more such issues were there which would needed higher/more complex care as near to home as possible. PHC was considered adequate for that. The few realities that negated the PHC capabilities to answer this found not much place for consideration over long years, when in fact, by their own admission, there was dissatisfaction over it. The fact was that despite all efforts and designs the primary care apparatus was not optimally functioning. Due to these factors, the number of people developing complications where the primary care failed kept on increasing, who required higher care but it was not realized. The Design, Manpower and Infrastructure of Curative Structures at Periphery The question of what design of advanced care from the manpower point of view, infrastructure and instrumentation, and, most importantly, at which level of population it should be situated, was important. The basic commonsensical idea that the next curative structure should be the support system of CHC and not PHC and sub-centre, was neither appreciated nor expressed that strongly and repeatedly as it deserved. The dire necessity of discussing that structure, its inadequacies when planned, and remedies never found much place in the fascination of primary care. Despite the most efficient primary care, there will be failures and people will need higher levels of complex care. My position in a service project in a remote mountainous area and severe climatic condition was different. Every day my fellow medicos and I were working to cure illnesses that



were clearly beyond the ability of the sub-centre and the PHCs as well. In fact these cases were medical college level stuff we had to handle. It would be small wonder if these were the questions I was going to bed with and rising next day to face them again. With the limited opportunities I had to interact with the health activists/theorists, these questions could not be asked and discussed. Segregating Curative and Preventive Health Work The need for segregating the curative and the preventive functions at the PHC level and hand it over to two different persons was another idea that struck and stuck with me. However, this idea also did not find any resonance in the thinking and the large literature the activists/theorists contributed to the primary health care. The physical structure, the manpower allocated in it, did not convey the signal that such segregation was possible at the PHC level. I was not able to decide what kind of structure and at what level could achieve this. In fact, the structure to solve the cases that were already beyond the primary care apparatus and the structure where the segregation of duties could be done was one and the same. However, it took me and my team many more years to realize this. The other idea—to build a separate mechanism—remained with me despite it being ignored. In 1987, the idea of separation and of everything else we need to do was complete. Years later I made a trip to Sri Lanka, and was impressed by the remarkable decline there of the above-­mentioned indices. In the eight-day exploration of the Lankan system, in November/ December 2018, two situations came up repeatedly: one was the separation of the preventive and the curative systems in the Lankan system from the topmost to the most peripheral level; second was the surprise expressed by those in the preventive sector of Sri Lanka, starting with the director of Preventive Health to medical officers working much more peripherally, to learn that it has not been done so in India. All of them claimed that their success was due to this separation. People involved with curative care and medical education also expressed the same (Shanthi Dr., 28 November 2018; Wanigatunge C. Professor, 2 December 2018). It also took me six years from 1981 to 1987 to comprehend what kind of structure it should be. The ideas evolved with the kind of work we were doing. The problems we were facing day in, day out in those hilly areas were actually worth the attention of a medical college. The composition of



a team, evolved by 1989, was when a number of basic specialties started functioning in our work. Yet we had no name for it.2 It took some more time to make the final connection between the two structures as intimately connected and responsive to the need, and utilize the capabilities of each other. Together it is a complete model, as will unfold in the four chapters to come.

Current Government Thinking About PHC The Indian Public Health Standards (IPHS), quoted so frequently in an earlier chapter, has directed to have one or two more medical officers in the larger PHCs (Rural Health Statistics, GoI) These larger PHCs by definition are ones where more than 30 deliveries take place per month. The addition therefore was to mean that this person will reduce the curative and the preventive work burden of the medical officer but the amalgamation of the curative preventive service will continue under the same men. This continues to be the accepted principle, and the primary care has been organized and expanded; many more ideas have been implemented since last four decades. None has worked. Adding one or two more medical officers, or a higher number of other staff, or the paramedics will not solve this issue. Such additions have always been inadequate. The ailments on ground zero at the community PHCs are many and need to be looked into in greater detail. Simplistic and much of the same kind of solutions will not help. The New IPHS and General Impression Post IPHS As pointed out earlier, the functions of the CHWs and the officer as a corollary have kept on increasing every time the new functions were added or new national programmes were introduced from time to time. The large addition was after the NRHM became active in 2012. To cope up with this, ASHA was introduced. To assess the needs of the system as a 2  From 1989 till 2006 and even later, when we tried to talk about the curative services with activist friends, in forums organized by them, the idea did not receive any appreciation. It was either brushed aside or politely avoided, since it did not come in the realm of primary care. On two occasions I had a distinct feeling that the problem-solving capacity of what I was proposing was so high that the theorists literally blocked it so that the problems remain unsolved. Instead of reacting to such treatment meted out, we continued to introspect on what we thought was correct, though we were disappointed and dejected by the treatment the ideas received.



whole, Indian Public health Standards (IPHS), in 2012 was also brought in. The IPHS document recognizes the workload factor and recommends considerable increase in the many needs of the public health system like the laboratories or X-ray Machines as well as the array of drugs. The last one will get a detailed analysis about the practicality of it. The trained paramedics were also increased a little so were the MBBS graduates in the system. Lately, AYUSH doctors have also been given a more prominent place, which is welcome. The AYUSH issue is surrounded by huge controversies since 2017 till date. It will have to be discussed separately, as shown in Appendix B, in order not to disturb and distract the narrative here. We appreciate that even if it comes 30 years too late AYUSH is formally included in the PHCs. They should however be in the CHCs.  Whether and how within the limitations of the structures it may be possible to provide the IPHS at all other levels, from PHC up, will be discussed in chapters to follow. The major limitation that remains is that both NRHM and IPHS retain the entire structure from the sub-centres to the sub-divisional hospitals. The fact remains that the entire chain has not given results and increasing manpower and facility will not solve the issues. NRHM and IPHS have not recognized this. The three issues—segregation  of curative and preventive services, problem-solving ability and mutual support—did not reflect in either. Manpower Shortage Still the Biggest Issue In 25,050 PHCs, there is an existing shortfall of 52.6% of health assistants (male), 37.1% of health assistants (female), 10.3% of doctors. About 36.5% PHCs are without a lab technician. The sanctioned strength of pharmacists falls short by 82% in the PHCs. This figure is somewhat intriguing. If the proposed number of 7954 additional PHCs is taken into consideration, the shortfalls would be higher (Rural Health Statistics). IPHS has proposed higher allocations but the ground reality is already highly deficient. IPHS has no mention of how to achieve the numbers. It merely talks of its perception of what should be available. The standards laid down by the IPHS are however not reachable in the short run given the already-existing shortfall in the PHCs and the sub-­ centres. Even if the community health workers, the PHC workers and the PHC medical officers are equipped today by the Indian Public Health Standards (IPHS) recommendations, I am afraid the PHCs cannot satisfactorily take care of many of the functions including the complex referred problem. The standards may give them physical infrastructures but they



will never be able to provide the manpower actually needed in the present system of planning. Hence, an alternate way of solving this problem will have to be thought of. The Pathetic Story of Referral against Upgradation Referral is the result of inability of a service at lower level to address a particular health issue. If it cannot be handled at the sub-centre level, it has to be referred to the PHC. For majority of the PHCs, it is impossible to take on the more difficult problems, referred from sub-centres below it. The story repeats through successive layers of health care delivery structure. The CHCs and the sub-divisionals are far more inadequate and more dysfunctional structures than even PHCs. The reasons behind this will be shown in detail in chapters to follow. The contrast with PHC is sharper because CHC is supposed to be endowed with much greater capability to solve complex clinical situations. IPHS has sanctioned a much bigger array of specialist professional medical manpower in CHCs and the sub-­ divisional hospitals. There is no mention about where the added and already-recommended manpower will come from. The recommendations for upgradation have not changed the problem-solving abilities through these three levels since vacancies dominantly continue and infrastructure does not improve. Then it is once again up to the district hospital or the medical college to deal with the complexity arising at the sub-centre level. District hospitals usually have the presence of professionals with required qualifications. Yet, there is no guaranty that clinically complex issues will be handled well. The general apathy, extortions of each item needed for care by each person involved, the delays caused thereby in actually start treating the case, the state of the infrastructure delivering care, rampant absenteeism, and greater attention to treating patients in private centres result in disastrous non-fulfilment of the five vectors—access, affordability, quality, equity and justice—every now and then. I have lived with this situation in the voluntary service project we ran, not a kilometre away from the district hospital for ten long years. Even the last place of treatment to the rural communities, the medical college, may or may not do the job well, pushing the patient further on to the private care thereby ruining him completely, health-wise and financially also. The patient just keeps getting tossed from one level to another. These are the daily realities of the hinterland the remote rural



communities suffer. The places and the numbers will be in thousands. The soft human power will have this as the biggest challenge to be met and fulfilled. How do we expect the health indices to come down then? The Supply Chain Management It falls short of the needs to keep the sub-centres and the PHCs stuffed with drugs, consumables, laboratory equipment and items for imaging services, in fact anything and everything that is needed. Lately, after the IPHS nearly 800 medicines have been added for provision to the PHCs. Given that there are more than 25,000 PHCs from near to the remote areas, it will be a highly difficult exercise on a day-to-day or week-to-week basis logistically for the government. The supply arm is vertically too long even from the state level down as shown earlier. The situation so far has always been that of supplies running out faster than planned for. Corruption in Supply Chain PHC officers take money or something else in kind from the patients. He is strictly forbidden to do that. His daily requirements are met substantially in this manner and the salary remains intact to a large extent. He has a free quarter, and all his links are well established. He in connivance with other staff who siphon the drugs to the private retailers, who sell them to the very patients who were entitled to get them free. Part of the proceeds goes to the PHC officers. The medical officers think that the graduate interns are an intrusion on their fiefdom and would like their role minimized. The PHC MO would willingly sign their attendance for 45 or 90 days and tell them to come back with some gifts for the certificate. How to address both these issues will be discussed more fully in the next chapter. Tender Processing for Supplies in the Government Corruption reduced the available money in the government exchequer in the secretive tendering processes prevalent so far. The process of e-­tendering set up by the new government in 2015 has ensured that the government gets its money in full. However, there is no guaranty that crony capitalism will not exist below this level since the fathers of the crony capitalism may exist within their power structure. The crony



capitalist companies involved below the e-tendering levels however will dissipate themselves considerably in distributing the money to many levels below and above. If ever the government becomes stricter to control this crony capitalism, obviously there will be more difficulties for such companies.3 It is not just the consumer but things have to be affordable to the government as well so that it can provide more to the poor people. Availability of Drug and Consumables in Public Sector and the Government Regulators In the second volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one, we will see that year after year more and more drugs were being withdrawn from under price control regulation, declining from 347 and intending to reduce to 34. The primary benefits of these measures to the industry and secondary recipients among the deregulators are incalculably huge. It added to the suffering of people if they have to purchase the drugs in private, out of their own pocket since the deregulation of drugs increased the prices. The drugs the government has to purchase thus become costlier, resulting in a great revenue loss. It will result in less quantity of drug thus purchased. It will affect the public health supply chain. Even if the generics are purchased, their cost also may go up with the brand prices. The government action to bring 814 more drugs under price regulation underlines that price regulation should be the norm and is most welcome4 (PTI | July 02, 2017, Economic Times Health World). 3  It must also be recognized that the new government in the centre has done much more from mid-June 2014 till mid-2017 than was expected in drug pricing. It has shown courage in throwing off the yoke of irrational combinations and opened generic medicine shops. The chain reaction of it benefitting the patients and even the pharmaceuticals in the long range is discussed in the second volume mentioned above. The government system, the National Pharmaceutical Pricing Authority (NPPA), was gripped with general apathy, listlessness, indifference on price regulations, which has now been corrected. 4  After demonetization, tracking and action on defaulters has gained momentum. As part of the process, the government has managed to shut out a couple of hundred thousand shell companies which has been well publicized. Hopefully, it will reduce the wholesale crony capitalism to fewer recognizable players of the power corridors. There were 433 government schemes under 56 ministries in 2017 which must have gone up by 2021  for direct bank transfers to the beneficiaries which have eliminated the difficulties in getting the money through the middlemen and agencies, saving human effort, money lost between and ensured full payment.



Functional Aspects of PHCs Inadequate Coverage Under a PHC The 25,050 PHCs officially cover a population range of 20,000 to 30,000 people with an average of 34,641, a total area of 129.66 square kilometres; average radial distance is about 6.42 kilometres. Number of villages covered by a PHC is on average 27. However, the entire population in this area, gone up by now to 50,000 is not able to reach the PHCs or the PHC is incapable of servicing them (Rural Health Statistics). Burnout: An Unrecognized Consequence The more one thinks of, the more exploitative this looks. If an MBBS doctor strives to do all that is expected of him properly, then such a person would almost continuously be on the grind, whole day and night, on all days. The doctor, it appears to me, would have made a mistake by becoming a PHC medical officer! Having got him, the government would see to it that this doctor remained there, which would cause him to suffer from the ‘burnout syndrome’. He will be of no use to himself or the system after a few years. And there is a likelihood that those who fill in false reports will not be asked a single question. The Manpower in PHC under the IPHS: An Assessment Medical officer—MBBS, 1 + 2 Medical officer—AYUSH, 1 + 1 Accountant cum data entry operator, 1 + 1 Pharmacist, 1 + 1 Pharmacist AYUSH, 1 + 1 Nurse-midwife (staff nurse), 3 +1 / 4 +1 Health worker (female), 1 + 1 Health assistant (male), 1 + 1 Health assistant (female) /lady health visitor (LHV), 1 + 1 Health educator, 1 + 1 Laboratory technician, 1 + 1 Cold chain and vaccine, logistic assistant 1 + 1 Multi-skilled group D worker, 2 + 2



Sanitary worker-cum-watchman 1 +2. The additional numbers are for more burdened PHCs. In type A PHCs, where the work is less (that is to say less than 20 deliveries in a month), 13/14 is considered essential strength; in type B PHCs, where the workload is high (more than 30 deliveries a month), 18/21 is considered desirable strength. The number of MBBS and the AYUSH doctors indicates the same additions for type B PHCs. See Appendix B in this volume over the huge controversies over AYUSH.  Under NRHM, there is a provision for two additional staff nurses at PHCs on contract basis, making it six and seven in type A and B PHCs, respectively. Availability of Beds in PHCs PHCs have to be equipped with four to six beds for patients. The increased numbers of staff nurses will be utilized well if there are admissions. In remoter  PHCs the utilization of beds will tend to be zero. There are hardly any admissions in PHCs. The deserted look of PHCs except the outpatient is depressing. With the migrants going back to the villages during the Covid 19 pandemic, there was every possibility that the spread will take place within the villages. At a population level of 50,000, there are just about 5 beds. With more than 25,000 PHCs with average bed strength of 5, there are already 125,000 beds. Till mid-August 2020, and much later as well there was no mention of PHCs coming forward to help in case of simple isolation, where no treatment needs to be administered. If so, is there any justification for such useless structures to continue and lock resources which are of no use anyway? PHC a Referral Unit for Six Sub-Centres The activities of PHC involve curative, preventive, promotive and family welfare services (Services PHCs, IPHS standards 2012). With all the new arrangement reduction in the work-to-time ratio, the principal folly in the planning has not been paid much attention to in increasing the manpower. The focus remains on incremental or more of the same kind of supplementation as seen above and earlier. That is why the thinking has never reached the idea of scrapping PHCs, as will be discussed below. This also happened because CHCs were considered apart from PHCs as a separate vertical in most of the functions.



The radical structural alteration to solve all these issues is the principal purpose of this chapter and this volume. In the chapter on manpower, its supply to CHCs has been discussed. Some more of these aspects will be discussed in greater detail with some new areas. Full details of the total restructuring will unfold hereafter. This chapter will take into account the new Indian Public Health Standards (IPHS) for PHC and the primary care till the PHC level. PHC unfortunately will remain a failed model even under IPHS. That is going to bear down upon the tone of discussion. The PHC Medical Officer, One and One More as Essential per PHC: Profile Those who have served more than 10 to 15 years in the PHC set-up, many a times in the same PHC, either by defying or by manipulating the government, are the true representatives of all the achievements and the stark failures of the system. When any new recruit takes over a PHC, he is an MBBS. By definition and default, he is not a public health man. He is an immature unwilling, unexposed, inexperienced doctor who has not been able to register for a decent postgraduate degree and hopes to get in it while and by being in the service. This is a common route in Tamil Nadu (Kelkar,  2021). The immaturity is an outcome of the left hand of the department of medical education. He has to err many a times for a few years to improve to a level but never beyond that. The right hand of health services and planners either do not know this or are not concerned. By various means they have to fill the vacancies. However, if they could not, no one could be bothered less. This MBBS has over 120 square kilometres and more than 50,000 people in actuality to care for, having an extremely wide spectrum of illnesses, many of which chronic and widely prevalent. It is not always given to the PHC officer to handle them effectively. The acute cases are beyond the powers of primary care. Some may become serious. Endemics break out. From the antenatal, delivery, the post-natal period, handling the neonate and general pediatrics, then adults and the old ones is, finally, his responsibility. They are flocking to him since he is likely to be the most qualified and/or the least expensive doctor to consult. The young recruit has no exposure to preventive health care to the rural population. Emphasis on this service in PHC is strong. He is barely getting familiar to the functions of curative services. Of promotional health he has no idea. On most days, he can do nothing more than simply



treat the patients with miniscule means flocking to him. Single man with a mandatory six-hour attendance in outpatient in two installments and emergencies, annuls all possibility of a score of preventive tasks, supervision and travel demands for supervision (see Appendix A) and so on and on, days and months on end!! Over and above, he is responsible for every function of the different kinds of workers in the periphery. He has to supervise them, collate the information he receives from the ground, forward it, or act upon the information, and also get all others to do and do it himself when orders come from the top. It is simply impossible to do all the work. Hence, it has to be either not done or reported as done in a dishonest manner, from which come out the government statistics. Typically, the government is contented that all the places in the record sheets were filled. If the PHC officer’s post is vacant, then almost nothing will be done at the PHC level. There is also a clear psychological divide between the three different capabilities—one can be either a clinician or a researcher or a public health man. One cannot even be any two, but only one. What can one do when the schemes are written by those who have long ceased to be anything else but administrators? Their main job is to balance the populism of the governments on one side. The other is to demonstrate to the people the implicitly understood wisdom of the politicians—that they must be seen to be solving problems. However, the schemes proclaimed should not be solving the problems. Whether it is Chile in South America or India, the logic of the governments or politicians is the same (Warner, David circa 1980). Solving a problem is immediately antithetical to their continued existence—it is like signing their own death warrant. But the activists were probably guiltier. Activists never wanted to realize and accept that this sort of an arrangement will not work, contrarily expecting large dividend from it. More or more evidence was produced and more strident demands that the governments should do something since such an arrangement is not working were made. Activists continued to say that this has to be ‘strengthened’, a word everyone likes to use; there cannot be any other arrangement, only this and it must work. Closer Look at the Numbers of the PHC Medical Officers The number of allopathic doctors at PHCs has increased from 20,308 in 2005 to 28,984 in 2012, which is about 42% increase. They exceed the number of PHCs by nearly 4000. The MBBS is comfortable in joining



government PHCs. In addition to reasons discussed above is the freedom to practise privately in most state government services and working away from the gazes of all and sundry. The excess number of 4000 could be less in actuality since many would be in postgraduate courses and some may be absconding, or would be located in the sub-divisional or the district hospitals (Rural Health Statistics 2012). Even then there is a deficit of 10.3% of PHC medical officers, mainly due to significant shortfall of 20.4% at all the levels in Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Karnataka, Madhya Pradesh, Nagaland, Odisha, Uttarakhand and Uttar Pradesh. On June 2015, there were more than 13,000 vacancies in Maharashtra for the medically skilled health personnel (Diggikar | 08 July 2015).5 Perforce the growing populations of India, the numbers the PHCs look after have gone up. The disease load and its complexity thus have increased in numbers. And all that the IPHS demanded and expected the government give was to add a second MBBS officer to all the PHCs and an AYUSH doctor, in type B PHCs. In Type A PHCs, it added only one AYUSH doctor to the existing MBBS.  It is elementary sense to understand that these numbers can never take care of the referrals from below within their list of functions. Taken with the pitiable numbers in CHCs of 80% vacancies in specialist cadre, it meant that over  an extremely high population level no effective government capability can be found. This did not come under any discussion in significant manner compared to the discussions on primary care. A solution to this will be offered here in minute details of planning.

IPHS, NRHM and the Peripheral Units On the other hand, not wanting to admit the failure of PHC the IPHS has made subtle suggestions to convert each PHC at the block level into a CHC  adding 25,000 more to the existing 5000  ones. In the present 5  The ridiculous ways a government can resort to, to fill vacancies will be clear in the instance mentioned here. On July 22, 2017, Maharashtra government issued a circular to all the allopathy doctors who had passed from the state colleges in Maharashtra, not just the newly passed but as old as those who passed out 25 years ago. It demanded that we must submit our bond certificate when we passed out to see who had not done the compulsory rural service as the bond had demanded. If it was not done, our names would be removed from the state medical council. This was being done to fill up all the vacancies in the state public health service by forcing us to leave what we were doing.



situation this will not work. Nor is it necessary to underake it. No one will be able to provide a single human, especially the five basic specialists or infrastructural element as provided for under the same IPHS and NRHM to even one such new  CHC.  There will not be any use  either to build 25,000 CHCs out of as many PHCs. It will be a disaster no one can manage. It also means the number of basic specialists will go up from more than 20,000 to more than 100,000. At 20,000 specialist cadre level, the shortfall is 80%!! If each PHC were to be upgraded to CHC, it would still cover only 50,000 populations it was serving earlier. This population segment is too small to provide adequate work to each specialist even if available. Such a PHC-cum-CHC model will neither be here nor there and will be another dysfunctional structure scattered all over. The proposed CHC will become merely a replication of PHC.  The IPHS is still not solving the issue of grossly inadequate capabilities against the complexity of the disease load. The reader may refer to the earlier discussion on the ‘shortages’ of the doctors about the required ones and the non-available ones. This gap now will become extremely wide for the numbers the governments want. Thus, IPHS does not really add to the solution of improving PHCs. As we shall keep witnessing, it does not add any workable solutions all along the public health care delivery system. PHC Conversion to CHC Under IPHS The one and probably the only most important decision taken in the area of the public health care delivery at the periphery by the IPHS is to convert only one of the five PHCs into CHC. The first gross shortcoming of this idea is that it does not in any way take into account the existing physical structure availability even when it is not functioning well. It therefore does not treat it as an already-existing valuable piece of physical asset. This means that huge money will be spent on infrastructure development of that one PHC. Along with being totally useless, it will officially open broad avenues of corruption with ministries and bureaucracies as the only beneficiaries. There are many inconsistencies in the IPHS document about the PHC upgradation. At places it is pushing PHC physical standards so high to almost resemble a CHC even when it is not to be converted. But the CHC concept and its construction as handled in IPHS are discrepant. For instance, the IPHS and the NRHM document finds the PHC area of 4000 sq ft as too big for a PHC and wants to reduce it to 1600 while pushing the structure to resemble CHC or making it a CHC. If we read the IPHS,



the building maps they are giving, the way the PHCs or the CHCs should be in their ideas, it will become amply clear that no one has read the document as it was prepared in full and carefully before release, not noticing the grossly inconsistent and contradictory descriptions.

The Other Personnel Provided in PHCs Pharmacist: One Post per PHC and Related Issues of Pharmacy The pharmacist or the other technicians provided singly in PHCs would be available six days a week eight hours per day minus the leaves. If they have to be residents  within PHCs, a number of issues follow—lodging, boarding, out-of-duty hours work and so on. In the framework of labour mentality, will anybody ever agree? Will a PHC be able to give medicines with number of patients coming in at all hours if they are riddled with a single pharmacist? No. It will mean the patients have to purchase what is free for them, outside. The quanta of medicines and the varieties provided in IPHS for type B PHCs are 112 allopathy drugs including their variations of doses and forms. Children have to be administered seven vaccines 17 times over a period of zero to five years of age. In addition, there are 30 medicines in every obstetric delivery kit plus 10 more under Reproductive and Child Health (RCH) for sexually transmitted infections (STIs). It takes the tally to 159 drugs. The other consumable items required for use run in hundreds. They are separate from this list. It is impossible that even one plus one more pharmacists can ever take care of inventory, distribution, replenishment, weeding out expired drugs and inspecting the drugs which are bound to get spoiled before expiry, the drug logistics in short. The IPHS does not seem to have thought about it. When there is going to be no pharmacist for 16 hours a day, all 24 hours a day on Sundays and holidays (he will most probably be working with another private store in the locale), who else can do the drug disposal? Some who can are the staff nurses. In the state of mind prevailing in cadre at this level, will the staff nurses agree to handling drugs for the rest of 16 hours of the time? Most likely they will not. Even more certainly they will not take the burden of inventory, weeding out expired drugs or replenishment.



IPHS Recommendation: One AYUSH Doctor/AYUSH Pharmacist in Type-B PHC This is the most horribly ill-planned initiative, as the discussion will show. Depending upon which AYUSH doctor the PHC gets, the paraphernalia of the drugs that the allopathically trained pharmacist will have to handle will be as follows: 100 Ayurvedic drugs or 113 Unani medicines, 38 Siddha medicines or 481 Homeopathy medicines, excluding the variations in each medicine of Homeopathy lot (Indian Public Health Standards (IPHS) Guidelines for Primary Health Centers 2012). There will also be one AYUSH pharmacist. The AYUSH doctor and the AYUSH pharmacist should be from the same branch. This cannot be assured. In that case the AYUSH doctor will have to do the drug distribution. How do we expect one pharmacist to properly give drugs for which he has no training, maintaining the stocks, inventory and replenishment of these 732 or more medicines, which are bound to have an uneven rate of finishing. The entire drug logistics of nearly 900 medicines will have to be handled by one or two persons under a supply chain that is precarious at the district or state level. That opens gateway to pilferage that cannot be pinned upon anyone. The entire planning is riddled with serious faults. The least that even a PHC should in that case have are four or five pharmacists, one each from Allopathy, Ayurved, Homeopathy, Siddha and Unani. Against the huge shortfalls of 82% already existing, how can this be possible? If this is not done, there will be uneven distribution in the chain of PHCs. In addition, one cannot at all be sure that there are enough AYUSH pharmacists to place them in say 25,000+ PHCs. The planning hovers on the boundaries of absurdity. The AYUSH system has five different systems that need their own drugs. If there is going to be one AYUSH doctor, he can handle only one of the four systems of the drugs.6 What should be fate of the other three sets of drugs? If he or she leaves the service, what should be done with drugs of his specialty, if we do not get a replacement from the same branch? If we get an AYUSH from another system to work, the remaining three types of drugs will be of no use. In that case, what do we do with the other drugs? Do we send all the other types back to where it came from and procure again if an AYUSH doctor from another system is next appointed?  It is an additional issue whether the new  AYUSH graduates deployed here have enough mastery of their own pharmacopeia they are to use. 6



Thus, the recommendation of appointing one more AYUSH will complicate the matters further. The same operational difficulty arises with an AYUSH pharmacist whose appointment has also been recommended by IPHS. He or she will have the knowledge of one of the four branches. Are we to assume that the rest of his job is to read labels and dispense the drug according to the instruction of the AYUSH prescriptions even if he is not trained in the system? If that is the job, then even an allopathy pharmacist can do that. What is the need to mention and employ separately an AYUSH pharmacist? These are some operational issues which are common to both the PHC and the CHC in drug logistics. The number of AYUSH medicines to be made available at PHC level for use and their further distribution to ASHAs is more than 500 (IPHS 2012,). It makes the supply chain management more daunting. Ayurvedic therapeutics is not as simplistic as the allopathy. Choosing a right drug by following some sort of an algorithm takes more training and understanding of Ayurved or Homeopathy than is needed in Allopathy. Hence, many a times it could be less predictable in its effects than the simpler and definite patterns of illness which the allopathy medicine treats and can reliably place many of its medicines in the hands of community workers. AYUSH treatments could have the same potential risks like allopathy—it may not work; at times the illness will take a serious turn under it. The best use of AYUSH drugs is left in the hands of AYUSH doctors. This will be discussed again in this and the next chapter on CHCs. We also do not really know if IPHS thinks that the drug distribution will be a mechanical, non-­ intelligent action. The really pragmatic act is to place any of the AYUSH doctors at the community level as AYUSH, who can then use his armamentarium effectively. AYUSH doctor at the community level can in actuality be left to arrange for his medicines rather than the state taking it upon itself. If he is also trained in CHC as proposed in the previous chapter, he will handle the dual issue of the therapy and the referral in a more appropriate manner, better than the community workers. 

Nurse Midwife (Staff Nurse)

IPHS has suggested three +one or three + two additional staff nurses on contract. The staff nurse is such a valuable product of the system, versatile, capable of being trained for many more complex tasks and can be a great force in the quality of care. It is also scarce. In the PHC system, those staff



nurses who have a good grounding in obstetric care are no doubt of immense help and value. Hence, the increase should be most welcome. However, their presence will become useful only if a variety of other cases and the difficult deliveries are accepted on a regular basis and the obstetric care functions as a part of the wider variety of admissions. These staff nurses should be capable of judging in a short time if the delivery can be safely done or an early referral is wiser than doing it in PHC. It will also depend on how many of them  will be capable of delivering a difficult labour for which this is the first envisaged stop. Here the referral has come from the dai, or the auxiliary nurse midwife (ANM), who thinks the delivery cannot be managed at home. PHCs cannot be considered as valuable unless the indoor work is done routinely with satisfaction leading to people’s faith. The overall experience is such that the more remote the PHCs are, the less of this indoor work will be done or not at all, due to the generally poorer infrastructure, a result of the conception of the PHC in the earlier versions. (The new version will also not work as shown.) To handle indoor work competently the lab, the X-rays should also be functioning reliably, competent lab and the X-ray technicians and medicines relevant to the common serious problems should be available round the clock. Then and then only the inpatient activity will improve and have people’s faith in it and an admission will make sense. For that to happen, there will be issues of housing the staff nurses within the PHC or very close by. The issue complicates if the nurses are married and have families of their own nearby or further away. On the other hand, if admissions are not or cannot be accepted, the staff nurses are a waste in the PHC set-up. The more ideal and comfortable place for them is the CHC, as will be argued later. The restless question in the mind of the reader will be, if the number of staff of every denomination is being increased manifold when the basic available numbers are so few to begin with, how can these numbers be met? In the present thinking, it is just not possible. Let me however categorically say that the question will be answered amply satisfactorily as I go along the discussion but in the context of CHCs. 

Health Workers (Female)

IPHS has created this post in PHC/block level. Within the work profiles and the system of primary care as thought of, this lady must be in the population doing all such work as the ANM, CHWs, ASHAs, her counterparts in the six sub-centres attached to any PHC are doing. Sitting in the



PHC she will neither work in the field nor work in PHC. In fact she will do nothing. If she does go to the field, she will be making rounds of the same populations being already visited by the sub-centre staff. Hence, redrawing the plan and place for her is necessary as will be done later. 

ANMs and the PHC Work

As a rule the ANMs have poor skills to work in the wards. Assuming that there are admissions in the PHC, she cannot take on the ward for a full shift to relieve the staff nurse for non-obstetrical work. Will she add to the competence of delivering a woman which the others have found risky and hence sent to PHC? No. This is waste of manpower. If not, can she relieve the pharmacist? Can she help lab work? She cannot, unless she is intensively and informally trained, which will not happen in PHC and will not be allowed in the place she is trained. These are details in which the devil lies. How much attention has NRHM/IPHS paid to these mundane matters? All such small matters translate in huge numbers of manpower time wasted. 

Health Assistant (Male)/Health Assistant (Female)/Lady Health Visitor

This cadre has been retained and has numerically increased on paper. But there are significant shortages of these two as shown above. These two relate to the six sub-centres as supervisors and assisting the CHWs. In the preceding chapter, this cadre is discussed in some detail. With the recommendation of PHC liquidation in a slow-phased manner, these two will have to choose to go for higher skills. (See the next chapter.) 

Health Educator

This post is well defined. Supervision, training, educational/awareness activities, touring and administrative functions, assisting PHC officer in record-keeping are the broad divisions this role can be divided. These functions duplicate some and overlap some with the health visitors, male and female, and go in the inter-sectoral coordination. The emphasis it has also been  led is  on educational and awareness. If these two activities are  redefined, this person should ideally be like a secretary to the PHC officer, which he anyway deserves. But that should then be a dedicated job, titled as such. As a health educator, it is a waste. In the new thinking,



the same public health person should be transferred to the CHC, removing the duplications overlaps and inter-sectoral coordination. 

Laboratory Technician, One Post

All the issues discussed in case of pharmacists are applicable to this cadre ditto. My answer to this and all such questions about the deployment, numbers, work and capabilities as recommended in the IPHS/NRHM documents is No. All of them will meet justice in their work and do justice to the population in a larger setting like CHC, which I will describe subsequently. On top of it all, is the low quality or the absence of the laboratory or X-ray instrumentation, which makes their presence much less useful. Driver Subject to availability of vehicle and a vehicle subject to the availability of a driver is a vice versa game. It would be a worthwhile study to see in how many places both a well-maintained vehicle and a driver are available and how many days a month or year such a vehicle runs for actual PHC work, as well as in how many places either the driver or the vehicle is absent, or both are present but the vehicle is broken down.7 Why go far? There is another problem of vehicular superfluity in urban areas. In a city like Mumbai, hundreds of ambulances are without a regular daily workload. They are a direct evidence of the colossal waste of money by well-meaning individuals who do not have much understanding of the needs. They are in search of a contraption that moves around which can show the world the name of their mother on someone else (Lele, 2015, Personal Communication). A few conclusions from all the discussion could now be drawn before going to the answers for the various difficulties raised so far: 1. The sub-centre functionaries are burdened with a load of functions without any consideration of work-time-distance-hands availability. 2. The same is reflected in the PHC and on the PHC medical officer. 7  In June 2015, the transport commissioner of Pune stopped salaries of the Repair and Maintenance Depot officers of government transport vehicles, mainly buses, demanding an explanation as to why 300 buses were idle? Within a month 60% buses were plying on the roads, with more to follow. (To note: the commissioner has been picked up by the Prime Minister’s Office (PMO) in New Delhi.)



3. At both levels, rationalization of functions is a must. Many suggestions on the sub-centre community health workers have already been made. 4. PHC as a first point of referral can do very little for clinical cases the sub-centre workers cannot take care of. 5. The staffing pattern in PHCs, before and after IPHS, has many inconsistencies which make it further ineffective and cannot meet expectations 6. The PHC conception also is incapable of accommodating or expanding with the IPHS recommendations. 7. The segregation of the curative functions from the preventive primary care functions seems to be necessary. 8. To address the segregation, new structural changes seem to be required. 9. The sub-centre-PHC apparatus needs the support of a more capable centre at higher level without which the health indices cannot be brought down. 10. Excessive emphasis on primary care as the most important should be removed and consideration for curative functions to take care of a lot more clinical work should be accepted. 11. An attempt to create suitable structures from the above three working closely should be undertaken. 12. That affordable, accessible and quality curative care, with justice and equity as equal necessities is not achieved in the present system. 13. The new formation should also solve the chronic severe shortage of men, materials and services. 14. Hence, it is not just primary care sans secondary health care. It has to be both.

The Relentless Charade of Curative Care The relentless charade of curative care by the activists has been going on because it has got displaced from the public health care. It is now firmly placed in the private sector and has become exploitative and costly. It must be recognized that it happened due to inadequate answers given by the public health care system. The simple fact is that without a capable higher-­ level care/cure centre in the primary care, its success will be seriously truncated. Those involved in curative care have miniscule knowledge of



primary care ideas, and the primary care protagonists have not known the capabilities and value of the work of the other group. This dichotomy has to end. CHC: First Curatively Oriented Unit The curative aspects in public health care system were first described with the kind of structure at periphery and the personnel needed for it to be delivered. This was the first clear outline of the CHCs. Since then 5000+ CHCs have come into existence (Naik JP, ICSSR-ICMR Report 1981). The rest of it was the description of the primary care, its apparatus and giving a hope of health for all by the year 2000. My surgeon wife and I were sure of the impossibility of its success by 2000 even then, notwithstanding the enthusiasm over the idea. Yet, no one could speak up against the primary care. One has to deal with these monopolizing contractors of primary care not because they are wrong, they are not, but because of the distorted picture and unjust blame they put on others involved in curative care. The entire preceding text of this chapter was a build-up to a most important, but drastic, idea, which will now be put forward. The solution to all these actions is the core of this volume: the reorganization of the public health care delivery system. The whole spectrum of actions follows. In this chapter, the fate of the PHCs and the changes that should ensue will be discussed. CHCs and not PHCs seem to be the only answer after years of deliberation. Principles to Dismantle PHCs Rationally, Relocate Resources to CHC What will be the political implications of dismantling the PHC structure? The reflex answers will be ‘disaster, or political upheavals and unrest, deprivation of the already severely deprived’ and so on. It need not be so, in real terms. 1. One can ask three questions. One—in quality or quantity terms how much has the model served or accomplished for the severely deprived? Two—what is the logic of this step we are suggesting? Three—why is the hitherto continued model with ‘due diligent’ tinkering from time to time fails repeatedly? The answer to all the questions is the same. We have loaded a horse only an elephant can bear. We need an elephant.



2. The entire physical structure and presently available manpower of PHC will have to be dismantled over time, based on certain criteria and in phased manner, not one time and wholesale. The strongest support for this proposition is simple. Manpower to support both the CHCs and the PHCs is grossly inadequate and will be more so even after measures suggested by IPHS  from here on are implemented. The idea is to consolidate the available numbers in fewer places not far from the locales of PHCs. 3. The second reason is the functionally poor profile of PHCs presented above, which does not satisfy any of the five vectors of health care. The impossible list of functions cannot be carried out since even the newer provisions of IPHS cannot meet the same. The corollary is that ineffective manpower is locked up in 25,000 PHCs. It needs to be freed and deployed meaningfully elsewhere nearby. 4. All PHCs are not alike. Somewhat better functioning will be found near big cities where these are not particularly needed. In remote areas, there are too many PHCs which are either moribund or irremediable or the distances for different hamlets reaching it, get much less as compared to the higher health needs. 5. If one of the five PHCs is converted into CHCs, functionally the other four simply become redundant. This has been shown at different places and the mechanisms for that are elaborated. Lastly, even if all human endeavours give its best in PHCs, the basic ideas on PHCs will not be able to give the best to the people.

