Mains Paper 2: Education
Prelims level: NMC Act 2019
Mains level: Primary care practitioners
Hospitals, for the early part of Japan’s history with modern medicine,
catered only to an affluent few.
The government limited the funding of hospitals, restricting them to
functions like training of medical students and isolation of infectious
Reciprocal connections between doctors in private clinics and hospitals
were forbidden, thwarting the possibility of the two groups creating a
strong nexus; on the other hand, a sturdy lobby of clinic-based PCPs evolved
to tip the balance in favour of primary health care.
The Japanese Social Health Insurance was implemented in 1927, and the
Japanese Medical Association (JMA), then dominated by PCPs, was the main
player in negotiating the fee schedule.
Healthcare scenario in India
In India, on the contrary, a hospital-oriented, technocentric model of
health care took early roots. Building urban hospitals through public
investment enjoyed primacy over strengthening community-based, primary
Alongside this, a private sector with rampant, unregulated dual-practice
system (doctors practising in both public and private sectors
This allowed doctors to constitute a powerful group held together by
This influential doctors’ community, which saw a lucrative future in
super-specialty medicine, buttressed the technocentric approach, which also
happened to concur with the tastes of the affluent and the middle class.
This trajectory of events has had an enormous impact on the present-day
Indian health care.
Focus on hospitalisation
While the well-to-do section has always rooted for ‘high-tech’ medical
care, this preference has now trickled down to even the subaltern section,
which lacks the wherewithal to pay for such interventions.
Colossal health insurance schemes like Ayushman Bharat that harp on
providing insurance to the poor largely for private hospitalisation when the
most impoverishing expenses are incurred on basic medical care are at least
partly influenced by the passionate popular demand for the so-called
high-quality medical care and bespeak the deformity in the health-care
The way this has affected medical manpower and its dynamics also
It took 37 years after the landmark Bhore Committee report (1946), which
highlighted the need for a ‘social physician’ as a key player in India’s
health system, to finally recognise family medicine as a separate speciality
and another decade and a half to actuate a postgraduate residency in family
The highest professional body representing doctors in this country, the
Medical Council of India (MCI), itself came to be dominated by specialists
with no representation from primary care.
There is a proposal to replace the MCI with a National Medical
Commission (NMC) but the situation is unlikely to be much different with the
Effects of NMC Act 2019
The current opposition to training mid-level providers under the NMC Act
2019 is another example of how the present power structure is inimical to
primary health care.
Despite the presence of evidence proving that practitioners of modern
medicine (say medical assistants) trained through short-term courses, like
those of a 2-3 year duration, can greatly help in providing primary health
care to the rural population, any such proposal in India gets robustly
opposed by the orthodox allopathic community.
Proposals to train practitioners of indigenous systems of medicine, like
Ayurveda, in modern medicine are also met with similar opposition.
Such medical assistants, and non-allopathic practitioners, have time and
again been written-off as ‘half-baked quacks’ who would only endanger the
health of the rural masses.
Such criticism ignores the fact that nations like the U.K. and the U.S.
are consistently training paramedics and nurses to become physician
assistants or associates through two-year courses in modern medicine.
Examples of U.K., Japan
Many countries, including the U.K. and Japan, have found a way around
this by generously incentivising general practitioners (GPs) in both
pecuniary and non-pecuniary terms, and scrupulously designing a system that
strongly favours primary health care.
What this careful nurturing has meant is that while a community of
professionals in our part of the world has thwarted positive change,
professionals of the same community in these countries have helped defend
that very positive change.
Three broad takeaways emerge
It is imperative to actively begin reclaiming health from the ivory
towers called ‘hospitals’.
This could help in gradually changing the expectations of the layman and
reversing the aspirations of medical professionals from being unduly
oriented towards high-tech, super-specialty care.
Given the current trends, however, this looks like a far-fetched
We need to find a way to adequately empower and ennoble PCPs and give
them a prominent voice in our decision-making processes pertaining to health
This can create a bastion of primary health care professionals who can
then fight to keep their enclave unscathed.
A gate-keeping system is needed, and no one should be allowed to bypass
the primary doctor to directly reach the specialist, unless situations such
as emergencies so warrant.
It is only because of such a system that general practitioners and
primary health care have been able to thrive in U.K.’s health system.
In view of the current resurgence of interest in comprehensive primary
health care in India, one earnestly hopes that these key lessons will be
Q.1) Consider the following statements about Pradhan Mantri Shram Yogi
Mandhan: 1. It is a mandatory and contributory pension scheme.
2. Centre and States give equal matching contribution.
3. For all the intended subscribers, JAM Trinity is essential.
Which of the above is/are correct? a) 3 only
b) 2 and 3 only
c) 1 and 3 only
d) All of the above
Q.1) What is special about Japan in the context of health-care services is that
it managed to contain the clout of specialists in its health-care system and
accorded a prominent voice to its primary care practitioners (PCP) in its