So in 1956, ignoring dissent from six of its members, the Bhore Committee recommended a halt to the training of Licentiate Medical Practitioners. This was taken up by the government of the newly independent India and the Licentiate Medical Practitioner was eventually abolished entirely in favor of a single grade of doctor—the idea being that they would train so many new doctors that the country wouldn’t need a lower grade professional.
Things didn’t really go to plan, as 2015’s rural-health statistics show. Yet the Indian Medical Association has repeatedly condemned the mid-level practitioner idea. When the West Bengal government introduced a three-year training program for rural practitioners in the mid-1980s, the Association mounted an attack. “We had several demonstrations and rallies. Ultimately, because of the IMA's strong opposition, the government had to stop it,” says Dubey.
In 2005, an Indian government task force recommended a new three-year Bachelor of Science course for health-care professionals to meet the physician shortfall in rural areas. The plan was approved by the Indian cabinet, but hasn’t yet been implemented by the Medical Council of India, the country’s top medical regulatory body.
Chowdhury is exasperated. “The Indian Medical Association is a clan of Brahmans,” he says, referring to the most elite caste in ancient Indian society, who considered themselves intellectually and spiritually superior to others. “They never listen to any argument, any reasoning, any justification.”
The Indian Medical Association may continue its campaign against rural practitioners, but others have bought into Chowdhury’s ideas. Not least Jishnu Das, an economist at the World Bank, whom Chowdhury approached in 2012 to help assess the impact of the Liver Foundation’s training. According to Das, Chowdhury, unusually, wants to use research to understand the efficacy of his own program, rather than merely prove it to others. “I still remember him telling me that they wanted the evaluation protocols firewalled from implementation, so that there was no chance of contamination. He was very clear: ‘We don’t know whether this program is doing harm or good, and we need to know. Once we have the results, we can see whether it’s an improvement or whether we should just shut it down.’”
Das has since run a randomized controlled trial comparing the quality of care of rural medical practitioners trained by the Liver Foundation with care from qualified doctors. The results are not yet available. But Das’s previously published research does show the rural practitioners in a good light.
A 2015 study found that, contrary to popular belief, unqualified doctors weren’t the sole source of unnecessary treatment. Das and his team sent 22 patients coached to present symptoms of three diseases to qualified and unqualified rural doctors. The team then graded their abilities to accurately diagnose and treat the diseases. They found, not surprisingly, that qualified doctors provided correct treatment about 30.9 percentage points more often than unqualified ones. But there was a bombshell: Qualified doctors were 26.7 points more likely than unqualified providers to prescribe needless antibiotics to patients. Unqualified doctors indulged in overtreatment too (several other studies confirmed that over-prescription was indeed a big problem among rural practitioners), but the unnecessary medicines they prescribed were typically over-the-counter drugs such as vitamins. During interviews, Das says, the rural practitioners seemed wary of prescribing strong antibiotics, whereas qualified doctors showed lesser caution.