The Budgeted Manpower in PHCs The total manpower that is already budgeted for in the IPHS and NRHM presently is listed below. As shown above, the vacancies in many categories are substantial. It only means that the entire manpower, if available, can be relocated. It will be freed by the dismantling processes.  The figures are rounded off for simplicity. 24,000+ medical officers, MBBS 24,000+ pharmacists 24,000+ ANMs 48,000+ staff nurses on contract 24,000+ laboratory assistants 24,000+ male health assistants and 24,000+ female health assistants— both will go for new role assignment in CHC



24,000+ health educators—new role assignment in CHC 24,000+ drivers and vehicles. 24,000+ upper-division clerks 24,000+ lower-division clerks Moveable assets of laboratory, beds and so on Fixed assets of the building to be liquidated, or the rent saved 96,000+ Class IV employees These are available budgeted numbers, which makes reorganization eminently possible if done in rational manner described below and in the next three chapters. In almost all categories except PHC officers, there are significant shortfalls shown above. It indicates that there are considerable unspent budgetary portions lying there year after year with reduced pressure on exchequer. All of them are important cost centres. This human wealth from 24,000 centres has to be deployed in just over 5000 CHCs (see below for calculation) which adds four to five people from important categories to each CHC.

PHCs, Phased Closure: Principles, Processes and Potential Changes 1. It will have to be done against all the political pressures and the common rhetoric of anti-poor, hence by default the American- and European-­guided policies and slogans of free health as a fundamental right, and so on. 2. All the PHCs located in urban areas whether they are dysfunctional or not will have to be closed as quickly as can be since there are many other agencies which can fill the gap.8 This number is not significant compared to the far-flung PHCs in the hinterland. 3. It is not at all difficult to relocate these people as an immediate measure to many higher-level government outfits in the cities wherever there is a shortage of manpower. 9. Assuming that there are about 20% of the PHCs out of 24,000 clearly seen as irremediable, despite effort of decades and past experience, the first phase could look at how quickly these can be closed. 4. The four PHCs coming below the fifth as it becomes CHC should be closed and manpower shifted to the CHC above them. This also 8

 This will be discussed again in the chapter on urban poor in greater detail.



solves the issue of relocating them not very far from where they were working. 5. The PHC closure process actually starts from the creation of CHCs. All related aspects to it will be discussed in the next chapter. 6. There will be fierce resistance during the transition particularly from PHC doctors as all avenues towards filling of their pockets will be closed. (See above.) It will however achieve some measure of justice to poor people. 7. These officers and other personnel should not be flung far and wide but relocated to the nearby CHC, which will have a more urban location. 8. In the same phase, the PHCs which have a potential to get converted to CHCs must be identified. The selection criteria are as follows: first, it should be in more urban location, for example the second biggest town in a Tehsil; second, it may be the nerve centre of large number of villages around, with which it has good communication by road; three, —the location may be central or as near as possible to the bus depots and/or railway stations; and four, it has been functioning within its limitation well enough for the dependents to have faith in them 9. Some of these medical officers may be due for postgraduate diplomas or degrees and could be sent off. 10. When the PHC manpower is to be given to CHCs, the immediate implication is that no one loses a job. The relocation in many categories of workers will precede by the retraining for different skills to satisfy new needs for the functioning of the CHCs. The numbers of skills needed are many, and it should not be difficult. Not accepting the same will result in the exit of such people. 11. For some the relocation issue will not arise and the solution could be far more satisfactory. 12. Dr Manmohan Singh was keen on the National Skill Development Council’s good functioning. The General Paralysis of the Insane (the tertiary stage of a disease not commonly seen now) wasted the idea in both UPA I and UPA II. 13. The NDA, or the BJP, government has vowed to implement the idea of skill development, which is most welcome. Yet, when it comes to health-related skill development, the new government is not really ‘hands-on’ with what they should do that is relevant, or is quality- and result oriented. The skill development will be discussed again in dif-



ferent contexts and some useful ideas about developing skills as well as people who use them will be elaborated upon. 14. Nature abhors vacuum. At the periphery there will be vacuum as there will be no doctor if the PHC is wound up and there may be a spontaneous reaction, but this is not the right reading of the situation. 15. In a population of 50,000, under the closed PHC there will always be a few qualified doctors of the different streams. Closure in fact will increase their responsibilities more, resulting in the proliferation of the services they offer. It will include drugs, X-rays and the basic laboratory functions. These professionals are operative even now. This is how the rural dynamic works. 16. They may not be that greatly dependable. There is enough and more fraud in these labs but all the same what can never be made properly and consistently available in PHCs at least becomes available there. How to build upon these initiatives for quality is for us to think. Methods are available for this as well, which will become obvious in pages and chapters to follow. 17. Hypothetically, even if the vacuum is complete, the situation becomes more than ideal for the AYUSH doctors, who, as proposed in Chap. 5, will be trained  in CHCs and will become much more competent when they settle in this vacuum. Surely there will be ample space and more freedom for them to move in the vacuum created by the PHCs at a population level of 20,000 to 50,000. With them will move in their own medical supplies at some cost which the population is ­willing to pay because it can. They would not want to say as the PHC says—it is not available. 18. The care after dismantling PHC will get concentrated at fewer hands because people will prefer to go the AYUSH doctors instead of listening to the health workers ‘after a point’. This will lead to a single-step referral system to CHCs. It will be one step—from the doctor to the CHC—because there is no default structure in between. 19. A doctor where there was none is a morale booster for all the peripheral community workers. In addition, the community health workers also can get help by these doctors in many cases without having to refer anywhere. Even the so-called quacks will move in or surface visibly.9 9  The quacks are no small matter. In the early 1990s in a then industrializing city in Maharashtra, the only doctor who gave human insulin to people with diabetes was a quack,



20. Contractual third party payments with these doctors can be worked out for those who cannot pay and are far below the poverty line by using the insurance schemes which is receiving a bigger thrust now. See the chapter ‘Health Insurance, National Health protection Scheme and Public Private Partnership’ in the other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). 21. Voluntary sector organizations will find the population level of 50,000 or more suitable to deliver care. Notwithstanding the many other issues in relation to their activities mentioned elsewhere, voluntary agencies with a desirable profile need support. A full chapter is devoted to health institutes and voluntary agencies in this volume. We have by now enough experience of them. 22. This is also the promise of public–private partnership without making any noise or being demonstrative or administrative about it in a much cordial informal way than the contractual obligations and hair splitting arguments over it. It is an arrangement between people and the provider ‘appropriate for the job’ and the locale. 23. Help and facilitation rather than control and checks are the need. One of the emphases of this volume is to indicate where and how the government ignores the contribution of the private and voluntary sectors, unnecessarily competes with them, causes duplication and creates obstacles and wastes more capacity and resources. It is argued that it should withdraw from such places, not be the doer of everything but a facilitator. 24. There will be space for even an occasional MBBS to go and settle somewhere in the population segment of 30,000 to 50,000. The CHC will be his fallback like others. This is how the rural dynamics plays. And yet our health planning refuses to acknowledge these fellow practitioners, as well as the voluntary agencies. It plans as if the job has to be done only by the government, however badly. In the government attitude, they do not exist. 25. With the CHC coming up with specialists, the peripheral doctors will have a much better place to send their patients instead of sending them to the ineffective care facilities of PHCs or a dysfunctional CHC or an SDH in similar dire straits. The anxiety of complications develwho assured people of restoring the erectile dysfunction common in diabetes. Some MDs in allopathic medicine were later trained by the pharmaceutical giant Novo Nordisk in diabetes who then started the use of human insulin.



oping will also be reduced. With these predictable changes. the CHC model will be even more relevant and can still be in an approachable distance.

New Thinking About the Staff of the PHC None of the staff mentioned above and discussed below has any need to shift from the PHC if the PHC is being upgraded to CHC. If the PHC is being closed, it is for the staff to decide whether they want to continue acquiring new skills or make an issue of being displaced (from their comfort zones) and be removed from the service. 

Pharmacist, Laboratory and X-Ray Technicians

For every four PHCs closed, the pharmacists and laboratory technicians presently working there will shift to the upcoming/existing CHC. It will make up substantial, if not full, requirement of one CHC. IPHS numbers stipulated that CHCs are much smaller and far more inadequate for all three categories. They will have a more equitable work pattern in fulfilling many important functions they cannot in PHCs. 

Nurse-Midwife (Staff Nurse), Additional Staff Nurses

This is an experienced cadre, ineffective in PHCs for reasons discussed above, which will be very useful when five specialists are working round the clock in the CHCs. Their absorption will automatically happen in CHCs, and they will also be coming to more urban location. All four categories mentioned above will automatically provide near-adequate numbers to run their work areas 24 × 7.  ANMs, Health Worker Female, the Lady Health Visitor, Health Educator, and the Health Assistants, Male and Female There are several options that can be made available for these categories. The important thing is to utilize and enhance their capacity and skill set, so that they can be upgraded at a later date. The options are as follows: 1. The better ones among the ANMs and the lady health workers can then be subjected to the graduate or general nursing course without



any reduction of time frame of training. Their erstwhile training will only help them do better as registered nurses in future and be given priority in the government institutions. This should be followed by the promise (within limits of availability, feasibility and possibilities) that on completion of their training they will be located either in their own places or near to the place in which they are married. 2. Laboratory technology is another avenue more suitable for the ANMs who have shown promise. 3. The other options particularly for male workers are X-ray, MRI, CT, 2D ECHO cardiography, dialysis and ultrasound technologies under the National Skill Development Corporation. This will at once solve the issue of forced unemployment, greater opportunity and better candidature. I do not mean to suggest that these options cannot be handled by lady workers. 4. Ideally, these people should be paying for their own upgradation. Without that the value of justice done and opportunity given to them will not be realized by them. Today the situation of the country-side is such that parents or husbands would be willing to take it upon themselves to raise the money if it is reasonably within their means and would want progress. I have seen this in Tripura, in the hilly Kodagu district of Karnataka and in the villages of West Bengal umpteen numbers of times. While being trained they will be paid the salaries they were drawing before the dismantling. 5. Cold chain and vaccine logistic assistant are underworked and idle. Several such categories thus can be identified in the details I will not go into. In a busy system, whoever is present must have a little more work that one handles easily. Cold chain and vaccine functions could well be a part of the nurse cadre. Adding people who do not add much to the average efficiency or competence of the system should be eliminated.

Multiskilled Group D Workers

Driver 1/PHC: The sine qua non of a dysfunctional PHC is a broken-­ down vehicle lying unrepaired for months and an arrogant, pain-in-the-­ neck driver. The reasons why vehicles do not get repaired are many and generally known to all. By bringing this vehicle to a CHC location will solve the problem of repairing it. The driver is not to be paid if he cannot produce an explanation as to why it cannot be repaired at the CHC



location. This is the way to get the idle vehicles available for the CHCs or even the PHCs till they are dismantled.10 CHC will be a busy place. It will need vehicles, and the code of conduct for the drivers will change. They will have to assume many other jobs which are eminently within the capacity of any human being of average intelligence. They will have to change their behaviour or be shown the door. You cannot depend on Drivers, Doctors and Dawood. 

Upper- and Lower-Division Clerks

In PHC, they were in excess, idle and a cause of intrigue. In CHC, with a large increase in the volume of work, they will have enough and more to do. 

Class IV Workers

As discussed earlier, every effort should be made to encourage them to become better and climb the ladder of the paramedical services. It is for the system to stimulate them, kindle something in them and make them a beneficiary of the new initiatives of National Skill Development Corporation. My own experience over long years is that at least two out of four can easily span the transition. 

Health Assistant Cadre

In case of PHCs, for health assistant (female)/LHV, the shortfall was 38.2% and that of health assistant (male) was 52.6%. It means that for every five PHCs closed there will only be three lady health assistants and two male health assistants. The unspent budgetary provisions for the remaining five unfilled posts, gets added to the general pool. There are several options and pathways for each of these categories of workers. The male workers may run to the urban areas to do as many varieties of jobs as he can, once removed from his comfort zone in PHC.  Or if an opportunity is provided to upgrade him and acquire new skills mentioned above  and get better paid eventually, he may shun the gateway to the towns and cities and opt for newer skills and continue in CHCs. 10  The drivers are useful in doing different work in mobile camps and for the large-scale activities in a project. In a government system, such motivation and involvement is not likely to fructify. The general experience is that all the intrigue starts with a driver in a set-up, engaged or idle. It is the culture that needs to be changed.



The proportion of women who would do the urban transition and translocation is much less for obvious reasons. They will stick to their newer job and different nearby placements even after better training. The important point is not about the shortfall. It is about those who have remained within the public health system. Past experience shows that majority remains because they like something about their jobs. They have a sense of self-actualization in it. It is on this sentiment we have to build. The idea may appear challengeable but this is truer if a male worker has remained in the job. The unavailability of other options and need to stay home, to look after the fields, and so on are secondary reasons merely complementary for staying on.11

Other Gains of Closing PHCs: Improving the Quality of Quacks Quacks (excluding the Vaids, Hakims, Mantriks and the Ozas mentioned earlier) are a powerful institute since people have implicit faith in them. The advantage of quacks is the self-limiting nature of 60 to 70% of illnesses which would anyway get cured or will not harm the ill person even with their treatment. The ‘strength’ the quacks have is their knowledge of allopathic therapeutics that they have gained from pharmaceutical company representatives, which in most cases comes handy. There are clear cases of abuse of antibiotics which are frequent. There would be other inappropriateness in what they do. But these can be overcome. The author stands by them, having taught them in West Bengal Rural. I am clearly aware of their hunger for better knowledge, their gratitude for being recognized as a caregiver for an extended hand for help. To overcome their weaknesses, we need a supporting second-level curative structure powerful enough, so that they can refer say to the CHC or even similar private sector structures developing in rural areas for admission/opinion, even accompany their cases and visit them later to learn what is being done. Here they are on an unequal footing. What they could not manage gets managed here. All the other qualified doctors also should be honourably invited to do these things, without fear that they will be

11  In 1976, I met a leader of the Bus Conductors Union in Mumbai, who mentioned to me that most conductors, as they begin the day, put their hand to the landing of the bus, place it on their heart and then climb up. No one builds on such sentiments.



ridiculed or abused but learn better ways of doing what they can do. There should be a trust between the two. It will have to be cultivated.12 The PHCs and the Non-State Players Instead of closure of the PHC, can PHCs be handed over to private or non-state players a feasible option? There are only a couple of examples of this measure. Is it in the same format of manpower, or will the pattern of manpower change, how and where will be the increase and from where is it supposed to come? The detailed terms and conditions of taking over a PHC pertaining to these aspects in particular are not available. If the format of the PHCs is not changing during the take over then it is the devotion to work, faith in the concept and a masochistic willingness to bear the suffering and hardship, the sole factor to make a PHC work. The followup of these takeovers has not come out as a paper or information. This type  of arrangements in more diverse ways have been discussed in the chapter on Health Insurance, National Health Protection Scheme  and PPP in my other volume mentioned at several places here. (Kelkar, 2021) This trend should not be encouraged for PHCs. Such takeover also makes a good copy for the media but will not work on a large scale. The reason is that the model to be taken over is so ill conceived. If the taking over agency is going to add manpower, then it is not going to be a takeover alone but a new experimental model. Nothing is known about this either. It is merely an individual’s response of excellence and not a system’s response of excellence. This distinction is crucial. It is the average manpower trained in the  system to serve it in various capacities at different times, achieve individual growth and maturation in this system while benefitting it—this is the way work should be carried out. Individual sacrificers is not the answer. (Kelkar, 2021)

Closure of PHCs, Deserting the Poor First, we have to remove the chronic myth that free health services near home is a must because we have paid taxes. People like to pay even to these ‘so-called’ unqualified or non-allopathic practitioners if they think they will get better-quality treatment/service or mental satisfaction. This 12  As an example, I may point out my own experience using methods of involving quacks and teaching them. It has met with gratifying response in West Bengal Villages from 2011 to 2013.



creates a sense of freedom from being a beggar but becoming an honourable transactor by paying value for value. An opportunity to pay to get service is a need of those who respect money. For the last 30 years, we know that what is free is not valued. We must also realize that continued unlimited free treatment is not possible. We do not have the resources. And the majority of this free treatment goes to the most frivolous people. The issue really arises when people are forced to pay for what they are entitled to get free because of the frauds perpetrated on them. The real question also is, how to provide for excellent service in serious illnesses and save the life of poor and prevent their disastrous financial ruin, which is a common outcome. To make quality service available, even if it is taken a little distance away from the remotely located poor is justified. Having one PHC in utter doldrums is as good as not having one. Eliminating it results in saving budgetary costs, which is also equally important. To produce and provide a good referral system, the prime function of primary care, is facilitated by removing the layer which does not help. It is also achieved by creating vacuum and adding qualified practitioners to it. All in all, this will benefit poor. The time to and timing of referral where a problem will be decisively solved without any intermediaries or at least stabilized is equally important for the poor and not so poor. Today the number of communication channels is many and varied. The relative distance of 20 to 25 kilometers when it comes to serious cases is not the issue. The distance idea will come under explanation in the next chapter. For less urgent illnesses, the same agencies can be utilized to span the distances and send and get the services at the doorstep. When the disproportionate time–work balance at the remote periphery is restored among the four or five categories of workers, these and such other networks can be extremely handy.13 In the next two chapters, we will see how the CHCs will be built and how their functions will enlarge, over and above the IPHS and NRHM ideas and change the rural health scenario. We will also see the irrelevance of the subdivisional hospitals and what we should be doing about the district hospital.  There is a large-scale network of agriculturally related activities using connectivity, sophisticated beyond common perception, the semi-literate people are using with alacrity in a backward district of Yeotmal in Maharashtra, where ITC has established choupals, something like a temporary storage and movement of goods. These services have been used to transport blood samples and carry the reports back to villagers. Reuters have similarly established an online system in villages for agricultural information transmission which can be used for health communication. With digital India going full swing, the connectivity should not be a major issue in times to come. 13



Concern About National Programmes National programmes are a large part of the primary care particularly from PHC down. The hands that actually work it out are at this level. The existing difficulties in carrying out the national programs have already been discussed briefly in the previous chapter. Chapter 10 will deal with national programmes without PHCs and clarify how it will be achieved. In conclusion, there are significant lacunae in the conceptualization of primary care which also is the reason for its inability to deliver its objectives even partially.

References Duggal Ravi, Gangolli Leena, 2005, Ed Review of Health Care,CEHAT, Mumbai. Reddy Prof K Shrinath, 2005 Public Health Foundation of India (PHFI) site accessed 25th/26th August 2015 and in Express Healthcare January 2013, pp 32, 33. Banjot Kaur, October 2018, Down to earth. National Rural Health Mission 2005–12,—Meeting people’s health needs in rural areas Framework for Implementation, Ministry of Health and Family Welfare Government of India, Nirman Bhawan, New Delhi-110001 No.L.19017/1/2008-UH. Shanthi Dr, Director of preventive health Kandy, Sri Lanka, in personal interview on 28th November 2018. Wanigatunge C.  Prof, Clinical Pharmacology and medicine, University of Jayavardenapura, Sri Lanka in personal interview on 2nd December 2018. Rural Health Statistics of 2014, Government of India. PTI | July 02, 2017, Economic Times Health World. Services PHCs IPHS standards 2012, Ministry of Health and Family Welfare GoI. Warner, David circa 1980, Where there is no Doctor. Diggikar Ranjana | 08 July 2015, 8:14 AM IST ET Health World Newsletter. Indian Public Health Standards (IPHS) Guidelines for Primary Health Centers 2012. Lele Dr Bagaram, 2015, Long serving employee of Mumbai municipal corporation, Personal Communication. Naik JP, 1981 Health for all by 2000, An Alternate Strategy, ICSSR-ICMR Report of the Working Group. Kelkar, Sanjeev, 2021 India’s private health care delivery: Critique and remedies, Palgrave Macmillan India. Rural Health Statistics, 2012, Statistics Division Ministry of Health and Family Welfare Government of India.


Structure and Function II: The Community Health Centres

Two Ways of Restructuring the Community Health Centres Before we go in the development of community health centres (CHCs), we will briefly discuss the process of closure of primary health centre (PHC) here because development of CHC is its greatest precondition. There are two ways now about how to enable a CHC to become what it is envisaged by the government and the features added herein by me and argued for. There already exist more than 5300 CHCs. Humongous data is available about the details of these CHCs in government documents. If the chief deficiency of manpower is set aside, infrastructural aspects and the capacity to expand as will be described here, a large number of them appear to be suitable for it. The proper upgradation of these will be the least troublesome, least costly and a sensible way, that is, ‘start with what you have’. The second set of CHCs is announced by the National Rural health Mission (NRHM) and Indian Public health Standards (IPHS), which wants to locate the CHC where earlier a PHC had existed. Every fifth of the PHC will become a CHC. The second idea is extremely defective for the following reasons: 1. The planners do not seem to be aware of the existing more than 5300 CHCs with a lot of infrastructure. IPHS does not even mention them. Details discussed below of what it would like to do with © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




many aspects of these existing CHCs are therefore conspicuous by absence. We have to therefore assume that no one has tried to find out whether the already-existing asset is utilizable or not. This is typical bureaucratic planning. 2. Thus, it has to be assumed that the government will go for lot of building work in making every fifth PHC into a CHC. Undertaking massive building work is an open avenue of corruption and a guaranty of substandard construction. 3. This is colossal, criminal waste of money. For proper planning it is mandatory that this asset should be carefully scrutinized on several parameters followed by certain actions, as discussed below. The lazy and callous bureaucrats will not do it. It has to be forced upon them. 4. Every fifth PHC becoming a CHC should be on hold till the process described below is not completed. 5. One CHC out of five is not a rule of mechanical thumb. Location where the CHC should be developed is important. The fifth PHC should meet those criteria also discussed later.

Selection of CHCs Hereafter, the existing CHCs and the one out of four to be converted are taken at par for discussions, and each will be individually mentioned if the context demands it. 1. For an efficient and highly utilized CHC, the location is the most important. How many of the CHCs will fall within the area covered by the group of five PHCs or is most easily approachable, should first be earmarked. 2. The next criterion for selection will be the inherent capability of the PHC/existing CHC to easily expand. That may or may not reduce the numbers of eligible CHCs. 3. Expansion of a thus suitable existing  CHC will be much easier, much less costly and much faster. The details of buildings and the infrastructural elements in it are discussed below in detail. 4. For those remaining should then be taken up for infrastructure assessment and needs. In these areas, conversion of the one out of five PHCs to CHC should not be undertaken as a mechanical thumb rule.



5. To complete the argument, the expansion of the fifth PHC will be costlier, slow and difficult. 6. The PHC conversion should be considered only when no previously exisitng  CHCs satisfying the criteria or capable of upgradation appear to exist in the area of five PHCs.

The Process and Consequences of CHC Build-Up 1. The speed to bring the CHC up to date in the model suggested here, expanded beyond the NRHM/IPHS conception of it is extremely important. 2. No PHC staff as well as chattel assets should be dismantled without a proper CHC developed in the vicinity. The emphasis on this should be noted, although the PHC  closure is the most major modification here. 3. As and when this process becomes operational, staff from four to five PHCs will be relocated. It will also mean that there will be much less manpower shortage at the junior level of experienced resident medical officers (RMOs), general duty medical officers (GDMOs), interns and AYUSH doctors; this is partly discussed in detail in the chapter on Chap. 5 in this volume. 4. There will be a reasonable increase in the paramedical manpower in this process. Some of them will need a different set of skills for different functions they should be capable of absorbing as discussed in the previous chapter. 5. This function can be accomplished in a decentralized manner, as described later. 6. Some consideration within feasibility should be extended to relocate these people as near to their previous places. 7. The resistance of the PHC officers to relocate, as all sources of ill-­ gotten money stops, has no moral basis. The resistance will have to be overcome with a strong hand. 8. The one important change this will bring about is the abolition of thin and ineffective PHCs spread widely. 9. The structure will remodel in fewer highly capable models doing everything the PHC was supposed to do and much more. The distance will increase from the customary 7 kilometres to a maximum of 20 kilometres for higher care but will not affect the acces-



sibility, availability and quality of services with equity and justice discussed partly in the chapters preceding and will be done in the next two chapters as well. By definition it will be affordable or free under National Health Protection Scheme (Kelkar, 2021). 10. Lastly, with a well-functioning CHC no one will even notice that the PHCs are closed. 11. The proposal is to develop 5000 CHCs from the existing resources of the closed 25,000 dysfunctional units of PHCs. There will be other resources created without any significant burden on the exchequer, efficient to address the curative and critical illnesses to a large extent. These resources, particularly the human, have been discussed earlier and will receive a mention at many different places. Other resources will be discussed in this and two more chapters to follow. 12. There are nearly 700 districts in the country now. Within them are metropolises, capital cities, A- and B-type cities, and their easily approachable hinterlands, within a radius of around 20 kilometres. None of these need a PHC or a CHC (or even sub-divisional hospitals, SDHs) because all kinds of medical services, within and around them and close to their own hinterlands, are available. This will further reduce the number of dysfunctional units and release locked-up manpower and instrumentation. 13. Hence, the number of CHCs needed will be for 500 districts only which do not have adequate public health facilities. Each such district will be able to show good results with just about 10 CHCs and no PHCs. This figure is likely to vary between districts from 10 to 15.1,2 14. It is far easier to manage 5000 units across the country, within reasonable distance from each other and from the deeper, remoter communities, from the logistical point of view as well. 15. It would be much closer to the administrative government centres. There will be corresponding changes in the administrative struc-

1  However, the kind of CHC model I proposed should be implemented in the form of health institutes in these cities with some superspeciality. I have separately dealt with it in the chapter ‘Health Institutes, Voluntary Agencies in Health Care’ in his volum in chapter 11.   2  We have loaded a horse with what only an elephant can carry. We need an elephant now, with the horses working with it.



ture in the proposed model to ease logistics, and many other reasons discussed later. 16. The vertical arm of managing health care logistics in public health is extremely long. With elimination of PHCs, the most difficult length of the arm is cut short. The long arm above the CHC level will also be cut down and simplified in its structure to help logistics. It will be argued that it will not destroy the principle of decentralization but will make it rational, practical and effective. 17. The discussion to follow will make it amply clear that it will serve all five vectors—the accessibility, affordability, quality, justice and equity—much more efficiently than may be thought. It will be capable of doing much more work than is thought by most planners. 18. The elimination/building process should be done with a sense of urgency without undue haste. The actual modus operandi of it is also described in detail. Before going to that it is better to have a brief look at the CHCs operating so far and the issues these are beset with.

Evolution of CHC Under Government Prehistory of the Community Health Centre, CHC The idea of something like a community health centre is as old as 1973 in India. It got a little more impetus in the 1981 report on ‘Health for All by 2000’ (Naik 1981). It mentioned the four basic specialities of medicine, surgery, gynaecology and obstetrics and paediatrics. Curiously there was no anaesthesia back up provided at that time. The rest of the ideas were the X-rays, laboratory, 30 beds and allocation of staff which to me looked sketchy even then. The same model was described in NRHM 2005. In 2012, two new ideas were introduced as essential to the conception of CHC: one was of the blood storage facilities and the second was that of an anaesthetist. The legal basis was given to the CHCs as being established and maintained by the state government under the Minimum Needs Programme (MNP)/Basic Minimum Services (BMS) programme. CHCs were also given the status of the First Referral Units (FRUs) as their conception was found to qualify for it. FRU in the government parlance is defined as any facility equipped to provide round-the-clock services for Emergency Obstetric including surgical interventions like caesarean sections and newborn care, in addition to all emergencies that any hospital is



required to provide. It should also have blood storage facility on a 24-hour basis (NHRM 2005–2012). Community Health Centre Staff: Before and After the Revised IPHS 2012 For the sake of coherence of the analysis and comments, different topics are discussed together even if these appear at various places in the IPHS document. At first the structure proposed by IPHS and changes/additions over the NRHM will be described and then it will be analyzed. S peciality Services per IPHS IPHS has extended the earlier NRHM recommendations shown below, as it did in case of PHCs shown in the previous chapter. There could be minor variations in this profile. The basic allotment in 2012 is sound even though the vacancies in consultant positions are 80%: General surgeon, 1; MS/Diplomate of National Board (DNB) (General Surgery) Physician, 1; MD/DNB (General Medicine) Obstetrician and gynaecologist, 1; Diploma in Gynaecology and Obstetrics (DGO)/MD/DNB Paediatrician, 1; DCH/MD (Paediatrics)/DNB Anaesthetist, 1; MD (Anaesthesia)/DNB/Diploma in Anaesthesiology, DA/or an MBBS specially trained in Anaesthesia. The last idea will come under a detailed consideration only to be rejected in the end. One ophthalmologist is recommended for five CHCs—a highly sensible measure. Medical Officers Trained officers in anaesthesia are essential for utilization by and for the surgical specialities. They may be on contractual appointment or hired from private sectors on per-case basis. Doctors trained in speciality and general duty are four in number under IPHS; this gives rise to two different cadres positioned in one level in both NRHM and IPHS documents. The first category of trained in speciality will demand and deserve different/higher provisions compared to the general duty doctors. This can lead to some strains and many complications. What these complications are and how to eliminate the same will be discussed below later. The cadre of junior/resident/general duty doctors and issues



related to them will come up at a few different places also. Anaesthetists and anaesthesia in particular will come for discussion at several places.  urse Midwife (Staff Nurses) N Additional seven nurse midwives (staff nurses) and one + additional contract staff nurse are prescribed; two more are now provided, taking this number to ten with the assumption that the 18 out of 30 beds will be provided, that is, an occupancy of 60%. It will not be so, as discussed below.  aramedical Staff: Pharmacist/Compounder P This number has been increased to pharmacist one +one (desirable). Pharmacist—AYUSH, one, has been added in both the PHCs and the CHCs. Lab Technician The number has been raised by one more to two. Other Paramedics Radiographer, one; dietician, one; ophthalmic assistant, one; dental assistant, one; cold chain and vaccine logistic assistant, one ; OT technician, one; dresser (certified by Red Cross/St John’s Ambulance Service), one. The same numbers have been retained. Administrative Staff Registration clerks, two; statistical assistant/data entry operator, two; account assistant, one, and administrative assistant, one, have been retained. These are useful categories whose job profile can be drawn in each situation specifically. They will not be discussed any further here.  ommunity Health-Related Workers C Multi-rehabilitation/community-based rehabilitation worker, one +one, have been retained. Health worker (female)/auxiliary nurse midwife (ANM), one; health educator, one; health assistant (male), one; health assistant (female)/ LHV, one—this cadre has been removed from the earlier model of CHCs. The reason probably is the retention of the entire PHC sub-centre chain. However the redundancy/ineffective contribution or wastage in the PHC system should be accepted. Assigning them a new role and skill in CHC will rectify the defects and give more manpower and strength to CHC



since these are people already experienced in health care. It is also much needed because the functional capacity under the modifications additions/suggested here will lead to many more health measures the CHCs will become capable of executing. In these measures, these people will be immensely helpful. Lastly, this cadre will not lose their jobs unless they refuse to adapt to new roles and training for newer skills, as mentioned in the previous chapter. Ward Boys The number of ward boys, from two, has now been increased to five, and are to be considered as nursing orderlies; as has been mentioned in the previous chapter, filling up a position need not and should not necessarily come from people trained for that particular job. A variety of jobs in health care need some training and hands-on experience for the safety of the patients. The lowest-rung ward boys cadre, if trained well, can do excellent work. They are also of considerable help to all the lady workers in the wards, emergency rooms and elsewhere. For ten long years, we met with our manpower needs in a remote hilly health project by these upgradations.  river and Other Menial Staff D A single driver is changed to a desirable number of three. Three drivers and three functioning vehicles add a lot to the capabilities of the CHC, for example debulking widely prevalent medical disorders in the community, shown later. Dhobi, that is, the washerman, one; sweepers, three; mali, one, chowkidar, or guard, one—they have to be contracted from outside sources, a good idea for partial peripheral outsourcing. Ayah, the female menial worker, one, does not find a mention, and is assumed to be removed from the CHC but is required. The discussion about ward boys above applies ditto to the ayah cadre as well. Thus, a total of 46 essential and 52 persons desirable are to work in the CHC (Indian Public Health Standards (IPHS) 2012).

Block Public Health Unit Block Public Health Unit is an important idea, which needs a more detailed coverage. It will be done in the next two chapters. Here the staffing alone is described.



Block Medical Officer/Medical Superintendent, One, under NRHM/IPHS Qualifications Senior most specialist/MBBS ( a) Preferably with experience in public health (b) Trained in Professional Development Course (PDC) Responsibilities Coordination of national health programmes Management of ASHAs Training and other responsibilities under NRHM Overall administration/management of CHC and other duties Quality and protocols of service delivered in CHC Public Health Specialist 1  ualifications Any One of the Many Q MD, Preventive and Social Medicine (PSM) MD, Community Medicine Postgraduation degree with Master’s in Business Administration (MBA) Diploma in Public health (DPH)/Master’s in Public Health (MPH) Public Health Nurses (PHN), One +One Qualifications and Requirements Degree or diploma in nursing Will be trained for six months in public health The Health Educator A PHC should work in coordination with block public health unit for organizing health education services.



Statistics As of March 2015, there were 5300+ CHCs supposedly ‘functioning’ in the country. Of the specialties, following shortfall was found: surgeons, 74.9%; physicians and paediatricians, 79.8%; and gynaecologists, 79.6%. There is no figure available for anaesthetists. Only 751 CHCs have four specialists. There are vacancies in 1182 positions of general duty medical officers (GDMOs). CHCs are short of 32,406 radiographers, 8321 pharmacists and 13,691 laboratory technicians. These are extremely telling statistics which clearly indicate that most CHCs do not function at all. To complete the statistics: we have 593 districts, 755 district hospitals and 1006 sub-divisional hospitals for the 640,867 villages surrounding them (Rural Health Statistics, 2014). This boils down to one sub-divisional hospital for every five CHCs. In addition. there are 1253 mobile medical units supposed to be running in the country. They also have a different story to tell. All these elements will come under scrutiny to see how and whether it serves the five cardinal principles the health care delivery should. Physical Infrastructure CHC Post-IPHS The CHC should have 30 indoor beds with one operation theatre, labour room, X-ray, ECG and laboratory facility. Drug list to be provided for CHC is the same as PHC. The issues arising therefrom are already discussed and will not be repeated even when these are extremely important. Manpower in CHC Post-IPHS The five basic specialists are the most needed element in the CHC. Adding anaesthetist in 2012 has made the arrangement suitable for adding an element like HDU, or the high-dependency unit. HDU is not there in the present concept of CHCs under NRHM/IPHS.  This volume strongly recommends adding HDU to the plan. Each and every aspect of this seemingly impossible idea has been discussed here arguing for the opposite. Below is analysis of some of the functional groups mentioned in the manpower.



Issues Related to Medical Officers The need for five specialists is firmly established in both the IPHS and the CHC concept now. This is fundamental to the idea of CHC and will be discussed frequently in different contexts. Even then the concept of having medical officers trained in any one of the five main specialist areas of medicine, gynaecology and obstetrics, surgery, pediatrics and anaesthesia, preferably at the medical colleges with experience of minimum two years— has been retained by NRHM/IPHS. MBBS doctors given short-term specialist training or experience of at least two years in the particular speciality have been considered eligible for appointments if speciality post is vacant (Rao Sujatha 2013). There is no doubt that this is a tentative suggestion and clearly indicates that the government is diffident of its ability to provide fully qualified five basic specialities. Such appointments create too many complicated logistical issues discussed below. Therefore, while it may be justified, how to do it by avoiding the complications it creates is discussed below in detail. The complexity of issues this idea gives rise to, described in detail below, will make obvious the need for a much simplified system. The latter is also provided here. About the In-Service Candidates in PHCs 1. The preferred recruitment route, eligibility and conditions of pre-­ training experience is not mentioned. This cadre will come from MBBS graduates completing their internship, those who have not been able to get in the postgraduate courses after repeated efforts, and the MBBS already working in public health care. 2. Preference for the segment will need different criteria for specialized training. For example, in-service candidates who have long been away from teaching environments will have certain handicaps. It will be difficult to believe that all such MBBSs, largely from the PHC pool before being selected, will have the capacity to change over to a specialist training. It will also be difficult to judge their inkling, if there is any, left in them in the service years about the branch they would like to be posted. 3. Getting in a branch with no interest and inclination will raise legitimate concern about the adequacy of quality and their performance.



4. It may be a good idea to apply National Licentiate Examination (NLE), as proposed in the National Medical Commission (NMC), which will assure some quality for placement for specialized training to the in-­service candidates before getting them in such short-term training once it becomes functional. About the Fresh MBBS Graduates 5. National Licentiate Examination, NLE, as proposed in the National Medical Commission, (NMC), will assure some quality for placement for specialized training for the just passed-out MBBS.3 6. The quality of freshly passed-out MBBS without undergoing NLE cannot be vouched for since the standards have been disturbingly low as demonstrated by both NEET at the entry level and NLE at the passing-out level. For a thorough discussion on this, refer my earlier volume, India’s Private Health Care: Critique and Remedies, Chapter 6 ‘Regulators and Regulations in Health care’ (Kelkar, 2021). Hence, arbitrary criteria will not help. 7. In any case, the governments—either the state or the central—will have to plan the process in minute details. It is described below. 8. The numbers included in each speciality will have to correspond to the needs in the field. This becomes a little simpler since each state or union territory has a much smaller number of CHCs for these calculations. 9. The nature, the places, the identification and imparting the ‘must and the desirable skills’ should be detailed (NRHM 2005–2012). It has not been done here but will be clarified below. 10. Many from the above two segments, MBBS from PHC and the fresh MBBS, may not want to undergo specialized training in a branch they have no interest in. This may become an obstacle.

