On Friday August 14, 2015, this newspaper in an article headed "Doctors to serve in primary healthcare facility" reported that the Punjab chief minister had approved a policy that it will be mandatory for fresh graduates of public medical colleges to spend a year in primary health facilities. This policy might seem rather useful as far as improving the availability of physicians in rural areas is considered. But a closer look clearly suggests that whoever initiated this idea either never thought this through or else has no idea about ‘ground realities’.

First it seems entirely peculiar that on one hand the Punjab government is trying desperately to divest control of the rural healthcare while at the same time it is going to impose fresh and untrained doctors on the very people that will after privatisation run the healthcare in the rural areas. Second, the very idea that ‘fresh’ graduates that have had little training in how to take care of patients will be forced to work independently in rural centres is a frightening thought at best. Third, what about fresh graduates that do not go through one year of house job and therefore are not eligible for full registration with the Pakistan Medical and Dental Council (PMDC)? Without such registration physicians cannot practice medicine under any circumstances.

It would seem that this policy initiative has only one of two possible purposes. One possibility is that it is an attempt to intimidate the Young Doctor’s Association (YDA) into towing the government’s line or else they will all be sent off to work in villages for the rest of their professional lives. The second possibility is to coerce women that do not plan to practice medicine after graduating from medical colleges to not enter the medical profession. Frankly, in either of these attempts, the government will fail miserably.

Let me first address the question of women graduating from medical colleges. At the present time, more than two third of all fresh medical graduates are women. Based upon conservative estimates, as many as half of them will never practice medicine. Even if all these women did complete house jobs and registered with the PMDC, it would be impossible to send them off to remote villages and small towns to work in rural healthcare centres. First their parents would never allow single women to go off to these places and if they get married, their husbands would also not let them do that. And if the government tried to post them in remote places against their wishes that would never be allowed by society or by courts. The problems of security and accessibility notwithstanding.

If the women are not forced to go to the remote rural healthcare centres and only the male graduates are forced to do that then that would make an interesting discrimination suit against the government. In essence it will be impossible to send ‘fresh’ graduates to any rural centres or basic health units as a compulsion based upon what I have said above.

But there is one other very important reason why fresh graduates should not be forced to work in these places. The reason why fresh graduates are called fresh is because they are indeed fresh and do not have the experience to run any such rural centres and provide appropriate care on their own. And posting them in such situations will endanger the lives of their patients.

Here it is important to disabuse bureaucrats and politicians about their outmoded ideas concerning modern practice of medicine. Fifty years ago a fresh medical graduate who had done a year’s house job could well run a healthcare centre. Medicine has advanced so much over the last few decades that a fresh graduate would be almost completely lost in such an environment. Today a physician running such a centre has to have the ability to read X-Rays, ECGs, ultra-sound tests, basic laboratory reports and have a thorough knowledge of different diseases and medicines available to treat them. Besides medical knowledge, basic surgical skills are also needed to diagnose and perhaps even operate on some emergent problems. So, the physician working in such environments need to be reasonably well versed in medicine, surgery, paediatrics, obstetrics and laboratory examinations. A rotating house job for one year does not provide such ability.

So then what can be done to provide physicians for the rural health centres? First, let the privatised facilities develop their own guidelines, pay scales and experience to hire physicians based upon their requirements. For those facilities that are still run by the government, a way to adequately staff them with appropriately trained doctors will require some form of planning. The first step is to accept the long standing demand of the Young Doctors Association (YDA) and create a proper professional pathway for doctors.

Doctors should be inducted into a rural healthcare cadre. First they should undergo at least two and a half years of intensive multi-specialty training and only then should they be posted in rural dispensaries and health centres. Based upon their pre-appointment training they should be encouraged to complete a Fellowship of the College of Physicians and Surgeons (FCPS) in the specialty of ‘primary care’. Two years in a rural health centre should allow them to take the examination for FCPS and if they pass, they should get a higher pay grade. Besides adequate remuneration, facility has to be provided to do ‘private practice’ to augment the government salary.

After a predetermined, option to be transferred to a larger hospital should be available. However, if adequate salary and private practice is available, many physicians might opt to stay in one place. Here it is also important that some mechanism for continuing education is in place to familiarise these physicians with the latest developments in medicine. Two unique problems will become evident as time goes on. First is initial posting of doctors to a particular area. Clearly non-medical issues like location, security, access, closeness to a major city, living conditions and eventually educational facilities for children will all become important considerations. The second problem will be that relatively lucrative posting from a private practice point of view will become desirable and things like nepotism and even direct payments will come into play.

Another extremely important variable that will determine success of any rural healthcare programme is going to be the support facilities available. Even the best trained and dedicated physician cannot function without nurses, pharmacists and well stocked pharmacies, functioning laboratories and medical support from specialists available at accessible government hospitals.

A majority of doctors graduating from medical colleges happen to be women and that many of them will never practice medicine is a fact. It is also true that the public sector medical colleges spend a lot of money educating doctors and that many of these graduates will never practice medicine is indeed unfortunate. But then what about all the doctors that took civil service examinations and joined the bureaucracy. Perhaps, they should fork out some money for starters.