Health needs more care

By proposing a staggering, never-before increase of 10,000 medical seats in existing government medical colleges in five years, the Union Cabinet has made an important statement: that it is serious about health and recognises the need for swift and extraordinary strategies to improve the state of health services and human resources in India.

Media reports say that this increase will improve the doctor: population ratio from 1:2000 to 1:1000, address the country’s increasing burden of disease, and bring doctors to rural areas. Yes it can, but only if the government is also willing to address the numerous hidden challenges rather than follow the same old ‘business as usual’ paradigm in medical education. This increase needs to be understood in the context of ground realities that would impact the effective utilisation of this additional human resource.

First, let’s look at what this increase really means. At present, India produces around 45,000 graduates annually (Medical Council of India, 2011-12); if another 10,000 seats are in place, then by 2024 we will have an annual turnover of around 55,000 graduates. This will mean around 4 lakh new doctors in 10-15 years, in addition to the current pool of an estimated 6 lakh. So the increase in seats should definitely improve the current physician density of 0.65 doctors per 1,000 population. 

This ratio has meaning only when we compare it with other countries.  China, an important comparator, produces around 65,000 doctors annually, and has a larger pool of 1.9 million registered doctors.

It also has a higher physician density of around 1.5 doctors per 1,000 population. Even so, besides doctors, China has an additional 2.4 million registered ‘assistant doctors’, and around 1 million ‘village doctors’ (terms as used in China)!

Merely increasing the number of medical seats by 10,000 may not lead to improved health indicators unless the government is able to ensure universal access to quality health services in rural and tribal areas and urban slums.

 The present configuration of health services needs to be redesigned and provide competencies aligned with real health needs at different levels of the health system. It is critical to invest in developing mid-level and nursing cadres in the long run, and in the shorter period, to upgrade, strengthen and empower existing human resources in villages.

Over the years, thousands of Indian doctors have emigrated overseas and there is nothing to suggest that this trend will not affect the additional recruits.The government and the Indian Medical Association estimate that between 1,000 and 3,000 doctors migrate overseas annually, but in reality this could be more. India has not been able to put in place a system to track doctor migrations but the medical registers of other countries provide a good picture.

In the USA alone, 1,676 Indian doctors received ECFMG (Educational Commission for Foreign Medical Graduates) certificates in 2011; needless to say they formed the largest proportion of foreign graduates. By contrast, there were only 289 from China. If even 30 per cent of the new graduates decide to migrate overseas, we would have spent Rs 3000 crore subsidising `Obamacare’ or the UK’s National Health System!

Similarly, if the majority of these graduates get absorbed by the private commercial health sector in the better-off urban areas, their presence is unlikely to change the abysmal doctor: population ratios in rural and tribal areas that can be as high as 1:45,000.

To get maximum returns on the Rs 10,000 crore for the new medical seats, the government must get serious about introducing radical reforms in the country’s archaic public health system and transform it into an attractive proposition for young medical graduates and also post graduates. Not just salaries, but doctors’ living conditions and facility infrastructure will also need to be rapidly revamped, side by side with upgrading medical colleges.

There are other practical considerations. The current distribution of medical colleges in India, even of government medical colleges, is skewed in favour of the more developed states - 148 (41 per cent) of the 362 colleges recognised by the MCI are located in the southern states whilst the northern states (with poorer health indicators) including Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Uttar Pradesh and Rajasthan have only 70 (19 per cent). An increase of seats in existing medical colleges is also likely to benefit the southern colleges more, unless the distribution is carefully monitored to prevent further inequities.

To this end, the government has taken a welcome decision of setting up 58 new medical colleges (with an overall intake of 5,800 students) linked with district hospitals in under-served districts.

 This move should improve the infrastructure and quality of medical services in these hospitals. But it also raises concerns about the availability of sufficient good quality faculty.

Analysts in the National Commission on Macroeconomics and Health (2005) have shown that the greatest shortage of medical teachers is in the pre and para clinical specialities like anatomy, physiology, bio-chemistry, pathology etc. MCI allows only 30 to 50 per cent of non-medical teachers in these departments; the rest must be medical post-graduates.

Along with undergraduate medical education, the government and the MCI also need to conduct a review of post-graduate education to develop adequate medical faculty overall, to meet the post-graduate study demands of an increasing number of graduates, and to meet the health workforce requirements.

For example, a much-needed speciality like Family Medicine only exists as a post-graduate diploma and is not included in the positions at government primary and secondary facilities.

The MBBS curriculum has long been criticised for being too hospital-centred and tertiary care-oriented. Much of the practical learning happens in hospitals that are well-equipped with technology and diagnostic aids.

Students coming out of this system find it difficult to perform independently with limited diagnostic support systems in the general conditions of rural primary and secondary care settings.

Recognising the mismatch between medical education and health needs globally, a Lancet Commission on future health professionals’ education launched a new vision of medical education in November 2010:  one in which professional competencies will be adapted to local contexts while drawing on global knowledge, that will move beyond the silos of professional specialisations, and connect the education and health sub-systems.
Can India do this?

(Meenakshi Gautham, PhD, is Research Fellow with the London school of Hygiene and Tropical Medicine, New Delhi. Manish Pant, MD, is Adjunct Associate Professor at Public Health Foundation of India, New Delhi)