3  National Medical Commission bill, which signed the death warrant of the corrupt and degraded Medical Council of India, has met with fierce opposition which managed to stall it from 2017 to 2019 May. It has now been passed and has become a law under the government formed in June 2019. NMC is the best thing to happen to India’s Health Care. An extensive discussion of NMC will be found in the second volume on private health care delivery, published with this one, which the reader is exhorted to read for better understanding of issues.



11. Those not getting in the postgraduate courses may be interested to join the branch of specialized training of his interest, which will be facilitatory for them to prepare better for postgraduate degree later. 12. However, he may still not join the branch of his liking under the idea that he will not get enough time to prepare for the postgraduate course if he has to also work. This illogical thinking is quite likely to operate in today’s psyche of young graduates. That will be another obstacle for recruitment. 13. Every in-service candidate selected will mean that some place in the state public health service, usually in PHCs, will fall vacant. 14. Then there is a question of where will they be posted? If they have to be posted back to PHCs, then the training is a waste. 15. If they have to be posted in the CHCs, as of now the CHC situation and its infrastructure is in a deplorable condition which will not change even after their posting. It is not a question of just filling up the posts because the specialists are not available. It is the human life which is coming under the care of these people. 16. Then the nepotism and corruption in admitting these candidates cannot be ruled out. 17. This is a complicated logistical exercise. 18. There is every possibility that the enrolment will be uneven. 19. The output may/will not match the needs in the periphery.  ogistical Issues of the Training Itself L The medical colleges will obviously be the places where these specialized trainings can be offered. Colleges will have an additionally responsibility to teach these candidates also, along with their PG students working in the branch. Creating such a separate cadre to train will result in certain consequences which will not be conducive to training atmosphere. During the training period, this is what will happen: 1. If many more such trainees are added to the already-existing PG students from a separate cadre, each person’s work quantum will get further divided. 2. To overcome that or a new way of teaching has been proposed in this era of technology, with the help of mannequins or by simulator or using virtual techniques.



3. This type of training is costly, demanding creation of labs and instructors. 4. It is proper to ask if this can be juxtaposed in the dilapidated medical colleges in majority states. 5. The serious functional objection to it is that it makes the trainees’ familiarity with techniques second hand. 6. It is quite uncertain whether it will cover all aspects of training. 7. Instrumentation or simulation training is of limited benefit without ‘face to face, on job and hands on’ training and teaching on patients under specialists. 8. Since the numbers will be much higher, there will not only be strains between the PGs and the trainees to get to do more work but a strife which would be ugly. 9. In any training, most important are the hands-on experiences. This will not then be achieved. 10. This will be all the more so since the NRHM document shows how eager it is to pump in so much training and of such diverse nature (as will be described in some detail later). NRHM is also in a hurry to place them in the curative services. 11. The enthusiasm gives an impression that in rural and the CHC services, which essentially run for poor, specialists are not so important. 12. Alternatively, it can be interpreted as the surrender of the government, disguised in the enthusiasm that specialists are anyway not going to be available either in CHCs or in the sub-divisional hospitals. 13. In that case we have reduced the lives of the people from the hinterland to less-than optimal care. This is a grave injustice. 14. It is a bit uncertain that the Directorate of Health Services will have a mechanism to get them adequately certified by the medical education before deployment since there is no coordination between the two as shown earlier. 15. It is also doubtful if the Directorate of Medical Services is capable of or will do the deployment depending upon the needs at the periphery. The corruption in this process is legendary. Even if we take that away, the strong doubts about this process will remain.



Other Measures to Get Fully Qualified Specialist Services in Rural Areas The centre has proposed to reserve half the seats in PG courses for MBBS graduates working in government hospitals and are also willing to sign a three-year bond after degree. (Pallavi Smart, Jan 05, 2017, 07:31 IST) It is one of those ‘cart before the horse’ kind thinking which will create greater difficulties. It does not mention if  the remaining 50% completing postgraduate courses also give a bond? The issues considered for both categories would be as follows:. 1. Apparently, there is no metnion of specific number of years such candidates should have served in the government. Longer the years, the lesser competent such a doctor becomes a consideration kept uppermost in mind. It is srongly suggested that these candidates can appear for it up to 35 years of their age.  2. The bond system should be eliminated as a whole from the arena. Reasons for that have been amply discussed in earlier chapters. 3. Hence, even if specialized training followed by the three-year bond makes sense, such an isolated measure should be dropped since the same can be achieved by methods described at various places in these chapters. 4. Next is the difficulties faced during placements. Will there be places adequately powered where they could be absorbed? As of now the conditions in most places are so poor that the placements are more likely to be a mismatch and waste of manpower, in the prime years of young or the in service postgraduates due to situational handicap, and no further learning and maturation with consequent waste of training will result. (As will be discussed later, the idea of starting a CHC should be undertaken only when five basic specialists are placed in it together, not one here and one somehwere else.)  5. Will it then be worthwhile for the governments to enforce and execute the bond they have signed? Will it give justice to the postgraduates? Without preparing the proper centres for specialists, such thinking will only make the government finally retract from such ideas. 6. Whether it should be mandatory for the in-service candidates desirous of joining PG course to pass the postgraduate National Licentiate Examination (NLE) now, with all other younger graduates to get in to the postgraduate courses; we believe that it must be so because of the quality of understanding issues, as discussed above.



7. As years go by, those entering the government service will have passed the same; hence, their eligibility for PG courses will directly depend on their marks.  The idea we have extended is that with those NLE marks they apply for a PG course only after two years. NLE mechanism is getting established and will be enforced  in a couple of more years. 8. One complicated issue that will arise is when an MBBS, having spent some years in service, having passed the NLE to do so, will now want to apply for a PG course. In that case, how will the NLE score of this candidate be compared in order to declare them eligible for a PG degree? Should their scores of NLE be compared with the NLE scores in the year of application to PG or with those who passed NLE with them? The latter option is rational.  9. Now there is not/will not be any PG entrance examinations as such, only NLE. For how many years the NLE score of an in service doctor should be considered valid? This question can be linked with renewal of registration. Once an NLE score is beyond the years of first renewal, which is five years now such a government candidate has to reappear for an NLE. 10. Or should all these rules/suggestions be ignored and a wholesale admission for PG courses should be given to in-service candidates? Tamil Nadu is one such state which will be most happy with a blanket 50% reservation for in-service candidates, irrespective of quality. 11. These questions are raised for two reasons. One there should be an objective, a quasi-human independent mechanism, for selection for PG courses. The second consideration is that the one who goes for PG has the requisite wherewithal for the system to be sure that the doctor will have quality. 12. If wholesale admission is used, there will be vociferous and violent argument from the doctor community. The objection will be the further reduction caused in the number of already-inadequate seats to the freshers, particularly from the upper class. 13. Even more fundamental but rightful question to ask is, can a much simpler scheme can be devised? A Much Simpler Scheme for Training, Admission and Deployment In Chap. 5, the way to deploy medical graduates, postgraduates and in-­ service candidates in the CHCs, as well as how the training will happen, is already discussed in detail. It resolves each and every difficulty described



above. Adding more details below and reconsidering some of the deployment aspects from Chap. 5, may achieve greater clarity and simplicity. It will then be easier to streamline this process in a smooth manner. 1. The PG cadre should be the only one to be trained for specialist functions in medical colleges. 2. This caveat rules out any place for the ‘short-term speciality training’ proposed above and should be abandoned completely to avoid all other issues described above. 3. The main entrants will be the interns after spending two years in a CHC. 4. The PHC officers will finally be in the CHCs and will be eligible to try PG courses after spending at least one year in the CHCs. This year would help the PHC MBBS to get an idea of which branch of postgraduation he would like to get in. This is a great benefit and necessity that he does so. 5. Those who do not succeed in getting a PG could still be considered in this important category of trained manpower suggested by NRHM if they continue to take interest in a particular branch and continue working under those specialists to do more complex jobs in CHCs. He will then have  a far better capability to ease the pressures of consultants. This will be informal training with no tags of certification attached. It is just an avenue to give opportunity for those who could not get a PG seat but like to work in a speciality. Unlike fresh graduates who have to go out of the system after three years the PHC oficers shifted to CHCs can continue  since their terms of appointment in government service will be different. 6. The decision to hold a single all-India common postgraduate entrance examination has already cut through a lot of loopholes. This particular aspect is discussed in Chapter 6 ‘Regulators and Regulations in Health care’ in the other volume, India’s Private health Care Delivery: Critique and Remedies (Kelkar, 2021). 7. An additional place for training is the DNB examination. For work experience, hundreds of places have been selected for the candidates to work for their DNB speciality degree. Should the in-service doctors be sent to them? 8. The National Board of Examination is soon likely to be submerged in National Medical Commission. Due to the Covid 19 pandemic, many routine decisions remain pending. It should be remembered that more often than not the teaching, the hands on the DNB candidates get, is



far too less than satisfactory. Even if they are able to clear the DNB, there is much that may remain less achieved than one wants. [These deletions are made to accommodate the long addition in points made above and not because they werev incorrect in any way.] 

MBBS General Duty Officers: Numbers, Role, Training and Related Aspects Two MBBS general duty officers are added by IPHS, to be increased further if the patient load increases. To start with, this number is too small even for a 30-bed CHC with 60% occupancy. IPHS agrees with this reality, only as a possibility which is a bit too diplomatic. CHC has to provide, on its own admission round the clock services with doctors in eight-hourly shift duties.  These numbers will be inadequate for that service and the overall load. The solution offered by the NRHM is to compensate shortages by resource or the block pooling concept, among the available doctors from the PHCs covered under the CHC. The PHC doctors in addition to routine OPD should also do shift duties to provide an emergency service at CHCs (NRHM 2005–2012). Sujatha Rao in many of her writings has also suggested these measures (Rao Sujatha, 2017). This entire hotchpotch idea needs to be critiqued and commented upon in strong words. 1. The prime emphasis on the trained MBBS previously has now been removed and two MBBS general duty officers are added. 2. At best this can or will be an arrangement for records. It means the already-burdened and -malfunctioning PHCs will function even worse. If the planners expect the PHC medical officers to do double duties with an incentive of more money (which incidentally is not mentioned), it is unjust and the costs go up. 3. Certainly, the quality of services will deteriorate in two ways. If under the name of having to go to CHC the PHC medical officer is likely to abandon the PHC work half way, allowing the quality of PHC function, to go down further. 4. If he does a full duty at the PHC the quality of the service he may render in the CHC, probably in the nights, under his exhausted condition is comprehensible. The short duration of the duty hours and how it affects not just the care quality but learning has already been extensively discussed in manpower development and deployment.



5. It is impossible to understand why the whole world wants to preserve this failed SC PHC structure and model, as is seen above. Instead, why not close down the PHC and shift the doctors wholesale to CHC, as I have been arguing again and again? 6. This is not only an important but a complex issue, as is obvious from the long discussion just preceding. Some may call it a simplistic solution, which it is and will not give results. However Ms Sujatha Rao needs to be strongly defended over it. This is not a callous, off-thecuff solution she is offering. Under the rigid conception that PHCs must continue no other solution can be offered. If at all, this is a solution arising out of helplessness. The government is not in a position to think about how to restructure the system but is continuing the piecemeal, incremental or more of the same kind of solutions. We will be obliged if Ms. Sujatha takes a look at what this treatise is offering.

Workload, Financial Viability and Non-Availability of Doctors 7. The reason the government planners may give for this meager addition of just two general duty doctors—as far as I can guess—is whatever the workload, each of the five specialists should be able to manage it easily even without these two general duty doctors. Or they may argue that it is financially not viable to give more MBBS or that so much of its numbers cannot be found in the already-prevailing situation of shortages. The way in which shortages should be viewed is already discussed. 8. It is not only the question of specialists managing the workload alone. That the specialists will somehow manage. There is no doubt that all the specialists in CHC (or at any other higher level, private sector corporates for that matter) gynaecologists, obstetricians, paediatricians and neonatologists are in need of under-trainees for the general as well as the critical care management. And when there are ways, well described in Chap. 5, why not do it? 9. The second and more important reason for providing as many junior, resident and such other category doctors is the training of graduates. At every stage of the health care delivery, the just-passedout or any MBBS must be on the scene and operative. That is the



only way to learn the craft of medicine. Prof B. M. Hegde has come out independently in support of such an idea in his usual forceful and convincing manner and many more ideas  expressed herein (Hegde 2009).

More About Specialized Training of MBBS The specialized training pertains to all the five specialities to be present in the CHC to make up for the vacancies of the specialists, if any. So far I have discussed the follies of what the NRHM/IPHS think without reference to the particular specialities. Such a training has different potentials and limitations within the five branches we need to have a look at, which NRHM does not. MBBS Trained in Internal Medicine and Paediatrics Leaving behind the NRHM/IPHS ideas and thinking on the discussion so far and the fair, initial picture of CHC emerging, a few things need to be repeated: 1. The idea of training is for  the in-service candidates or the fresh MBBS or the interns or the AYUSH doctors expected to work in CHCs as proposed herein,  in internal medicine and paediatrics but not in medical colleges. 2. All of them will learn their skills in these two basic specialities while they work in CHC by the bedside and through other academic activities discussed earlier and will be talked of again. 3. Internal medicine is vast. That is the largest care component in any acute / regular curative service. Those doctors, trained for a couple of years in postgraduate tenure, can lift the burden of medicine and paediatrics in medical colleges. In CHCs, even if the CHC doctors of different categories are without a formal degree, they can similarly lift the burden of medicine and paediatrics as the PGs in medical colleges. 4. Both the higher level of training and the bedside basics are the all-­ important components of training. When cases with higher complexity are admitted, higher support for the investigative and therapeutic equipment is needed. Without it, neither a definitive and quantitative diagnosis can be reached nor can a calibrated,



focused and minimalistic effective treatment be offered. Without these, even a qualified MD could be as limited as these doctors will be. The malady of the CHC and the SDH is the gross lack of both. With the training component, this also needs to be rectified to get much better results.

The Government Logic and the Ground Realities about Anaesthetists 1. For over 30 years, since the concept of CHC was first articulated, till 2012 there was no provision for anaesthetists in the CHCs. There must have been a counterargument over this long period about why the anaesthetists were not necessary. 2. Most surgeons can or were expected to manage spinal anaesthesia and supplement it with IV sedatives and complete majority of the surgical and gynecological cases. It only emphasizes that there has been no consideration for the surgeons or physicians who are battling at the most disadvantageous places against death and trying to save life. 3. In the absence of an anaesthetist even if these two surgical specialists were to be available, there will be significant limits to how much work they will be able to take up especially in acute cases. 4. This is such a basic, the most logical requirement that it is difficult to believe that the planners could not see it for such a long period. Later declaration in the NRHM document to provide an anaesthetist also does not mean that the provision has come in existence in majority of the hospitals. It has not. There is a world of difference in having an anaesthetist and not having one. The difference is not just being at the head of the operation table or critical care alone. To repeat, it is everywhere in the management of rural surgery to rural medical acute care units to be able to take up more and more difficult cases, and save far greater number of lives than otherwise, with the same amount of salary, if that is what matters more to the government. They relieve the surgeons and physicians who intubate and operate with fear gripping their throat hoping that no complications arise. Is that what the planners wanted the doctors to work in and under such situations day in, day out? Do the planners think that the specialist doctors



would willingly go to these daily guillotines and man the CHCs? If it was to be so, why do nearly 80% vacancies exist in CHCs at the national level according to their own statistics? Have they heard of burnouts in medical careers or are blissfully unaware of it? Or does the government think that all the doctors who choose to work at such places are masochists who enjoy such pains? Does the government not know that in today’s more and more formally rigid world, doctors who substitute for other disciplines have their degrees and careers at stake whether they work in the grossly sub-optimal circumstances or the best ones? Or is it implicitly understood that ‘if something is not possible at your level shunt it’. Do they understand the inhumanness of such an attitude? These planners who sit in the plush A/C offices, who make plans and push them down, do not come from this battling cadre of surgeons. Otherwise they would not resort to the above logic. MBBS trained in anaesthesia even if there is no anaesthetist in a CHC with adequate elementary infrastructure will be a powerful change agent in routine and acute surgical cases and to a great extent in handling critical care. The details of the training and how much is adequate for these three branches are not necessary here: as much as a candidate can absorb and reliably perform would be the most pragmatic answer. We repeat that there is no need to develop a new cadre for these requirements as shown above. The graduate doctors will absorb the skills by and by within the CHCs. Surgery, Gynaecology Surgical and Gynaecological surgical problems have limits in training the MBBS. We need specialists for that. Needless to emphasize, these trained MBBS can still take on much more work or assist in complicated surgeries than can be imagined, in the CHC.  A few more considerations are described below about the role of MBBS informally trained in general and gyanecology and obstetrics surgery and anaesthesia. 1. To be able to do a caesarian section or hysterectomy or a laparotomy for a duodenal perforation without creating a complication needs years of good hands-on training and a good teacher to work under in referral tertiary centres for long years. 2. The experience of treating complications, however created, needs much more work experience.



3. The most frequent of these complications is sadly the missing out on a proper and full diagnosis of the presenting case. Instead of emphasizing the surgical skills for MBBS, the emphasis should be on the full and correct diagnosis in these two (and for that matter any speciality) in CHC. The MBBS and the AYUSH will be finally going out into the periphery that they have served in CHC in a limited manner. Making a good effort at diagnosis and the potential complications will lead to early referrals to CHCs they came from to save many more lives. 4. Complications arise from undertaking or not undertaking surgery at the most appropriate time. Such cases are difficult to salvage by the time they come to the tertiary centres and are in no way the cup of graduates. 5. Most complications created in these two branches arise from both public and private surgeons from A and B cities as well since that is where the hinterland patients finally come. It underlines for me the need for much greater quality experience even in cities. 6. Even tubectomy, medical termination of pregnancy (MTP) and dilatation and curettage, D&C, so often done in the PHCs or in camps, are fraught with so much danger. Examples of that are frequent due to rashness, overconfidence and the zeal to go for numbers or for money. Much more work experience and extra efforts for a proper asepsis in operation theatres is needed which must be understood.

Other Worker Categories in CHC Under IPHS This section will deal with all other non-doctor categories mentioned in numbers above but not functions at the beginning of this chapter. Their numbers needed as the picture of work requirements and other features of CHC evolve is discussed. NRHM/IPHS: Nurse Midwife (Staff Nurse)—Seven + Three Posts The strength has now been increased to 10 assuming 60% occupancy, that is, 18 out of 30 beds. This is an indication of how incomplete the idea the planners have of the power of a five-specialist unit in a population of 172,000 to 250,000. Most hinterland population are underdiagnosed and under-served. As a result, nearly full to excess admissions are a norm in similar smaller units, with the earlier insurance schemes. With the National



Health Protection Scheme, the numbers will go up further. There is absolutely no doubt that whichever and however remote or poor a place in the countryside, there is no dearth of work for each specialist of the five especially if units thus constituted are operative. This is reflected in change of the CHC capacity from 30 to 50 beds which NRHM also proposes now. The staff nurses will then be required in much greater numbers. There are examples of private agencies with low tariffs, run only for a reasonable profit to sustain and develop further. They are nearly always with full workload since no other capable structure nearby is there from the government side (Azim 2015). The reasoning of 60% occupancy and limited number of staff nurses therefore does not stand. It is not just the indoor beds. In addition, nurses are needed to maintain and run the operation theatre and assist operations when two busy surgical faculties are operating. The number ten for staff nurses does not take this in to account. We need experienced nurses for that. Ancillary workers attached to the OT without a trained nurse will not do. In that case management from asepsis to maintenance will be slow and imperfect with its own dangers of operation theatre sepsis, a blot on the system. A registered staff nurse is far more than just the one who is looking after the few random beds by rotation. The significant shortfall thus arising for the nurses should be augmented and it can be met as proposed in this volume. An addition of high dependency unit (HDU) to CHC is implicit in the model I have proposed here. It will push the required number even higher. It will also call for muh more experienced and expert nurses for managing HDUs well. S ignificant Barriers in Procuring the GNM Nurse for CHC In ICUs of the government medical colleges, the nurses get trained in critical care management. The requirement there is also large and unmet to a variable extent. Therefore, bringing them to CHCs will not be easy. These general nursing and midwifery (GNM) nurses can be recruited from the nursing schools if a nearby district hospital has one. The CHCs however outnumber the district hospital (DH) by 10 to 1. Hence, DH will not be able to supply the numbers since most staff nurses will be needed in the DH itself. The new output from the existing medical college nursing graduates will be in high demand first in the medical colleges and then in the district hospitals. CHCs with HDUs, if built, will still be in short supply. One more reason of this shortage in the government system is the corruption in appointing them, as mentioned earlier. The natural



beneficiaries of it are the private, large, or corporate hospitals. CHC can be an attractive place to get in the government system but corruption blocks it.  Way Out for Getting Nurses for CHC A One more way to meet the limitation is the slow and cautious, phased developments in the CHC. No CHC should be opened unless all five basic specialists and as much trained staff as possible are available. It would be wise to start only fully equipped CHCs, one by one, even if the speed is slow. The reason is to demonstrate to the people (and the planners as well) the blatant success of such units. It will then accelerate the development of the newer CHCs. In this way, the additional numbers of GNMs can come from the closed-down PHCs. In theory, roughly 48,000 nurses from as many PHCs are to be made available to 5000 CHCs. However, on ground these many staff nurses are not available. The demand will be high and the supply meager. We have already shown the mismatch between the PHC level of functioning and the staff nurse there and advocated closure. This source will be adequate to start number of CHCs, some with HDUs in early phase fairly quickly (See later also.) This source will dry up in a few years as the PHCs continue to get closed.  eed for a Decentralized System for More Graduate Nurses N The next option is a GNM nursing school at the CHC itself. The recommendation of 50 beds in a CHC fulfills the statutory as well as sensible requirement of 50 beds to open nursing schools. The workload required to train can come only when the bed capacity is 50 with high occupancy. ANM schools should also be started in CHCs which are working to full capacity of 50 beds. More will be discussed about the ANM schools later. These two measures will provide with more hands in a couple of years to accommodate more work, meet the actual requirement and even open more CHCs. The appropriate time to start these two schools would be a couple of years after the CHC has come to its full capacity and delivering high volume of work. The time taken to reach this stage will be extraordinarily and surprisingly short, may be a few months or a year if the initial supportive staff is adequate and well trained. It will take the two yeras mentioned or even more time to get the teaching cadre for the nursing schools. The CHC itself will take time to come



to grips with its work and systematization of work of all people to address this task. All the nursing schools functioning in the government medical colleges for their own requirements must continue. The CHC Nursing School is the response to the need of the periphery, in the absence of which the huge disease load shifts to medical college. In addition to nurse teachers, the specialists as well as the community health officer (see in the next two chapters) should be a part of the nurse teaching cadre. This can be done effectively by opening the doors of seminars, clinical meetings and on-round teaching for the nurses along with graduate MBBS and AYUSH doctors. I have experimented with each of these methods mentioned in this volume for years and have been rewarded. Pharmacist/Compounder; Laboratory Technician, Radiographer The issue of severe shortage of well-trained quality laboratory, radiology, dialysis, ECG technicians, emergency room attendants and operation theatre technicians within the public as well as the private sector is discussed routinely in the health forums. The reader is requested to refer to the detailed comments on all these trained people in the discussion on PHCs and the sub-centres. At CHC level the numbers sanctioned greatly fall short of requirements, and it becomes a graver matter since the complexity of work on a 24 × 7 manner cannot leave any services unavailable. Any health outfit has to cope with heavy work willy-nilly for at least 12 hours every day. Casualties in the nights are unavoidable and much greater numbers of the above and all categories will be required in CHCs than provided. The high numbers required in the categories mentioned above initially should come from the closed PHCs. These numbers make up for the requirement only partially because of the already-existing vacancies there. Few more numbers can be made up by getting these technicians in the skill development initiative which has many categories of these techies. Unfortunately, NRHM does not mention its own kin, the National Skill Development Corporation and under it the Health Skill Sector. The same principle of recruitment stated above in connection with the staff nurses is applicable here—unless one CHC is given the full number, which will have to be much greater than provided under the IPHS, the second one should not be filled in. The skill development will be  discussed  later to make up for shortages.



Dresser: One Post: Certified by Either Red Cross Or St John’s Ambulance Service Firstly, this number will be too small for CHCs. Secondly, there is no particular need for this category. The additional small training component without a broader base will be a hurdle and waste of capabilities since more than one function can be handled by them. Suffice it to say that any ward boy intelligent enough should be trained in the CHCs by the surgeons and should become an important part of the operation theatre staff also as a dresser. Ward Boys and the Ayahs, the Lady Menial Workers In any health care centre, one can easily spot the brighter and interested ward boys and ayahs capable of further development as ANMs, technicians in other departments and as departmental assistants. As pointed out earlier, we talk of vacancies but do not talk about those who have remained. Once employed, majority of them stay there for long and work diligently. They like their work; they are sensitive to it. They become better over years. And yet they do not think about rising higher, under the impression that no such avenues are available for them. It is for the in-charge doctors of the CHCs to spot them and open a better career path for them through the skill development route or by training them for more skills within the CHC. It will fortify the manpower at all levels. The other staff like ward boys and ayahs already working and familiar could also be inducted in the skill development by a process of interview to assess their suitability. I have discussed this again in little more detail in the chapters following. Additionally, the quality check on their work will be needed before they are accommodated in the more demanding complexity. Sweepers In the name of human dignity, this post should be abolished. What the presence of this category leads to is a specific and categorical denial from Ayahs and ward boys to do the cleaning work or emphasizing the class and the caste divide. From both these viewpoints, abolition is in order and the work is delegated to other upper categories.



Shape of Care in CHCs We now need to discuss how the care will shape in the CHC I have proposed. For the discussion to remain lucid, the medical manpower deployment, specialists, PHC officers and the interns and AYUSH and the methods of teaching discussed earlier should be constantly borne in mind. The most important is to establish logic of medical care in all the branches explained partly in the chapter of medical education. Logic is absolutely essential for the knowledge of disease in its longitudinal spectrum, its causation, its investigation, diagnosis and treatment. Good medical practices are not easy to learn but the best chance to learn them lies here, to share and lift the burden efficiently. Complexities of Disease Profile This profile in a population of 172,000 to 250,000 under five PHCs is changing. It is rising in numbers, in non-communicable diseases. Better management of these patients means travel over long distances to district hospitals or medical colleges or to the private sector situated more or less at the same distance as the first two. Then there is a loss of work for the day and money and additional expenses. The senseless crowding in these care facilities would still not give justice to these essentially chronic cases. The distance also means that easier, adequate follow-up resulting in quality care and better quality of life and mitigation of the secondary or tertiary complication would not be optimal. In the absence of competence in the periphery, it adds to the crowding for the treatment of tertiary complications, for example dialysis in end-stage renal failure in diabetes. Hence, there is a teaching component for specialists to first learn how to deal with these chronic cases. The mindset to manage acute care and the mindset to manage chronic ones lingering over long years are different. Thus, continuing medical education arises as a new need which has to be factored in within the CHCs. We have given adequate number of examples and methods to improve this earlier. A medical specialist in CHC trained for this will cut away the disadvantages of this population travelling long distances in large numbers, resulting in better outcomes.4 4  Most medical specialists have realized the need for such a training over two decades now, in government or otherwise. Any mechanism erected to do it well will be flocked by them. It needs a little facilitation from the government side.



Gynaecology and obstetrics in the new CHCs will result in the same logistical reductions not only in routine delivery cases but also where the medicine consultants need to support that care, anaesthetists support taking up more critical or cases requiring longer duration of surgery and a larger number of junior doctors to execute the care.5 All the schemes in maternal and child health care today emphasize on institutional deliveries. The indices related to these cases will have every chance to substantially reduce at CHC. A large number of medical officers will not remain superfluous since CHC with these arrangements cannot but be a busy place. More About the Role of Surgeons in CHCs Surgeons in CHCs should have a substantial background of gynaec and obstetric surgery. This does not add much strain to a well-qualified surgeon and is an integral part of what some respectfully call Rural Surgery. Association of Surgeons of India also has recognized this category for orientation of surgeons in Rural Surgery (Arun Bal Dr, in conversation, 2014). If the surgeons cooperate with the gynaecologists, most gynaecological surgeries, even the extensive ones, can easily be undertaken at the CHC level. Arun Bal and my wife Sanjeevanee have been the epitomes of the Rural Surgery. Governments need to recognize the rural surgeons who are contributing to people’s health today. Surgeons can easily do some elementary orthopaedics, a suprapubic cystostomy, emergency tracheotomies especially in children, thoracostomies to treat pneumothorax in acute emergency, or when shifting is not easy which could be life-saving. It may not even be necessary after thoracostomies. What should be done to provide services for the other basic speciality branches like ENT, ophthalmology, orthopaedics, urology, nephrology and so on? This will be discussed more wholesomely once our ideas about CHCs progress over the chapters to come. Whether it is NRHM or IPHS, the key concept of acute care is limited primarily to the specialists’ ability. If the infrastructure can be provided with it, better care can be extended. Else the insensitive escape route 5  In Sonamukhi, a small town in West Bengal, not even a block level, with a population of just about 19,000, my surgeon wife removed a 15 kilogram ovarian tumor in less than two hours. No medical college or big private hospitals in Durgapur, Bankura or Bardwan wanted to touch the patient. All the backup of even an HDU that she had was not required post-surgery.



always present is to let the case be transferred elsewhere. That is the reason why the instrumentation has not been paid adequate attention. But profile of acute or critical care today is altogether different and the treatment methods have improved greatly. Its availability lowers mortality and morbidity indices in a given locale. Even the elementary technology of electrolytes, renal parameters, liver function tests and simple X-rays and to intubate a patient improves health indices. CHC today is essentially a cosmetic unit that adds to the numbers on paper and is a post office for referral, merely a conduit which at best can tell the patient which specialist to approach, not always where. Powers of the Services in CHCs Unless the full team of fully fledged five specialities is assembled in a CHC, it cannot deliver consistently even the elementary second-level care. Due to this stringent demand, initially the spread will be uneven and slow. There is no alternative to it if the CHC has to give quality care and relief close at home. Its value cannot be overemphasized. Unless quality is achieved, equity and justice cannot be achieved. The spread of CHCs within a district is worked out by us which is roughly 20 kilometres from its area of coverage which is easily accessible today. The feasibility to reach the centres, where the illness will be treated with guarantee, makes the distance quite irrelevant. The opportunity will be further and fully utilized if an HDU is added. In fact it is a must. That it is possible to do it will be shown as the narrative proceeds. The CHC thus constituted can do humongous work beyond the imagination and expectation of planners, activists or the people and will be blatantly succesful. The reasons for that are that no one has worked on such a model, experimented with it, applied it to solve the rural health issues year on year. It is necessary to experiment CHCs evisioned in each state, in as many places possible. Causes of Non-Availability of Specialists for CHCs 1. The poor living amenities in CHCs are an important cause for it. In many taluka towns, there will be sub-district hospitals but the issue of decent living conditions still exists. Failure of its upgradation is an important issue in specialist non-availability. 2. I believed for many years that the pitiful living conditions as the cause should be self-evident to explain the paucity of the doctors



and the specialists. Apparently, it was not the focus among the planners or the activists all these decades. 3. The existing CHCs are largely situated at the administrative level of a block at 100,000 or higher population levels but essentially semi-­urban. The city-bred doctors do not like to locate there. The question of extremely poor availability of the specialists in SDH is also thereby answered. 4. Any doctor who has reached a specialist status will have family obligations and ties which are not always bound to the hinterlands for him to willingly locate there. 5. The family responsibilities of educating children for a well-learned man may not be served in the small towns, fully and always. 6. The ‘perceived’ lack of work is compounded by the absence of other specialists for the same reasons. 7. Every year the activists are more strident about the health budgets sinking lower and lower, and most of the budget gets consumed by the salaries. The actual health expenditure, for drugs and laboratory equipment and other facilities, has no money left. These are also the reasons for the poor conditions of the public health care delivery infrastructure which the specialists do not want to get caught into. 8. The first barrier thus was: no projects—no men, no men—no projects! This is the truth of the matter most simply put, be it PHCs, CHCs or any other contraption in the public health system. 9. There is nothing enticing, appealing or simply pleasing in most of our PHCs, CHCs or the sub-divisional hospitals and the district hospitals just like the medical college described earlier. This is what a city-­educated doctor sees when he first comes to these cursed structures in his internship. It is a ‘culture shock’ for doctors. That is the time when he decides not to step into this place again in his lifetime. 10. There is also a ‘cultural lag’ between the doctors and the populace. When doctors in a large number are together in a project, residing within the campus, the culture shock and the cultural lag are buffered effectively. 11. Yet we need to also accept that nobody was serious about these issues till the IPHS came into being in 2012. Otherwise, by and by some things could have been improved. IPHS is a gallant effort to correct this. It is heartening to see this need being addressed by



mentioning decent facility for all who are required to remain on the campus. IPHS document however needs design improvements, prioritization and a method to achieve this as shown earlier. 12. To lift the level of present state to a much better one will be expensive. That is why I have already critiqued the number of 56,000+ new buildings allocated to sub-centres and the PHCs, which should be put on hold and the fund directed to CHC for this purpose.  acilities and Its Absence F These are the people trained with so much effort. If they are supposed to be in the public health care, it is not for testing their ability to endure physically adverse situations. They are here for improving health of their people. The skewed unequal concentration of doctors between rural and urban is a situation the planners have created, not the doctors. The science of ergonomics, of creating a work place to suit the person who is going to work there, is not a western fad, nor is it asking for moon. It is a simple human necessity. The lack of facilities to do good clinical work ensures that no doctor can practise to his satisfaction since he has learnt to use facilities to do better work with it. Absence of facilities is the beginning of work referred elsewhere or done badly or the deterioration of the doctors. It will further and more effectively kill the urges to do better or any work at all. This is tragic because this is a system-generated injury. Doctors do not like this to happen to them, hence do not want to stay in public health system. This is the age when they have to start consolidating good clinical habits. The existing public health care does not help in any way. It does not take a long time nor does it need huge incentive to willingly learn to practise by the knee-jerk method and send the patient away. The doctors are today prescription peddlers, losing their correct abilities eagerly, unrecognizably unknown to them. The better-quality MBBS, who avoid the injustice of these situations or survives them intact, will go to big cities and practise their half-baked skills, or go abroad to posh careers. They will never look at these ground realities of their own countrymen. This is a colossal waste of manpower we spend on and exert so much to create.



 ureaucracy and Government Vis-à-Vis Health Care B The failure of health system, like any other system, is a deliberate and engineered failure at huge costs by the great Indian bureaucracy in connivance with the politicians to save them. They are intelligent people. But they are Indians and they will never do anything for anybody except their own cadre, guard territories and play turf wars and politics. Their interest in producing meaningful work is zero. Then we have a great constitution for a handmaiden which gives them some excuse or the other, some law or some rule with the help of which they can say with impunity as to why a proposed measure cannot be undertaken. This machinery thinks that solving a problem will lead to their redundancy, without realizing that any change will produce greater challenges to do better. There is unwillingness on part of the government to accept or even consider suggestions from outside the pale of the government machinery and their expert committees. The reflex response is of its economical non-­ viability or impossibility to generate money needed. The worst hits are the doctors and the nurses. The exchequer has already spent much money on their graduation and postgraduation. Why should they be given such monetary incentives from the taxpayers’ money to work in public health system and from where do we get the money? This is a false argument. In the chapter on primary care and NRHM, I have demonstrated the grandiose schemes costing enormous money. If the government can suggest them even when they do not have money, why should they be averse to consider alternatives? Within these self-created constraints the government expects the doctors to go to the hinterland and threatens to bind him or her there for life, but not pay him. At the end of ten years, a professional is created. He has to be given some sense of security for something he does not want to do. The best is the financial incentive and security. That is the value the state should attach to the doctor they have trained. This will free him from the sense that he is being exploited. Good payment also gives a clear message: ‘You are getting money you cannot get in the first three years of your practice even if you resort to the most crooked of the ways; hence do justice to the work profile.’ If the government does not want to do this, then let them stop making any further schemes for public health care forever. Alternatively, the government could sway the public opinion crookedly that they need more doctors and encourage more capitation fee colleges to come into existence, allow the most sub-standard institutes continue



to give doctor certificates. It can then try to fool the public in saying that by this measure all the shortages of the doctors, their skewed distribution, will be made up, and gleefully watch where it will land the people in. One more fundamental flaw in the government thinking about manning the public health care units is the permanency of the doctors, which  especially the specialist doctors are most scared. Introducing a temporary element of service, as shown in Chap. 5, will be responded to if the full model is made available. The fresh  specialists also recognize that some more experience will make them more suitable for private world and will opt for it.  otential Sources of Specialists Working for CHCs P It is not necessary to assume that each specialist has fixed his eyes on US and Western Europe or large cities, metropolis and megalopolises. They have their own temperament which may not be able to deal with these severe pressures, strains and complexities. Only a few survive these pressures. These people will be on the lookout of less-pressured decent centres. A large number who get admitted to government medical colleges come from smaller towns, and often want to go back. Initially, they need the supportive structure and some money which will enable them to first work and then settle in their own towns. They do not see the government job as a preparation for them to go back, serve or settle in the private sector. And the last argument about much better pay structure, which neither activists nor the government, in fact no one, can win is that if you want the results, then spend. Quality does not come cheap. And if you throw peanuts, you will only get monkeys. The focus of one who wants to become a doctor is not only the adulation and gratitude he gets from his patients. They also feel their self-­ actualization will be best served in this profession. This self-actualization, in the psychology of Abraham Maslow, is the joy and happiness which is incomparable; it is the greatest state of mind. We do not have a system to give him work to achieve this state. Rather than giving him a dose of morality and sermon on societal debt, we should be paying him more and decent conditions to work with.  he Remedy Over the Shortage of Specialists in CHC T The best way is to utilize their experience at a stage immediately after their postgraduation when issues like children’s education and so on have not surfaced. In most socialist democratic countries, whatever the financial source of their education, the youth is compulsorily conscripted in army for three



years with regular pay. It supports my argument. Collaterally, it will discipline our youth to learn some responsibility. Instead of the army, the doctors may be conscripted in CHCs. All they need really is adequate and comfortable living conditions within the campus, internet facilities in their hands and a decent pay. This will enable them to survive the three years and a couple of years after they leave public health care and before they start making it on their own. This will slow down the congestion at the city levels and to an extent cut the malpractices in the name of survival. Not all need to go to the CHCs. If there are vacancies in the medical colleges, those should be filled on priority due to the emphasis we are placing on the under-graduate and post graduate education. The criteria for such selection are described earlier in Chap. 5. In the initial period of this system, once the medical college vacancies are filled, the processes of manning the CHCs should start. The CHCs may not have the extra private specialist power available to the district hospitals. Hence, the preferred place after the medical colleges should be the CHCs.  eaching and Work Profile of Five Specialists T Some additional points have been made here and some repeated to get a coherent picture of how these years and years afterwards will be spent by the specialists. In the revised IPHS CHC document, there is no mention of the idea of teaching to the general duty medical officers or AYUSH. It will benefit both, but the teachers more than the students.6 The mentality towards teaching is described in detail earlier. The specialist teaching fresh graduates is a must on their job descriptions. If the bed strength is increased to 50 and an addition of a GNM/ANM school is added, the specialists’ content of teaching should be systemically incorporated. There are many ways of doing it. The present linear mode of teaching is least productive and should be replaced by practice-based contents, learner needs and so on, collectively called problem-based learning and other methods described earlier. To make teaching part of the work, a change is needed in the lookout of administrator.

