Friday, 2 March 2012

Emedinews:Legal question of the day: What are your comments about the contempt petition filed before the Delhi High court in February 2012 as regards the BRHC course

Legal Questions of the Day
(Dr MC Gupta,
Advocate & Medico-legal Consultant)
Q. What are your comments about the contempt petition filed before the Delhi High court in February 2012 as regards the BRHC course?
1. This is a contempt petition filed by the original petitioner Dr. Meenakshi Gautam, a public health specialist, in the earlier Writ Petition (Civil) No.13208 of 2009 in which the Hon’ble court had vide its order dated 10.11.2010 given the Medical Council of India two months’ time to finalize the curriculum and syllabus of the 3.5 year Primary Healthcare Practitioner Course, the implementation of the introduction of which was approved by the Union of India. The course was named ‘Bachelor of Rural Health Care (BRHC)’. A further period of two months was given to the Ministry of Health and Family Welfare for the enforcement of the same. Thus, BRHC should have been introduced by March, 2011 as per the timelines stipulated by the Court in its order.
2. The facts in brief of the previous Writ Petition No. 13208 of 2009 leading to passing of the order dated 10. 11. 2010 are (as described in the contempt petition) are as follows:                    
i) Since 1950, the Govt. has been formulating five year plans and health policies with a view to fulfill its principal duty to provide health care to the citizens. Yet, the existing health care systems are entrenched with inequalities and unable to meet the needs of the people. As per WHO statistics estimates of 2007, around 70%-80% of our country’s population, especially in rural areas  is un-served or under-served as there is a health human resource crisis.  This situation is particularly acute with respect to essential primary health care. The Petitioners had pointed out that there is an acute shortage of well- trained health care providers who can deliver primary health care in rural areas. The main source of professional primary healthcare in rural areas is through the network of Primary Health Centres (PHCs). However, these are very few and far between: by Government’s own statistics there is 1 doctor for 35,000 people whereas the recommended norm is 2.5 trained health workers (doctors/professional nurses/midwives) per 1000 population.  Many of the remote PHCs do not have doctors in position. On the demand side, people living in India’s roughly 600,000 villages need a well- trained health provider within easy walking distance who is available 24 hours and who can take care of the bulk of common illnesses like fevers, diarrhea, respiratory infections, malaria etc., who can provide first aid in emergencies, and who can identify and refer complicated cases in a timely manner.  In the absence of trained primary health providers, this care at first contact is currently delivered by informally trained and unlicensed practitioners who form the backbone of rural primary health care. The message that we get from this situation is that villages need trained mid-level practitioners at approximately 1000-2000 population. Even if all the PHCs in India were fully staffed with doctors, this primary healthcare need would still not be met with doctors alone.
ii) The gross inequities in availability of health care and skilled health professionals were highlighted by WHO in its 2007 report titled ‘Not Enough Here, Too Many There’.
iii) In 1983, the Govt. formulated a National Health Policy with the goal of ‘Health for all’ by 2000. This policy envisaged overhauling of the existing approaches to education and training of medical personnel. It emphasized that a shift in focus to primary health-care services is essential.
iv) National Health Policy of 2002 made several recommendations including expanding pool of medical practitioners to include a cadre of licentiates of medical practice, use of paramedical manpower of allopathic disciplines, periodic skill updating of public health professionals and establishment of statutory professional councils for paramedical discipline to register practitioners, maintain standards of training, and monitor performance. This policy draws its line of argument from various national five-year plans which have also suggested creating a cadre of professionals for rendering primary health care as opposed to the present system which is not sensitive to the needs of the majority of the people in India.
v) Various commissions, committees, national five-year plans have repeatedly held that providing a trained health care work force for rendering primary health care is a public health priority. In the high-level 9th Conference of Central Council of Health and Family Welfare chaired by Union Health Minister, where all state health ministers and officials participated, the resolution was passed that all states should introduce a 3-year diploma course in Medicine and Public Health in order to provide man-power to address rural health care needs, on the lines of Chhattisgarh and Assam legislations
On 13.11.2007, it was resolved in this Conference that “All State Govts. bring out an enabling legislation…so as to introduce a 3-year diploma course in Medicine and Public Health in order to provide manpower to address rural health care needs.” In the last 4 years, there has been no forward movement to implement the resolution.
vi) For over 60 years, the fundamental rights to life and equality guaranteed under Articles 21 and 14 of our Constitution have been denied to 80% people in this country who are either poor or situated in rural, remote or tribal regions. Health and medical care are either inadequately provided or completely absent from their lives.
