Chennai: The ratio of doctors versus patients in India is on an all-time kink. How do we make doctors and treatment accessible to the needy? Will ‘health for all’ become a reality in India? India Medical Times spoke to medical professionals to find out an answer to these questions.
Despite the government’s vow of ‘health for all’ and ‘nutrition for all’ there has been a perpetual imbalance in the quality of medical education and delivery of healthcare systems in India. There are many factors that drive the imbalance such as the low quality of healthcare infrastructure and lack of physicians. Based on the WHO guidelines the ideal doctor-patient ratio is 2.8 per thousand people. But the current ratio in India stands at 1:2000 and could touch the set limits only by 2031. We have 1.5 hospital beds per thousand whereas the WHO recommended ratio of hospital beds is 3.3 per 1000.
Dr Guru Prasad Mohanta, professor, department of pharmacy, Annamalai University, listed reasons for the disparity and ways to bridge the gap. “The healthcare sector is a service sector. It does not earn revenue and so has remained a neglected sector. The government has failed to raise resources for improving the scenario. Hopefully, the universal health coverage scheme in the current five-year plan would address some of the issues including the human resources. The different tiers of the health system from primary to tertiary with different expertise and facilities will enable us to address the issue effectively. We can balance it by having different tiers of health workforce. The government initiative of starting rural medical course is not making any headway. The already available staff like pharmacists and nurses can be little more trained to make them eligible to prescribe in primary care centres where we have lack of doctors.”
Dr N Ramakrishnan, vice president, Indian Society of Critical Care Medicine, said the migration of qualified doctors to other countries is a major reason for the significant void in the number of medical professionals in India and the resulting disproportion. “A significant proportion of qualified doctors leave the country in search of greener pastures and some doctors pursue careers that do not directly provide clinical care to patients, such as administrative roles, pharmaceutical industry, healthcare informatics etc.”
India enjoys a towering status in the number of medical colleges. There are 387 medical colleges in the country. Out of them 181 are in the government and 206 in the private sector. The total number of medical seats is 51,979 for MBBS and 23,931 for PG courses. But this is not enough even to reach out to one sixth of the country’s burgeoning population.
This disparity has resulted in a dispiriting clinical scenario. The healthy life expectancy in Indians is 55 years whereas it is close to 70 in other countries like China, US and Japan. About 40 per cent of deaths in India are due to infections. The country is often considered as the diabetic capital of the world. It is estimated that about 100 million Indians will be diagnosed with type-2 diabetes in 2040. All this is because the mainstream public healthcare does not reach the needy. The system is incompatible to serve the requirements and has not been reformed for years. The National Health Policy was last updated in 2005. Initiatives such as the National Rural Health Mission with the aim to provide effective rural healthcare to 18 needy states boosted high hopes but have failed to work. With public funded healthcare initiatives barely getting off the launch pad, today about 70 per cent of the overall health spending in India happens only through private service providers.
Dr Ramakrishnan pinpointed the reason and the government’s inaction to better the situation. “It is obvious that the doctor: patient ratio is currently inadequate in India. But as in most countries, the rural-urban gap of healthcare is even wider. Much has been debated about the introduction of Bachelor of Rural Medicine and Surgery (BRMS) course to bridge the gap and make such community healthcare providers available in rural areas.”
On the government’s part, felt Dr Mohanta, “more allocation should be made to the health sector. The amount of allocation should be directly proportionate to the country’s population and the total revenues to see a visible change. Health has been accepted as fundamental right. Both central and state governments have a lot to do to improve the healthcare system.”
Dr Ramakrishnan suggested the following alternatives to address the shortage of doctors — skill development of nurses to cater to some of the needs in the community; training of mid-level providers such as physician assistants and nurse practitioners to work under the supervision of physicians; and the wider adoption of telemedicine and tele-education.
Dr K Ganapathy, president, Apollo Telemedicine Networking Foundation, said, “Innovative, out-of-the-box thinking will only bail us out of the huge kink in the urban-rural divide in our country. We need to capitalise on our other assets namely the phenomenal increase in the information and communication technology. Telemedicine is the only way in which healthcare can be made available in suburban and rural India. Technology has clearly demonstrated that today distance is meaningless. Remote monitoring and virtual visits are eminently feasible. Pilot projects and proof of concept studies have been carried out for the last 13 years in different parts of India. Unfortunately, it has still not been scaled up and is not being used either by patients or doctors. Perhaps more importance has to be paid to WiiiFM (What is in it For Me!).”
At the grassroots level, both government and private medical colleges should provide equitable quality of education. Dr Mohanta said that there should be more transparency in the admission procedures and more quality upgrade in terms of curriculum in private colleges. However, adding more colleges would be a viable solution in the long haul.
“It is necessary not only just to produce more human resources but to serve the people too. Even the private medical colleges have affordable and free medical facility. In a commercialised scenario, the treatment offered in medical colleges is assumed to be more rational because these are transparent procedures. The clinical teachers are being observed by their students, the future doctors. They are duty-bound to explain the rationality of the treatment,” Dr Mohanta said.
Dr Ramakrishnan was of the view that infrastructure in government medical colleges should be enhanced to give the students adequate exposure. He suggested active role for corporate hospitals and policy changes to facilitate smooth flowing of processes.
“Private and big corporate hospitals have infrastructure and large volume of patients and several of them are getting affiliated to the National Board of Examinations and offering speciality training in postgraduate medical courses. To quote an example, training in infrastructure intense specialities such as critical care was initially started in private hospitals, and only recently the Medical Council of India (MCI) has approved this sub-speciality and government institutions are the first ones to start offering DM Critical Care. It would be appropriate to tap the availability of experts in private hospitals to train more critical care specialists, as it would otherwise take a long time if we relied only on government institutions to offer such training. There are other issues too, whatever the number of doctors available, these are skewed in the favour of urban areas,” he added.
Dr Ganapathy suggested a paradigm shift in approach. “What is urgently needed is a massive campaign on a war footing, to draw the attention of all stakeholders in the ecosystem that telemedicine can make all the difference – whether it be for virtual rural postings, for tele CME (continuing medical education) programmes, for tele-education, for tele-mentoring, or for remote-examination and diagnostics. ‘Tele’ should form part of every healthcare provider’s armamentarium.”
by Vijayalakshmi Sridhar