6  A famous criminal lawyer from Pune used to say—the buffalo may not get shaved but the razor sharpens. Here the buffalo is the student and teacher the razor.



 ore about the Internship in CHC M There are a few more aspects about interns and internship that could not be covered earlier. Interns are going to be a part of the CHCs. Hence, some more consideration about its status is called for. Internship started at a time when the medical courses were not so long and as vast and not so loaded with the advent of superspecialities as they are today. The reasons are discussed in Chap. 4. As a result of it, the intern today is confused without knowing how to apply knowledge in the day-to-day clinical situations. As argued repeatedly, the basics have to be strengthened. It is possible only in CHC as conceived by us. Internship programme is taken very seriously and is meticulously followed in the West. We have its skeleton for modernity but neither the culture nor the discipline. We want to go to America to get more money but we do not like the American work culture here. We want our rights but not our duties (Bapat 2011). On top of all the planning of internship, the reality is that the doctor has to repeat the internship once he is abroad. No one believes in what you do or learn here. The other harsh reality is that hardly anybody becomes the specialist he or she wants once abroad. Whether one who goes abroad is a graduate or a postgraduate qualified in a particular branch does not matter (Bapat 2011). It seems wise to concede the irreversibility of the desire to do postgraduation after MBBS.  At least this is the case with 80 to 85% of the MBBS graduates (Bapat, ibid). That in turn would mean that proportionate increase in the total number of PG seats in government colleges is necessary. If we accept to do this, and if the decision to do PG in a particular subject is firm, why a person should spend/waste his one year of his internship in doing all kinds of jobs (in PHCs) or in medical colleges and become a Jack of all trades? He could accordingly plan his internship year (Bapat, ibid). But flexibility of approach and innovative thinking is not an Indian attitude. I would however like to defend internship with the experience through all the branches of medicine even if a person has chosen the branch for his postgraduation that early. Since the last one decade at least, the situation of even the basic specialities seems to have deteriorated so much that gross and elementary mistakes occur from all the specialities. Speciality practice of internal medicine is not a license to missing a chronic appendicitis or an acute peptic perforation. Examples of this kind can be cited as a daily occurrence at thousands of places. That is because doctors today are not firm and thorough with their basics. And all the problems start or occur at



the basic level. Hence, I believe that particular period should go for making these basics so pucca that it will serve them all their life. It is also my claim that the scheme proposed here will achieve this 100%.  emuneration for Interns During the CHC Tenure R For the sake of differentiation for experience and consideration of remuneration the interns may be considered as junior to PHC medical officers becoming RMOs after one year in CHC. The remuneration should be relooked at in the second year in which they will have to be paid more, which need not be at par with the salaries of the medical officers who would have come from closed PHCs, whose payment structure does not change. NRHM and CHC, Ideas for Betterment NRHM wants to increase the number of beds to 50/CHC. The number, increased from 30 to 50 is ideally suited to get the full model operative by eligibility to start an ANM and a GNM school as mentioned above. NRHM wishes to create new community health centres (30–50 beds) by IPHS standards. With a 80% vacancy status of the specialists, NRHM better not talk about new CHCs, more so when the standards laid out now are too high for even the existing CHCs to be met with. NRHM wants to place CHCs under a decentralized administration by a local hospital management committee under a normative standard of IPHS. These are the Promotion of Stakeholder Committees, Patient Welfare Committees or the Rogi Kalyan Samitis (RKS). As per the Rural health Statistics, 2014, 54,925 such committees have been established. There is a parallel example with many agencies brought together in Maharashtra. People reclaiming the health care, people taking hold of the health care, supervising them and making them work are the new ideas in hospital-based health care. People should be involved in its management supposedly are taking roots (Khunte, Walimbe, 2012). With the Patient Welfare Committees, societies have been formed at the state level with mergers from other agencies of health. There are several forms in which this supervision is conducted; at times, it is just a supervisory, and at times it is run by the coordinated efforts of health functionaries, people’s representatives and the community members.



This penchant for pushing in multiple agencies is utterly disturbing. Some of these ideas were discussed in connection with the government planning for PHCs. It needs some explanation. First of all there has to be a direct authority of the states on CHCs to oversee their functioning. We do not subscribe to this idea of relegating the same in full to these agencies. The central issue of ill-equipped CHCs remains unsolved despite many agencies. The intention behind creating bodies like Patient Welfare Committees could either be to divert the attention from the main issue so that it is not solved properly and the discontent continues. By themselves, such committes are exactly like in Panchayati Raj Institutes over PHCs and SCs. Neither have the resources nor the human expertise to solve the basic deficiencies of the health care delivery apparatus at the ground level, be it CHC or PHC. Creating another body of the Patient Welfare Committees from among the same people involved in the Panchayati Raj Institutes (PRIs) at higher population level makes no sense to us. This is a classic example of creating multiple or multilateral agencies and duplicate them on multiple levels without solving the problems. It is also quite possible that the Patient Welfare Committees like other committees will become an unavoidable irritant/a tyrant force, like the Panchayati Raj Institutes, (PRIs) in SCs and PHCs since they have now been superpositioned over the hospitals. These committees are likely to be filled up by the sycophants of the politicians and will serve as a political tool to dominate or exploit the system and loot where possible. It is unfortunately a national trend a tragedy which surfaces as soon as any system starts working well. The health systems are already helpless. The RKS and the PRI will either clash with each other and individually or jointly, with the PHC or the CHC or the community health workers, and make more demands on this health system on one hand and demand much more from the government on the other, which the government cannot give. That will make either or both effectively null and void with a litter on the battlefield. There are reports of how the availability and working of the facilities as well as the personnel functioning have improved after the Rogi Kalyan Samiti or similar bodies that have taken roots in Maharashtra. In some instances, they have been successful to solve issues spanning across different agencies. It is also encouraging that the meetings of these committees have become a part of the government agenda. The credit is due  (More Abhijit Dr, 2012). Notwithstanding this or such



reports, the politicization till the last level of population is less likely to result in consistent and widespread culture and attitudes that seek solutions. The CHC going under the local stakeholders thereby will become a stand-alone structure and the property of the hospital management committee. That in itself is a disaster for all the reasons mentioned above. However, such a step will also limit many of its potentials which will otherwise become manifest if we start thinking about a group of CHCs as discussed in great details in chapters to follow. The ownership must remain with the state government as well as the administration. This eagerness of NRHM to offload everything to some other agencies is manifest everywhere. This will be counterproductive to an affordable, accessible, competent model. The Law of Care Inverse to Distance This is an important concept that leads us to the necessities of an HDU unit in CHC. It states that the chances that a sick person, least of all children from remote villages, to survive or remain salvageable is a time and distance function. If they reach a competent centre that is able to handle the illness, within a short distance of 15 to 20 kilometres and even time, the chances of recovery in the hinterland are high. These chances continue to decrease as the time–distance between the two increases (Vaidya 1987).7 The CHCs inadvertently covers an area of 160 kilometres. Thus, it will serve the law of better care within this distance. From mid-2011 to February 2015, I have been in rural Bengal and Tripura and, therefore, am more familiar with some of the recurrent horrors we saw. We saw scores of small children from the remote villages of Bardwan and Malda dying every day in Bardwan, Malda, and, finally, in Kolkata Medical Colleges. If not an epidemic, it was disaster. On 4th of October 2016, the same thing was seen happening in the Malkangiri district of Odisha, where a large number of children died due to Japanese

7  Dr Madhavrao Vaidya was the chief of the famous and old Karnataka Health Institute for over 40 years. The time–distance idea and its importance was his discovery which he shared with me. In our work in the hilly tribal areas, majority of our work came from within 20 to 30 kilometres distance, covering a population of 100,000 with a radius of influence over 50 kilometres.



Encephalitis. In Gorakhpur, Uttar Pradesh, in 2018, we saw a repeat of this. The medical college resources locally thus were overwhelmed by such flooding and the children just died. The IPHS was formalized much earlier to these disasters and still the children died. It means only one thing: that the IPHS remained on paper and the governments did not provide either the manpower or the equipment or the medicines in adequate measures or could not, or worse, did not bother about it at all. To say that the higher-level machinery was unprepared for an endemic like this is also correct since these seasonal illnesses are a yearly recurrence. Dying because there are no infrastructural functioning facilities across a distance of 150 to 200 kilometres on an average, in 2012/2017 and 2018, is not acceptable. The primary care as such has already failed since so many children got fatally sick. The point that was getting highlighted again and again in these episodes of children dying was the utter lack of infrastructure between the villages through PHCs, CHCs and any other set-up right through to the distant district centres in Malda or Bardwan, including the medical colleges present there. The distance between these two colleges and, the villages and that of the the Kolkata colleges, turned out to be too large for the children to survive. As a professional I can understand people afflicted with invariably fatal illnesses, of which some of the children were dying. I could possibly accept the high numbers in a stoically professional manner, remembering all the plagues and choleras and poxes that have killed billions in the past. We have been talking about the health indices arising in the hinterland. The aforementioned examples more than adequately justify the need for CHCs capable of reducing these indices as near at home as possible. The critical indices give the final assessment of the capabilities of any health system. Villagers move to specialists only when matters become serious. Long travels needed to reach better centers, offer no hope that the indices would come down. HDUs and Critical Care For the last 30 years, the greatest need for the services in the hinterland known to all those who worked there is the medical intensive-care units which could look after such emergencies, treat majority of them, or support the remaining patients, stabilize them and send them more distally but safely. It has not been thought of as possible for the public health care delivery system. The CHCs, even today, do not include the concept of



HDUs. It is my clarion call to the government and each one connected with health care to realize the importance of these facilities being near at hand in distant communities. There is only one total answer for disasters described above, in other words lowering the critical indices of health. An HDU or a NICU/SICU, that is, a neonatal/surgical intensive-care unit in CHC and a medical intensive-care unit at every district hospital and medical college is a must anyway. It is a far-easier exercise than may be thought even by the planners. If there is a denial to establish HDUs on any grounds, it will be an eyewash. Here we strongly advocate establishment of HDUs in CHCs as well. Fortunately, physicians and anaesthetists are taking a lot of interest in getting trained or even obtaining some formal qualification from critical care societies which work with ICU/HDUs at many places, even remote as in Agartala, Tripura. But that essentially is in the private sector, because the workload is high in terms of both emergency and complexity since there is no answer for it in the government system. The issues related to the raising HDUs will be taken up in the next chapter. In conclusion, this is broadly the outline of the initial reconstruction of CHC. Hence, it must now be seen as to what else the restructured CHC is or can be made capable of delivering. The full picture will emerge over the next two chapters.

References National Rural Health Mission—Meeting people’s health needs in rural areas Framework for Implementation, 2005–2012, Ministry of Health and Family Welfare Government of India, Nirman Bhawan, New Delhi-110001 No.L.19017/1/2008-UH. Indian Public Health Standards (IPHS) Guidelines for Community Health Centers Revised 2012 Directorate general of health services, Ministry of Health & Family Welfare, Government of India. Rural Health Statistics, 2014. Rao Sujatha, Collected comments, ex health secretary in GOI, 2013 PDF articles no longer available. Pallavi Smart Jan 05, 2017, 07:31 IST, www.mid-­day news. Rao, Sujatha, in ‘Do We Care?’ Oxford University Press India; edition 1, 3 January 2017. Hegde, BM, What doctors Don’t get to study in medical school, 1st edition Paras Medical Publishers 2009.



Azim Sabahat Dr, 2015 CEO of Glocal HealthCare Private Ltd, Kolkata. Arun Bal Dr, 2014, founder president Diabetic Foot Society of India, Premier foot surgeon of India in conversation. Bapat R, 2011, Post mortem, Manovikas Prakashan Pune. Khunte, Walimbe editors, March 2012, People are reclaiming the public health system, Sathi, Pune, supported by NRHM, GoI. More, Abhijit Dr, Khajagi Arogya Sevechi Dasha ani Disha, Sathi, Pune 2010. Vaidya, Madhav Dr, 1987, Chief of Karnataka health institute, Ghataprabha, Karnataka, in conversation with the author. Naik JP, 1981, ‘Health for all by 2000.’ By ICMR-ICSSR. Kelkar, Sanjeev, 2021, India’s private health care delivery: Critique and remedies, Palgrave Macmillan, India.


Structure and Function III: Expectations and Realization

Preamble It is demonstrated in the preceding three chapters that the National Rural health Mission (NRHM) has not grasped the ground realities. It seems to lack knowledge of the rural dynamics to offer more comprehensive and appropriate planning especially for manpower. It does not have any new answers, no new workable ideas about addressing the central malady to provide competent care at deeper and faraway levels of population nearer to their homes. The devil lies in detail and the NRHM document woefully lacks in providing them. It has also over-reached scores of areas of no concern.

High-Dependency Units High-dependency units (HDUs) are a little lesser form of regular intensive-­ care units (ICUs) available at many places. The difference is technical in the norms and availability of gadgetry and support. HDUs are relatively easy to establish than ICUs, especially in the periphery and have proved to be extremely useful which prompts us to make it an integral part of the CHC concept, although it clearly falls outside the government conception.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




Cost an Immediate Concern The previous chapter ended on the necessities of high-dependency unit, HDU, in the hinterland and its relation to reducing the morbidity-­ mortality indices. It is a costly affair in a free health care system but there are ways to minimize the costs and make it affordable. To begin with, each newly created community health centre (CHC) need not have an HDU as long as the rest of the unit is constituted as discussed earlier. That does not load the exchequer immediately. Initially every fourth or fifth CHC should be equipped with a general acute-care unit or an HDU. It should start from the more urban locations for which some criteria have been laid out below. This in brief is the answer to the immediate objections likely to arise on costs of HDUs and its affordability to the public health care delivery. A few preconditions to establishing HDU are discussed below. Mandatory Infrastructure and Manpower A functioning anaesthetist, regular or well trained, or an MD in medicine or an MBBS with exposure to basic critical care skills within CHC should be available 85% of time in a month. Today, the trend to specialize in the critical care management is on the rise. This is a welcome trend. Some of these trained professionals can be brought to work in bigger CHCs. There should be a reliably functioning basic pathological laboratory with the prescribed 40 odd tests and a reliably functioning moveable 100 MAS capacity X-ray unit and technicians to operate it round the clock. This is a versatile strength, and almost anything that is needed in the CHC setting can be done with quality. Digitization and remote reporting are not an issue today even in the remote towns; they do not cost much more money but save huge amounts by high-fidelity transmissibility to a distant radiologist to get an opinion without having to employ one. The necessity of remote reporting occurs far less frequently because the specialist clinicians are good at reading the images. An Existing Paradox in Acute or Critical Care It is about the money government is and will continue to spend over the private sector even after Ayushman Bharat for intensive care treatment wherever needed. But it is not thinking of creating such units within the public health care delivery system both in the remoter or in more urban



centres. Hence, barring government medical colleges, there are few public health services which have the capabilities of handling the critical care, especially as one steps out of a city. The idea of equipping the district hospitals (DHs) with a regular ICU of different varieties like trauma, paediatric ICU has not been there till recently and the process must be on to establish these in majority places. These facilities are situated mostly in the private sector. In most insurance schemes so far within the public sphere, there is a component of acute care as well. The government is prepared to pay for it for those who are or will be covered by such schemes. This has been a heavy toll since the outgoings have been disproportionately high compared to the insurance money that the governments collect or put in. The money more likely than not runs out, sooner than later with all such schemes. The most glaring example was the Rashtriya Swasthya Bima Yojana (RSBY). In my volume India’s Private Health Care Delivery: Critique and Remedies, published with this one, the issue of health insurance is discussed in great detail (Kelkar, 2021). At the same time, private sector being what it is, will continue to raise demands of increasing the insurance amounts or raising the tariff, at times resort to coercion by refusals to do the work for the fees given or do so if the money due to them does not reach well in time or is greatly delayed. Some state or the other is in mood not to cooperate threatening to do so every now and then. Causes of the Paradox Economically the arrangement is adversely affecting and logically difficult to handle. If the same is offered by the government in the public health care delivery system, logically it will cost one-hundredth of these amounts. To establish and run them so far has not been possible for the government, or so the government thought. This is one of the principal reasons to write the treatise to show how it can be done. It is possible to do so. Then, why has critical care never been considered by the governments within its own system? The governments are acutely aware that even the primary care is not being delivered well. The structures it erected for handling the more complex cases, requiring higher skills, are not delivering such care in the CHCs and the sub-divisional hospitals (SDHs) either. We have seen the causes for it in the preceding chapter. The DHs are senselessly overcrowded and



the record of services rendered by the specialist there is in no way satisfactory. It is aware of that also. We have seen the successive conceptions of the structure. Is it possible that the governments were not able to think out of the box or break the mold of its own structural elements? That seems to be a likely answer. It is equally likely that internally it accepted its defeat but overtly continued to dish something or the other out to cover it up. It could well be a deliberate and engineered failure by the bureaucracy determined not to solve the issues as mentioned earlier. Why were even the most elementary steps like strict ban on private practice for the public health men not imposed? All these explanations put together point to the one accusation likely to be valid. It is the deliberate neglect of the public sector to facilitate the growth of the private sector the activists are so fond of making. I am not in full agreement with this for the reasons extended earlier and the other likely causes for this mentioned also earlier. The discussion above and the discussion to follow fundamentally rules out any objections to develop HDUs at CHC levels, ruling out that the costs are unaffordable within the budget constraints. We will now see how best and frugally this task can be achieved. The Costs, Usage and Feasibility of Establishing HDUs 1. It should be possible to establish HDUs, one by one. HDU then will not become a sudden high economic burden for which money can anyway not be provided immediately, with manpower. It is well understood. 2. Even if a lot of money is placed in the hands of the rural people on a large scale, to go anywhere they want to in acute illnesses, lowering of the indices substantially will still be impossible for many reasons. A structure near at hand is needed for reducing the indices. 3. The HDUs should in its core conception be a reasonably charging unit, for people above the poverty line with a manpower trained to give frugal and rational treatment. Not all populations are below the poverty line, and many will be happy to utilize these services peripherally with low or reasonable tariffs and a facility as near to home as possible.



4. Mere four to six beds with one ventilator make a huge difference. Any arrangement that can establish HDU can offer the neonatal high-­dependency units when a paediatrician is already available in the CHC. 5. A percentage of the earnings from each CHC HDU can be diverted to make HDUs in another CHCs possible. I can predict that this will happen faster than one may think. 6. The modifications in CHCs and addition of HDU is a formula already stolen by many innovators with reasonable profit while taking help from venture capitalists and other institutes of finance. 7. They have been mightily successful even when they are charging considerably. One such figure available in a chain of rural CHClike hospitals with HDUs is Rs 3000 per day, which covers majority of the services including the drugs. I am in the know-how of these since I have worked them up to make them economically feasible units. More are being replicated at a fair pace. 8. These are developed and are being run with the money of largescale investors who think that even in rural health scenario such units will give them a decent return, and they get it. What people need beyond a point is quality service paid for, and not free but incompetent medical help (Azim 2015). 9. CHC HDU model also serves at least a substantial rural divide— there is a general imbalance at any one locale of better-off segments which constitute about 40% and the rest which are the poor. The first segment will be willing to pay for this facility reducing the economic burden of running an HDU. 10. Within the badly off segment, one is developed enough to be able to reach health care delivery services and is able to interact with them to draw some benefit from various financial instruments available. The other is so badly off that they are incapable of even this. The classic fact is that the entire machinery after the district hospitals downwards is incapable of helping either of the two segments, much more so in the acute care segment. 11. The second great divide is between a whole track of well-irrigated land, or industrializing areas or those developing as estates, against dry non-irrigated lands, without water storage tanks, industry or estates with poverty in abundance. The segment residing in the first situation will best use the CHC HDU model without wincing but willing to pay, helping the services to move forward. In this



segment, relative affluence has set in, ability to draw benefit better, although the health culture may lag behind. The earlier tea and now the rubber estates in Tripura are a good example of how the people get lifted above to the better-off segments. 12. The other tract of land is the one without irrigation. In such populations, the CHCs are an ideal model for the poorer sections also. That is because even if it costs them it will be insignificant compared to going to the private sector in a large town or losing a person. Number of schemes will and have come for their help. 13. It has taken the thinkers and planners an unduly long time to realize and reluctantly accept that running costs, if not the capital cost, in health care must come from the beneficiary even in public health sector. 14. The quantum of tariff could be irrationally low, or nominal. But it is absolutely necessary that a trickle of return revenue must get established. Without that it is not possible to run and have an increasing number of competent centres developing normally in places where they are needed serving the population within a short distance from them. 15. Anyone, including the governments, may raise one well-designed model of a project and run it free. But it is then impossible to raise the second project and run it free on the support of donors or any other health personnel or any other agency for that matter. 16. In the chapter ‘Philosophical and Social Basis of Reorganization’, I have described many contexts which make this emphasis on free care unnecessary. The reader may look that up. 17. Free health care will not work. People are willing to pay reasonable tariffs when it is a serious illness. 18. Lastly, just as the CHCs can be a deterrent to corporate hospitals in daily cares, HDU is the additional instrument that can reduce the flow of people who cannot truly afford it but are helpless in going to the extremely high cost of the corporate units. The cost of establishing a low-charging HDU should mean little difficulty that can be overcome. In the absence of such low-cost units nearby, people are helpless and resort to the self-destructive corporate sector route. 19. It must be a constant reminder to all of us concerned with health care that 40% among the less poor sections of people get pushed below the poverty line newly every year because of a catastrophic



illness. They also become bankrupt and lose their means of livelihood. We owe these people something. The HDUs can reduce this substantially. 20. We will go into the cost differentials of setting an HDU also to show that the cost bogey is incorrectly founded. 21. The final argument is that it is not whether but how fast the government can make itself afford it. It is not a money question with profit with the HDUs or its affordability to both government and the people. Planning and raising money is an imperative. The paradox mentioned above cannot continue. HDUs are achievable.

Meeting the Capital Costs to Raise HDUs The sound business principle is to earn back the initial cost and then reduce the price after depreciation is taken care of. It leads to a period when only running cost recovery with a mild degree of surplus can be earned and reinvested in the project for automatic growth. The same principle can be applied to the HDU in CHC. Nothing succeeds like success! The HDUs are not just the authorized entities to sign death certificates. For every HDU, there are more success stories than failures. It is a self-advertising model requiring no extra efforts. When differential tariffs are paid, there is adequate money earned. This has actually laid some agencies to invest in similar units. The other plank on which money can be raised to establish an HDU under the corporate social responsibility (CSR) is the achievement of this unit. I am aware that CSRs are in demand for various big schemes but if this has to happen with CSR or any other agency, then it is only a question of recovering the running costs which are much less. A systematic promotion of this idea can bring more money than one may imagine. In that case the HDU can run like a charitable service. The issue would be to levy charges at all or a portion of the recurring costs or differential tariffs for those able to and not able to pay. The last option is the best. The word charitable has got about half a dozen different definitions in the statute books (Seshadri BS, personal conversation, 1992, the Commissioner of Income Tax, Bengaluru Circle). It does not necessarily mean free. It is in essence a reasonable not-for-profit-alone tariff where the money earned does not go to an individual but to a body which can only reinvest the



surplus in improving the unit or replicating it by carefully choosing places guided by the discussions above. The venture capitalists or investors will see or already have seen money in this model even at the bottom of the pyramid. Stand-alone HDUs are no longer an infrequent phenomenon in the cities. Stand-alone dialysis units are another example of extending critical care. The costs need not be high for profit. In the charitable hospital our team and I worked for ten years, quality drugs were sold at 10% profit margins on total expense of procurement, far below the maximum retail prices, MRPs. For what we invested once, we earned 40% profits every year by simply turning the stocks over. Utilizing the third-party payment systems which are going to be available far and wide in the communities can help sustain the model and is a source that can encourage building this model. National Health Protection Scheme would become the biggest boost for HDUs in CHCs. Had it been available during the Covid 19 pandemic, the villages could have been taken care of for acute care. Logistics and Manpower in CHC/HDUs The discussion below expands on quite a few ideas expressed somewhat briefly in the preceding chapter. It will cover many more aspects of what is possible, has been achieved in field and some ruthless steps we have to take. There will be a time when conventional wisdom and rules will have to be thrown out of the window. This is necessary and will work. How this will or can be done is now explained in greater detail. The CHC and HDU have common needs. The planners are tentative about CHC build­up itself, having little confidence that it will work since it has turned out to be a stillbirth. Courage to experiment with HDU is not there. Before entering the discussion, the legitimate question would be whether CHC/ HDU will serve the five great principles of health care, namely affordability, accessibility, quality, equity and justice. My answer is—Yes.  ynamics of Manpower Reallocation and Development D Primary health centres (PHCs) and sub-divisional hospitals as discussed are the main sources for CHC for manpower once closed. It will give the initial momentum for the newly developing CHCs. These numbers will dwindle over time. It merely shows that the system has enough redundancy or waste or mismatches between qualifications and utilization using



which the numbers can be made up. The mathematics has already been shown in regard to doctors and partly with paramedics. The CHCs in expanding or duplicating mode will have to look at the other decentralized systems to get the manpower it will constantly need to give quality service. These sources have already been discussed in great detail. The semi-urban location of the CHCs will also be a factor which may facilitate the procurement. This issue can be answered by stating that the CHCs are capable of becoming self-sufficient in different kinds of manpower it needs. There are many other advantages built in the concept of CHC.  This chapter will acquaint the reader with both these aspects with many such examples in the pages to follow. Better Nurse/ANM Development in CHCs The complexities associated with the availability and placement of these two cadres are many. Today their examinations, selection, training and deployment are handled by the state centrally. This will also result in uneven selection of the candidates, the more urban having a better chance to get in. The opportunities of employment in the rural population will decrease. Placements entail pressures and persuasions to get into the nearby urban areas from where majority of them would have come. These persuasions are welcome to the bureaucracy to manipulate. One of the reasons states retain the centralized systems is the power to manipulate each and every process. It covers the doctors as well, a huge source of income for the directorates. The supply will be uneven between more rural locations of the CHCs. The more remote places thus are likely to remain vacant—one of the most characteristic features of the present system.1 This centralization should be broken up.  reating Manpower Resources from Within: ANMs C The NRHM and Indian Public health Standards (IPHS) have increased the number of beds in a CHC to 50, the most welcome decision discussed earlier. This makes CHC eligible to start both the nursing and the 1  Just as the decentralization and delegation of powers to the lower levels is not acceptable to the states, any super-centralization which snatches these powers from lower and gives it to an agency above is also not acceptable to the states. One example of it could be seen in the tremendous resistance to a single centralized MBBS and postgraduate entrance examinations raised by the states and sadly supported by the Supreme Court, as discussed in the second volume on private health care delivery, published with this one, in the chapter, ‘Regulators and Regulations’.



auxiliary nurse midwife (ANM) schools. It is not just following a rule but an organic necessity to have that many beds (and patients) available. The idea of decentralization has been thrown in by NRHM without context, structure and functions. This is where all the three will shape up fully. 1. The ANM schools are located at different places other than medical colleges and district hospitals mainly. These should be shifted to a CHC, with their teaching staff mainly and initially from the DH and later from the medical colleges as the CHC numbers grow, the CHC functions have been streamlined and the inpatient strength has risen nearly to 50. 2. DH has a large number of students in both categories, ANMs and GNMs which adds to the unwieldy structure of DH which is difficult to manage. 3. It will also reflect on the quality of education and skills imparted. Higher the numbers with two different streams of unequal levels taught, greater is the dilution of adequate attention to the more needy students. 4. Hence, initially only the ANM schools should be shifted from DHs and from medical colleges to CHCs later, as medical colleges can bear the burden of two streams more easily for a while longer. That still justifies shifting to CHCs later for reasons described below. 5. Small group teaching should be the norm. It is the best form to teach. This can be better employed in smaller structures like CHC with 20 ANM students. 6. In call notice there should be a mention about which of the CHCs the selected candidates will be placed, both for training and for appointment. This may encourage the more rural unemployed but eligible women from around those CHCs to appear for selection. As mentioned earlier, the brighter ones from the health army around the announced CHCs could also apply or should be encouraged to do so and preferred in placement near to them. 7. This will prevent large-scale and long-distance dislocations during training; the economic benefits to the family in semi-urban rural setting can easily be understood.



8. The school should be residential. Their parents have an easy access to know their well-being.2 These are simple practical matters well experienced, are proven and have merit. ANM Schools Located in CHC: Other Benefits 1. There are many. This arrangement is not just for creating far and wide, at the bottom of the pyramid, rural employment. That is a byproduct. 2. CHCs, from where the primary care needs to be extended peripherally and deeper, are right in to the communities. An ANM school in a CHC has the advantage of mixing the field close by, for on-job hands-­on training and the class room training quite easily. The district hospitals will not have the field training advantage like a CHC since they are distant to the communities. 3. The ANM training in wards, not specifically done but a byproduct of being in the CHC, can serve as a preparatory course over time for upgradation to general nursing and midwifery (GNM) in due course. Ward training is somewhat lacking in the present arrangement in ANM schools. 4. Even when the upgradation is few years away, the ANMs are a useful source to assist the staff nurses in CHCs where the workload and activities will be heavy. 5. It would also be advantageous to go for the same GNM school in the same CHC once it arrives later. 6. The ease of efforts to facilitate continuous upgradation of manpower thus gets an institutionalized automatic operating mechanism. This is easy only in a CHC due to its compact structure. Working in CHC wards and other departments will give them the skills that are needed at the CHC level. 7. The experience in wards will come handy in the debulking operations described under what a CHC can do more than just treating those who come to them.3 2  I have observed these rural dynamics and how well these work during my 4 year stint in rural Bengal and Tripura from 2011 to 2015. 3  These are not theoretical or armchair ideas. These are the modalities of upgrading and multi-skilling women and men of just normal intelligence. Their many faceted services in



8. The NRHM document talks of clear path for career development sans detailed plan. This plan can serve as its template. 9. The issues of percentage representation for ANMs coming from rural and urban locations, processes of selection and such other issues can be decided on later. We need not go into it here. 10. The methodology of education should in the long run be the problem-­based learning (PBL), as argued in Chap. 4 in this volume. It is a long-drawn-out process but adapting the medical college PBL particularly for GNM training is an eminently suitable and easy option. I have studied many curricula for nursing training while writing these two volumes. All the limitations of the medical college education are equally applicable to the GNM training. Practical relevance of practical content are dislocated from each other in these curricula.4 11. Who will teach the ANMs? That no doubt is the next big question for which the NRHM document has given a substantial answer in the form of Block Public Health Unit, the structure of which is given below with comments and modifications suggested to it. Block Public Health Unit is a new idea which will be more fully discussed in the next chapter.  aramedics Outside CHCs: Facilitating Quality Enhancement P Services spread thin, widely scattered, multilayered and ineffective is the sine qua non of public health care delivery in India with simultaneous loss of quality and upgradation opportunities. PHC, sub-centres (SCs) and SDH manpower has already been recommended for relocation in CHC. Outside these personnel are the laboratory and X-ray technicians mixed proportions in the mass campaigns to debulk the communities on a large scale, year after year, were extremely valuable to us. We have achieved this by in-house training in the mid-1980s when National Skill Development and many other facilitations were unheard of; our manpower needs in a climatically severe, difficult-to-commute and hilly tribal rural district further underline the validity of these ideas in today’s conditions. 4  Under Novo Nordisk Education Foundation, I have been a party to developing many special programmes for teaching nurses and dieticians and many more skills for each other and in diabetes management. Our partners ranged from Sydney and Newcastle to Denmark and World Diabetes Foundation. It is not a difficult matter to develop the training sequence without reaching the complexities of PBL. The principle is to teach in sequence in which things happen in the wards.



scattered in remote laboratories of individual national programmes. It will be discussed in detail in the next chapter. They should be relocated in CHCs. National Tuberculosis Control Programme has already consolidated a large number in CHCs with its personnel so far scattered. The process of quality enhancement following can be described as follows: 1. The first step is to test their skill level in their hitherto work area. There will be need for some revision and addition of the knowledge leading to functional and quality improvement. 2. The upgradation of their skills should initially be through monitoring and further training in other laboratory techniques as required. These are people already exposed to laboratory techniques and will no doubt train better than a new recruit. It will be an on job training. 3. They should then be taught various other higher-level techniques of the laboratory they may not be familiar with. Over time all of them will be familiar and proficient with all the techniques or skills to be undertaken in CHC laboratories. 4. In CHCs, the first need is to run all services in a 24 × 7 manner. These technicians will help to fill the numbers needed for it. 5. This manpower is large enough to also make up for attrition, retirements, dismissal and when a greater number of CHCs gets commissioned. 6. CHC is the ideal place for them to work, much smaller than a district hospital or a medical college, more personal and intimate. There is more accountability and can reach their skilled perfections since monitoring is easier in closeted atmosphere without being irksome for both. 7. The workload reduces the learning curve. Increasing workload can then be handled with greater efficiency. Supplemented by a learning atmosphere in the CHC, as has been insisted all along, the employee would feel optimistic to be encouraged and facilitated if he/she wants to go for higher skills. 8. Various methods of inclusive teaching like clinical meetings and other activities are mentioned earlier. These techies like the nurses and ANMs should also be a part of it. This facilitates a better cohesion and understanding about the work various groups do and under what strains, and helps people to be proactive towards each other on a personal level.



9. A much greater understanding about the ward work in particular as the most crucial is needed. In any hospital set-up, it is necessary to establish the centrality of the functioning of wards. They are the poor guys who work not just round the clock but continuously carrying the burden of keeping alive a sick person. Every other department works intermittently, after office hours without the presence of a sick person on their vicinity. Yet, universally ward personnel do not get either the respect, or facilitation of their work but contempt from other departments. Such coming together will help to bring about this understanding. 10. This is easily possible only in a CHC. No such things can happen in a district hospital or a medical college. This paramedical cadre will be reconsidered in the discussion on national programmes as well.  raining Ward Boys and Ayahs for Higher Skills in CHCs T An uncharted route is to develop the same lower cadre within the CHCs for a diverse array of functions that can be taught to them over time under and within the ward/emergency system. The reason to undertake this exercise is the certainty that there will be lot of work and the CHCs will need extra manpower. They could then be included in the cadre as assistant grade workers, with an increment in remuneration if for some reason they cannot get in the official skill development programme. This process has been worked out by us and some others. The methods to achieve that are simple.  uality vs Qualification: An Important Consideration Q Qualification above quality, one of the sacrosanct principles of government, bureaucracy and corporates will have to be abandoned and quality above qualification will have to be adapted. This seemingly trivial change will be resisted since the power of government or bureaucracy lies in granting that seal and expecting to extort gratifications in return. Quality can be built by careful teaching in informal settings to those who can absorb higher skills and responsibilities. It can very well be considered more valuable if the responsible people find the quality good than government or private institute certification which can be dubious and can lie. Yet, the principle will have to be recognized. These people could later be more formally trained officially to be absorbed in the system with various options



mentioned in these pages again and again to work the system better. This is not the cup of PHC and can happen only in CHCs and above. Their valuable in-house help constantly working under trained nurses cannot be emphasized enough. This has been practised year on year successfully in several places in voluntary sector and the various works in a cure facility we have run with them without mishaps. These people can be trained so well and be exemplary that even without the registered nurses being present in full quota or if scarce, the work can go on quite well or as good in most areas. Doctors in emergency rooms, orthopaedic surgeons, sisters in the wards rely on them, request them to help openly admitting their knowledge and talent and thank them. Different people can be trained for different roles, or one person can be trained in different functions within CHC ideally suited for this. The methodologies we have evolved are simple. Once a qualitatively higher skill is acquired, they could be given more responsibility and more emoluments. Then they could be shifted to acquire another skill and/or go up on the ladder within. We have to look at them in this emancipating manner.5  aking Up the Shortcomings of National Skill Development Initiative M They are a key to the solution of the manpower anywhere and everywhere. The National Skill Development Council has thought up a category called Emergency Medical Assistant, among many other skills. In the routine, unimaginative approach, there will be new people admitted to these courses who are unfamiliar with health activity in any form. Many of them will not know whether they like it or not till the end of their training. They will get employed and come to boss over these very ward boys, who are already well versed with the procedures. Given the same training by facilitating the entry of ward boys in skill development courses, they will become far better workers and assets as they return. Such a cadre improves the ability of CHCs to satisfactorily take on more work and, most importantly, the mass campaigns discussed in other places. 5  The idea that a peripheral worker should be Jack of all trades and Master of at least one was first voiced to me by Dr Madhavrao Vaidya of Karnataka Health Institute, Ghataprabha, whom I have mentioned elsewhere. Both of us have implemented this in our individual project work in involuntary sector. Today, in the government or private or corporate sector it does not find favour. There is reluctance to be master of any one and remain somewhat incompetent and unwilling to be a Jack of one trade only. Jacks of many trades are particularly needed in all varieties of health care.