vii) In 2007, a Task Force appointed by the Ministry of Health and Family Welfare, Medical Education Reforms for National Rural Health Mission, recommended the introduction of the 3-year Rural Practitioner Course to fill the vacuum of health care providers in rural areas.  However, all these proposals had run into opposition from vested interests and in particular MCI. This is despite the fact that MCI’s own sub-committee in 1999 had noted that the existing system of medical education has “utterly failed” the health needs of the majority population in our country.
viii) There is ample evidence of different types of models of mid- level cadres from many countries. We have described this evidence in great detail in our past petitions, and also annexed the said documents. There are both nursing as well as non-nursing types of models of mid- level practitioners. These include health assistants and community medical assistants in Nepal, clinical officers and assistant medical officers in 47 sub-Saharan African countries, Health Officers and Health Assistants in the Western Pacific Region to mention a few.
ix) World Health Organization (WHO) review (2001) of mid-level practitioners in the Western Pacific defines these workers and states that “Mid-level practitioners are front-line health workers in the community, who are not doctors, but who have been trained to diagnose and treat common health problems, to manage emergencies, to refer appropriately and to transfer the seriously ill or injured for further care.”
x) Latest WHO review (2008) of mid-level health workers defines mid-level workers as: “Mid-level workers are health care providers who have received less training and have a more restricted scope of practice than professionals; who, in contrast to community or lay health workers, however, do have a formal certificate and accreditation through their countries’ licensing bodies.”
The said review notes that “evidence suggests that for over 100 years different categories of mid-level workers have been used successfully to provide health care, particularly to underserved communities, and that the use of MLWs has been widening in both high- and low-income countries.”
xi) Thus, the petition 13208/ 2009 was filed seeking directions to the Government from the Hon’ble Court to introduce a short-term course for training mid-level health workers for primary health care in rural areas and then license and regulate graduates of the said course.
3. The grounds / facts as listed above make sense and I do not find anything wrong in them.
4. If the Ministry of Health or the MCI took a stand earlier and have now revised their stand, they should state so in their reply to the court along with the reasons for the change. If they have not changed their stand, they need to follow the court’s orders and apologise for the delay or explain the reasons for delay and give a specific undertaking to the court in a time bound manner to implement the court orders.
5. The public and the health professionals and the medical community should be grateful to the petitioner Dr. Meenakshi Gautam and to the senior advocate (and son of the former Law Minister Sh. Shanti Bhushan) Sh. Prashant Bhushan, for agitating before the courts an issue which is crucial to the health of the Indian people but has been ignored by those vested with the responsibility for planning and providing for the healthcare of 1.3 billion people.
6. There is nothing offensive in the proposal for the BRHC course. After all, there used to be an L.S.M.F (Licentiate of State Medical Faculty) course in India which was a four-year course after matriculation. That means 14 years of study. The BRHC course would presumably be a degree course given after fifteen and a half years of study (10+2+3.5) followed by one year internship. If the LSMF doctors after 14 years study could provide good medical care to people, there is no reason why BRHC graduates 16.5 years study cannot provide good health care to people.
7. The medical community can take a sigh of relief from the fact that the LSMF graduates were qualified medical doctors while the BRHC graduates will be labelled as health care providers. There is no reason why the MBBS fraternity should be alarmed at this.
8. As a matter of fact, the introduction of the BRHC course will, from the point of view of the modern medicine graduates, have the following beneficial effects:
a. It will markedly reduce quackery (including quackery in the nature of allopathic practice by Ayush graduates).
b. It might lead to a situation when Ayush colleges either close down (like the MBA courses / colleges now-a-days) or convert into BRHC colleges.
c. It will lead to creation of a large number of new jobs for modern medicine graduates who will be needed as faculty in the BRHC colleges.
d. It will raise the status of MBBS which has been currently reduced to the lowest degree in the medical / health field. With BRHC in place, MBBS doctors may as well act as referral doctors for patients referred by BRHC graduates.
e. When BRHC graduates are in place, the need for obligatory rural service for MBBS doctors would decrease.
f. With the BRHC graduates are in place, MBBS doctors posted in rural areas will not find that they are left to fend for themselves with no staff, equipment and facilities in remote areas. It is natural that equipment and facilities will have to improve with BRHC graduates in place. In other words, service in remote and rural areas will be less of an ordeal for MBBS doctors.  
g. MBBS doctors having nursing homes will be able to employ BRHC graduates without any problem instead of employing Ayush graduates which is illegal in terms of the NC decision in Prof. P.N. Thakur v. Hans Charitable Hospital, NC, 16 Aug. 2007—

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