Medical education is in the news for all the wrong reasons. The government's decision to extend reservations in institutions of higher education under the Centre triggered off a storm of protest, led by medical students. What has been lost in the heat and dust of the protests are fundamental issues. Is privatisation of medical education hurting the capacity of the system to deliver quality care to the majority of people? Is the quality of education good enough? And, of course, why is the state health education sector on the brink of collapse?
Medical education in India does not address larger social needs for health care
Health education should be sensitive to health care
That India is short of doctors and paramedical staff in absolute terms is hardly news. But behind bare statistics is another story. There is a big skew in the distribution of health care personnel -- for instance over rural and urban areas. And, equally important, there are serious questions about the training doctors receive in terms of its utility for different categories of diseases and, therefore, delivery to different categories of people.
Let's take a look at the big picture in terms of numbers. who's World Health Report for 2006 shows there is a global shortage of health professionals. The greatest shortfall occurs in south and southeast Asia. India, Bangladesh, and Indonesia top the list. The number of registered doctors in India has increased from 61,800 in 1951 to about 645,825 in 2005 -- that's 0.60 doctors for 1,000 people. Compared to this, Cuba had 5.91 doctors for 1,000 people in 2002.
The Joint Learning Initiative, a global health network launched by the Rockefeller Foundation suggests that, on an average, countries with fewer than 2.5 health care professionals (doctors, nurses and midwives) per 1,000 population fail to achieve an 80 per cent coverage rate for deliveries by skilled attendants or for measles immunisation. India has 5.9 doctors, 0.8 nurses and 0.47 midwives for 1,000 people, which adds up to 1.86 health workers for 1,000 people.
Apart from the fact that this figure falls considerably short of the desired figure, it also does not indicate the distribution of health professionals and does not, therefore, show how supply relates to demand. The statistics for the state sector reveals a pathetic scenario. According to the Union ministry of health and family welfare's (mohfw's) Health Information of India , 2004, the the country had 67,576 government doctors: meaning one doctor was serving roughly 15,980 people.
The current availability of doctors does not meet the recommendations of several past committees. In 1946, a committee headed by Joseph Bhore, an Indian Civil Service officer, had suggested one doctor for 1,600 people; another committee in 1948 had recommended one doctor for 1,000; and an Indian Council of Medical Research-Indian Council for Social Science Research joint panel had recommended in 1980 that six general practitioners and three specialists should be available for 100,000 people. As far as specialists are concerned, the situation on the ground comes nowhere near meeting this figure. The government's estimated requirement of specialist surgeons, obstetricians and gynaecologists, physicians and paediatricians in 2001 for community health centres in rural areas is 12,172, but only 6,617 positions have been sanctioned and 4,124 positions have been filled.
An Escorts Heart Institute and Research Centre document prepared in 2005 said India would need at least one million more qualified nurses and 500,000 more doctors by 2012.
If one looks at the distribution angle, the situation is worse. The World Health Report for 2005 showed that one doctor might be responsible for more than 200,000 people in some rural areas. The urban-rural skew is well illustrated by Chandigarh, a predominantly urban area, where one government doctor is available for just 654 people, which is the best figure in the country.
The striking feature of this statistic is that there is no necessary statewise correlation between the number of medical colleges and the availability of doctors. Maharashtra, which has the highest number of medical colleges, one government doctor services 20,010 people. In Andhra Pradesh, which has the second highest number of colleges, there is one government doctor for 13,468 people. Unsurprisingly, both these states have a large number of private medical colleges, which typically do not send doctors to the state health sector (see table: Private matters; see graph :Growing pains).
The growth of the private medical sector is bleeding public institutions. The All India Institute of Medical Sciences (aiims) has been nominated as the top medical college in the country in 2006 by an India Today-AC Nielsen- org - marg survey. But even aiims is facing a shortage of manpower. The minister of state for health and family welfare, Panabaka Lakshmi, told the Rajya Sabha on May 12, 2006, that the college had 479 faculty members against a sanctioned strength of 543. During 2003-2005, 20 faculty members either resigned or took voluntary retirement. In 2006, V S Mehta, head of neurosurgery, Anoop Misra, professor of medicine, and S N Mehta, head of surgery, have joined private hospitals. Lakshmi said this level of attrition was normal at a centre of excellence.
Clearly, if aiims cannot hold on to faculty members, it is unlikely other institutions, especially those in smaller centres will be able to do so. This is, in fact the case, with grievous repercussions.
In view of the shortage of doctors in the state sector, there is an obvious need for a revamp of the medical education sector to redress the balance between private and public medical colleges, to meet the needs of public health. At present, private colleges, which number about half the number of medical colleges, reserve some seats at subsidised tuition fees. But the number is small, which puts a big strain on government colleges, given the limited public funding on medical education. Public debates, unfortunately, miss the big issues.
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