Clear and present medical crisis: India has few doctors to treat its people

The country has one government doctor for 11,000 people. The WHO recommends one doctor for 1,000 people. The situation is worse in rural India where a government doctor serves over 30,000 people

The government aimed to radically reform India's healthcare system with the National Medical Commission (NMC) Act, 2019, which the Lok Sabha passed recently. The legislation was met with protests, and the controversy shifted attention from a core problem: India's acute shortage of doctors. The Act sought to replace the Medical Council of India (MCI) with a new organisation called the National Medical Commission (NMC). While most MCI members were doctors, NMC was to have more technocrats. It sought to rein in India's much-maligned medical sector. But many doctors, feeling their interests were undermined, went on a strike against it.

The need for reform

Lawmakers have long felt that MCI failed to regulate the medical profession without bias or favour. "MCI, as presently elected, neither represents professional excellence nor its ethos. The current composition of the council reflects that more than half of the members are either from corporate hospitals or in private practice," said the Standing Committee on Health and Family Welfare in a report presented to Parliament in March 2016.

"Even doctors nominated to represent the state governments and the central government are nominated from corporate private hospitals which are not only highly commercialised and providing care at exorbitant cost but have also been found to be violating value frameworks," it said.

"During my years in the health ministry, we noticed that MCI (as well as the state medical councils) were reluctant to take action against errant doctors when complaints of negligence, malpractice and unethical conduct were received," said Shailaja Chandra, former secretary in the ministry of health and family welfare.

"The MCI, as an elected body, did not want to antagonise doctors. The NMC Act gives an opportunity to reorient curriculum and medical teaching. The outcome depends on the overall mandate given to nominated members of the NMC and their own predilections."

"The National Medical Commission will perform very well if the members are conversant with the country's demographic, economic and social developments in the forthcoming two decades; the needs of a fast-ageing population as well as existing and emerging public health challenges. The members of the Commission and its expert bodies will need to formulate a curriculum which is of contemporary relevance and capable of responding to both public health needs and new areas of clinical specialisation," she said.

The missing doctors 

But can the new law address the core problem: the huge shortage of doctors? According to government statistics, there are just over a million doctors registered with the MCI and various state medical councils. The country has 479 medical colleges: privately and state-owned. The number of doctors has increased by around 38 per cent since 2009, but the number of medical colleges has increased by 60 per cent during this period. 

In India, there is one government doctor for 11,000 people. The World Health Organization (WHO) recommends one doctor for a thousand people. The situation is worse in rural India where a government doctor serves over 30,000 people. In urban areas like Delhi, there is a doctor for every 2,000 people — far better than any other state in India, and yet below WHO standards. The poorer a state is, the worse its residents fare in terms of access to medical professionals.

The number of people served by a government doctor in Uttar Pradesh and Bihar is, respectively, twice and thrice the national average. The gravitation of doctors to the more lucrative urban markets is exemplified by West Bengal. The state has a better doctor-to-population ratio than the national average, but the same ratio in its rural parts is twice as bad as the national average. In the midst of this shortage, Indian doctors are flocking to the lucrative developed world. While there are just over 27,000 government doctors in rural India, there are over 22,000 Indian doctors - those who obtained a degree in India - in the UK. There are almost 50,000 Indian doctors in the US - comprising almost 23 per cent of the country's licenced medical practitioners. About 4,500 government doctors moved to India's rural areas through a decade from 2007 to 2017. Meanwhile, there were 6,500 more Indian doctors practising in the US in 2016 than in 2006. In half the period, the US witnessed far greater accretion of Indian doctors than did India's rural parts.

Expensive medical education 

A primary reason for doctors leaving India seems to be expensive private medical education. Certain private colleges in the country charge more than Rs 1 crore for a five-year undergraduate MBBS programme. A two-year MS General Surgery programme costs Rs 1.15 crore. In a country where per capita income is around Rs 1,20,000 per annum, medical education can be prohibitive.

As a result, students are flocking to other countries for cheaper medical education. According to the National Board of Education (NBE) statistics, more than 50,000 students from India went abroad for medical education between 2015 and 2018. Of these 20,314 went to China, 11,724 went to Russia, 8,130 to Ukraine, 5,335 to Kyrgyztan and 5,894 to Nepal. When these students return home, they have to pass the Foreign Medical Graduate Examination (FMGE) to qualify to practise in the country. Barely a fraction of such students pass the test.

For students who got their degrees from Russia, just about 1500 - or 13 per cent of these students -managed to pass the test to qualify to practise. Similarly, just about 12 per cent of the students who got their degrees from China managed to qualify. According to the new Act, any student with a foreign medical qualification will have to pass the National Exit Test on coming back to India in order to qualify to practise as a doctor here. 

The rot in the system

India's state-owned medical colleges, among the country's best academic institutions, charged subsidised fees. But privately owned institutes have far outstripped their growth, leaving many people with few options other than turning to expensive private colleges, many of which until recently were charging the now-outlawed "capitation fees" running into several lakh or crore of rupees. It would not be fair to say that students from the much cheaper government colleges aren't also moving abroad.

According to a 2016 study by the US Federation of State Medical Boards (FMSB), the largest number of Indian doctors in the US had obtained their degrees from Osmania Medical College in Hyderabad, a state-owned institute that admits 250 students each year and charges a fraction of what the country's private medical colleges do.

Many of India's money-spinning private medical colleges are owned by politicians - that is seen as a deterrent to setting up a common academic framework for quality education. When the Narendra Modi government introduced a common medical exam for the country in 2016, Tamil Nadu was up in arms. A handful of politicians and their family members in the state - including those from the ruling All India Anna Dravida Munnetra Kazhagam (AIADMK) and the Opposition Dravida Munnetra Kazhagam (DMK) - have interests in the medical education business. The Modi government, through the new legislation and subsequent executive actions, also wants to radically alter the nature of medical education in the country.

Stemming the rot 

The government plans to set up 72 state-run medical colleges in districts with no such facilities by 2021-22 at an expenditure of Rs 24,375 crore. The new Act itself has various provisions to regulate India's medical education system. It envisages setting up medical undergraduate and postgraduate education boards in addition to medical assessment and an ethics and management board to oversee the medical education ecosystem. The new law will also regulate the fees in half the seats in private medical colleges.

But can these measures do enough to address the pressing shortage of doctors in the country? A 2017 paper published by Basant Potonuru in the India Journal of Public Health said India would be unable to achieve the WHO target of a doctor for every 1,000 people even by 2030. Potonuru's paper said that reaching the WHO target would require the registered stock of doctors to "grow by 151 per cent in the 20-year period from the stock of 2010. Given that only 14.41 per cent growth was achieved in the stock between 2010 and 2014, a rate of 151 per cent for the rest of the 15-year period looks like an impossible target to achieve."

Chandra said, "The government recently announced that 72 new medical colleges would be established. That will certainly improve avenues for medical education but the existing shortage of medical teachers and the lack of patients in already functional colleges will still have to be overcome. Unlike other skills which can be learnt through books, simulation and internet-based learning, doctors must largely learn skills by watching and practising under the supervision of medical teachers. They need patients to watch how treatment is given in out-patient departments, patient wards, operation theatres and intensive care units. The shortage of teachers and patients will be faced by the new medical colleges."