Four new skill-based short-duration training courses under the name of Certificate in General Duty Assistance (CGDA)—the General Duty Assistant (GDA)—have now been announced by Indira Gandhi National Open University (IGNOU) in collaboration with Ministry of Health and Family welfare with the objective of creating a workforce which can be employed by hospitals and health care facilities to provide support to nurses, doctors as well as other health care team members. It underlines the relevance of what we have said above. The issue of admitting those already working in hospitals discussed above is not mentioned (Swarajya Staff—Jan 07 2019, 12:28  pm). In corporate as well as in government culture, such works are extracted to the maximum extent without ever upgrading them. It saves money, and also because their humanistic genes are dormant. Prioritization of the CHCs and Their Placements The idea of NRHM/IPHS of creating one CHC from among five PHCs, if existing nearby CHCs is found unsuitable for infrastructural development, is welcome with an additional proviso that all the other four PHCs should be closed down. However, there are a few important but unmentioned issues in these two documents which need clarification: 1. Most intriguing issue is whether these new CHCs are going to be added to the existing CHCs. 2. In that case what about these CHCs, their assets, the meager manpower that already exist there? Are they going to be laid waste or moved to the new ones? There is no cognizance or mention of such a serious issue but is not a surprising one. 3. Given the incremental ways in which the government has worked in health field there, there is every possibility that the NRHM wants it that way. 4. No one need be surprised if the government thinks that the CHC is not working, let us upgrade one of the five PHCs. It will work. 5. There is no manpower in either of the CHCs or even PHCs. This is wasteful duplication of everything which still remains grossly inadequate. And not a word about its management is there. 6. We make amends here and say that the conversion will not necessarily be of the PHC but that of a CHC already existing in the area of five PHCs.



7. Every effort should be to give preference to the existing CHCs. The government statistics shows that most CHCs have a building owned by the government or is rented by it with variable assets and infrastructure. 8. A PHC should be chosen for the upgradation if the structure of the existing CHC or the land around it is simply insufficient to expand it. Such a CHC should be liquidated and assets moved to this selected PHC. 9. The chosen PHC should have substantial space around to build for residential and ward facilities, expanded place for specialist OPDs, the investigative facilities, space for the future ANM/GNM schools and mass campaigns. 10. The more spacious the PHC building is, the better it is. It is however not a must if adequate land space around is available. Some Out-of-Box Thinking 1. The area of five PHCs to choose a CHC spot need not always come from within the administrative boundaries of tehsils, or districts. They could be from a cohesive unit of a few linked districts. The CHC then may cross the boundaries across districts. 2. In that case it is possible that a CHC with people’s preferred contact can be found. Our understanding of India’s geography is that more often than not a CHC will be present in a nearby district’s border areas. 3. It is a simple question to ask: Where will these people be going or actually go for specific needs? That can be answered by planning CHC localization there. 4. The sick population does not consider these borders but crosses over to another district if the facilities are better. 5. Thus, these five PHCs should be adjacent. Each PHC, as seen earlier, has an area of 21 square kilometres. Together these would create an area of about 100 square kilometres and population coverage from 172,000 to about 250,000. This population size is more than adequate to create enough work for the CHC for the professional satisfaction and the population needs that are presently not getting addressed.



6. Thereby we are ensuring that these populations segment travelling across the district boundaries get a sense that this is also the centre for them to go. Not all CHCs will have this issue. Only the border area CHCs will have. 7. This ensures and delimits the area of outreach of a CHC for community work it has to support. This placement idea and its orientation are necessary to visualize all the positives of CHC and how to translate them in reality in a large population segment. 8. Mentioned elsewhere also, the location should be central to the town or as near the bus terminals or the railways if the latter is the dominant travelling mode of people or the main bazaars. 9. These people, as the experience goes, come from adjacent areas, small towns and villages for which the town in which the CHC is placed should be called the nerve centre. This applies to any units which has a referral unit potential, be it DH or medical college.  ositives the CHCs Can Achieve P The positives discussed below are not conjectures that this may happen. These are the concrete achievements of many people and projects in the years of their work in the hinterlands or in places away from the district headquarters. 1. The very first thing a CHC thus located achieves is affordability, accessibility, quality, equity and justice for the community. 2. The experience of working in rural, hilly and/or backward regions indicates that 80 to 85% of the health issues of any severity or complexities can be resolved at the level of CHC if the five specialists are available with adequate infrastructure. 3. In the prevailing situation there is a senseless overcrowding of the higher facilities in public health like the district hospitals and the medical colleges. A well-located CHC can drastically stem the flow, to much benefit of all concerned. Such senseless crowding is seen in some middle-income countries also even when a good infrastructural build-up is spread widely and deeply enough (Dissanayke Prof Upul 2018). 4. The point that emerges is of a lean and efficient horizontal health service which will be discussed in the next chapter.



5. The 5 or 6 CHWs from the 4 or 5 PHCs, 20 to 30 of them in all, will now come under the direct contact of the public health specialist, which has now been placed, at least in concept level in each CHC. In addition, we have suggested that the layer of the PHC officer and the supervisors be removed. This will improve the primary care in many ways. How such an improvement can take place is the topic for the next chapter. 6. Such CHCs will also serve the purpose of remote hamlets and sparsely populated regions in the CHC area. It is supposed to have three ambulance vehicles under one control and not under the control of three PHCs. 7. With some effort put in, the 1253 independently functioning mobile units can be attached to the CHCs to reach such inaccessible areas on regular basis to help. 8. The same mechanisms can be used to bring people from the remote areas for regular as well as the mass campaigns described elsewhere. The issue of vehicles is discussed again in connection with SDH. 9. A really large number of medical emergencies are salvageable in HDUs in the periphery and shifted to the general wards to recover within a few days and sent home even with average medical intelligence.6 10. The remaining hypercritical few can be brought to a transferable condition to be sent to a higher centre within a day or two, with support and stabilization, or even sent home. Complete heart blocks, myocardial and cerebral infarcts and/or haemorrhages, gastroenteritis with shock, black water fever with acute renal shutdown and mounting acidosis, hyperglycemic and hypoglycemic emergencies, acute respiratory failure can be named, met with routinely in CHCs. 11. A number of cases related to the maternal and neonatal mortality indices can be salvaged by such units easily. Today, it is not possible to salvage easily, obstructed labour, massive post-partum haemorrhage or retained placenta since there is no nearby competent centre, nor travel facilities. Thus, the ratios of maternal, neonatal mortalities get unfavourably skewed. 12. CHCs thus positioned can obtain supplementary services like blood transfusions and special laboratory investigations or even get 6

 Since 2011 to 2015, I have seen this in rural setting in West Bengal and Tripura repeatedly



a CT Scan done easily from centres within reasonable distances which have come up in rural India. 13. Lastly, the anaesthetist, with the backing of an HDU, and a well-­ trained surgeon can show dramatic results in reducing mortality of trauma which has risen to a high level in the statistics. The issue long neglected was how to tackle this failure which was never satisfactorily answered. 14. The child deaths of West Bengal and other places mentioned earlier is the best illustration of what happens if efficient CHCs or the sub-­divisional hospitals, not far flung in the periphery, are absent. The massive numbers from across the state erupting unexpectedly cannot be dealt with, saving at least some. 15. One may note that the PHC is nowhere in reckoning to deal with any serious issue. 16. One unrecognized power of one or more CHCs together (actually, even just one can do this) to ‘debulk’ the population from a set of diseases in a particular area from time to time through mass campaigns discussed elsewhere. 17. This will be possible due to the above arrangement between the public health specialist who can now direct the entire CHW force under him from time to time for such focused campaigns to detect cases. Any malady widely prevalent in a population of 172,000 which either the public or private health care has not been able to address can be easily accomplished. 18. The law of ‘care inverse to distance’ mentioned above requires that a competent structure like the CHC under conception here, should be available within a radius of 15 to 20 kilometres in easily negotiable terrains. In hilly or jungle regions, this distance could be halved. 19. Therefore, it is logical and desirable that these really competent CHCs should also have an efficient HDU. 20. Step out of the city limits and we have few such centres in today’s situation within public health care delivery. In emergency cases, these units are the direst need of the hinterland. No single practitioner in that area can own, build or develop it. 21. CHC HDU model also serves at least a substantial rural divide mentioned in detail above. In many places the private units have filled the vacuum much to the chagrin of poor people. 22. In extremely poor populations, the CHCs are an ideal model. The poor people do not have to go to the larger towns or the private



set-­up neither of which they can undertake and lose the person. All this is avoided. 23. The fullest possible developed model of the CHC as it continues to unfold hereafter is the only answer we can provide and with fair amount of satisfaction and safety. CHCs Beyond the Tehsil Level 1. CHC HDU is not only a sub-taluka level model as the reader may think. A population of 1,72,000 means that there is a substantial town locating the CHCs, and these kinds of facilities are not exorbitant to ask for. However, I would rather see these at tehsil level at present since there are none there. The government need not, for the few years to come, concentrate on larger cities and thereby save the resources. 2. In A and B or capital cities and metropolises there are many government or private agencies of different qualities and costs to serve people. However, I would like to assertively say that the awesome power of this CHC construct is such that they will not only become successful in the cities but will be a deterrent to many malpractices in the city, whether run by the government or run as a model for service by other agencies.  This however is not the priority at this stage. 3. CHC thus has the ability to take on the private sector. As pointed out elsewhere, the city-based private sector is largely dependent on the patients coming from the hinterland that they wait to exploit. The shock a running CHC can give to the private or the unbridled segment will come in two forms. One is that the numbers will fall since 80 to 85% of curative problems will be getting solved to a considerable extent within a distant 100 square kilometres with more or less the same quality but greatly facilitated in many other ways since it is near at home. An area of 100 square kilometres is just 10 X 10 kilometres. Numerous such areas which are far away from the city practitioners can be plotted to establish CHCs. 4. The blatantly clear message it will deliver to the private sector is that they have to cost their services, improve the quality of services and be vigilant about them, and be far more careful since these services are now available at comparable efficiency in the public sector with far less cost.



5. We need not even talk about controlling the extortionist agencies of the private and corporate health care. We do not have to regulate their working. We do not need to violate the sacrosanct liberties of the individual to do his own business as he may see fit. It is the most non-offensive, most non-confrontationist, most subtle, most non-­competitive and positive way of controlling the unbridled malpractices of the private sector. 6. Such quality CHCs can attract the patients, woo them away from the glamour attraction psyche that draws and pushes them to the private sector. 7. Another win is the creation of a feeling of safety in the remote poor communities the CHCs can create. In our tribal work, for ten years we were able to achieve it through the service project we ran. 8. The private sector can also create this sense of safety but costs are so high that a possible sense of safety is bitterly tinged and submerged in anxieties. The experience of four years in West Bengal and Tripura indicates that the private set-ups either do not understand this or are unable to achieve this. This is an iniquity we can remove. The corporates will have to think a great deal about costs, to create a sense of greater safety and need greater competence above the CHCs if such CHCs are working. 9. This ‘Sense of Suraksha or Security or safety’ is a tremendous emotional concept. It prevails when the community at large has confidence that the service will treat them with justice, affordability and quality. Suraksha encompasses the faith that help and support would be available in serious disorders also any time of the day and night, that they will be treated fairly and competently. 10. Such a sense pervading in the community at the individual as well as collective level causes immense beneficial physiological changes which need a lengthy description but is probably not necessary. A well-­functioning CHC can achieve this for a community. To plan health services, we should take such ideas and emotions on board. 11. The concept planning of single CHCs can be taken to planning as a group of CHCs in specified joint areas particularly with respect to the specialist services to be made available, other things remaining the same. The effectivity of that will solve even greater number of issues at much lower costs. This will be discussed in the next chapter as well with reference to sub-divisional hospitals. Establishing



critical care units in groups of CHCs first is the single greatest need of the countryside and the hinterland today. 12. One of the last and probably the most unfortunate aspect of this should be kept in mind. The corporates, once constrained by the performance of such effective CHC  units, will give a battle cry against them as more and more people turn to the low-cost competent CHC like structures within government and the voluntary sector as well. There are many sagas where these bitter wars have been fought. The duty of the government is to protect the CHCs at all costs.

Monetary and Financial Consideration of the CHC/HDU Saving Money Is Earning Money There are many ways of saving money in working the CHC system described, from within the government. This money can create CHCs as well as the HDUs. With it there are ways of earning money as well from within the government. Some of these were discussed at separate places and are now being brought together with some repetition for coherence. Saving on Infrastructure 1. Adequate infrastructure within the CHCs already exists in original CHCs (Rural Health Statistics 2014, 2012). Additions proposed would be the only and one-time costs for quality durable structures. 2. Money will be saved by moving the existing chattel wealth like labs, drugs and such others from the closed PHCs and the sub-centre to the CHCs. 3. The immoveable asserts can be put to other uses for some other ministries getting money by rent or an outright sale. 4. If a PHC has to be chosen for upgradations under conditions mentioned above, the expenses for additions may be considerable, but again one time.



5. There is a large number of usable but defunct hospital complexes belonging to government, private and public trust lying waste. The number of such hospitals for sale is larger than one would imagine (Azim 2015). Acquiring these buildings will come cheaper than building new ones for CHCs. 6. These hospitals also have different equipment lying idle. People trying to build new chains of second-level hospitals acquire them wherever they can (Azim, Ibid.). It requires government initiative and private acceptability of such proposals for the revivals and resurrections. Saving on Doctors and Paramedics 1. The additional general duty doctors required for the CHC come from the four PHCs below it once closed. They are not a cost centre because their salaries are budgeted. 2. The specialist cadre is budgeted for the CHCs. Much of it is unspent and lying there. Revisions for better emoluments could be a fraction of it. 3. Paramedical human resources, freed from the closed PHCs, release staff nurses, pharmacists, lab technicians and X-ray boys making up the stipulated requirement of ten in each CHC. They are also budgeted for, hence no extra expenses. 4. The number of ANMs that becomes available from the PHCs is for deployment in the field since their low utility in CHC and need for more hands in the field are already budgeted. 5. Lady and the male health visitors will get new role in the CHCs as described earlier. The new skills they may acquire may not always be a change in the grade; hence, they are not a cost centre of significance. In addition, it removes an unproductive hence unnecessary supervisions layer already discussed. 6. As clearly explained in the first chapter of this volume, there is simultaneity of rearranging, reducing, destroying, relocating and renewing or reorienting or tweaking, within the system removing the ineffective clutter without causing any economic burden and jeopardizing the five major principles.



Phased Closing of the CHCs: Frees Manpower Already Budgeted 1. CHCs which are too close to each other are the first ones to be considered for relocation and/or closure. Practically speaking, no two CHCs should be closer to each other than a radial distance of 25 to 30 kilometres. 2. Some CHCs could reasonably be considered as so moribund and/ or so inadequate in infrastructure that it would not be worthwhile to revive them but close them and merge whatever manpower is available in an upcoming CHC nearby. 3. There would be CHCs in the same towns which also have a sub-­ divisional hospital. The unit which is functionally doing better, and which has better infrastructure, better instrumentation and more ­credibility with the people of the town for its professional service, should remain and all other entities closed. The budgeted staff from the closed ones could be moved wherever required and possible, preferably in the remaining facility. 4. There could be situations where neither could be closed. In such cases, it would be worthwhile to consider conversion of one into some specialized but separate services, like eye care or high-end investigative facility, dialysis, blood bank, orthopaedics and ENT, or training—the last being of utmost importance. Without having to spend much, it will help raise the quality of manpower.  ptimal Utilization of the Specialist Consultants O The costliest cost centre is the specialist in any system. The basic framework is the five main specialties in CHCs. These need not be repeated in every sub-divisional hospital since the distance between the CHCs and the SDH too is often small. Similarly there is no need that every kind of specialist should be available at each CHC or SDH either. This problem arises because the equity/justice principle, which insists that each and every facility in the rule book should be available at each and every PHC/CHC/ SDH and the other structures of public health care delivery. It is budgeted also. Due to proximity of many of these facilities, it is a waste. The non-­ availability of competence from bottom-up still continues. SDH facility, as has been conceptualized today, has many more specialists in addition to the basic five. The specialists do not like to stay in SDH but want to work in DH. The same faculty structure is repeated at the



district hospitals, and there will always be vacancies in SDH and even in DHs. Same faculties are available also at the medical colleges. The SDH and the DH again are in close proximity. Since many medical colleges, mostly capitation fee and some government, do not have their own hospitals, they utilize at district level the DH and its specialists. If the majority CHC positions are not filled, many of these are bound to be vacant in SDHs since these specialists would rather work at the DHs/medical colleges in the district than in SDHs. This is wasteful planning of high-cost manpower. The way to sort it out is to dismantle SDHs. It will save considerable costs as shown next. Each smaller speciality outside the five basic specialities cannot have adequate work at the population level in every CHC, hence creating all the infrastructure facility for it in every CHC is wasteful. The number of postgraduate seats is much less in these smaller specialties compared to the basic five. The sensible way is to take away the specialists and their assistants of the numerically smaller branches like ENT, ophthalmology, orthopaedics, skin, psychiatry and dentistry from SDH and deploy them initially in every fourth or the fifth CHC. Mathematically speaking, the CHCs outnumber SDH 5:1. Hence, this manpower anyway can be given only to one of the five CHCs. If the on-ground experience demands their placements in more CHCs, every third CHC could have these smaller branches. This will save money on one side and the system becomes more effective and lean.  hinking at the Level of Five CHCs as a Group T The rural realities and the corresponding CHC tailored for its management will first prevent wastage of manpower and save huge costs. It will also deliver quality service in the hinterland without any or little inconveniences which are nothing compared to the absence of services. In any one district, all the ten CHCs should be considered as just two units, consisting of four to five CHCs. This will help planning for many more and/or smaller specialties well spread across the district. This arrangement will not violate the law of inverse care by keeping the distances short for any facility in at least one of the groups of CHCs. This leaves some space for others from different streams like institutions and voluntary agencies to render their services to the population as well. Creating specialized units among the CHCs can easily be undertaken by the placement of specialists in smaller branches like ENT, orthopaedics, urology and ophthalmology, which need not have the five basic specialties at all. Such CHCs will stand out as distinct in a big way so that the drainage



for these ailments automatically shifts to those areas. The other CHCs could feed them by selecting more difficult cases, for a better job without much hassle. With good management of public information system within these five CHCs, the unfortunate occurrence of a critical case landing in a centre where the said specialist is either temporarily or chronically absent should be minimal. The village communities today are alert, well linked within themselves, speaking to each other and even guiding people on their own to better facilities. The information about the availability of specific services and the reputation each doctor establishes is passed around quick and fast. This force leads to good utilization of even smaller services. Today, even the remoter communities and the CHC networks are not an unbridgeable reality and people may prefer to travel from a nearer CHC to a farther CHC just because one specialist is talked of better by peers. The thinking of the planners has not gone to this depth.  ttitudinal Changes Needed Among the Specialists A The rationalized differential spread of specialists in a geographical area can be even more efficacious and cost saving if specialists could travel to other centres for a couple of days to make up for the temporary absences or non-­ availability. This may not be easy because of the attitude of non-­cooperation, of not wanting to put an extra mile found among them. People in public service are immune to many legal hardships compared to private individuals. They are far less accountable to their action, inaction and work quality. Many know their own incompetence and do not dare to go into practice privately for the fear of being exposed. In public health service, the timings are fixed, free time abundant and private practice being legal gives them double earnings in many ways. Against this kind of incentive structure if the specialists are asked to go to other centres to work for a few days or on special occasions (about which we will discuss in mass campaigns), they have every reason to refuse because of travel and its hassles, the lessening of the daily leisure time they are accustomed to getting at home, spending extra time, and the eternal questions—why me, is it a part of my job profile and what is the benefit or extra money?—whether the money is worth the trouble and so on. The present generation of the individuals who are working at different levels of health care are addicted to their comfort zones in their young years so much that slightest variation arouses ire, a paranoia towards the management or the authorities as being untrustworthy and vengeful,



having some indecent design to trouble them and so on. Just as this is not appropriate, it is also a fact that the authorities or managements are no doubt absolutely untrustworthy today.  educing Professional and Ancillary Workers Within Health Services R This measure will save more money than any other since these are professionals, higher up in the hierarchy and in a much higher pay structure. In addition, it will cut the long vertical arm of health care delivery short and make it a lean, more horizontal efficient system. 1. There is no need that each district headquarters should have all the directorates, district-level health officers and so on. All of them could be reduced to units of three to four districts getting one health ­headquarter. How this measure can facilitate work with less numbers is shown below. 2. In every province or state, there are geographical entities existing in the form of four to five adjacent districts, automatically and organically connected, economically and culturally linked, thereby having extra communication facilities. Talukas of one district juxtaposed to another district will have more links with the other district to go for health needs also. The formation of a single headquarter should be in one such among the four or five districts linked this way. 3. The 700 districts thus could be reduced to only 140 units among 28 states and 10 union territories.7 4. What services or directives that need to be given from the state to each district headquarters can now be given from the state to these six to eight units depending upon the size of the state. 5. Such a small number of units will reduce the top-heavy administration and expenses which become huger as the levels go up. 6. Savings can be achieved additionally by progressively eliminating the district officer posts as they retire or take voluntary retirement. With them would go the district directorate of each and every national programme but gets consolidated at the Group District Headquarters. The expenses will automatically plummet. 7  In the long history of ancient and medieval India, it has experimented with many types of governance systems, not just kingships. Janpadas or substantial areas were known to be governed by the people themselves. Deen Dayal Upadhyay had identified 74 such areas in postindependent India. The multi-district units suggested here have a root in this idea also.



7. This decentralization should fit well for all the CHCs in many other functions like the entity of the community health officer in short supply today, the conduction of the rather dysfunctional national programmes extensively discussed in the next chapter. It will avoid the repetitive functions of each district collating the data arising in the field and passing it onto the state headquarters for further collation. 8. In creating the vertical national programme, both central and state governments have created many unipurpose doctors like the district tuberculosis, district malaria officers. These doctors have already been in the public health and are conversant with the techniques of primary and higher-level community health services. From managing one district and one programme, they could take charge of the regional five district units first, taking charge of all the national programmes instead of just one. This reduces the numbers in this highly paid category, provides enough work for each and can balance the priorities in getting work done for different national Programmes. 9. All the remaining younger men should be posted as community health officers at the CHCs. There will be a perceived sense of being peripheralized (which is another way of saying demoted), but soon these officers will realize that from their dreary offices they have been now brought into the live teaming active CHCs and are directly liaising with community workers and have become much more useful.  onsumables and Cost Savings C We Indians are poor in our social coordinates to use a much larger term to include the civic sense as well. It is a beautiful concept elaborated by a senior friend of mine Dr R. H. Tupkari, a metallurgy professor of repute. Aside of the civic sense, civic values, the concept takes in the narcissism of people, social behaviour with others, elders, attitude towards learning approach they take, the increasing alienation the youth has caused for itself, the lack of interest in knowledge, the state of the country, the consumerism and so on. It is sad to say that today the social coordinates are completely broken. This mindset change, unless it becomes a mission within each locale of work, will not happen. The concern for saving resources with optimal use will not be internalized unless each one realizes that it gives substantial cost reduction. It will lead later to profit and may give more money to all,



if all of them do it. This type of change is a long arduous journey but the managers of any facility should try that. Reduction in water and electricity bill, use of lifts and so on could be publicly praised or celebrated. It can be achieved only by creating a culture for it through the role models of doctors with additional realization that it is actually a global necessity. The practice of frugality poses some difficulties. But the items are in hundreds and the total of saved money can be huge. What would have been considered impossible—the social behaviour during Corona—is becoming a culture now. Frugality and optimization also could become one. Additionally, in any system, even a well-functioning one, there will be a built in redundancy of 20 to 30% in every cost head. Keeping it as less but not hovering around the fringe of slight deficit as is commonly believed to be correct in management practices, but it is not, will be the job of the managers. Earning Sources for the CHC The National Skill Development Corporation (NSDC) is an ambitious scheme for developing health manpower for different essential paramedical skills. The agencies doing this job for the government have to create a specific, considerable and well-equipped infrastructure for common classroom teaching for about 10 to 12 categories. Each agency, to be hired, will and should look for on-job/in-ward or practical training in a hospital not their own. Creating hospitals  for training purposes is thoroughly impractical for such agencies economically.  An existing  hospital agency should be involved in skill development. Their costs will go high if private hospitals are hired for it. The fees for these relatively disadvantaged people taking these courses will rise. This is counterproductive to the larger ­numbers who cannot afford such fees but would like to get trained will be hampered ( aspx8h December 2018, at 21:53). They could instead pay the government district hospitals (DHs) and CHCs as and when these come up for training the paramedical workers. The sensible way for such agencies is to add the few structures like classrooms to the CHC structure for their own and others’ use again and again. It will be required since these agencies are expected to train a high number of people, as the NSDC aims at very high numbers (http:// If an agency has developed the infrastructure adequately and can run it well, DH or the CHC of course is not compulsory. But if the agency has



more teaching manpower and is looking for training more number of students, they could utilize the district hospital at much less cost. The hitherto supervisory people like LHVs and others who are already in the system and want to remain there will find it more suitable if these national skill development and upgradation effort is carried out in their CHC or nearby. As per the present terms of the skill development ideas, the trainee has to spend money, but the job is guaranteed. It is up to the governments to find for this cadre preferential entry, facilitate financial arrangements for them to leave their earlier job and go higher or in a different channel within the health system. Since 2014, there is already substantial contribution by the government for the trainees which will help.  ser Fees for CHCs U The same is applicable to diagnostics and outpatient fees. The purchase costs in e-tendering will be less than in open tendering systems and can be offered at much lower prices than outside. Such arrangements by turning over stocks many times a year earn much greater profit even while selling cheap. (See above also.) Even if nothing else is achieved financially, it will lend value to the work and effort of the CHC. While some cheaters may feel happy, for majority people availing it,  a small feeling of being obligated and helped, leading to gratitude, will develop. This could lead to faith. The National Health Protection Scheme, which is likely to consume in it all other schemes in near future, will be there for the below-the-­ poverty-­line population. Making a government project charging fees and displaying the tariff board makes people aware that outside the tariff board there are no charges for any other  services are admissible. The patients could then possibly demand the service without ‘persuasion’ and with more boldness. This money can be divided into the state, centre and CHC for upgradation of any element if properly justified.  rugs and Its Optimal Management D In my other volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one, great many drug-related issues are discussed in the chapters ‘Perspectives on Pharmaceutical Industry’ and ‘Pharmaceutical Industry and Clinical Medicine’. (Kelkar, 2021) There are other issues arising in the public health care discussed below. It is also discussed in Chaps. 6 and 7 in this volume. Drugs are perpetually needed in large quantities  and costs are high. Issues related to optimum usage are described here in some length. The



government has already extended the National Essential List of Medicine beyond 500, and purchase of these generic drugs is already in motion. It has reduced the outflow of money. These are much cheaper and, if charged to the patients, reduce costs, and a reasonable inflow of money continues to refuel the generic good-quality drug purchase in increasing quantum. Wastage of drugs is extremely common due to non-use or expiry. Hence, sensible methods of ordering and dissipating the drugs should be a priority function, especially in CHCs and HDUs. Both these factors are directly related to non-cooperation of doctors to write generic prescriptions, their addiction to writing combinations and specific brands they like or are benefitted from. Every effort should be made to make most of what is already spent and to make it a money saver as well as money earner. A slight surplus must come back by fixing the prices for just 10% profit. We have experimented with this for long years and earned in our charitable work while the final prices were way below the MRPs. To be able to run an optimally devised drug service, following are the main principles and good practices: 1. There is no alternative but to stock the drugs under the generic names and specifically cut out combinations, except a few. 2. Generic single-drug items, mostly from the National Essential List of Medicines. 3. The quantum of the bulk orders can be made precise with experience and should be renewable every 90  days. This should be the model. No other model will work profitably. 4. This is more and particularly so when we go to the C towns and below where the supply lines become long. The lesser number of times we have to put the logistical demands of the consumables to be purchased, the better return it will give. 5. In a CHC set-up, one need not be worried about the airs and whimsicality of the doctors. The doctors in CHCs must be clearly told that generic prescription practice is expected and they must stick to it. The government initiatives since 2014 have made this in to a crusade. It has to work in the public health care. 6. The doctors have to realize that these practices create waste and reduce profits to a considerable extent in private set-ups also and it is a national waste.



I nsurance Schemes as Cost Savers By themselves these schemes are not useful for the CHC or any other government outfit as a source of money. Rashtriya Swasthya Bima Yojana (RSBY), that is, National Health Insurance Scheme, was a labor ministry initiative and not of health ministry. This was useful to get money as intergovernmental transfer. RSBY was an excellent scheme with well-arranged operative details. It ran into money shortage for some of its inherent issues. Now the RSBY will be resumed under the AYUSHMAN BHARAT, or the National Health Protection Scheme (NHPS). These schemes are discussed in great detail in the other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). What would then be the utility of developing CHCs with so much effort? The answer is given in the section ‘An Existing Paradox in Acute or Critical Care’ and repeated here briefly. Like all insurance schemes hitherto, NHPS largely depends upon the private sector to deliver indoor curative care. This is a costly way to deliver it and will meet its nemesis at the altar of the private care. This has been the fatal flaw of all health insurance schemes. Resorting to private sector is inevitable since there are no competent and satisfactory facilities in the government sector exist to provide the service. Unfortunately, the Modi government has not been able to address this issue of developing such facilities for getting standard and satisfactory treatment yet. The answer to this dilemma is the development of CHC. Several advantages of CHC are described and more will be described in the final chapter. Its greatest achievement will be to reduce the numbers going to the private sector, thereby reducing costs enormously, still leaving the option of using it sparingly when CHCs, DHs or the government medical colleges cannot answer certain highly complex but numerically much smaller clinical conditions.  HC as an Economic Driver C In a community of 172,000 or 250,000 for a single CHC, huge paraphernalia of ancillary services develops around a CHC, be it places for the relatives to live, eateries, medicine shops or transport and so on. CHC thus becomes an unintended stimulus to the local economic growth. It becomes an employer to the local communities directly/indirectly. To get maximum benefit for being the economic driver and to ensure work, properly locating the CHC in a town is a highly significant strategic component. CHC has to be easily accessible to almost everyone who



comes in to the town for its success. Even a smaller population segment can serve as CHC if it’s a nerve centre to a large number of villages around with a dependent population of just about 100,000. Tehsil place (the sub-­ district headquarter) or the second largest town in it, which is accessible to majority of the population within 15 to 20 kilometre radius can also be chosen. In India an average-sized district will have 12 to15 Tehsils. Here the Law of Care Inverse to Distance is satisfied. Even in a town, the location must be so central. Such a CHC, if it is off the town centre and not near the bus terminal, a big market or the railway station, damages the increase in the footfall permanently. This is seen more in case of private or trust bodies wanting to establish hospitals. They often are off-centre because somebody gives land free or at highly concessional rates. It should be prevented from happening for CHCs. From the earlier calculations, an average-sized district needs about 10 to a maximum of 15 CHCs with full complement and smaller speciality units. In actuality these choices are not difficult at all. The people’s dynamics works it out correctly. For example, from the Tripura state, the patients go to Silchar, which is in Assam and is located 50 kilometres north of Agartala, just beyond the border, even when good railway connection is available. Approximately 1006 out of the 5000 suitable places in talukas have sub-divisional hospitals. Depending upon the logistics, they could very well be downsized into a CHC. In general the SDH should be closed as detailed earlier and the assets merged into the CHCs at more distant places that have a population segment of 172,000 or more.  he CHCs and the Non-State Players T On this background, the CHC appears to me a much better model for such handover or takeover than the PHCs discussed in the same context. The reason is that there is only one basic condition for its success. It has to have in place a group of five basic specialists. It is easier to constitute the remaining workers and infrastructure then. The rest is a turnkey transfer of technology elaborated in the current chapter all along. Additionally, several existing models in the NGO sector have shown this to be the most feasible and highly effective model. More about it is also discussed in my other volume (Kelkar, 2021). In the next chapter, I will deal with the remaining aspects and the benefits of the reorganized CHCs and the closure of sub-divisional hospitals with particular reference to national programmes and the role of



community health officer (CHO), the community workers without a PHC and SDH and their optimal utilization through the CHO. The next chapter will actually draw a much clearer picture of how things work or will work.

The Sub-District Hospitals The Naïve Planning Closing sub-divisional hospitals to save money, share chattel and infrastructural assets with CHC for saving cost for the restructuring is necessary because they are redundant, cause duplication, are too numerous and too close to existing non-functional CHCs one way as well as district hospitals the other way. The manpower allocation of the SDH is much larger, given below (Rural Health Statistics, March 2014). Whatever that may be available is better distributed to the CHCs and bring all the facilities far too nearer to the villages. If it is not done, neither will have adequate manpower. The proximity of these two units also interferes with the functional growth of each other. In addition, the sub-divisional hospital has no greater competence compared to CHC  mainly due to vacancies of the specialists. SDH merely serves the ill-fated purpose of the referral process, and maligns it by adding another layer of incompetence exactly the same way the PHCs were rendered redundant by establishing a faultily conceived CHC.  Definite Presence of Private Players—A Reason for SDH Closure A At the population level where SDHs are created, there is a definite presence of private sector as nursing homes, hospitals and rarely an institute, small or big. These are the only ones which may be able to provide any help in cutting down the intolerable journey of a sick patient over 50 or 100 kilometres. As soon as this gets noticed, the activists may raise voice against the government, accusing it of bolstering the private sectors at the cost of the public sector. To remind again—it is not deliberately done by the government. It is a fallout of the planning of the last 60 years. It is the planning of those officials who have no idea of what the rural realities are and what the needs of the rural India are. Not just the closure of SDH but the excess as planned, if removed, will be a cost saver. It can then fortify structures which can do a much better job peripherally as seen earlier here. Even when recommendation for



wholesale closure of SDH is made, it is also discussed to bring about the faulty planning, which is out of sync with today’s situation. Human Resources at Sub-Divisional Hospitals A. Hospital Superintendent; Five Basic Speciality Doctors—Medicine, Surgery, Gynaecology and Obstetrics, Paediatrics, Anaesthesia The non-working post of a hospital superintendent is not required. One of the many specialists could do the job easily by rotation. When there is already a 80% vacancy for all the five basic specialists at the CHC level, what is the point in creating the same positions at the SDH over a short distance from CHC? The reasons for the non-­availability of the specialists is the same for both CHC and the SDH—both are quasi urban/rural positions—whereas the least the specialist wants is to get posted to the district hospital. B. Other Specialities: Dermatologist/Venereologist, ENT Surgeon, Ophthalmologist, Dental Surgeon and the Orthopaedician They need not be present in each SDH or in each CHC as has been discussed earlier. We must also cognize that these people are available in private sector whose services under the PPP should be utilized (Kelkar, 2021) and will be discussed later also. C. Radiologist at Each and Every SDH Radiologist at each and every SDH is also superfluous. Today the real need of a good radiologist is in a centre with sophisticated imaging facilities like ultrasound, Doppler, CT and MRI are available. The district hospitals within the public system is the lowest they should come to. In CHCs, well-trained technicians are enough, as discussed earlier. The patients from the CHC can always be physically referred for high-­ cost imaging like CT and MRI over much shorter distances than going to medical colleges, and can be brought back to the CHC and treated. It is a commonplace reality today since these imaging facilities are available at present ubiquitously, making the radiologist redundant in SDH. D. Casualty Doctors/General Duty Doctors/AYUSH Physicians in SDH



They are far more useful in CHCs and their role is discussed above. Keeping them in already-dysfunctional unit is costly, with no benefit. It is a deliberately designed deterioration of these young officers. E. The Public Health Manager The presence of a full public health unit, the details of which are given earlier but not discussed fully yet, is redundant in SDH. This unit with the fully defined role of the CHO at CHC will be discussed in the next chapter. F. Forensic Expert in SDH When imagination runs riot and making a show of fanciful ideas becomes irresistible, such ideas are born. In plain terms it means we need 1000 forensic experts in the country to be produced by the 261 government medical colleges we have. There are hardly any seats for a postgraduate course of forensic in the medical colleges. Much of the autopsy work is done by the pathologist and the work of analysis is done by the central/ state forensic laboratories by technicians. In India today, forensic work done even in an institution like AIIMS comes under severe doubt, as seen in the case of the wife of Shashi Tharoor, a former diplomat who represented India in UNO for many years, Sunanda Pushkar’s death. In mid June 2020, autopsies conducted in the city of Mumbai on Sushant Singh Rajput and Disha Saliyan have come under severe criticism. What do we expect from the so called-forensic experts at the SDH level? G. Pathologist with Diploma in Clinical pathology DCP/MD (Microbiology)/MD (Pathology)/MD (Biochemistry) None of them are required in the SDH. Pathology is intimately connected with the technology today, which has made the majority of the tasks far more precise. They have also been pushed down to the technician level. No objections. This gives more time for the faculty to find how the subject could be taught better to the graduating and graduates working in various places. These practising doctors badly need basics of pathology taught to them. A regular pathologist today should take on a much more complex role in histopathology, blood banks, assisting the forensic work, upgrading the technology in the public health system, quality checks and so on by being stationed in the district hospital or the medical colleges. Their wider



availability in private sector needs to be utilized by bringing them in the system and not by referring patients to them outside. A microbiologist is definitely required at the district hospital or the medical college level. The principal job of him/her would be to teach and regularly visit CHCs to lend a helping hand for the infection and quality control or antibiotic strategies and standards of laboratory and the equipment. H. Dental surgeons with their Technicians: They are a viable option in one or two out of five CHCs since the cost of setting up a basic unit is not high. Dentists could lend their hand in campaigns like oral cancer detection which will create work for them. Dental Surgeon in his own private set-up at SDH population level could be facilitated and strengthened by assured supply of patients under specific tariff agreements. SDH is not the place for him to be placed. I. Paramedical Workers: Pharmacists, Physiotherapists, OT Assistants, ECG Technicians and Laboratory Technicians All of them will find CHC work wise a much better place and belong there, as already discussed. Their consistent presence will make the CHC functioning efficient and quality of care better and for adding newer CHCs. J. Ophthalmic Assistant/Refractionist, Dental Technicians



They should go where their specialist go—CHCs, or DHs or medical colleges but not SDH. K. Staff Nurses As the CHC starts functioning optimally, the need for well-trained nurses will be high there, not in SDH. The requirement of staff nurses at different places is discussed before also; it may not be only CHC. L. Ambulance Networks under SDH



A more general distribution of ambulances in CHCs for the emergency transfer of critical cases to the CHC looks more logical than in SDH. CHCs have already been provided with three. If a CHC cannot handle a case and wants to send it to another CHC or to the district hospitals, the peripheral availability of these vehicles would look even more logical. The aim is to reach a person in 20 to 25 minutes in urban and in 1 hour in rural areas if someone dials 102 or 108. A competent CHC if available in 15 to 20 kilometres, as the justification to locate ambulances in CHCs increases, to cover the time–distance specification. That makes SDH irrelevant. The situation of the contract drivers and others employed by those who run these services is said to be atrocious. Extended duty hours, 50% of the agreed payment, the remaining being taken away from them by the contractor, no good place to rest and sleep, at times not able to eat for a full day are some of the issues. In the arrangements above, their running time will shorten and they will be placed in more comfortable environment in CHCs. In conclusion, a blueprint or a ‘transfer of technology’ is available with us for any one body, charitable institutes or even business houses who wish to do something in the name of people. In our rural setting we faced all the issues leading to poor rural health care. As we sorted them one by one, also studying what was going on, the model that is being described emerged. We did not get encouragement to put this forward till late. Today we feel happy that many more talented and versatile people have created similar models with far better ideas and resources than our resource-poor setting had.

