Relevance of Bridge Course from Bachelor of Dental Surgery to Bachelor of Medicine and Bachelor of Surgery—Is it a Valid Option to Aid Improve Rural Healthcare Scenario in India? A Questionnaire Study

INTRODUCTION

Health care is one of the key indices in determining the nation’s economic and societal well-being. India is one of the developing nations with a dearth in the population versus healthcare worker ratio. With increasing levels of privatization, health care is one of the mainstream departments that have seen drastic degrees of privatization with the best healthcare facilities centered in the urban areas. Currently, about 75% of the health infrastructure including manpower and medical resources is centered in the cities where only 28% of the Indian population resides.¹ Considering the large volume of the Indian population still residing in the rural/two-tier cities (82%), with a continual rise in the counts of contagious and noncontagious diseases, the demand for healthcare needs in these areas is seeing a steep increase. Though various strategies are being implemented by the government to improve the rural healthcare facilities, deficiencies still persist due to the alarming rate of increase in population in these regions as a result of which meeting these demands presents as a huge challenge. It is essential to provide the best of healthcare facilities in rural areas considering India being an agriculture-driven economy and humanitarian concern. Continual improvement in the economy, rural infrastructure, and access to technological advances is important to cater to the medical needs of the rural health population. However, lack of manpower to cater to the rural healthcare system has been a greater challenge to circumvent.

Irrespective of the volume of medical graduates exiting every year, the perennial dearth in the ratio of doctors to population is evident in the rural health setup with minimum doctors working in the rural areas.² Nonequitable distribution of the medical infrastructure with overcrowding of the urban areas has been considered the primary issue with a definite lack in the availability of medical graduates in the country. To circumvent the later issue, the proposal for introducing new medical courses in the form of Bachelors in Rural Health Care (BHRC) was put forth; however, it was not adequately supported considering the retrograde nature.¹

To circumvent these foresaid issues, in 2016, the government had proposed the bridge course for Bachelor of Dental Surgery (BDS) graduates with an agenda to increase the manpower in the rural health sector. Though this proposal has received considerable opposition, it should not be ruled out considering the persistent dearth of healthcare workers at a grassroots level.

We consider that among all the medical/paramedical personnel, dental professionals could be well-suited beneficiaries for bridge course considering similar comprehensive training in basic and clinical medicine. However, this process of bridge course is extremely challenging considering the hurdles that include the additional medical subjects that they need to be trained in, ability to work in minimally equipped health center, the future of these graduates, and possibility of their interference with the career of medical graduates. Considering the foresaid facts, we thought an insight of the medical, dental practitioners and graduates on the pros and cons of the same, will be beneficial as they will provide baseline ideas and issues that need to be addressed prior to consideration of implementing bridge course. Thus, the aim of our study is to bring forward the opinions of the medical and dental fraternity and students on the bridge course for dental students to improve rural health care in India and analyze the pros and cons of the same for the both the fraternities and the beneficiaries (BDS graduates) and the healthcare system as a whole.

MATERIALS AND METHODS

This study followed a cross-sectional study design conducted between May and August 2019. The objective was to generate the opinion of the medical and dental fraternity regarding the benefits, limitations, and hurdles of introducing “bridge course” to meet the shortage of doctors in the country, especially to serve in underserved areas. A questionnaire study was conducted that was answered by the fraternity and the trainees from medical and dental hospitals in government sector and private sector. These colleges were chosen randomly by drawing a lot from a list of dental and medical colleges. The staff, undergraduate, and postgraduate students formed the study population. After explaining the objective of the study, a predesigned, three-page questionnaire comprised of 19 questions (Table 1) was distributed to those who were willing to participate in the study. The data were then computerized and categorized on the basis of their field of practice. The questions were mainly based on the pros and cons involved in bridge course for dental graduates.

RESULTS

A total number of 541 professionals took part in the survey with a major contribution from the medical graduates of 37.9% followed by BDS graduates of 30.0%, 22.9% of Master of Dental Surgery (MDS), and 8.9 % of medical postgraduates. A total of 91.3% of the population in consideration was aware of the proposal of bridge course for BDS graduates. About 53.1% of the population in consideration opines that there is a feasibility to train the BDS graduate to practice family medicine in rural areas. Most of the registrants opine that the current teaching (68%) of basic medical sciences at the dental colleges is inadequate and an additional training of 3 years (58%) is essential to enable a BDS graduate to practice family medicine. Gynecology, family medicine, and emergency medicine were considered the most important specialties that the graduates need to be trained in as a part of their curriculum that reveals that modifications in the medical curriculum are necessary to effectively utilize the training time frame. There is no definitive consensus over issues including legal bonding restricting the practice of bridge course graduates to rural areas and the adequacy of current rural healthcare setup to support the practice of family medicine by dentists. However, majority of the participants opined that the curriculum should be restricted to government institutions, and their admissions should be merit-based with even postgraduate dentists given the eligibility for the program (60.4%). A total of 64.7% of them support specialization benefits for these graduates.

Majority of the participants opined that both the statutory bodies of the Medical Council of India (MCI) and the Dental Council of India (DCI) should be responsible for endorsing these graduates and dealing with medicolegal consequences. Varied branches have been proposed to be added to the curriculum with gynecology and emergency medicine being the cornerstone of practice.

