Opinion The doctor is out

Six questions need to be answered in such a debate. First,why did the minister single out the US? Second,are the facilities for postgraduate and super-speciality training inadequate in India,compelling people to go abroad? Third,if they are inadequate,how can they be scaled up? Fourth,will the returning doctors stay on to work in India? Fifth,will they have enough opportunity to utilise their newly acquired skills? Sixth,what is the global policy on health workforce migration?

The first question was curiously evaded by most commentators. Why was only the US named? Why not the United Kingdom,Australia,Canada or New Zealand? Perhaps because,it is only the US which is now asking for a No Objection Certificate from the Indian Government. The US regulations for the Exchange Visitor Visa (J1 Visa) clearly inform the student: “you will be required to return to your home country for two years at the end of your exchange visitor programme” (Section 212-e of the US Immigration and Nationality Act).

So why pillory our minister for a measure which essentially reflects US policy? While the bond sounds coercive,draconian and illiberal,it is merely a reminder of an honour code that requires persons who have benefited from heavily subsidised education in India to return to serve the country. It is seldom enforced legally and can easily be dispensed with. If retained,it may spell out a commitment that is transcribed from paper to personal sense of duty.

It is true that the existing facilities for advanced medical training are unable to accommodate the many aspirants. In a few medical streams,there is a need to go abroad to learn new techniques or gain expertise in areas that have not yet opened up in India. There is no restriction on doctors going abroad for these reasons. The expectation that they should return after training is legitimate but cannot be enforced,except when it is the US law that demands it.

We do need to increase the number of post-graduate and super speciality seats in the country. Besides the medical colleges,which are regulated by the Medical Council of India (MCI),there are also post-graduate training programmes in other hospitals,under the auspices of the National Board of Examinations (NBE). These include the hospitals run by the railways,the army,public sector undertakings and a number of charitable and private hospitals. The NBE offers 6,000 seats at the post-graduate level and 450 at the super speciality level.

We still require more doctors and specialists (though the need for nurses,paramedics and community health workers is even more). Medical colleges which now offer only undergraduate courses must be upgraded to offer post-graduate courses. District hospitals,if improved,can host medical colleges or link up with the NBE system. Quality will have to be assured,of course. The NBE has set up speciality boards to define the accreditation criteria,required competencies,curricular content,training programmes and evaluation methods for each discipline.

There is need for more faculty to staff the existing and new medical colleges. Specialists are also needed for district hospitals. Sadly,the legacy of unwarranted rivalry between the MCI and the NBE has led to the former refusing to acknowledge the equivalence of degrees awarded by the NBE. This is despite the fact that NBE conducts the only nationally standardised examination in each discipline,in contrast to the widely varying examination standards across the many medical colleges. The health ministry,which set up the NBE to develop national standards,should intervene to accord NBE degrees equivalence,which even the judiciary has upheld. That will help to fill many of the vacant specialist posts in medical colleges and health services.

Doctors will still go abroad for training,although in smaller numbers. A framework must be developed to facilitate their return to suitable employment in India. The new AIIMS-like institutes,upgraded medical colleges and revamped district hospitals should benefit from the return of well-trained specialists who can improve existing departments and start new ones. Others may choose to work in the more lucrative private sector but that too is better than losing them to other countries.

Merely bringing back the doctors from the US will not help. Many of them may notionally fulfil the bond requirement by returning for a month or so and then moving on to the Gulf or other countries,even if the US bars their return. A “positive” pull-back factor is needed,in terms of good healthcare infrastructure and reasonable remuneration,to retain them.

There is an emerging global consensus on health workforce migration,which calls for attention to the needs of developing countries,while respecting the right of individuals to travel to other countries for education or employment. In 2010,the World Health Assembly adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel. The code encourages destination countries to support training programmes in source countries,so that expanded human resource development can overcome the effects of migration. Norway set an example even before the code was adopted by investing in the training of doctors in Central European countries so that the needs of those countries could be met along with its own. India may not seek such assistance from countries which import Indian doctors but must,even on its own,invest substantially to scale up its human resources for health.

The writer is president,Public Health Foundation of India,express@expressindia.com