References Azim, Sabahat, CEO of Glocal HealthCare Pvt Limited, Kolkata, 2015. Swarajya Staff—Jan 07 2019, 12:28 pm. Prof Upul Dissanayke, Director National Hospital Colombo Sri Lanka, personal interview November 2018. Healthcare Sector Skill Council, website accessed on 8h December 2018, at 21:53] Rural Health Statistics, 2012, Statistics Division Ministry of Health and Family Welfare Government of India. Rural Health Statistics, March 2014. Kelkar, Sanjeev, 2021, India’s Private Health Care Delivery: Critique and Remedies. Palgrave Macmillan Chennai]


Structure and Function IV: The Final Picture

Preamble So far we have been looking at the curative functions and how the community health centre (CHC) should or can be shaped for that. Now we need to look at the CHCs from the preventive primary care perspective. The two questions are: Can the CHCs proposed so far and now presented below deliver it more effectively as compared to the system available until now ? Can the National Rural health Mission/Indian Public health Standards (NRHM/IPHS) ideas as a whole deliver it, or is a new modified structure/system needed to be brought in? Will the added functionaries under IPHS to the CHC idea help for better delivery? These questions are sorted out in the following discussion. This will help to get a much clearer picture of the primary care without any primary health centres (PHCs) below.

The New Additions Public health specialist has been mentioned in the previous chapter with qualifications and responsibility for the preventive/community work in the CHC and the national programmes and to provide efficient primary care (NRHM 2012). He is part of the Block Public Health Unit. This is a welcome idea leading to the differentiation from the curative work and the preventive work by two different professionals. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




I have titled this newly created post as the community health officer (CHO) in the CHC. We will treat this unit as the CHO unit for the ease of discussions. This was the most important shift/split required to take the burden of the preventive primary care functions and the national programmes. PHCs have done their job within their considerable limitations. Now these two jobs should be rearranged with its machinery from CHC up and down to the most peripheral level. Planning Deficiencies within the New Additions The PHCs are not abolished and the hierarchical structure of the government system continues. It will make this community health officer at the CHCs depend upon the input that he would receive from the four or five PHCs under that particular CHC. This CHO has just fallen back on the PHC officer and through him the front-line community health workers (CHWs)  without having any directive control over the CHWs, thus becoming just another conduit. The conduit or an unproductive supervisory level/layer will merely pass all the information coming from the periphery up and pass on orders that came from above. The district medical officers or the directorates for various national health programmes from the district or the state will issue such orders to be passed down. That is not a productive arrangement since it has left the CHC CHO without a meaningful job content; he will remain underworked or underutilized, with no controls or initiatives left to him. It is a chronic problem in government planning, which wastes money on duplication, redundancy and other defects repeatedly stated so far. The mention in the NRHM/ IPHS guidelines that ‘the manpower at CHC has been rationalized... to ensure optimal utilization of scarce manpower’ simply falls flat here.  aking CHOs Available M The availability of professionals trained in this area who could be posted as the CHO to manage is sparse. That is a concern. It can be partly resolved by the reorganization of the district and state health directorates as discussed in the earlier chapter. To make amends in this area, this volume has proposed that all the front-line, five or six community health workers, (a generic term I have used all along) of four to five PHCs should directly liaison with the CHO, which has been discussed briefly in chapters gone by and below in greater detail. 



As the NRHM/IPHS document says, the public health specialist should be ‘preferably trained in public health’. Dr. Manmohan Singh creditably found an alternative in the form of Public Health Foundation of India (PHFI). It has a specific mandate to train more medical graduates to address effectively this need. PHFI in addition conducts courses to train people in different modular areas. These areas are attempted to be made complementary for increasing the IT tools in different health areas of work. I could not gather as to how many doctors have taken this diploma from PHFI and are actively working in the public health care delivery system. Increasing the number of postgraduate seats for preventive and social medicine would probably result in much less than half of the posts getting filled. Many of these seats may even go unfilled for reasons like locations or something else. Offering a diploma through PHFI seems to be a more pragmatic approach. For those who do not wish to practise and are looking for an alternative, it should be quite useful. However, the couple of programmes of PHFI which have completely eclipsed these are related to training hundreds of doctors yearly in cardiology and diabetes. In fact, PHFI is recognized today by them and not the diploma course in public health. The paucity of these professionals is encapsulated at other places as well in the NRHM document stating that a speciality degree in medical branch with MBA/DPH/MPH can also do the job. Here the contradiction is obvious. How many of the medical branch degree holders will be willing to this job even singly, abandoning clinical practice, leave alone in addition to their main job! I nadequate Scope for Work of Coordination NRHM wishes this CHO or public health specialist in its parlance to be responsible for coordination of national health programmes, management of ASHAs, training and other responsibilities under NRHM (NRHM 2012). As we have already shown, any PHCs below the CHC is utterly useless to achieve coordination in national programmes. In addition, the word ‘training’ hanging in the middle without context also does not mean anything at all. Training ASHAs: This is a short-sighted inadequate view since it does not include all the other types of CHWs who have been there for ages. Nowhere do the revised guidelines mention the unification of cadre under a single category, may be ASHA, nor does it talk of equity of reimbursement of this entire cadre in one.



 ifficulties Created in the Management of CHCs D NRHM: Looking after the overall administration/management of CHC and being responsible for quality and protocols of service delivery of CHC, that is the medical specialists.  These are the duties of a  separate  medical superintendent (MS) prescribed by NRHM. He should instead be compulsorily a practicing medical specialist only and take admin responsibilities of the curative services by rotation. Extra MS post is not recommended; it is waste of human resources, superfluous and expensive. Contrarily the medical superintendent should never be involved in public health. We have shown the fallacy of two responsibilities mixed up in PHC adequately forcefully. The additional NRHM idea that a public health care person can be made responsible for quality, protocols, the curative functions of the CHC and its service delivery is completely incorrect. It will create more schisms and irritations in the CHC working. He is not a competent person either to assess the specialists working and no specialist will take it kindly. To somehow make up for the numbers they do not have for the posts they have created, NRHM says with impunity that a postgraduate in any medical faculty with MBA training could look after the community work and also serve as a medical superintendent. This counter-logic is as false as the preceding one. It should be obvious by now that availability of a specialist will be far more valuable at the CHC level. If such a person ever decides to do public health work, he may be better placed in the Group District Unit of five or six districts so that he has no conflict with another specialist of his own branch also present in the CHC. In no situation a person of whatever qualification should do two jobs. It is either community health or medical speciality, the latter with a rotating medical superintendent’s job among specialists. This is also an indicator of the addiction to create supervisory layers under the assumption that people left to themselves are unreliable. It suggests that the government mindset has not changed to a facilitatory one.  dding More Functions, Services and Workers as Revised Guidelines: A NRHM Ideas One of my recurrent criticisms of the government is that it has created (mostly as an on-paper exercise with nothing working below) an excessive number of functions at all levels of health care. At the sub-centre (SC) and the PHC level these are impossible to carry out, as described in detail in the earlier chapters. It has now added new ones with crass negligence of the work–time ratios, capabilities of the front-line workers and the



constraints they face. These functions cannot be carried on, especially without increasing the numbers. Under the revised guidelines, a multi-rehabilitation worker is added as support manpower (for the CHO) (NRHM 2012). Moreover, this single multi-rehabilitation worker is to carry these new functions listed below in a population of 172,000 to 250,000 populations under a CHC.  What grandiosity? These functions require a physiotherapist and quite a bit of instrumentation and many assistants among other things. Many of the functions are designed to again depend on the inputs by the CHWs or ASHAs. That increases their burden even more. We will list these functions without any comments if the above criticism applies to them. Any new comments, if added, will bring in the gross defects in planning. I cannot refrain from saying that all of it is simply absurd.  edical Rehabilitation Services: National Programme for Health Care M of Elderly 1. These workers are not defined in place. The distinction between their movement in community and stay in the CHC is not fractionated in time or days, nor is it possible to do that either. We cannot know from which department this worker is to come. 2. Compilation of elderly data (again) from PHC and forwarding the same to district nodal officers: this adds another tangent to information processing without much relevance of what to do about it for the CHO. Such ideas are in response to some fad or international directive that the services should have a component for elderly and disabled.  3. Visits to the homes of disabled/bedridden persons by the rehabilitation worker (again) on receiving information from PHC/sub-centre. 4. Issue of Disability Certificate for obvious disabilities by CHC doctors. 5. Community-based rehabilitation services: again, by whom, where, how, and under what instrumentation needed; possibility of building this activity in 5300 CHCs, which presently are dysfunctional in every way, and the PHC-converted ones have plenty of faulty construction or other limitations. 6. What about the availability of instrumentation to these 10,000 places? How will these move into the community, which is much more unproductively skewed, if it is being taken for a single household with one patient? 7. At lower levels, having just one worker for a huge population is ridiculous. The whole idea is not feasible.



8. Basic treatments like exercise and heat therapy, range of movement exercises, cervical and lumbar traction; see points 5, 6, and 7 above. 9. Referral to higher centres and follow-up—is it going to be at the sub-­ divisional hospitals (SDHs) or district hospitals (DHs) or medical colleges? What then is the point of locating them in the CHC? 10. If these cases need instrumentation, it should be available at the CHC to be used upon. If it can be so, why refer to higher level? 11. Logistically, even for making a decision to need higher referral the patients will have to first come to the CHC. Added to that will be the patients seen at home. If patients start coming to the CHC, this multi-rehabilitation worker will never be able to step out of the CHC. 12. Geriatric clinic twice a week: this includes physical medicine and rehabilitation (PMR) as an essential service for primary prevention of disabilities. As a medico I know that people need this kind of treatment after they have developed disabilities. No one is known to have prevented these disabilities by these methods since the likely disabilities cannot be prevented, nor can they be predicted. See points 5, 6 and 7 above. What happens to the departments training physiotherapists? Are they to be let loose in private? Don’t they have any role in CHCs? Why create a separate cadre and duplicate? 13. The geriatric idea, taken from countries like Australia where it is well developed, in poor imagination is being transplanted in the rural communities. Even if there was to be a mention of its being weighted in favour of urban services in medical colleges, one could be less harsh about it.  ral Health, Dental Care and Dental Health Education Services: One O Dental Assistant It has been explained in the previous chapter that they go where their specialists go, that is, the CHCs, and also help oral cancer detection campaigns. Isolating them from dentists, mentioned in the discussion of SDHs (previous chapter), makes no sense. Dental services will also do root canal treatment and filling/extraction of routine and emergency cases. This is an industry of millions of dollars in urban locations where I have not seen a dental assistant doing any of these. The teeth of the poor are probably far more dispensable.



School Health Dental and oral health education in schools will form a part of a larger collaboration with nutrition, and adolescent health. NRHM lumps too many ideas in one without a word about by whom, where, availability, competence to do it; it mixes up things so much that it becomes unworkable. I have considerable reservation about the community workers handling the adolescents. Can they do what even the educated parents find difficult to achieve? Adolescents in particular are part of specialist paediatric functions which are not available yet. Adding cadre after cadre for highly differentiated work profiles across 5000+ non-functioning CHCs is easy on paper, not in actuality. Such people as described above will have to be trained, and then deployed, and work should be done by them on a national level. It will be years before results can be apparent, or perhaps it does not happen at all, which is more likely.  he Third New Functionary and New Functions as Planned T The health educator at PHC should work in coordination with block public health unit for organizing health education services. The health educator in PHC under the scheme I  proposed is to be shifted to CHC and given a new role. This could be a role of a coordinator. She is also most welcome to assist the public health unit in its myriad responsibilities especially dealing with the CHWs. Abolition of PHCs automatically shifts this cadre to CHC and should be a part of the CHO team looking after all the primary care responsibility and the national programmes. A better role for her would be to assist the public health nurse in this unit (see below). The issue here once again is the range of functions over a large population which is impossible to achieve, as described above. As far as educational activities go, the public health unit has few such activities listed. The education is going on at the sub-centre level. This unit sitting distally will have to fall back on the CHWs again, increasing their burden.  he Fourth New Functionary: Public Health Nurses T The support to the CHO for this much-expanded work is expected to come from the public health nurses (PHNs) for which two are more desirable: a graduate or a diploma in nursing person will be trained for six months in public health. This would be a valuable addition and a job in evolution, particularly when the CHWs of four to five PHCs are directly linked functionally to



the CHC.  It would be for reorientation of the CHWs, retraining, gap learning, and logistical support and so on. This nurse should in fact be like a secretary to the CHO helping him in each job to be described below. Making them available with quality training across 5300 CHCs still remains a challenge for which no immediate success is apparent. 

Advantages of a Community Health Officer at the CHC Public health specialist in NRHM parlance or CHO, as I have termed him, as said before many times over this creation, is the most significant addition the NRHM has made in the CHC concept. It will be extensively discussed and an attempt to draw a full picture of CHO will be made. The sources from which they will become available are those with postgraduate degrees in preventive and social medicine, those who have taken a diploma or degree in public health from outside the medical colleges, or from abroad or those who are in the state government services as a DHO, or a director of one particular national programme, or in-charge of more than one sitting in the state-level health directorate. Geography for Operation for the CHO A population of 100,000 at the block level1 is 1 by 15th of an average district and 1 by 15th miles closer to a CHC with a community health officer than the district headquarters is. In the system hitherto this officer is generally available only at the district headquarters with one of the characteristics described above, with a distance of 20 to 50 kilometres from the community. Sitting at a distance he may have a mixed or narrow vision of the district. He has to be brought down to the CHC, which mostly will correspond loosely to the taluka Centre or a block more distally. As a general caveat in the discussion to follow, CHC will mean either an existing one being reconsidered or the PHC to be converted. Which one finally becomes the CHC NRHM wants, and I want, is what matters in where it will be located. In these two types of CHCs, the logistics, instrumentation, building requirements, manpower available and needed to be put in, all differ. The nomenclature is irrelevant. 1  The block-level populations from 100,000 have moved up considerably and variably, which must have been noticed by the reader throughout the volume. Population level of the block as 100,000 was defined in administrative parlance many years back.



Functions of the CHO Vis-à-Vis CHWs in CHC The following discussion presupposes that the scheme has accepted the elimination of all the PHCs and wholesale shift of all its assets to the CHCs. It keeps the sub-centre structure as it is the line function of all those who work at the sub-centre level which now will change considerably. The community health officer will have all the functions of a DHO in the new scheme at the block level. It will be much easier to visualize the state of all national programmes and other primary care areas from this vantage point and will be easier to travel far more frequently. That leads to a more stratified action plan he has to instruct the CHWs. He can decide the emphasis of each work much better than the DHO, who at best will issue a sweeping order to concentrate on a particular action to all the CHCs and PHCs. The CHO has (or should have) the additional power to decide on the priorities of areas under him including the national programmes. An officer of his level can then balance what the district or the state needs to know or advices to do urgently for whatever reason against what he thinks the community workers should do and in what manner. The two demands, one from the ground and the second the district/ state orders demand, will not always be at loggerheads. When they are, the CHO should do his own thing. This will be the first indication of making the functions relevant to the situations which are different in different pockets. This will also lead to a minimum disturbance of the natural work rhythm of CHWs. This eliminates the necessity of continuing to undertake irrelevant national programmes for the sake of targets, to which I will revert later. This sixth medico, the CHO and the details and the shape of his direct liaison with CHWs of four PHCs is described below. Thus, we have foreshortened the long vertical arm to a direct and short link. The CHO will track their activities on computers since the CHWs, as proposed earlier, should be online to report the work of CHWs and raise their requirements. With it the entire face, the ways, the speed and the effectivity of community health work will alter. This CHO will become a key person now in many ways, as described below: 1. He or she has roughly 24 sub-centres which were reporting to the four PHCs. That means, theoretically 24 male and female community workers, 24 ASHAs and many more Anganwadi workers who would



now directly report to him. The numbers may not be fully filled especially the Male CHWs. 2. Initially there will be a paucity of the CHOs at the CHCs as they keep developing. A developing CHC should be started when it has services of all five basic medical specialities even if the CHO is available only to one of the two, three or four CHCs. That is not a deterrent in some way it could well be an advantage. 3. In fact it is argued that a regular CHO may be placed in every three to five CHCs for even more effective functioning. 4. In that case the CHO would have to coordinate the work of 96, 144 or even 192 workers. If it is done increasingly through digitization, already on the increase rapidly will become much easier, faster and cleaner, as shown below, and earlier also by the time we have proceeded along these lines to reorganize. 5. The CHWs send him the reports every month electronically or on paper initially, which he has to consolidate. A total of 48 community workers, 2 PHCs, and a population of 100,000 from the point of work–time balance is too low for the CHO. Hence, all the workers from two or more CHCs would produce better output in the same time frame. 6. Hence, for every three to four CHCs, one CHO would be acceptable. 7. The earlier system of weekly supervised work by the lady health visitor and/or the PHC officer, weekly reporting and attending meetings weekly, excessive emphasis on frequent training disrupting the work, in the hitherto system resulting in reduction in the available time and adequate number of hands to do the myriad duties, will have to be scrapped. 8. In this new proposal, peripheral workers from three to four PHC coverage areas, that is one CHC area meet the CHO every month for discussion in the CHC headquarters about abnormal findings, in the community and to discuss what needs to be undertaken immediately. Depending on the number of CHCs under CHO such meetings will take place either together or on different dates. Such an arrangement will merge the individual consideration into a common consensus leading to more effective action. 9. This increases the actual time of these workers by three days when they do not have to attend the superiors on a weekly basis and keep going to the PHCs every now and then for meetings. 10. The unending frequent training obsession should be reduced to one training per year.



11. These peripheral workers will also merely point out the places where the sanitary and other works need to be started and about unfinished works that need to be completed without having to deal with the Public Works Department (PWD) or the Public Health Engineering (PHE). 12. For this famous inter-sectoral coordination, this officer is more capable and likely to be listened to by the PHE and Sanitation Department people to do the necessary job and followed. 13. The 5000 or more CHCs will now become the main store for everything—starting from drugs to consumables to equipment, the educational material and drug. Supply of all these can be better managed logistically and provisions could be made in advance of the meetings. It is certainly many more times effective than managing the same with 25,000 PHCs which would run short of various materials at various uneven times and cause dysfunction. 14. The CHO may travel once every week to cover just one group of CHWs of one PHC or as a group of nearby locations but need not strictly follow any pattern. 15. In actuality the travel will depend on the abnormality of situation in any one or more sub-centre areas where the peripheral workers will benefit by his visit. This is a yearly itinerary. 16. The proposition above does not need more than 1500 CHOs in 5000 CHCs. Developing the cadre of the CHOs has three answers. One is the PHFI mentioned earlier. Among the PHC officers, there would be a number who would like to be trained or selected for this. After the dismantling of repetitive directorates, these officers can then be consolidated in fewer District Unit DHOs with all national programmes under one. This will result in a surplus cadre for the CHO job and are posted as suggested in the previous chapter also. The government medical colleges make up for the rest of the numbers.

Critique of the Issues Related to the National Programmes In Chap. 6, we have briefly discussed these in relation to the workforce available at the PHCs. We then discussed about the infrastructure of these programmes and the manpower under it and why this cadre and



instrumentation should be brought to CHCs, in the previous chapter. In the same chapter suggestions were made to restructure the top-heavy unipurpose directorates of each programme to reduce the expenditure in the government system and making more public health men available to work the system at the lower levels of CHCs. Now we will take a review of the national programmes as a whole and various issues that have been thrown up. Any policy document cannot be considered complete unless it is done in detail. National Programmes and the Covid 19 Pandemic Challenge Before going further, it is reasonable to mention the latest challenge the execution of the national programmes have met. It is the Covid 19 pandemic. The onslaught of it was so strong and urban focused that the entire state and central machineries were drawn in the vortex of combating it. In time the activity percolated down to less-urban levels and the challenge intensified with migrant workers going back to their villages in hundreds and thousands in numbers. Over the months it was realized that two important programmes have been hit badly, one that of universal immunization programme and the routine activities relating to tuberculosis, by far the biggest challenge in public health. As a hypothetical question, it may be asked if the structure detailed herein of the pubic health care was to be available could these two activities have been managed better? In modesty, without exaggerating the merits of suggested changes so far and further the answer would be yes, it could have been better managed. There are two extenuating situations which must be kept in the background. One is the way Uttar Pradesh has managed to keep the Covid 19-infected numbers in check if we compare the proportion to its 220 million people. Compare it to the unpardonably ugly and incompetent management in Maharashtra or New Delhi, both highlighted elsewhere in this and my other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). One conclusion is that even a pandemic can be checked if the district administration is alert and functioning. The second is that in that case it would be easier, if not perfect, to keep running the other national programmes as well.



About the Existing National Programmes There are at least ten national programmes running for infectious diseases. There are many more about the non-communicable diseases now, which probably are even more taxing: diabetes, hypertension, blindness control, iodine-deficiency diseases, mental health, oral hygiene, fluorosis, deafness, household survey mapping, communication and counselling needs, geriatrics and health statistics and many more activities under the same, writing reports on all this, attend to school health and adolescent problems, and so on. Universal immunization is not a small programme either. Independent Verticals All national programmes are central government programsme. They in turn have been pushed on them by the WHO, which runs more than 200 such programmes across the world (DAWN Conference in London, Nov 2003). The WHO is aware of its long vertical components which inevitably result in isolation of one from all other such vertical programmes in any given country. The WHO is also aware that such programmes are thrust upon the country without bothering about whether the country has the wherewithal, especially whether it has adequate manpower to be able to handle many such programmes at the farthest point of communities in villages. Each new programme thus is expected to be carried by the same set of poor peripheral workers as if no other programme/work exists for them to take care of. All these matters become significant when it comes to India, a country so vast and populous, developing in a mixed economy for over four decades (DAWN, ibid).  id Things Go Wrong with National Programmes? Where and How? D The health literature often propounds that the central governments manipulated the state governments by funding and forcing through the many national programmes on the state health machinery causing dysfunction. It is probably an error of perception. National programmes were not by themselves wrong. What failed was the appropriate expansion particularly in the bottom of the primary health care to deliver them effectively to the population. One of the reasons could be the top-heavy health machinery from the states level down. In the long years of the health literature, there has not been any thought given to restructuring/downsizing of the health machinery at all levels to meet the shrinking budgets. Instead, multilateral agencies and authorities were added particularly after



NRHM, adding to the overheads. I would consider this also as a significant factor as to why the programmes could not be delivered well.  xecutive Integration of national programmes E All national control programmes finally integrate at the primary health centre level and then at the sub-centre level. From there each one of it turns back to its respective national programme machinery which has no concern with what the other agencies of each national programme are doing. This machinery is situated in the state as well as district headquarters. These directorates can be anywhere up to 100 kilometres from the remotest population segments. There is no live connection between the state/district machinery and the remotest CHWs. This state  machinery does not have enough work. The skilled manpower and equipment coming with each national programmes duplicates, hence wastes itself (Park 2015). This burden needs to be effectively discharged and rationalized by restructuring. The details below will show how this responsibility could be redefined.  ow Will It Now Change with the New Structure? H The PHC CHW workers will now come under the CHO of the CHC after the PHC closures. Its functions as well as the lines of reporting are thus without intermediaries. Shorn of all this, the model through the primary pivot of the community health officer will look something like the following: Below is the graphic representation of the new model under discussion. The model at its best representation (Kelkar 1998): 172,000 population, 50 bed centre with 6 HDU beds, area of coverage 225 square kilometres, 125 to 175 villages, no PHCs below and SDH above



Chiefs –Curative & Community Health Officers -Integrated Office

Pathology / X-ray / Blood storage, Pharmacy, Rational optimum utilization of all these facilities, Generic prescription and medicines,

FHW, MPW, Anganwadi workers, ASHA, ANM, dai, Direct Liaison Training / Situational prioritizing of working areas

Medicine, Pediatrics, Surgery, Anesthesia, Gynecology Obstetrics critical Care and HDU, Multispecialty Slots

National Programs/ statistical bureau base / Epidemics / Calamities/ Inter-sectoral Collaboration by the CHO, not ASHA

6 to 8 MBBS + AYUSH Fresh grads work under the specialists, learn and firm up critical clinical reasoning, Improve ability, skills and Complex tasks, skills development in ethical empathetic empowering

Nursing School Entry – CHWs & ANMs; Local people, preferential entry for LHV, HAF, HAM, for nursing and all the 17 training courses floated by NSDC; the ANM Schools for 20 numbers

A model corruption free competent problem solving institute, having people’s faith, creating a sense of security, inspiration to other institutes to emulate, 10 such institutes change the life of a large segment, Developmental, Educational, Agroeconomical Activities

Collaboration of N G O s, VOs, Private partners for a purpose, Govt. Channels

 hat Does the New Model Mean? W The primary and secondary care both need to be supportive to each other at the CHC level. In the model proposed above, a diagrammatic representation envisages an integrated office for the CHO and the in-charge of curative service the medical superintendent (MS). MS will be described in a few lines later. The point is that each service should essentially take care



of their own tasks while retaining a live contact with each other on a day-­ to-­day basis. The integrated office can take up implementing national programmes with the help of the CHWs, taking care of routine primary work to beginnings of epidemics or contain calamities, collaborate with voluntary agencies for mass campaigns and so on, far more efficiently. The community health officers are by their very training greatly suitable for it. National programmes are a classic example of top-down, vertically exceedingly long health planning and suffer from all the disadvantages of it. Their execution at districts as well as at primary health centres and sub-­ centres is nowhere near optimal. Some programmes are forced down strongly; some have low priorities because of the varying expediency of the people at the helm of the affairs. There is no concern about the different realities on the ground level as different population segments being attended get smaller. The local problems ‘submerge’ in the national programmes. Hence, finally how many work hours should be allotted to which programme, and how and with what priority, cannot be decided. One well-known example is the family planning programme which had top priority and could push all other programmes aside due to this kind of pressures, in the decades gone by (Kelkar, 1994). The programmes may be changed, expanded or cut down from time to time from the top, in central and state levels. The priority changes are not necessarily in step with each other. The programme management gets fragmented and scattered among the multilateral authorities, making it difficult to link them for an impact. Many of them continue to run along traditional or outdated lines (Kelkar ibid).  ectifying the Deficiencies in Executing National Programmes R These measures lie in having a mid-level agency neither too far from the last population segment nor too far or too close to the district directorates. Hence, it is necessary to make the CHC or a group of CHCs the nodal and controlling agency with much more latitude and discretionary powers to conduct the national programmes and not the district headquarters and the directorates which sit in the state capitals doing no great work. I will illustrate how it could be done in the following discussion: 1. The biggest strength that CHCs now gets under the new structure is the CHO who can deliver much more by cutting down the long ­vertical arm of the national health programmes from above as well from below.



2. He should also be given the charge of all the machinery of different programmes for reasons mentioned above (Park 2015). One such example of the above is the sputum testing centres for the National Tuberculosis Control Programme flung far and widely scattered, inadequate in quality microscopy (Park, ibid). These centres have now been brought into the CHCs. The policymakers have to now give the CHO all other national health programmes also to be effectively consolidated at his level of CHC. This will eliminate its multilayer, multilateral and multiauthority structure above and make the same still more effective below. 3. Having a clear idea of what the ground realities are since he is close to it, the CHO can make rapid transitions from a temporary push to some programmes if abnormally high findings surface, say in Malaria parasite detection. Then the control measures can be taken up in segmented populations for a short term without affecting the daily work related to the national health programmes of any other CHW area. This is something neither the district nor the state can handle effectively since there will always be an unacceptable time lag by which time the opportunity for effective work is lost (Kelkar, 1994). Illustrating Changes in Greater Detail 1. The CHC is the place where all the sample collections will have to be sent by all the 96/144/192 peripheral workers by using existing regular transports from villages to the place where CHC is situated. As we have already seen, the distance would not be more than 20 to 25 kilometres at its farthest. 2. The frequency of sending samples could vary. The idea is to use some ingenuity and try to send everything in the shortest time after collection. Few such ingenious examples of the existing channels of communications from the villages to tehsil towns have been given already. Utilizing these channels can be and is highly effective. 3. All the diagnostic works of such specimens should be carried out for malaria, tuberculosis and so on, at the General Laboratory at the CHC on all the specimens that come from the 96/144/192 periph-



eral workers. None of it need go to district laboratories and directorates. The first consolidation of the findings will happen at each CHO office, for the number of CHCs coming under him. 4. On those reports over which action needs to be taken at the periphery, the orders will be given from CHC through the CHO. 5. This simple arrangement cuts down the time for quick and regular or extra drug supply now concentrated at CHCs since this also comes to the peripheral workers from the CHC. 6. Such an arrangement will easily detect the clustering of particular cases to a particular locality easily to effect concentrated action and further investigation. In West Bengal, I have seen a fierce short outbreak of falciparum malaria in a village and eight people dying in quick successions with blackwater fever. Additional two who came to us were suffering from one of the severest acute renal failures I have seen in last 38  years had to be transferred post-haste. No community action was taken that we could come to know. 7. All the personnel who have been involved in the diagnostics for all the national programmes should duly get transferred to CHCs. Those who can detect an AFB-positive sample can also detect malarial parasites and do other diagnostics, working like a multipurpose laboratory worker. (The laboratories of tuberculosis Control Programme have already been consolidated at the CHC level; Park 2015.) 8. This arrangement will also lead to a better-quality control over the diagnostics process. These people also can be of help to the general laboratory work once due training is imparted to upgrade the skills. This is extremely helpful since the work at CHC is expected to be heavy. Those already working in the general laboratory could lend a helping hand to the samples of the national health control programmes. 9. For example, further follow-up with X-rays of the index case as well as the relatives staying with a tubercular patient could be more effective since the treatment initiates at the CHC.  If it gets proven that the family members also have tuberculosis, it is more likely to lead to simultaneous treatment within a household and the drug resistance may get reduced. 10. If this function was to go to the district, as presently happens, speedy directives are never obtained since the entire process is long winded,



the location where action is urgently needed gets submerged in the general data deluge and the political considerations that prevail at higher levels. 11. In times of Covid 19, while the urban machinery was geared up, the CHC laboratories could have at its least served as specimen collection centres up to the remotest areas. Over time when simpler tests like Rapid Antigen Tests were made available, the CHC labs would have been far more useful to trace and isolate the type of Covid 19 eruptions the migrating workers might have brought into the villages. As pointed out repeatedly, in these two volumes, there is an absence of any competent or functioning structure dealing with any aspect of health care in the hinterland. This biggest deficiency if corrected and available could have shown itself to be a capable measure in dealing with Covid 19.

National Tuberculosis Control Programme (NTCP) To illustrate the foundational concepts of national programmes and what happened to them, I have taken up the National TB and Blindness control for discussion below. The first is the central paradigm of communicable diseases and the second of non-communicable diseases. This will naturally be followed by what the new format of CHC can do better for them. In order to demonstrate how this horizontalization of the two vertical arms will be achieved at CHC, studying the design of the tuberculosis programme prior and after the RNTCP and DOTS would be instructive. The prior model was also a well-thought-out National Tuberculosis Programme from the national to the last community level. The model run by the National Tuberculosis Institute from 1962 till 1992 has been more or less dismantled at the behest of International Agencies, particularly WHO (Park, ibid). The First Model and its Shortcomings The earlier programme did not pay much attention to two aspects: one the rapid development of private sector, which however is a post-1980 phenomenon; second was the general apathy of the government programmes in having an inclusive attitude, something which is being talked about since 2014. For the same reason, the NTCP did not pay attention to the



private sector and the grass-roots and larger voluntary agencies participation. The component of X-rays for diagnosis had many loopholes operationally. The Mass Miniature Radiography, MMR, Odelka camera had a roll film at the District Tuberculosis Centre. That meant the results could be available only after an unpredictable interval when the film was over. That was a serious impediment which caused serious delay in early diagnosis and starting early treatment and a delay in getting the patient into the process. The last reason led to loss of enthusiasm on patient’s part to get diagnosed. For reasons I could not fathom for over years, a Mass Miniature Radiography machine on a mobile van did not gain currency in all these years since 1962. In mid-1980s, many cancer service societies in intensive early mass diagnostic campaigns, especially in rural areas where tobacco chewing is rampant, carried a portable X-ray devise but the twain of TB and Cancer did not meet. This would have been far too useful for mass detection and testament for debulking TB (and cancer)  in high-­ endemic areas. Additionally, the mandatory three-sputum examinations and positivity of at least one was the only real criteria for starting anti-tubercular treatment. This meant at least three to four visits of the tuberculosis centre or to a remote laboratory to get sputum reports, resulting in loss of work. Then there would be a monthly visit to get the anti-tubercular medicines, half of which would not be available. That was not the era of communication as it is today; hence, expecting the District Tuberculosis Centre to reach the patient as soon as the film was read was out of question. (The general inertia of the government system of course would be a reason even today as to why it will not be done, a matter we hope to overcome by structural change.) The system of diagnosis by sputum microscopy was weak and far flung and of poor quality. There were 13,000 + Tuberculosis Microscopy Centres located everywhere—in PHCs and CHCs and the sub-district and the district hospitals. Such cumbersome arrangement discouraged patients to go again and again for treatment once they started feeling better as they always do, and default. There would be no way to detect if he goes to another health care provider after the first default and even less about what he is getting treated with. These are the beginnings of the multidrug resistant (MDR) tuberculosis. There are other biological--cum-therapeutic issues which I believe have also contributed to the rise of MDR tuberculosis which are as discussed later below.



In 1985, a large-scale debate was organized by the alert and watchdog Medico Friend Circle with the officers of National Tuberculosis Institute (NTI) Bangalore, in Bangalore. A strongly worded argument ensued during which the activists demanded that X-ray diagnosis is also a diagnosis which cannot always be supplemented by sputum, however truly it may be the gold standard. The reluctance of the NTI officers for more X-ray diagnosis was to us at least then unexplainable. Detection and Treatment of Tuberculosis: Unusual Issues of Animal TB Additional sources of transmission and infection of TB by the cattle, in nonhuman primates and Asian elephants as a major reservoir which can infect the caretaker and vice versa, have been claimed by some. Sixty percent of all human diseases and 75% of all emerging infectious diseases are zoonotic in nature (Mehta, Purvi Dr. 2018). The reason extended is the genetic identity of both M Tuberculosis and M bovine. Depending upon the host, these change their characteristic; hence, we are dealing with the same organism. As a fallout, every caretaker must be screened for tuberculosis and treated till the non-infective stage/or cure before allowing to cater to the cattle again. The infected cattle according to this view can be detected by the tuberculin test, and this major reservoir and link of transmission then can be exposed and treated. Asking the cattle owner to test the animals by tuberculin test to exclude an animal or detect the one which has tuberculosis is a far cry, and efforts to achieve this have resulted in failure. The mindset of the Indian cattle grower is not oriented towards precaution of this kind (Sane Sudheer, personal conversation, December 22, 2018, veterinarian, Pune). If the test is positive, the animal has to be given Isoniazid in adequate dose, thereby reducing new or flared-up tuberculosis among these animals. Treatment with Isoniazid will not be a burden to the cattle owner even if poor, since it is extremely cheap. It is argued that it will cut the transmission to the caretaker and to those consuming infected milk, substantially. The benefits of treating animals, including better uninfected milk yield and so on, do not need to be extolled. The on-ground reality is that treatment of an animal for TB costs INR 2000, which is also beyond the pale of interest of the cattle owner. He is not interested in saving money by excluding any animals he may have (Sane ibid). The contrary view also says that the tuberculin testing as is claimed is not completely



reliable to detect all infected animals. The symptoms may not appear till very late when it is pointless to treat. Therefore, boiling the milk before consuming it is the safest and best protection to save oneself from animal-­ transmitted tuberculosis (Sane, ibid). People who argue for the above methods on condition of anonymity have told me that the WHO and other Western agencies are not allowing or suggesting that India should go for animal testing in a large way. The reasons of why, if at all, are being withheld and are unknown. The Western world extensively used tuberculin tests and reduced the disease drastically by using prophylactic INH. These people also say that the Western world has stopped BCG inoculation long back and their entire clinical detection has been on the tuberculin testing and treating their animals with Isoniazid if found infected. Sane however does not agree with this. If it was done, it was done long ago and is of no relevance today (Sane, ibid). I do not wish to take any position in these contentions. I am raising these issues for adequate investigation if the high and mighty finds any substance in them and do justice. RNTCP, DOTS and Human Disease in India At the beginning of the RNTCP, the major step taken was to increase the number and spectrum of the stakeholders by adding more than 13,000 single private practitioners (Park, ibid). This segment and private organizations as well are expected to report cases if they come across any in their sphere of operations. This number however is too small considering the number of only private consultant-level professionals across the country to whom the government did not look particularly enthusiastic to reach out. The other change was to accept Directly Observed Treatment Short course, the famous ‘DOTS.’ It at once addressed two issues: once diagnosed, the patient will not default on treatment and will remain on it continuously; if he defaults, the chances are high that it will be detectable in a very short time and the same treatment can be reinstated without development of resistant strains. It will also answer the problem of case holding, since at least three of the four community health workers will be responsible for it (see Appendix  A). Normally speaking, there need not have been any dissatisfactions about DOTS. Yet there are. The reason for these disappointments is that it has not achieved what it was envisaged to,



to the fullest degree. For example, the number of people dying from tuberculosis in 1994 was 600,000. Today, it is quoted as 480,000 or 300,000 by different agencies. DOTS: A Bag of Mixed Issues and Disappointments 1. DOTS starts only ‘after’ somebody has been diagnosed and then put on treatment. The one reason why DOTS may not have achieved what it was supposed to is because the diagnostic machinery could not achieve higher percentage of diagnosis early enough especially among direct contacts. In the new scheme, we will have to think of how to overcome this. 2. The idea of directly supervised treatment by making a patient swallow the tablets in front of a health worker was no doubt an insightful idea. But it meant more visits of the CHW if it was to be a daily affair. 3. In addition, the place from where the medicines are taken out, to the place in which the patient can be approached and the time suitable for both, the patient and the community worker, for the DOTS to take place, are logistically difficult and will cost time. 4. To overcome this, the visits were limited to supervise only the intensive phase treatment. End of this phase is the time when a responding patient is most likely to default. This method also left 32 out of 72 doses to be self-administered, with all the concerns associated with it (Bhargava and Jain 2008). To ease the pressure on the health worker to visit daily, introducing a biweekly high-INH dose regimen was attempted. The four drugs for two months and Rifampicin and INH for four more months daily for any newly detected and previously untreated case was considered replaceable by this as a sound strategy. Thus, it was replaced by the thrice/twice a week regime. The extreme and disgusting ridiculousness of government functioning came across when the thrice-weekly regimen was changed back again to daily administration of anti-tubercular drugs. Responding to a PIL by Raman Kakkar, of Revised National Tuberculosis Control Programme, RNTCP, the Supreme Court ruled that it should be daily regime for all TB patients in the next nine months (IANS | January 23, 2017, 15:56 IST). Can things get worse than this?