The foresaid results are summarized in Tables 2 and 3 and Figures 1 to 3, for easier comprehension. Majority (94.4%) of the participants considered that bridge course may be a good tool to provide equitable distribution of healthcare workers in rural areas.

DISCUSSION

The healthcare system in India is extremely diverse with various forms of alternate medicine still in practice. Despite these, allopathy remains the cornerstone of the Indian healthcare system. The current Indian structure of public health care is a three-tier structure that was put forth in 1946 by the Bhore Committee regarding health.³ The primary contention was to provide basic preventive and curative health to the rural and the urban population. The subcenters (1 center for 5,000 people/1 center for 3,000 people) form the primary building blocks of this system. Each subcenter is the most peripheral contact of the healthcare system that is manned by one male Health Worker and a female Auxiliary Nurse Midwife (ANM) or healthcare workers to attend to the healthcare needs of 5,000 people in a rural area or about 3,000 people in hilly/tribal areas that are difficult to access. These subcenters work under the directives of the Primary Health Centers (PHCs) which are under the directive of the Community Health Centers (CHCs) affiliated to the government district hospitals. The PHCs and CHCs are established by the state government and form an integral part of the minimum needs program/basic minimum services that aim at providing primary health care at rural levels. Each PHC is manned by 1 medical officer and 14 paramedical personnel and is the referral center for three subcenters with an inpatient facility of 4–6 beds. The CHC is the next referral center that is equipped with specialty medical services and 21 paramedical personnel and acts as a fully operational referral center.⁴

Over the years, the National Health Policy (NHP 1983) of India aimed at providing PHCs to all by 2000. This was further built up by NHP 2002 that aimed at provision of health care to all by decentralization and the use of private sector to meet the healthcare demands. This mixed healthcare system inclusive of public and private healthcare providers has become a double-edged sword. While the healthcare facilities are extremely advanced, in par with international standards in the urban areas, the status of the same in rural/tribal areas is still the same. The National Rural Health Mission that was launched in 2005 took multiple steps toward the development of the rural health status including the employment of 27,421 doctors at PHCs and 4,078 specialists in the CHCs by increasing the medical graduate capacity by 54% and postgraduate medical seats by 74% between 2005 and 2013.^4–6

Despite these improvements in the healthcare system, the rural health has not seen the change that is envisaged in the urban healthcare facilities. Part of this may be attributed to the lack of ability to retain medical personnel in the rural health setup due to financial, lifestyle, and work pressure constraints.⁷ Apart from this inadequacy of medical personnel at the peripheral units leads to crowding of the tertiary referral centers, the CHCs and the district hospitals leading to a compromise in the quality of those can be provided for the patients.^7,8

A recent congress WONCA World Rural Health Conference held in New Delhi 2018 followed by consultation with various practitioners/academicians from India and abroad had proposed a four-point strategy to improve the rural healthcare setup which include a family-centered healthcare system, higher investments in health care, state-funded insurances for health care extended to PHCs, and empowerments of healthcare teams. Increasing the manpower, providing good wages, and access for continual improvement may aid in retaining trained medical professionals in rural health setup.⁹

Equitable distribution of healthcare workers is the first measure that needs to be addressed at the earliest to improve the rural healthcare needs. This can be augmented in case of need, to fulfill the existing deficiencies by bridge course for BDS graduates. This deficit in the healthcare system has been obvious during the current pandemic with dearth of doctors for fulfilling the duty, with dental graduates stepping up for the same. Bridge course may be an encouraging step that will provide a solution for the increasing demand of rural healthcare workers and also provide placement for an increasing number of unemployed dental graduates.

The proposal by the National Institution for Transforming India (NITI AYOG) was based on the fact that two major problems faced by the country will be solved. The first is acute shortage of MBBS doctors in the country, especially in rural areas. This may have an additional benefit in times of an epidemic or pandemic breakout as the bridge course doctors can be actively engaged in delivering medical services. Apart from this, dental students facing issues of recruitment after they complete their course can be addressed simultaneously.

Enhancing the current healthcare setup in PHCs by employing additional medical personnel through bridge course appears to be a lucrative option to reduce the rural healthcare burden. Employing a stringent curriculum including basic medical sciences with extensive training in the fields of family medicine, gynecology, obstetrics, and emergency medicine may aid in accomplishing the same. The training should be restricted to the government universities and colleges and entrance into the curriculum should be merit-based. These graduates may be facilitated to pursue specialty medicine; however, their practice should be restricted to rural health centers. This procedure can be enhanced by short- and long-term bonds similar to those followed in defense services. However, it is essential to ensure the retention of these personnel in the rural health sector to avoid mushrooming of these doctors in the urban/private hospitals. Apart from this, stringent care in maintaining a constant ratio between the demand and supply of these medical personnel should be regulated by the government to avoid career conflicts among the medical and dental graduates and the graduates of bridge course.

CONCLUSION

To conclude, addition of bridge course for dental graduates may be a lucrative option to enhance the current rural health setup, provided a stringent structured program can be orchestrated by the governing bodies with measures to retain these doctors in the rural healthcare system. However, due consideration of demand and supply of doctors should be in check to avoid exhaustion of human resources.

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