It's quality that matters

For the past few years there are frequent newspaper reports that India is facing a huge shortage of basic doctors to meet the WHO recommended minimum doctor population ratio of 1:1,000.

The ratio is used as the gospel truth by all Indian health policy makers and planners. A close scrutiny clearly indicates that the recommendations are somewhat arbitrary and on very weak scientific footing. The two parameters that have been used to arrive at the concept are the magnitude of coverage of measles immunisation and births conducted by skilled attendants. It is patently wrong to use these paramedic skills, which do not need physicians, as criteria to develop the notion of the minimum doctor population ratio. Yet, most probably overawed by the weight of the international agencies, the recommendations were just blindly accepted by the high level expert group (HELG)of the Planning Commission. The disastrous effects they would have on quality of medical education were ignored.

There is nothing sacrosanct about the recommendations. India has a doctor population ratio of 1:1,700 and infant mortality rate (IMR: infant deaths per 1,000 live births) of 53. IMR is a key index of the quality of health services. Sri Lanka and Thailand have doctor population ratios of 1:1,800 and 1:2,100 respectively. Yet, IMR in both the nations is about 12. On the other hand, despite better doctor population ratio (1:1,400), IMR in Pakistan is 34 per cent more than that in India.

The second and very serious weakness is that for computation of the ratio doctors of all hue and shades (generalists and specialists) have been lumped together, which is like putting apples and oranges together. Shortage of general doctors (MBBS) has been hyped as only 12 per cent PHCs are without doctors. On the other hand, the rural sector is facing acute shortage of specialists. Eighty per cent posts of specialists (surgeons, physicians, pediatrics,  gynecologists, etc.)  at the Community Health Centers, the first contact point of a villager with specialists, are lying vacant.  Therefore, even for minor ailments, people rush to urban medical centers. No wonder the outpatient of the AIIMS, New Delhi looks like a chaotic railway platform.

To be globally competitive and also to meet the demands of both urbanites and villagers, India must develop on a priority basis high tech medicine (ICU, cardiac bypass surgery, MRI etc), which requires specialists in the respective field.
India is passing through health epidemiological transition and life style related chronic disorders such as cardiovascular and neurological disorders, cancer and diabetes now form substantial disease burden. Patients of these disorders require continuous long term interaction with specialists; ordinary MBBS lacks the requisite expertise. Take for example cancer, which is today the fourth cause of adult mortality in India. At any given time there are 2.4 million cancer patients and about 1 million fresh cases are diagnosed every year in India which faces sever shortage of oncologists. We have only 1,500 oncologists, which is only 10% of their number in the USA. This should be true for other life style disorders.

Shortage of specialists

India is actually facing acute shortage of specialists not so much of generalists. It takes years of high quality medical education to create specialists and super-specialists. Innovative approaches, like making rural posting a part of MD/MS and superspeciality training, need to be seriously considered to make their services available to rural folks on priority basis. Instead, at the whims of the Health Ministery duration of rural posting of medical students is arbitrarily increased. Poor state of rural health is not so much due to shortage of basic doctors but due to mismanagement and rampant corruption. Not very long ago the Uttar Pradesh government was accused of fraud to the tune of Rs. 10,000 crores in India’s flagship health program, the National Rural Health Mission.

Sixty-year old Bhore committee’s recommendations are still the guiding force for rural health services in India. Keeping in mind the state of medical sciences and changing health scenario it is time to revisit the recommendations. It is unscientific to use a single doctor population ratio to project health manpower requirements. They should be defined separately for each category - generalists, specialists and superspecialists.
Annual budget of the AYUSH is about Rs 1,000 crore. India has some 7.8 lakh registered AYUSH doctors. If they are taken in to account, and there is no reason why they should be excluded, the doctor population ratio in India will be 1:750 which meets the WHO recommendations. Do we then really need more new medical colleges?

There cannot be a total moratorium on starting of a new medical college but the decision to create huge number of new medical colleges in not justified. Instead, it is now time to focus on quality of medical education.  Of course establishment of a new medical college is a huge money making business. Not very long ago the Medical Council of India was dissolved for corrupt practices.  One is never sure of the length and breadth of the corruption trail.

India urgently needs specialists and superspecialists, shortage of basic doctors at the PHC can be met without increasing the number of medical colleges. It is time to evolve strategies to improve quality of medical education to make it globally competitive.  There should a national debated on all aspects of doctor population ratio. Unfortunately, for reasons best known to them, the planning commission, MCI and MOH are all shy of having the debate. A nation of 1.2 billion is surely capable of making its own decisions and does not have to use international organizations as it crutches.  Cabinet decision to create huge number of poor quality medical colleges is a recipe for disaster in medical education, and needs to be revisited.

(The writer is vice president and secretory, Moving Academy of Medicine and Biomedicine, Pune)

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