The DOTS in Actuality 1. One consideration is that should the affected person is treated, however poor or illiterate or disadvantaged he may be, as an imbecile, a cheater, that someone has to stand over his head every day for two to three months to see that he swallows the medicines? 2. To put it otherwise, are we going to do something more and allow him to take charge of his illness or make him dependent like a child? 3. The drugs for the next week would be given only when the patient produced a finished pack of drugs. That was of course less than a guaranty that patient actually swallowed the drugs but it was assumed that he did. Whether the patient makes a visit for the drugs or the CHW goes and gives it to the patient, it is a time-intensive costly process. 4. The twice-weekly regimen has the unacceptably higher rates of relapses. This number rises further if there is initial bacterial resistance to INH (Bhargava, ibid). 5. INH resistance that arises in any chemotherapeutic procedure even with average compliance will be discussed separately below. 6. The matters become much worse in patients who have defaulted on treatment. RNTCP alone registers 200,000 such patients. This group forms 26% of all the drug-resistant sputum-positive cases (Bhargava, ibid). The reasons for that are biological and discussed below. 7. It is also known that sputum testing in a defaulter may not turn out to be positive even when the bacteria are still inside the lungs because such a patient also may not be able to produce a good sputum sample. 8. This will also happen because of the INH administered earlier, before default, which causes the mycobacterium to be still alive but has lost its property of acid fastness and escapes detection (Kale, Ashok, Personal Communication in connection with Tuberculosis, 2016). 9. Each completed DOTS treatment has an additional reward of Rs 150 to be given to the person who supervises DOTS, which will add to costs but I suppose is justified. 10. It can also be a frustrating process where number of people spread across the territory of the community worker who needs DOTS to be supervised are high. 11. Of all these factors however I think the weak link really remained with the diagnostic machinery.



12. The fragmented and remote-from-people character of Tuberculosis Control Programme has remained substantially unaltered. None of the changes could alter the vertical of TB. This is the challenge this monograph will address below. DOTS, the Programme and Some Difficulties 1. DOTS doses for intermittent therapies are fixed whether a patient is grossly underweight and/or malnourished. These two factors together can lead to drug toxicity and discontinuation for long periods of at least three weeks and truncated regimens. 2. The DOTS regimen later appropriated all the available tubercular drugs. It left the market for the private treatment providers with great difficulty in buying the drugs and following the treatment. The situation in the State of Tripura, where I worked from 2013 to 2015, for example, worsened steadily in this respect. 3. A barricade got erected if private practitioner diagnosed tuberculosis on the basis of an X-ray not always supported by detecting AFB in two sputum samples. Being sure of what he is dealing with, he prescribes smaller doses as the patient is underweight. After extensive search, the patients come back without getting the lower dose drugs. Perforce the patient goes to the medical college there, and the private practitioner has no way of knowing whether the diagnosis is accepted and the dose adjusted treatment started. 4. What will happen to the patient if the diagnosis is rejected at the government TB centre? What is the mechanism for follow-up of such patients? I am sure there must be some in the treating centres. The only reason to raise this issue is that the DOTS are a rigid automatic mechanism. At the physician level, medicine is a large grey area. Reaching or rejecting a diagnosis without doubt is a big exercise in medicine, requiring experience, judgement and concern in the grey areas. Giving a therapeutic trial is an important and accepted measure to reduce the uncertainties. 5. This virtually negates the role of private practitioners to treat TB in private while the government inducts them in the programme. Are they mere notifying personnel of diagnosed or strongly suspected cases of tuberculosis? Secondly, one more authority gets placed over them to reject their suspicion or diagnosis.



6. Granted that the two sets of physicians, private and those in TB programme of the government, are equally well trained in tuberculosis, the government doctors running the programme will make the same number of mistakes as the other and diagnose equally correctly as the other. This poses two more difficulties. 7. In case of diagnosis accepted, the availability of lower drug concentration suited for patients with lower than 50  kg weight is the most important issue. Patients with weight well below 50 kg in the malnourished populations having extensive pulmonary tuberculosis are common. For them the required Rifampicin doses are as low as just 300 or even 225 mg if we approximate them on the higher side so that they can procure the corresponding drugs with the same dose strength. Of the nine protocols of tuberculosis treatment, there is a couple where weight and appropriately reduced doses are considered. Yet, the low dose formulations are not easily available. 8. The reason given by the chemists for the non-availability of the lower concentration is that these concentrations ‘do not move’. This fixity of doses has resulted in the market going dry over the earlier available forms of Rifampicin as syrup of 100 mg/5 ml and 150 and 300 mg as capsules, and INH as a 300 and 100  mg single-ingredient tablet which makes individualizing treatment as per weight, nutritional status, side effects and discontinuation of only one drug, impossible. Similar is the case of Ethambutol, which used to be available in strengths from 400, 600, 800 and 1000 mg. It is to be taken once in a day for the first two months. The availability of the required strength has been an unsatisfactory matter for the last few years. 9. With the mechanical attitude for the fixed combinations, does anyone really care for these dose reductions? I do not think so because I have seen any number of cases who were prescribed these doses by even the private and well-trained pulmonologists doing this, leading to intolerance for the treatment regime. The chemist’s answer given above is a strong testimony to the knee-jerk practice that those who treat TB do not consider the weight and give unthinkingly the 450 + 300  mg combination of Rifampicin and INH. 10. The emphasis is that the Rifampicin 450 mg and INH 300 mg combination will be used for all. In biweekly regimens doses go as high as 600 and 900 mg. They are an invitation to intolerance, inability to eat, maintain nutrition in an already-serious catabolic state. The clini-



cal and the DOTS practice today seems to ignore the mg per kg body weight dictum. 11. These fixed and automatically practised regimens in DOTS create enormous problems even if the drug quality is good. Here I assume the quality of the drugs provided in DOTs is good, although government procurement always leaves one with a doubt about it. 12. These issues are intimately connected with the biology and the pathophysiology of tubercular infection.

The Biological Issues about Tuberculosis There are two issues of DOTS to be considered here: one is the intermittent therapy and the other is to take all tablets in a combination at a single time in the day in the first two months and how sound are these two therapeutic options in terms of the biology of the tubercular organism. It is known since last eight decades that in any case of pulmonary tuberculosis there are multiple populations of the tubercular bacillus existing in the lesion. These populations have a bursts of cell division leading to increased number of bacilli once every 24  hours at different times of the day and night. In 1986, it was found that time for M tuberculosis to replicate is around 24 +/− 2  hours. The doubling times of Erdman, H37Rv, BCG, and H37Ra were 17.7, 17.4, 44.6 and 98.6 hours, respectively. The doubling time of Escherichia coli was calculated as 82  minutes (Hiriyanna and Ramakrishnan 1986). Virulent strains of mycobacterium tuberculosis have faster in  vivo doubling times and are better equipped to resist growth-­ inhibiting functions of macrophages in the presence and absence of specific immunity (North and Izzo 1993). These findings mean that different populations of mycobacterium will reach their peak doubling time once a day but at different times of the day. This was the reason why the tuberculosis treatment was to be given daily and different drugs would be prescribed at different times of the day in order to catch the different populations’ peak doubling activity as near it and as many more times as possible when it is most effective in killing or bacteriostasis. When all the drugs are given at the same time, their peak levels will be reached shortly and then will be on continuous decline in minimum bactericidal concentration/half-life for the rest of the day. It will miss many of the peak levels of bacillary duplication cycles in rest of the



day as the effect during the many peak duplication activity at different times decline by a factor of 2/7, 3/7. On the drug-free days, many populations will have many doubling cycles with no kill. Pyrizinamide given twice a day will kill the bacilli even if these are inside the macrophages. No other drug has been ascribed this property. The intermittent therapies lose this advantage also. DOTS, the RNTCP and WHO accepted that the compliance was more important and minimization of the number of tablet days desirable, hence this compromise was reached. Since 2008, the pendulum has slowly swung back to daily regimen. I was not a fool, insisting on daily regimen of different tablets at different times for the last 25 years. Such high-dose intermittent therapy coupled with malnutrition and poor intake as is common will lead to discontinuation of the drugs upwards of three weeks due to severe side effects. Rifampicin, the most important single drug in the treatment of tuberculosis, is the most involved. After this episode, it will get eliminated, increasing the possibility of no cure and development of MDR. When drugs are used in appropriate doses, these are better tolerated. Even after weeks have passed and hepatitis has returned to normal, it is doubtful how many doctors will dare to restart Rifampicin. If we do not want to violate the mg per kg dose requirement in underweight patients, we have to use 450  mg of concentration on alternate days, which is a shabby way of treating. It will also lead to the sacrifice of the daily dose of INH 300 mg since that is also not available singly. The insistence on the appropriate concentration of drugs as per the weight is not a fanciful idea. It is sound therapeutics. The experts may not even condescend to discuss these matters in an open manner. One thing is clear that if WHO has to say something, it is to be followed. It continues even today. Contradicting it or differing and expressing one’s opinion is politically incorrect. Non-availability of the single drug in different strengths is a huge problem today. No one knows if this is also a cause of multidrug resistant (MDR) tuberculosis. Possible Causes behind the Rise of (MDR) Tuberculosis When Rifampicin is started, the patients are told that dark-red discolouration of stools and urine is expected. I often directly ask patients whether it is happening. The answer as observed in my days in Tripura in 2013–15 is



a clear-cut no. It means there is a lot of fake drug circulating in the tuberculosis drug market and/or in DOTS. The other possibility was raised in bioequivalence studies on fixed-dose combination of anti-tubercular drug formulations. The venerated combination of Rifampicin and INH seems to have run into an interaction with Schiff’s base in a complex of Rifampicin and INH, which is poorly absorbed leading to low concentrations of Rifampicin in blood (Pillai et al. 1999; du Toit et al. 2006). This is an extremely dangerous situation and could become a direct cause of MDR tuberculosis. The point of the Toit review is the necessity of a formulation technology which eliminates this possibility in fixed-dose combinations. The Troit verification of non-absorption of Rifampicin does not seem to have alerted anyone to test it in the 12 years gone by. There is another paper published by the Pfizer Labs certifying that the Pfizer combination does not affect the absorption of Rifampicin as measured by colorimetry in plasma. Aside of these two I could not find any paper disproving or proving the above possibility and its prevalence. Its consequences on the development of MDR are obvious. The rapidly rising numbers of people with diabetes by and large remains not satisfactorily controlled (DiabCare Asia 1996). It is an immunocompromised state which allows rapid growth of tubercular bacilli and worsens diabetes. It is not often that both these diseases will be properly managed. The significant number of people having HIV AIDS, another grossly immunocompromised state, also leads to flare up and gives rise to resistant strains for the same reasons mentioned above. As the number of drug-resistant TB is climbing steadily, central government has initiated a process for the medical colleges to incorporate the obligatory requirement of establishing MDR-TB centre as per RNTPC, at each medical college for its recognition. There are only 147 MDR TB treatment centres in the country at present. As per the new regulations, clinical establishments, including the private sector, all pharmacies, chemists and druggists dispensing anti-TB medications must provide details of the patient, prescription and medical practitioner concerned, to the nodal officer of the district failing which action will be taken against them. We hope it leads to better management of MDR TB (ET Health Our Bureau, June 2, 2018).



 he Toit Review and Drug Delivery in TB T It comments on the emerging technology of microencapsulation of active drugs in biodegradable polymers. It is attractive and has significant merit since it addresses issues of unacceptably low Rifampicin bioavailability in fixed-dose combinations. Liposomes, micro particles and microspheres have improved the sustained delivery and better efficacy of anti-TB drugs in animal models. It also reduces the dosing frequency. Anti-TB drugs are successfully entrapped and delivered in biodegradable polymers such as poly DL-lactide-co-glycolide (PLG). This is biocompatible and release drug in a controlled manner to achieve proper therapeutic levels. Such depots can show release profiles extending over several months, culminating in degradation of the entire polymeric device. Prabakaran developed an osmotically regulated capsular multi-drug oral delivery system. It comprises of asymmetric membrane coating- and dense semipermeable membrane coating-capsular systems for the simultaneous controlled administration of Rifampicin and Isoniazid INH. Development of biodegradable polymeric micro- or nanoparticulate carrier targeting alveolar macrophages that harbour M. tuberculosis is under process. Inhalation of aerosolized drug delivery does not go through the first-pass metabolism. It also maintains local, therapeutically effective concentrations. Systemic side effects decrease. Drugs are adsorbed on nano particles which then disintegrate separately and absorbed if they were administered singly, delivering the drug directly to the site of infection. Depot forming subcutaneous injections also can carry the drugs. Its use is limited due to epidemic proportion of tuberculosis. These technologies also come at enormous costs, not affordable, for such large numbers of tubercular patients (Toit, ibid). Discrepancies in Treatment Data and Development of Resistance in TB It is argued that non-compliance or non-adherence to the treatment up to 60% (in time or drug intake) does not result in drug resistance. It is attributed to the between Patient Pharmacokinetic Variability (Shrivastav 2011). The South African Studies contrarily demonstrated that even with 98% compliance with therapy the drug resistance developed. Therefore, it was conceded that there must be some other unknown mechanism operative. The confounding factor of patient variability and good compliance seems to be INH inactivation rates.



I NH or Isoniazid Resistance through Different Inactivation Rates This was discovered in a series of African/Brazilian papers published in 1967, 1981, 1991, 1999 and 2004 on cattle treatment of tuberculosis with Isoniazid (Kale A, ibid). The INH resistance was related to the rate of inactivation of INH in patient’s body. Fast acetylators of Isoniazid have a significantly higher risk of treatment failure and acquired drug resistance despite supervised drug administration. Fast acetylation of INH either does not reach or does not maintain its bactericidal levels for sufficiently long time (Gambo 2012). Patients with serum levels of 0.58 μg/ml or more were considered slow inactivators and those with levels below 0.58 μg/ml as rapid inactivators. Of the patients studied, 195 of 321 were found to be slow inactivators and 126 rapid inactivators. The half-life criteria for the time the desired levels of INH persisted in patients were also studied. Seven of the 24 patients inactivated INH rapidly with a half-life average of 64 minutes; the remaining 17 metabolized INH at a slower rate with a half-life average of 186  minutes. A provisional half-life limit of 110  minutes was used to define fast inactivators; 110–160  minutes, as moderate inactivators and over 160 minutes, as slow inactivators. It will be a worthwhile simple project for the ICMR to study which can be easily designed. If the correspondence between fast inactivators and resistance tuberculosis in them and vice versa is proven, then a simple therapeutic tool at the beginning of treatment can be established to anticipate MDR TB. It would be more appropriate to assess each patient individually, on the basis of: (a) drug sensitivity of the causative organism; (b) the initial blood concentration of the INH; (c) the rate of INH inactivation; (d) the duration of half-life therefrom; and (e) the response of the patient to the treatment, and in order to determine the optimal dose regimen. Now the recommendation to undertake CBNAAT (cartridge-based fully automated nucleic acid amplification test) before starting the treatment of tuberculosis to assess drug resistance has been incorporated, and this facility has been made available in all the district hospitals. The CBNAAT/Xpert MTB/Rif is a test for TB case detection and Rifampicin resistance testing. It purifies concentrates, amplifies (by rapid, real-time Polymerase Chain Reaction, PCR) and identifies targeted nucleic acid, its sequences in the TB genome (rpo b), and provides results from unprocessed sputum (Phadanvis 21/03/2018). It is time that the simple test of detecting fast and slow inactivators of INH should also be introduced as



mandatory if credible research mentioned above so indicates, since there may lie the key to all drug resistances. (Kale Ashok, 2016). Test to detect the INH inactivation rate consists of administering a standard dose of 5 mg/kg body weight and the blood is collected after six hours for INH estimation. Primarily, it has to be done for newly diagnosed patients to be started treatment patients. We also do not have data of any MDR patients tested for INH levels. That is why we do not know if INH levels are found to be low and how much high dose will help overcome this reaction for a sustained INH level. The therapeutic recommendation available is to increase the daily INH dose to 10–15 mg/kg to overcome rapid INH inactivation. A standard dose of 12 mg per kg of the patient per day can be considered for standard guideline (Kale, ibid). Given the vastness of the country and huge difficulties in organizing logistics for such large numbers is difficult. Post adequate research mentioned above, it could still be made operative in MDR area at least, covering the country over a period. This information does not seem to be incorporated in NTCP. The RNTCP and DOTS after reverting to daily doses needed an injection for enthusiasm. It had gone into a mode where eradication of tuberculosis academically was an incorrect phrase; control is all that was possible. Now it has been challenged when the prime minister of India launched the TB-free India Campaign to take the activities under the National Strategic Plan for TB Elimination forward in a mission mode for ending the epidemic by 2025, five years ahead of a globally set deadline. The summit in September 2018 in New Delhi set the stage for the United Nations HighLevel Meeting on TB. TB would be discussed first time in the UN General Assembly at the heads of state level. A number of steps like allowance for nutritious food and award on detection have been added to the earlier offers. Given the record of the government on Swachha Bharat hope will has gotten aroused.  edaquilline: The Breakthrough Anti-TB Drug B In last 40 years, this is the first anti-TB drug developed. It is now being advocated for use in MDR and extensively drug-resistant, XDR type of tuberculosis, exclusively and is highly restricted under a conditional access programme which necessitates that each patient is evaluated to justify the use. It is difficult to get unless an expert in tubercular diseases prescribes it, Dr Zarir Udwadia said.



The Indian government has controlled its easy access citing a fear of catastrophic spread of resistance in the community, if used without enough expertise. Unless this is done, the value of the drug will be lost in no time and we will face greater serious dangers. We agree with the principle. It is suggested that the modalities involving a specialist and documentation could be made easier. There is naturally a cry from people who see this as atrocious (Shelar Jyoti, December 06, 2018). The severe shortage of Bedaquilline is being attributed to India’s dependency on charitable programme for MDR TB drugs. Shortage is due to a pact of the health ministry with US drug maker Johnson & Johnson. It has agreed to supply 600 doses of these drugs as part of a ‘compassionate access program’ which is miniscule supply for nearly 100,000 multidrug-resistant TB patients in the country. This charitable endeavour was extended once again in 2017 when the health ministry said it would extend the access programme across 156 sites. Research shows that only one out five multidrug-resistant TB patients, who needed the new drug, got access to those (with difficulties). India should purchase and not look at charities to help. Adding to the woes is a lack of infrastructure in government institutions across India that is pushing patients to seek treatment in metros like Mumbai and Delhi (Venkatesan Nandita & Rajagopal Divya, November 17, 2017). Extra Pulmonary Tuberculosis: An Absent Feature RNTCP and all other national programmes once located in the CHC have common advantages. RNTCP has no component of extra-pulmonary tuberculosis even when it is a far commoner malady than one may think. It has never been addressed adequately in the health planning. Clinical suspicion of it is usually low. Suspicion of the same needs laboratory evidence to convince and treat people over a long time. Number of different pathological tests, simple in nature with high diagnostic yield, is available. These tests cost considerably in private set-up. Made available in the CHC by mass action under well-trained personnel, it adds huge value and quality to the services while reducing the costs and without any need to create extra infrastructure. X-rays with suspicious shadows in undiagnosed patients will add to the workload of sputum microscopy and develop later having tubercular culture and antibiotic sensitivity facilities. The laboratory in CHC will be its greatest asset as it can be developed as much as needed. Having blood transfusion and storage facilities enables



upgradation. Same is the case for people suffering from undiagnosed illnesses in other areas. The clinical diagnostic capability being available in full complement of five specialities, it is a boon to the health system. Some Thoughts on Eradication of Tuberculosis by 2025 the Indian Initiative The ministry and its high officials would be engaged in designing the campaign. Here are a few suggestions for them to think about. Public health care delivery undoubtedly covers the largest part of rural India. As shown before, the validity of data qualitatively and statistically has limitations mainly due to seriously skewed work–time–worker–distance ratios. Well-serving CHCs will also cover India the same way. But good functional distribution among the categories will improve data collection, which the PHC and SC were not able to do. The one-step reporting of 48 to 196 workers and development of Group Headquarters of Health Directorate covering four to five districts will be in a position to integrate data from below and up at the state levels. Human errors increase when data is treated at too many levels. There are other agencies also which independently collect data. Some kind of co-working will have to be designed so that disparate data from same subsets of population does not gather. The data then should be consolidated at the state and national level seamlessly. In TB in particular, once diagnosis is made, the journey to cure is fraught with difficulties of tracking a case to see whether the person continues to have treatment. Patients often change the treating agencies and the track is lost. Also lost are the details of the treatment—whether it has been changed, whether it is on the proper lines or not, the time continuity from one doctor to another, monitoring for progress and its details, and whether within the state or out of it. If they stop treatment and default, tracing is uncertain. With DOTS this has lessened at the rural small pocket population, but in larger cities tracking is not easy. Such a national data base must be made widely known to all practising doctors in and out of government. If he diagnoses a new case, the few relevant details of these cases should be entered in the database for which there should be access. In today’s vast computing power, pop-ups for repeat names across the data base are easy. That alerts the system and records could then be merged. If matters have to be moved in mission mode, enthusiasm should be generated among doctors from the lowest to



the highest level to help data creation by sending details, even handwritten with required information to the CHC or the district hospital or the medical college, which is the only solutions for tracking and cure. RNTCP has envisaged this indicating the parameters under which the information should be stored (Park 2015). An on treatment or defaulter patient goes to a different care giver or an agency earlier details of his treatment should be accessible to the new clinician from such a national/statewise database for better management. There are a great many more details attached to these processes which I need not go into. This will ensure case holding and continuity of treatment. The hope is that people concerned about national programmes agree to this far-more effective mechanism in the new public health care delivery arrangement. I hope people agree that the most major national programme is in doldrums and this mechanism to deal with it is convincing enough to put in practice. With appropriate variations of terms, all the national programmes for communicable diseases can be reorganized on these lines as effectively.

National Blindness Programme As suggested in the earlier chapter, each CHC need not do everything. In other words, in the public health microcosm of five or six CHCs in proximity with each other, each one should have some speciality of its own which the others need not possess. Some may develop blindness control as theirs. The CHC community health officers with around 500 ground force between them can easily segment and transfer the information of the blind people to that particular specialized CHC. A plan from among the full time as well as visiting faculty of ophthalmic surgeons about channelizing these people can be drawn easily. This will form a continuous stream of people coming in to be tested, operated within a day or two, and sent back in a total span of five to seven days with cure. Others found unfit for various reasons, would be examined, investigated, treated and made fit by the other clinicians, especially the medicine people and then operated. The CHC with regular surgeries going on, where people trained as operation theatre workforce has been deployed, where the ophthalmic surgeons can guide the preparation of operation theatres and post-­ operative stay for a couple of days more in the wards, will ensure that no complications ever arise. Precaution as better part of valour cannot have a better illustration in these blindness eradicating activities. In PHCs or when organized by voluntary agencies, these absolutely mandatory measures cannot necessarily be either built or obtained.



Today no surgeon can or should operate more than 25 cases a day. There should be a gap to prepare for the next operative session. The age has gone when we set the targets in absolute numbers. Today, even the poorest must have quality service. There has to be zero tolerance for complications. And eye is the most sensitive of any area. Even if we do not operate on eye, it is acceptable. But one cannot for any reason cause harm, the first Hippocratic Oath. And there are available extraordinary models of work by Aravind Eye Hospital, and considerable experience of the Mobile Eye Camps from an earlier era (Kelkar and Kulkarni 1987). Recently, a private health care agency in rural West Bengal ran a blindness control programme highly successfully, operating over 1400 cases in 18 months without any complications due to surgery. RSBY finally had no money to give them and the operations stopped (Azim Richa, personal conversation with the author, Finance Director, Glocal HealthCare Pvt. Limited, 2015). This will be the fatal flaw if such programmes are not built into the public health care system when the government will run out of money to pay the private players in NHPS as well. By doing continuous, standardized, low-stress model of evolved working across just 400 to 600 CHCs all over the country, one can achieve as spectacular a success as any. Debulking Disease Load in a Community Following account is based on our experience and of various agencies for years. In the absence of effective working mechanism/strategy or to deal with, many health issues accumulate in rural communities. The blindness programme described above is one successful programme. By creating a diagnostically oriented mass campaign followed by treatment not easily within the reach of the populations in the entire or even half of a district, these movements lead to the debulking of the problem. These are carried year after year in a concentrated period of time when the home logistics for people is favourable and agricultural field work is at the minimum. These programmes give a huge succour to a large number of poor or disadvantaged segments with accumulated disease burden, often over years. We were adept at creating mass campaigns way back in 1989 in Kodagu, a half tribal district with poor people distributed within 100,000 acres of coffee estates as labourers when rural communication was not easy as it is today. From 1981 to 1989, we were in the problem-solving mode for diseases afflicting these people. What finally emerged was the CHC model I have been talking about. Suffice it to say that we could be the longest



experimenting agency to develop a mature CHC, extending it beyond all the conception available since then. Mass campaigns we designed are completely different from the thoroughly useless health camps held even today, cosmetic in nature and aimed at glorifying organizations holding them. Mass campaigns like ours go from diagnosis, to investigation, to every modality of treatment with spectacular results. Mass campaigns can be successful only when a Central Strong Core of the CHC as described above is available. If the staff of the CHC can be fired with the idea of doing more for the people, it succeeds. It also requires a full-time, 24 × 7 in-campus culture emphasized earlier. These campaigns create tremendous work but are borne easily by the staff with fantastic results. It requires good management skills to organize them for zero error. The specialists capable of handling the focused campaign which falls within their competence can do wonders. The strong CHC core can bear the weight if other specialities are invited to do it. In more illustrative terms, these areas can be slotted in the CHC’s core wheel for short periods and then removed. Aside of the routine work, one or two such campaigns a year are ideal from all perspectives. These stresses improve the skills of the workers and speed of working with accuracy.  he Idea of a Programme, a Process and a Tradition T Every such activity is a programme when it is first done. It becomes a process if it is done twice in the same manner in a short period. The second time it may face unexpected difficulties. But if one sticks to it and carries it out a third time, then it becomes a tradition and settles in the minds of people.2 By then all improvements needed become apparent and a turnkey model emerges. Such activities often die after the programme stage most of the time.

Mass Campaigns and Gynecological Disorders: A Success Story and a Model Everybody talks of gender issues, gender discrimination against women and non-preferential status of women in getting health care and so on. Everybody talks of women empowerment. Unfortunately there are few models that actually achieve this empowerment in health sector also. And 2  I developed the idea of the programme, a process leading to tradition while working for curable blindness year after year in the rural areas This is going on for the last 28 years, even after I left it to local people for the later 24 years.



we know precious little about which health issues among women should be addressed and how. Pregnancy has received all the attention. It can meet its fruition with CHC models around. The system has looked after the peripartum mortality of mother and child but some major issues still are outside the thinking, both government and the activists. There is little information on health issues that sap the strength of women years on end in any community, rural or urban. The mass campaigns we created for women in Kodagu revealed to us such debilitating conditions and their prevalence: cases of chronic pelvic inflammatory conditions, anemia, issues regarding menstruation, dysparunia (that is, painful intercourse), urinary burning, non-gynaecological reasons for abdominal pains, high degree of genitourinary tuberculosis, vagina invaded by objects of which there is no guaranty of cleanliness, conditions requiring surgery, and diabetes and hypertension as a sub-class, which were found to be widely prevalent and never addressed on a large scale any time before. Menopause is a malady iatrogenically created today on a large scale by hysterectomies done at young age for no reasons at all which destroy their psyche. Natural menopause is becoming less frequent.

Analysis of the Strengths of the Proposed Model of CHC Bed Strength of 50 This is the ideal bed strength for a project like CHC. If it grows beyond it, it will be unwieldy to manage and maintain its quality and many other activities.  This bed strength is also suitable for small ANM and nursing schools.  These are field experiences of more than 50 years. An already existing CHC with 30 bed capacity can be extended to 50 beds without much expense if there are no space constraints. How big any such project could grow is discussed in the next chapter. Not a Top-Heavy Model Not at all! It is an extremely decentralized and horizontal power-packed unit with a match between personnel, functions and population. The six medical professionals is the only commodity the money cannot buy.



Far-­simpler mechanisms to acquire this heavy-weight manpower will build this top layer easily are described earlier. Additionally, there is a snowballing effect as the quality delivery and the feasibility of such centres increases without making it top heavy but such centres multiply rapidly. Superspecialities in CHC Mature units like CHCs can get the superspecialities to come to them and serve the remoter communities, at appropriate frequencies. The super specialities are willing to come to the periphery but do not have adequate infrastructure to deploy their skills and benefit people there and then. I must however add that the greater need of the country is still the basic broad speciality operators, in a decentralized distribution than are the sub-­ specialities. The need for super specialists in such a system reduces considerably. It makes their contributions more focused and economical. The orientation of basic specialists is peculiar, special and classic and the distant superspecialists will bless them for their work when they go there.  ontribution of Superspecialists to CHC Population C This is a legitimate question. It arises from the fact that high-end facilities like Catheter Labs, MRI, high-end vascular Doppler, C arm, CT scan and such others are beyond the scope of CHC construction. The main contribution thus will be judicious selection of those who need the high-end facilities and coordinate the logistics for a hassle-free completion of investigation and treatment at higher centres. The superspeciality contribution to treat becomes more meaningful if a well-functioning HDU is there in CHC. Cardiac surgeries which do not require cardiopulmonary bypass have been routinely performed in few district places in Maharashtra.

The Most Valuable Effect of Such a Huge Exercise Simply said, the Pressures Are Off! Each health problem becomes gigantic on account of sheer numbers, majority arising from a large conglomeration of hinterland population. Instead of viewing the system bottom-up, a top-down view will show us the medical colleges, tertiary, large private corporate sectors and district hospitals full of sick people, sick children, and the government system creaking under it. The quality of services is perpetually low. The infrastructure turns out to be poor or grossly



inadequate with a high level of dissatisfaction and chaos due to this pressure from sick people from below. As seen in a previous chapter, the poor children dying in droves and dozens in West Bengal, was the result of the absence of any public health care structure across 200 kilometres capable of taking care of these people. CHC with an HDU within available distance will be the halfway stop to improve many, take dignified care of those who would anyway die and refer fewer which can survive the distance after stabilization. The half-way stop cuts these upward pressures on district hospital from all round. Simple arithmetic will tell that the numbers from district hospitals refereed to still higher centre will also go down, leaving some scope to improve the work quality and resource availability. Among many other benefits, reduction in upward pressure is the most valuable contribution of CHC.

Blood Storage, Transfusion Facilities and CHC The first referral unit of the CHC as per policy guidelines should have blood storage and transfusion facilities. A CHC with two operating branches, emergency and elective surgeries enhance need for blood considerably. What are the ground realities of its availability in CHCs or around? Are there more issues that need consideration? Can the blood banking rules and policies be changed to make blood units available with greater ease at the CHC without harming the patient in any way? If the ground situation is not able to provide it, it will be serious limitation nullifying the entire CHC concept. In district hospitals and medical colleges, it is not so difficult. The donor base is higher and more willing to donate than in the hinterland. The concentrated population can support it at district level. Populations are more scattered in CHC area. Available blood has to be stored for use. Following is a short review of blood banking and what happens on ground in sub Tehsil level to meet the challenges. Blood transfusion and banks are tightly governed with stricter protocols, which continue to proliferate. Quality diagnostic screening for blood transfusion requires much more sophistication. The practice today is to separate plasma from the donated blood. The capabilities of modern medicine allows far too critical care cases to be accepted for surgical and medical interventions which require a large number of fresh frozen plasma and platelet-rich plasma. Acute conditions need  transfusions on  emergency basis. Many people routinely require transfusions over years when minor



antigens start interfering with compatibility. Greater technological competence is required to handle that. With many regulations, guidelines and protocols for the safety of patients, the CHC will have to get blood from a certified blood bank only. The storage capacity can be created more easily but the deep-freezing facilities will need near-continuous electricity supply. To overcome the electrical failures which may happen at crucial times, in situ generators is a capacity ignored by the IPHS. At a time when rural electrification is nearly complete and solar and wind-powered units are getting established the frequency may reduce. The capacity generation with non-conventional energy sources achieved in last few years since 2014 is much higher than was believed. Storage of blood units in CHC is not simple. Wastages are a part of any storage facility. 1. Anticipatory storage of groups prevalent in population and the immediate need do not often correspond, and search is set afoot for the non-available blood group. 2. Storing few units of blood for all eight major groups within CHC very likely leads to wastage. Not storing them will lead to non-­ availability or too late an  availability during dire emergencies like post-partum hemorrhage. 3. Voluntary donations are more difficult, may not be immediately available and need lot of persuasion. The need may not always be fulfilled. 4. When the requirement matches the stored group, it has to be tested for compatibility. The same holds for blood procured from outside. The technique is simple but the responsibility to certify compatibility is heavy. 5. In the present construction of the CHC, the doctors will have to take the responsibility. 6. If the CHCs cannot store blood for any reason, the supply then should come from the certified blood banks. Blood donated in CHC but stored elsewhere may also get wasted. 7. At times the doctors do not use all units and may return some. The time span of moving blood to and from CHC under proper storage and the number of times it can be done is limited even if it is carried through the cold chain. These questions will remain even when a quality CHC has been built.



8. The CHC will find it extremely difficult to fulfil the stringent requirements of blood storage and transfusion, even if it stores blood and the components on a small or a limited scale. 9. This will raise questions as to whether the blood storage facilities should be a precondition of the first referral unit the CHC is as formulated under the policies and rules. Insisting on this condition is more likely to leave a CHC defunct as it does not or may not be able to fulfil it and then will not be considered a first referral unit. The cases requiring blood transfusions will have to be per force transferred over long distances—precisely the malady we are trying to solve. 10. If the non-emergency requirements are removed, large majority of cases can still be arranged, blood units can be brought in coordination with CHC at the time of surgery without having to store it except in cold chain it is brought in. 11. That still leaves the emergency blood procurement. These are the cases intimately related to a few of the mortality indices, a purpose which gets defeated. Government medical colleges with blood banks as well as certified private blood banks are not as remote as may be thought. Private blood banking is a highly profitable business capable of black marketing in blood. In the deep interiors of West Bengal, it took about three hours to get blood units to the hospital we worked. Prior information about the blood group details and number of units on mobile networks was the key. Samples for compatibility testing were taken on bikes and the screened blood kept ready except for the last testing for compatibility. With due risks, the same procedures are followed even if cases are taken up for surgery, where they cannot wait for blood to arrive. The degree of uncertainty of availability, non-availability due to closure of blood banks in odd hour was certainly an issue sometimes but not a rule. Can anything be done at the CHC level to make it easier to get blood in routine and emergency cases? What can be reasonably allowed to change under the laws and policies? 1. At the CHC level, the donor’s blood for HIV or Hepatitis B can be tested by the rapid Elisa Test Kits, which are certified by the WHO as reliable as the more elaborate ones (Tongaonkar and Kale n.d.). 2. These activities can be checked by and are answerable to any of the regulating agencies of the state to which such CHCs are subject.



3. On a more cautious note, can, in addition to the screening mentioned above, a CHC or a hospital entity situated far deeper from a recognized blood bank be given the permission to draw and transfuse the blood whole after testing? This will help the doctors working in remote areas and their patients. This range today should be around 50 kilometres or more and has transport difficulties. 4. The point assumes significance since packed red blood cells with plasma removed is the norm, almost a dogma today. Are there any qualitative differences between the packed and whole blood transfusion? 5. Whole fresh blood has intact functioning platelets and other coagulation factors active, and has albumin and globulin in full measure if transfused immediately. Stored packed RBCs do not have this advantage if so considered. 6. Modern blood banks and blood bank officers are wary of the WBC component as the main cause of acute transfusion reactions and prefer to give stored blood as packed RBCs, the WBCs washed off and separately supply the components like fresh frozen plasma. 7. If this concession is given to CHCs in general, it may limit the fast and for-profit proliferation of blood banks in the urban as well as the rural areas. In this connection, Dr Ashok Kale and I have had many discussions. On that basis, as the author of this volume, I want to make few observations and some measures that can be undertaken even today. It is not a demand or criticism and is extended for the consideration of the authorities. It relates to the unfractionated stored and fresh blood. 1. We have transfused literally hundreds of fresh blood units in a rural tribal area from 1981 to 1992, after cross-matching them ourselves. Sometimes it was done in extreme super-acute setting like massive PPH. More commonly, it was given on elective basis, preoperatively, intra and postoperatively as well. 2. We have had a few acute transfusion reactions but no deaths. In those remote days, the quality of the transfusion sets could be a cause for pyretic reactions. As better sets became available in the later years, the reactions came down to a rare occurrence. 3. Almost all the transfusions we gave were first ever blood transfusions to many of the patients. Thus, we did not face any issues of patients requiring chronically repeatedly a number of blood units. This is an area of expertise which we agree.



4. These transfusions from 1981 to 1992 were not tested for Hepatitis B virus. It was not in practice then. These patients never came back to us with jaundice or any other problems in the 27 doctor years of five of us that we spent in the rural tribal area. These patients would have come back to us since we were the ones who had saved them. 5. Hence, it appears reasonable to ask whether the fears of transmission of viral diseases are exaggerated and we are losing the advantages of the fresh blood as well as depriving the remote population services for want of blood. 6. We also argue that such an arrangement will avoid considerable expenses for the already-resource-crunched population. 7. After 21 years, from 2011 to 2015 I worked again in truly rural areas inhabited by tribals, as well as in the North Eastern states. The government medical college blood banks were exploitative. These charged patients 20 times more than what was due, coming at par with private hospital in the same locale. Extra money was taken under the table. Can this be controlled in any way? 

Blood as a Carrier of HIV AIDS, Hepatitis B and C Viruses HIV-AIDS had significant fear potential when it came up as a new disaster in treatment avenues. There was the initial fear that it will spread like an epidemic to decimate the population. It did not happen. Infected blood transfusions as the rarer but more dangerous route and as an iatrogenic catastrophe, justifiably led to the stringent screening the donor samples of blood. All these fears have turned out to be overestimated, and the treatments today are far more effective. Hepatitis B and C Viruses in infected blood units are also dangerous, and the treatments far too costly with some uncertainty attached to its cure in spite of that. The carrier status of Hepatitis B or Hepatitis C virus (HCV) in a population of blood donors is just about 1.25 percent (Kale, ibid). In about 25 months in a North Eastern state witnessing and transfusing hundreds of units, we also found that such carrier status is very low in frequency. In patients who got tested for human immunodeficiency virus (HIV), Hepatitis B Surface Antigen HBsAg, or HCV preoperatively, the carriers were even lower in numbers. In this situation, can CHCs with competent laboratories be facilitated with test kits for these three powerful infective agents and allow local fresh blood transfusions?



The whole idea of fresh blood transfusion has been systematically washed away or fashionably pooh poohed in sophisticated centres. Multiple but routine transfusions in situations like thalassemia can give rise to difficulty in testing as minor blood group compatibility becomes essential. In remote or rural areas, such occurrences would be rarer, and in case of doubt the more sophisticated laboratories could always be approached for safer blood units because it is not an emergency. What about the rest for acute blood needs once in a lifetime? Infected blood transfused to an immunocompromised recipient is even rarer. Acute hemorrhage is not a sign of immunocompromised state. Suppose if the blood of a Hepatitis B or HCV carrier is transfused by mistake to an immuno-competent host, what are the chances that the body will eliminate the viruses? Can the Hepatitis e virus–infected blood also be cleared by the immune system? HIV-infected blood is another story which should not be mixed with this. A slight chance is there that the HIV-negative blood of a mischievous person can turn into HIV-positive blood without any dangerous behaviour after the donation, due to the long latency of manifestation. Is there any data available to answer the issues raised above? In conclusion, we would plead that these issues may be considered at the highest professional level and signal to proceed with the above suggestions be given if found safe.

Sufficiency and Efficiency of Ten CHCs in a District Lastly, a few issues about the sufficiency of 10 to 15 CHCs, which could not be highlighted in the previous chapters, are mentioned to fortify the idea that CHCs are a viable alternative with great potential. An average district comprises area of 4000 square kilometres. The coverage of CHC would be 225 square kilometres (Rural Health Statistics 2015). If the area of drainage to the medical colleges and district hospitals is taken into consideration, the area truly in need of CHC will be smaller and more remote, making ten numbers sufficient. Driven peripherally, the CHCs can then be situated not more than 20 to 25 kilometres from each other with all the benefits described earlier. It also satisfies the Law of Inverse Care. The truly remote areas in border talukas will find a CHC just across and people may have preferences for such CHCs. Such measures utilized by people will provide more than adequate work for all CHCs.



The human and investigational diagnostic capabilities assembled in CHC result in far fewer visits. Investigative results which take longer than few days are easily transmissible to community health workers today by electronic media with addition or change in the therapeutics and follow­up instruction to be given to the patients or to patients directly. This process will be further exploited in the management of all chronic disease. ‘All under one roof’, a common unique selling proposition in private care becomes an actuality in CHC. To get treated ‘as a whole’ in the CHC is the game changer. We emphasize that locating CHCs is a serious pan-­ state exercise that should be done carefully. Future of CHC: How Will It Develop Further?  evel of Medical Care Quality L Diagnosis remains the most important unanswered issue peripherally. The eternal question is: ‘what is wrong with me and how does it affect me?’ Absence of a diagnosis and inability to give proper explanation to the next question about future afflictions intensifies morbidity in absolute numbers in larger population congregation. Starting a diagnostically oriented centre like CHCs as close is the only answer. CHC should create a standard against whose capabilities the less-endowed practitioners of the trade have to learn from and practise better. This is greatly facilitated by proper discharge summaries and a return letter explaining the matter to the even remoter practitioner. As time goes by, the postgraduate-level practices, diagnostic manoeuvres and treatment modalities practised at such centres are received, internalized and practised by the peripheral physicians. The profile of medical care in a specified area changes rapidly over few years. CHC will also be an effective check on malpractices at many deeper and higher levels. It assumes the role of ‘support system and fall back’ for the community, most needed. These are the realities of rural dynamics not wishful thinking, discussed in detail in this and my other volume, India’s Private Health Care: Critique and Remedies (Kelkar, 2021).

The District Hospitals In such arrangements, the district hospital will be relieved of its senseless load and can concentrate on providing superspeciality services in collaboration with a government medical college. Sophisticated imaging



equipment, neurosurgery, cardiology and catheter laboratory are immediately achievable goals. Sophisticated ICUs, special poly-trauma units, dialysis, sophisticated laboratory back-up for rarer investigations are what the district hospitals should be looking at. The superspeciality practices will find the district hospitals a welcome place to go to and lend a hand under the new wisdom of the PPP. The medical colleges and their issues have already been discussed thoroughly. Further and much higher upgradation will then be a given. In conclusion, the model of CHC proposed herein in four chapters will have the functional capacity, manpower and ease of delivering both primary- and secondary-level curative services. It will not have any of the handicaps that the government design of CHC and PHC had.

References National Rural Health Mission—Meeting people’s health needs in rural areas Framework for Implementation, 2005–2012, Ministry of Health and Family Welfare Government of India, Nirman Bhawan, New Delhi-110001 No.L.19017/1/2008-UH. DAWN Conference in London Nov 2003. Park K, 2015, Textbook of Preventive and social Medicine, 23rd Edition. Kelkar, Sanjeev, 1998, Reorganization of Health Care Delivery, The Hitavada Daily, by permission. Kelkar, Sanjeev, 1994, Tuberculosis Control in India, essay submitted to Lite for Life Foundation, Mumbai. Mehta, Purvi Dr, Head Asia Division, Bill and Melinda Gates Foundation, quoted in ETHealthWorld | November 18, 2018, 10:16 IST. Bhargava, Anurag and Yogesh Jain, 2008, RNTCP in India: Time for Revision of Treatment Regimens and Rapid Upscaling of DOTS Plus Initiative, The National Medical Journal of India, 21, 4 187–191. IANS | January 23, 2017, 15:56 IST]. Hiriyanna KT, and Ramakrishnan T, Deoxyribonucleic Acid Replication Time in Mycobacterium tuberculosis H37 Rv Archives of Microbiology, March 1986, Volume 144, Issue 2, pp 105–109 First online: rqstatus/Cause_list.ASPX) updated 14th January 2015. North and Izzo, Mycobacterial Virulence. Virulent Strains of Mycobacteria Tuberculosis Have Faster In Vivo Doubling Times and Are Better Equipped to Resist Growth-Inhibiting Functions of Macrophages in the Presence and Absence of Specific Immunity. The Journal of Experimental Medicine 1993;177(6):1723–33.



Pillai G, Fourie PB, Padayatchi N, Onyebujoh PC, Mcllleron H, Smith PJ, Gabriels GR: Recent Bioequivalence Studies on Fixed Dose Combination Antituberculosis Drug Formulations Available on the Global Market. The International Journal of Tuberculosis and Lung Disease 1999, 3:S309-S316. Lisa Claire du Toit, Viness Pillay and Michael Paul Danckwerts, 2006, Tuberculosis Chemotherapy: Current Drug Delivery Approaches, Respiratory Research 7:118 doi:­9921-­7-­118. DiabCare Asia, 1996, Multinational Asian Study of Diabetes Care at the Tertiary Level, ET Health Our Bureau, New Delhi Saturday, June 2, 2018, 08:00 Hrs IST. Shrivastav, Shashikant, Texas University: The Journal of Infectious Diseases 2011; 204:1951–9. Gambo, Dr Clin Infect Dis 2012; 55: 169–77. Phadanvis, Devendra, chief minister of Maharashtra, Times of India dated 21/03/2018. Shelar Jyoti December 06, 2018, 00:49 IST. Venkatesan Nandita & Rajagopal Divya | ET Bureau | November 17, 2017, 11:09 IST. Kelkar SS, Kulkarni PN, 1987 till date, Conduction of Mass Campaigns for Reduction of Blindness, Ashwini Hospital, Madikeri, Kodagu, Karnataka, India. Tongaonkar RR, Ashok Kale n.d. Arogya Tethe, Special Issue medical profession and Consumer Benefits, edit Deodhar Dilip, Pune 411030. Rural Health Statistics 2015. Kelkar, Sanjeev, 2021, India’s Private Health Care Delivery: Critique and Remedies. Palgrave Macmillan India. Kale Ashok Dr, in a series of conversations with the author in 2016.


Health Institutes and Voluntary Health Work

The Idea of an Institute The concept of an institute in health field is a well-circumscribed idea that has evolved in my experience. It will go beyond all the structural entities described so far and will rise in its functionality far above. Voluntary agencies are also important. However low or hopeless the situation of any society may be, voluntarism is an indomitable trait which will be found, not always minuscule but remains by and large unknown till a catastrophe strikes.

Prehistory of Health Institutes Development of institutes for many years prior to this writing has been an ongoing process in which all types of institutes have developed in our country. Proper development of institutes is an absolute must to give and maintain a sensible direction of any field of life. Numerous people have reiterated that we have problems because we have failed to build good institutes. Going a step further one can say we have also failed to guard our good institutes and institutions and that we willfully, gleefully and cruelly destroyed our institutions and continue to do so. This is a great Indian pastime. The earliest of our medical institutes were our medical colleges, and even in their unsatisfactory state today we have a very large and almost enviable infrastructure in them, lying listlessly and dysfunctional. The © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Kelkar, India’s Public Health Care Delivery,




development of postgraduate institutes, more or less autonomous in working and supported indirectly by the governments, was next to follow. The creation of All India Institute of Medical Sciences (AIIMS), Post Graduate Institute (PGI) Chandigarh, Sanjay Gandhi Post Graduate Institute (SGPGI) Lucknow and JIPMER in Pondicherry took place. Even after decades they have kept up their standards. Then there were larger-sized private hospitals that have done yeoman’s work in cities and metropolises. Every big city will have such hospitals which are publicly owned as trusts. They are 24×7 running big machines but provide a sense of safety that one can go there and be looked after at all odd hours in serious situation. A string of other, somewhat smaller hospitals also developed in the last 40 to 45 years, many of which specifically arose as charitable institutes or voluntary agencies. As a continuous background development, ‘Mission’ hospitals developed throughout the length and breadth of this country, in the large and medium cities and at times large towns. Their numbers ran in thousands of secondary-level care hospitals (about which a lot more will be said at length here.) Many of them, if not all, will qualify for the label of institutes. Quite large are the other interior Christian outfits which may not qualify to be second-level referral centres but do a much better job than an average primary health centre of the governments does. The most recent of course is the advent of ‘Five Star Hospitals’ which has literally rocked all the sedate approaches to medical practice. With all the issues described about them in the other volume, India’s Private Health Care Delivery: Critique and Remedies, they have strong attributes of an institute and institution-ness.

Defining an Institute Institutes in any form have not been discussed in the health literature. It also is somewhat arbitrary to divide medical enterprises as profit making or charitable ones in defining an institute. The word charitable has many definitions in the myriad laws we have (Seshadri, B S ex-IT Commissioner of Bangalore, Personal conversation, December, 1990). Thus, charitable or profit-making nature of operation does not negate the status of institute. Similarly, the identification of a curative outfit as institute (or a research centre) does not become an institute just because the owners have adopted such names. A majority of these could have nothing of the institution-ness are research centres sans any research and practices that negate the status of an institute. By sanctioning such outfits, the



governments keep violating their own norms. Many of these are recognized by National Board of Examination (NBE) as their training centres for Diplomate of National Board (DNB) students. Yet there is no institution-­ness in these. A health institute is any curative/primary care/research or mixed health care outfit. In it, the owner does not have illimitable rights over everyone else. Nor does he have any unbridled functional authority since many of these would be governed by an outfit having a common ownership either of a public or a private charitable trust in its legal form. Foundations are another form which could be considered as a progenitor of institutes which could be for profit or not for profit. Trusts and Ownerships Public charitable trusts owning hospitals/institutes and calling them by either name is by far the best representative model for charity. Here the primary motto is service, which is often substantially free. Even if it is a charging unit the idea is ‘not for profit’. Barring deliberate fraudulent financial management by these trusts, the dominant and practised idea is to put the surplus back into the outfit and cause improvement in standards or facilities. This is the first step towards becoming an institute. Ownership of a hospital by a private trust or a family trust or a public trust formed by unrelated individuals for a common goal of running the hospital are the forms most commonly met with. The only and real difference between the public charitable trusts and the other two types is only one. In the second type, the entire property or assets are owned by the promoters of the trust, although they cannot and do not enjoy the de facto owner status as freely as if they had owned it. A slight distinction is or can be made about the vulnerability of the public charitable trusts against the private trusts. The latter is extremely difficult to destroy since the owner/promoters will not allow any undependable party to enter into the authority, since it is their property which is at stake, while the former can be in such dangers. Private and family trusts will fight back spiritedly, which the owners of a public charitable trust may not do to the same extent. Here, even if a battle is lost none of the trustees lose their own property in it. The ones described above are by far secular institutes or hospitals. But there are other types which could be difficult to define as either public or private trusts. They are the institutes set up by religious bodies. Numerically



the highest number is of the Catholic Hospital Association South India. They are governed by the church. There are hospitals from Waqf Board or other religious Muslim bodies, and there are trusts run by Hindu temples as religious trusts. Those who believe in secular values consider the religious initiatives as retrogressive or dangerous. But that is not necessarily correct. Then come the societies which can be secular or non-secular which create big health facilities or do some other major work in health area but are essentially governed by the Indian Trust Laws and society’s act, hence not greatly different, and all can be included in considering their abilities and function to be called an institute. Among the varieties of these outfits, the most essential qualities which will give them the distinction of being considered as an institute, among other labels they may carry, are given below. The institutes have played an important role in health care delivery. We need to define the institutes so that we can evolve some criteria to judge other health care outfits. In other words, becoming an institution is the final or the finest achievement for every outfit. There also is a big common area to all, which makes the institutes important. Characteristics of an Institute 1. The first and the most important aspect of an institute is the collective ownership. The individuals, who control it, are the authorized representatives of the society that has willed the institute in existence. Thus, in theory and by law, the society ensures that the property of the institute finally belongs to the nation and is at its disposal. This is of paramount importance. 2. This, in theory, also ensures that if it is doing well, its entire surplus after duly reimbursing all the services received and offered goes back to the institute and not to the pockets of an individual. This could be considered the true or the most acceptable definition of charity and a charitable institute. 3. The ownership pattern may vary but the de facto/de jure responsible owners are given the mantle of responsibility to keep it functioning in liquidity first. The profit consideration is secondary to caring. The profitability proportion should be such that it prevents an institute from going bankrupt on one side and does not become exploitative to the patients on the other. Not a difficult job really!



4. Once the state for continuation of the institution in a satisfactory manner is thus set, and the balance in profits and services is achieved, then the institutes ‘come of age, on their own’. Till then they exist in actuality but are not on maps, because familiarization on wide scale, recurrence of acquaintance from the society at large and the acceptance of the institute as a fact has not occurred. This journey is the hardest that an institute undertakes while it collects its power, its individuals, lays down its systems and decides on the terms of service they wish to offer to the society. 5. It should be a complete structure for the purpose for which it is erected and must have a defined specific objective. It should have all the relevant and related facilities for that under one roof. This is the form the multi-speciality or even a single-speciality institutions take. This idea has taken roots for many decades now and has turned out to be a form that patients prefer. 6. After due recognition of the fact that the spectrum of medicine being so wide that each of the facility should be physically made available at one place is not easy. Even if it can be called into the bedside of the patient from somewhere else, it is acceptable and considered adequate. It is not reasonable to have underworked full-time specialties since institutes will then become unwieldy and their functional qualities and economic state will plummet. 7. Therefore, highly  specialized nature of superspecialities in one or more areas is another important characteristic of an institute. These arise out of an institute and grow vertically. Each of these specialties could then physically separate to a nearby accessible location. This is highly desirable for reasons of agility. They can also remain within. 8. Such developments bring in more and more sophistication and can solve problems of higher and higher complexity which may be rarer at lesser levels of care but are the staple at higher levels of care. In India, rarity of a high-complexity disease spectrum still turns out to be high in absolute numbers. That is the reason that a number of institutes addressing particularly difficult forms of disorders have proliferated. 9. The highly specialized institutes should be able to take care of the acute medicine is another expectation from these institutes. There is a growing tendency in such institutes to avoid treating acute cases. They prefer to function in an atmosphere of cold cases, since these numbers flocking to them are high. They function efficiently in diagnosing and treating them. This cold work is far more conducive to



further and finer developments and research. However, those who do cold work may not pit them against research. 10. It is debatable if we could force these institutes to look into the acute medicine or not. If this aspect has to be catered to, then the other important things the non-emergent work allows them to do will not be done since even the acute case load in India is very high. If both the needs can be addressed, it is a great boon, but not many could do that. 11. It may however be considered justifiable to expect these institutes to separately create a structure to answer partially the issue of acute load, by one or more satellite institutes nearby or around it. The same applies for research. 12. More and more single speciality institutes need to develop. Within vast metropolises, such institutes could rise above the expertise available in the more general multi-speciality once. As an additional quality improvement measure these could concentrate on fundamental research which as a country we need badly. 13. The research labs coming to India from abroad is no longer a rarity, although the numbers may not be more than a hundred. Single speciality institutes could give them a complementary base to further the research. Research within a multi-speciality institute would be somewhat limited or could concentrate on the more practical business like trials.

Power, People, Expanse and Service Quality in Institutes 1. Institutes should be power-packed units able to help people in grave situations and complex problems more efficiently and smoothly, due to its combination of men and machines. This power should be maintained by the owners or administrators. 2. Private/public charitable trusts, which have developed highly specialized big-sized institutes, will have much less difficulty to get good people to work in it. When private bodies develop charitable or for-­ profit but large multi-speciality institutes, they have usually already targeted their core worker group that builds the place. 3. At times, unexpected pace of growth of the institute creates a need of more numbers of adequately and highly trained people. This continu-



ous disequilibrium remains in a dynamic for many years, which is welcome. 4. One major consideration of such tertiary-level institutes is their size. Size is the direct consequence, on the one hand, of the components of the original conception. On the other hand, it is the need at that locale that may determine the same. In thinking of institutes, we must think of size and its sub-speciality tertiary nature. If we do that, optimal-­ sized speciality institutes can become the next-generation institutes. 5. Institutes should have a manageable size where the human beings they deal with are not lost to indifference and gruff attitudes, turning in an inefficient crowded suffocating and unhygienic outfit, leading to a gross decline of every quality of medical practice. Having allowed it grow to this state, it will be extremely difficult to down size the same. One way to achieve it is to hive off a speedily growing  department  physically, nearby, without change in the ownership in foresighted manner early. 6. I believe that there is a ratio of how small a big project should begin or remain. It is directly related to liquidity, profitability and high quality and still retains the human and humane touch. 7. Equally true it is for those projects, which begin small, as to how big they should be allowed to grow before it is shifted  for relocation elsewhere. 8. A bed strength of 80 would in my experience be the economically most viable, functionally sleek, agile in its component structure, closely working, not to become an impersonal outfit, open enough for each one to see the performance of every one, and retain growth potential at the required, slower speed and quality enhancement. 9. Institutes, private or public, with a finite size will mean optimal utilization of resources and much shortened time from plinth to inauguration. It will also mean that there will be less frequent need for the cost escalations which are routine and excessive in really big projects. Since the size is finite, they could be conceived strategically to solve some specific prevalent problem. 10. When we put a self-imposed restriction on our size, replication is bound to occur and it should. Creativity of people and their availability will force multiplication. With the experience of earlier institutes, a turnkey construction or a transferable technology that can activate itself in the replication process with ease.



11. For a normally functioning multi-speciality with a steady but lower growth rate year on year, the optimal size is 50 beds. Many projects are built too large in capacity, which is a complete mismatch to the total population need and its affordability and a colossal waste of money. People build big and struggle for the lifetime to fill the capacity created. 12. Such things are often done in anticipation of being recognized on a large scale as tertiary care or referral centres for high-complexity diseases from private as well as government schemes. If such an institution does grow, the limit should be to cut off the bed strength at 80. Even that is not easy to achieve with an average occupancy of 95% even if such ideas are on. 13. Some people build too small and then they move to a much larger area often away from their original best suited locale. These are typically people who began with a good team and dedication with competence and grow rapidly. But as the law of Northcoat Parkinson goes, the large new buildings become the graveyards of such initiatives. 14. The smaller tertiary subspeciality or basic speciality institutes are far more useful for many reasons. For one, they are replicable models. It is less difficult to constitute a core group, facilitate their work at the government level and fortify it with inputs and proper men from the society of that locale to govern them. Its return on investment starts early and facilitates the automatic expansion to this size. 15. It automatically becomes a higher standard for people to look at and compare others with it and choose for their health issues. 16. It serves the basic needs of becoming a back-up service for a much larger population in the hinterland of a large city. 17. A second-level entity like CHC (improved upon the government concept) with the minimum of five basic broad specialties is elaborated upon in this volume. Such CHCs will occasionally need such a city-­ based unit, while it solves majority problems on its own in the hinterland. 18. Such institutes alter the practice of medicine in a positive direction and provide an impetus for growth over a wide geographical area. 19. An important effect of speciality institutes is it solves the basic problem of linking the primary-, secondary- and tertiary-level care, keeping away the extortionist private sector coming in to fill the gap. This brings the tertiary care level near at home for the population which needs it a great deal.



20. This discussion thus automatically suggests that we need to spread our tertiary care-level institutes also through the length and breadth of our country and not restrict them to very large cities and high centres. This comes with a caveat that setting up AIIMS in a dozen places without building the smaller basic speciality units in large numbers is not the right answer. It is also discussed here in many places in this and my other volume, India’s Private Health Care Delivery: Critique and Remedies.

Money and the Institutes 1. Transparency of dealing and monetary transactions as a hallmark of institutional functioning imposes a particular alternate culture and it is for the institute to adopt it. 2. The first thing is the standardization of the rates of services, public display of the same and strict adherence to it. 3. The second is ‘Do not falsify the reality when it comes to charging the patients’. 4. Be convincingly clean in all the matters related to money. While it imposes certain restrictions, it also liberates institutions from many negative considerations facing which these lose a lot of time and wastes its energy. 5. For example, once the initial period of meeting the expenses is over and the minimum income limits are set transparently, it is advisable to just stick to it for a few years. 6. This will liberate the minds of the governors of the institutes from the constant driving force of making more and more money at all costs and irrespective of all other consideration. 7. That shifts the energy of institutes to other noble goals, of teaching, training, learning, looking after the manpower, creating the institutional culture and ethos, to set the human resource (HR) department free to develop people quality. 8. Point 6 is important. If there was ever a bigger hoax in the industry or the formal parlance of business, it is the Human Resource Department (HRD). HRD does what the managers tell them to do. HR does not do what it should. The managers and their practices are cruel, unjust,



demeaning, and corrupt to the core. And all that the HRD does is not to let anyone see or voice that and terminate people if there are any dissents. 9. Indians do not have an institutional mind; its ethos is eons away from them. Indians do not like the rule of law, the discipline and the time consciousness. But it is necessary that the health planners understand that. To take our health care to a higher level, we need to build institutions which are stringent on all matters hoping to create institutional mindset.

Not Just Financial Honesty 1. Liquidity through a non-exploitative tariff and a decent profit margin so that the surplus is put back for growth, no other consideration, must be built in to maintain institutions. Institutes should then proactively step into the market to do many things. 2. The tariff structure should be such that for all the competence the institute may have, the tariff will be the minimum that is tolerable for adequate liquidity. It should be apparent to people that less competent units charge more than or as much as the institute does. Once this realization comes, many events take place. 3. This lower-than-expected tariff structure is an effective deterrent for others to charge for their services in an excessive and arbitrary manner. This happens at all the ancillary levels of drug stores, diagnostic facilities, consultant fee and indoor charges, not just at the facility-­ level charges. 4. In other or plainer words, it means that others cannot loot the patients in an inordinate manner. Any institute should consider stopping this exploitation by regulating its price structure. 5. But the major block to achieve this is at the institutional level itself. (a) The managers want to maximize the bottom line of the tariff, mostly due to their insatiable greed, and secondly their idea of the institute being better than all others. This is false ego based on somebody else’s incompetence, not their competence. (b) The second insurmountable difficulty is their disbelief in medicine being a turnover industry; hence, the profit margin has to be rather low and not maximal that can be extracted from the poor creature, which has had the misfortune to fall ill and come to them.



(c) The management is always in a state of thinking that after today all illness coming to them is ending; hence, extract as much as you can. This is unfortunate and incorrect. (d) They forget to hold the price line of their place as much down as possible since the common man otherwise would be much worse off. (e) Technically and morally, the institutes are not free to gobble up profits if they make any. Yet the frauds continue at the institutional level. (f) This puts institute people under a stringent position, some constraint on economic privation and considerable discipline, like an animal placed on a rotating drum, but this is the only guarantee that decays will not be allowed to set in and the institute remains a continuously unfolding proposition.

The Institutional Culture One most important norm of behaviour is the allegiance to truth in the form of evidence based medicine without carrying it to an inordinate level. See the chapter ‘Western Models in Health Care’ in my other volume on India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). Institutes should have equanimity to face the truth about their patient’s health and fortitude to express it as it is. Otherwise falsehood will breed in it. This allegiance to truth cuts out ‘any entertainment’ of the patient and his concerned people, but it is inevitable and must be so understood by the beneficiaries as well. This allegiance to truth is most mistaken about institutional behaviour by its beneficiaries. That does not always happen due to patient’s suspicious nature and the state of denial about his condition; communication quality and not-so-widely based credibility of an institute also play a part. Entertainment cannot, and should not, become the dictating norm of behaviour in an institute. Two other problems that can cut the very roots of the institute are ‘ego and greed’. Unfortunately, as yet there is no solution for this. Every care should be taken to weed it out. These two make institutions languish, something, which does not happen in Western civilization. An average Englishman is aware that the battles of the world war were won on the play fields of Eaton. Institutions make character of people. At least they should.



The Large-Sized Institutes When Schumacher wrote his thesis of small is beautiful, he was restating the principle of decentralization and small entities. This was against the background of too many big structures then prevailing, beyond the required number. The real critique of Schumacher is that a certain minimum bigness is essential and inevitable. And it should remain minimal. Large-sized institutes are disproportionately more capital intensive. But as training institutes their importance just cannot be undermined. They are less repeatable models. But they are needed since the smaller ones cannot fully cope up with all the post-postgraduate training and research. This is to be understood. The very large institutes by their very presence underline the need for a plethora of smaller high-tech institutes for which society has money, where governments need not spend their revenue. Managing Institutes Well One more issue is the required high-level managerial inputs, not easy to come by, not easy to implement, to use in the working style and develop as a norm. That would be one more drawback. The managerial aspects are extensively dealt with in the chapter ‘Corporate Hospitals’ in my other volume. India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021). To make the most important point of it is—from being a doctor/clinician-centric and guided by him/her, day-to-day management of large hospitals or institutes has now slipped into the hands of half-baked masters of hospital administrators who have destroyed the process of satisfactory treatment of the patients, earlier well in vogue. Optimization of Work in Processes Management aspect of importance is the adequacy of work to all, optimization of the systems so that time is not wasted anywhere in the processes in patient care, and patient- and not consultant-centric time allocation. These items are routinely ignored. The IT systems have created considerable issues about management extensively discussed in the other volume, India’s Private Health Care Delivery: Critique and Remedies, published with this one. The reader is requested to look it up as well.



High-Cost Gadgetry and the Institutes Such being the importance of institutes, it is also proposed in the above volume that high-tech cost gadgetry should be part of institutes, and not outside a treating facility owned by the private individual or a company. Hence, finally it is or will become the property of the state in some indirect way.  We could very well have costly machinery as defunct or underworked  becoming a burden that cannot be liquidated in the present framework. Hence, some regulation needs to be brought in. In this volume, information about various resources locked in defunct hospital complexes and how to utilize it for public and private health care have been elaborately mentioned. Giving these  dysfunctional or closed  units, an institutional form is easier and will be of great help. Institutional Mindset of Specialists Needed There are admittedly few quasi-tertiary initiatives but they support the thesis of institutional paradigm of health care. To build them, bands of institutionally oriented specialists are greatly required. These initiatives  are concentrated in type A cities. These arise out of the actions of committed individuals. One of the responsibilities of the society and its upthrown form, the government needs to ‘tend’ to these institutes carefully to enable them to come to their finest form, as detailed earlier. As a society we have just begun to understand them, and efforts are needed to accelerate and spread wider this appreciation. Lead role will have to be taken by media, highest apex bodies overseeing the norms prevalent in the medical field, keeping the political, personal and egotistical tendencies that are so rampant in our society strictly out of it in order that they grow. Institutional mindset is paramount.  The growth of institutes after this point is indicated by many characteristics. The presence of these characteristics at once defines them as an institute and the characteristics also become their functions. The processes that the institutes go through are as described below in brief. Institutes: The Standard Bearer and the Bench Mark 1. Once the target area and the profile of its speciality services are fixed and the performing ability and adequate competent manpower is established, it becomes a benchmark in that area. These two are an interdependent phenomenon. One cannot exist without



the other. And unless both are present, the other expectations from the institute cannot be served. 2. With the nature and complexity of problems it faces day in, day out, only three things can happen: it responds to the challenge in a more than adequate measure; it cannot or does not meet this challenge; or it does not bother about it. The first will decide the growth, the second disfavour among people if a better one comes up, and the third a ruin. 3. It becomes mandatory that institutes perform ‘better than yesterday’ on a day-to-day or a month-to-month basis as the time goes by. If the process is well set, then the power and performance, coupled, generates a standard against which the rest of profession measures its performance. 4. To maintain continuously improving quality, it is mandatory to evolve a system of audits of work quality of their people by their own people. Surveillance and reviews as well as mortality meetings and clinicopathological correlation (CPC) meetings must become a practice. The institutes should not be held statutorily responsible on any of these counts but they are expected to seek and to develop this culture, by themselves. 5. It is unfortunate that most such health care facilities at this level either do not do it or do it in a perfunctory manner. If it is attempted seriously, the response of the concerned people is low due to their disinterest, perceived lack of time, self-surety of infallibility and the likelihood and fear of errors committed/incompetence shown getting exposed. 6. To remain the torchbearers of the standard of care and implementing teaching programmes for the staffs at various levels more stringently, see that they are facilitated to participate and to increase ‘hands on’ elements in the teaching, conference attendance and virtual lab experiences and  online training with  special care will be required. 7. Once this upgradation (or prevention of deterioration) sets in, the daily performance improves. But an almost-impossible task is to create a desire for research as the next step. If ever somebody gets induced to do something, there should be facilitation and guidance to improve the quality as time goes by. 8. This is not an additional work; it is not or should not be tied to more financial benefits. It should be done from self-motivation. If such incentives are given, the outcome will be poor.



9. Wanting to do research could be viewed by the management as an important reason to retain the individual in the institute, even if there are whimsical elements in such individual. If it is affordable to tolerate such individuals wanting to or doing research could be the only justification to continue in an institute.

Institutional Performance 1. The upkeep of all the preceding functions, power, performance and fallback, audits, teaching, research and so on calls for a continued effort for this within the institutes on a daily basis. The institute should develop a culture of disseminating new and the updated information wherever, whenever, however possible within. It does not happen mostly on account of the way these are managed. 2. Unfortunately, as the institutes grow from their unmapped unfolding and unrecognized states to mapped, recognized, fully developed state, the curative services usually shoot forward and degenerate, almost without exception. Clinical services bring a lot of money; hence, the management does not take an active surveillance to see if it is deteriorating in any way. Even if it comes to the notice, they will be scared of open or covert pulling the specialists up while retaining and displaying all the gratitude for it. 3. Anything mentioned in the above pages which either defines or is expected of an institute and its failure therein is also because of the lack of an institutional mind, institutional ethos and discipline. 4. That is why the increasing work is not and cannot be organized, or streamlined. Ego of the clinical faculty in most cases, their strong adherence to comfort zones and scant regard for optimizing time functions and inability to place the institute first even at some inconvenience to self are common traits of Indians. 5. Unwillingness to provide for additional manpower in the face of increasing work is due to economizing. But that is not the only thing. Institute management cuts corners on expenses, exploit those who are already burdened without additional financial support wherever possible, and ignore quality. The last is the worst. The expense on m ­ anpower to maintain quality is the insurance money the institute is paying to continue to get more work, money



and to retain quality even after that. This is nowhere on the horizon of the thinking of management. 6. The institutes once established are able to make almost unlimited money, especially in private. At this state and stage of the development of the institute, almost anything goes. Carelessness is bound to seep in and performance becomes sub-optimal. 7. One of the worst forms of desire such bodies take is to set their eyes on having a medical college for themselves. It is considered to be an honour, prestige and recognition of the quality. Having written a few chapters negating the need for more non-governmental medical colleges in this and in my other volume, India’s Private Health Care Delivery: Critique and Remedies (Kelkar, 2021), there is no further need to repeat the objections here. 8. The teaching function also suffers in institutes once these start growing. It is discussed below in a slightly different context. On Government Colleges, DNB Centres and Decline of Teaching 1. The simplest way to keep up to date is to teach. Therefore, the specialists in high-level centres practising curative medicines must also teach. They are in an enviable position to ‘indulge themselves’ in search and research, teach and learn but they do not. See Chap. 8 on CHCs in this volume for more details. 2. The National Board of Examination, (NBE), selected a large number of private institutes as DNB centres under specific criteria to teach the DNB students. These created lot of expectation in improving teaching for postgraduate students. Unfortunately these centres as a majority rule did not really care to tend them in any way—teaching, on-job/hands-on training, stimulation to acquire knowledge or research. 3. Eligibility of an institute in terms of qualified manpower and facilities does not guaranty even basic teaching. Every such institute needs a person who has a long-term vision as to why the candidates should be taught well. He should also have time for that and authority to exert it on those concerned for these works. NBE has not looked for the availability of such persons before selecting a place. If such an exercise to decide on the willingness, aptitude and feasibility of time of the specialists to teach was undertaken or not is not clear but it would be superficial.



4. That is why the situation of teaching for DNB has not improved anywhere. There is hardly any centre which has preserved a long tradition of teaching culture. The speciality members at this stage will be interested in everything else but this. This led to poor-quality teaching for DNB students, and the scheme has met with some clear disadvantages. 5. Teaching students gives much less money. And money alone makes the mare go. 6. All other aspects of teaching described with respect to the community health centres (CHCs) in this volume are applicable here also.

Issues with State-Owned Institutes 1. In government institutes, the overall drive to maintain a high-­ purposive, academic atmosphere is a major challenge. 2. Often the state-regulated institutes will fare much worse on account of the rigid lithic and unimaginative way of government dealing with the institutes and failure to provide manpower and adequate managerial skills. This repeatedly comes to light. Go to any big city and one will find a couple of examples of this. Some need simple good governance. Some need more inputs. 3. Do we have solutions for that? Suppose we insist on a built in condition, that these will be ‘training institutes’. It will still not solve the problems for many reasons scattered across the two volumes. If that was workable, all the medical colleges owned by the government would have flourished exemplarily. A change in the work culture to make them work well becomes an asset to the people, and the government must be brought into the system. Time will tell if Indians can really change their working habits. Changing culture will still be a far cry.

Summery Regarding the Health Institutes Thus, for higher-complexity conditions, teaching, training, creating standards, creating academia, changing medical practices, as storage and repository of high-cost machinery, the professional’s fallback, support, and so on, decentralized liberally spread institutes of high-quality and



governable size are needed. The need is to develop ‘institutional minds’. Otherwise there will be too many people, too small for their shoes and chairs. There is no denying that India suffers from dwarf and unenlightened leadership of clay feet walking in big shoes, in all walks of life. Nothing can be more damaging to creativity and progress. Whether it is health or by implication, education, judiciary, industry, agriculture, the same issues will surface everywhere. If one area can be improved, others may take inspiration and one could have ten noble examples of institutes in ten different walks of life in different places where an honest deal is possible. Will that change the habits of our people? Will it make us more honest? Is it possible at all?

Voluntary Agencies and Health Work The spread of VAs in the health field is quite remarkable. These represent a sizeable number in the primary health care area. Their presence in the form of second-level care is also well felt. VAs in the form of tertiary care units are fewer but generally have done fairly good work. There are others. VAs which may not involve physically in health work themselves but are carrying out a different array of functions like economic upliftment or education are of considerable importance to any thinking on health care. Equally remarka