India faces a poor healthcare scenario and  huge shortage of doctors is alleged to be underlying cause. They say it needs to desperately ramp up the output from medical colleges . Will more doctors mean better healthcare for India’s 1.3 billion? A closer look at the facts raises serious doubts. It’s rural areas and government hospitals that need more medicos, and there’s no evidence to suggest that graduates from for-profit colleges (even govt colleges) will bridge this gap. Increasing medical seats in medical colleges can’t help address this shortage. Will city kids trained in technology-intensive settings and metropolitan culture take to serve the poor rural masses? Quite often we meet un-employed doctors in big cities scouting for petty contractual jobs.
According to a WHO report on India’s health workforce, based on the 2001 census, the number of doctors with medical qualifications was 2.7 lakh, 82.6 per cent of them in urban areas. By rough estimates, India has over 9 lakh doctors now for a population of about 1.3 billion, a ratio of one doctor for roughly every 1,450 people against the WHO recommended norm of one per 1,000. In 2011, 31 per cent of Indians lived in urban areas. Assume it’s now a third of the total or about 430 million.  Assume also, that only 70 per cent of the doctors now are in urban areas. That would still mean 6.3 lakh doctors in urban areas against the need for 4.3 lakh. That’s an extra 2 lakh or nearly 50 per cent more.  So the problem is with the distribution of doctors and not with their numbers. Many doctors especially retired but otherwise fit and a large number of freshly qualified doctors remain in a state of unemployment, but continue to live and try for settlement in the cities.

Even in the urban areas the service conditions and working condition of doctors are not very attractive. Many are offered contractual jobs with no security of service and wages being paltry. No doubt more than a quarter of CGHS posts of general duty medical officers (381 out of 1,383), all in urban areas, are lying vacant.  Health minister JP Nadda recently told the Lok Sabha.’Hundreds of posts are lying vacant in top government hospitals including AIIMS. Even in PGI several faculty jobs remain unfilled. The reasons for these vacancies listed by Nadda included low rates of joining of those recruited and non-availability of eligible SCST candidates for reserved posts. The low rate of joining could be due to poor working conditions or inadequate professional incentives. The non-availability of SCST candidates certainly can’t be ameliorated by more private colleges with no caste reservation. If anything, it could exacerbate the problem.

In contrast, in rural areas there would currently be at best 2.7 lakh doctors to serve close to 870 million people, or one doctor for about 3,200 people. To meet the WHO norm, rural India needs 6 lakh more doctors. More than half of all MBBS seats are now in private colleges. It’s irrational to expect that more such colleges will bridge this gap. That’s not to suggest products of government colleges are eager to serve in rural areas. More than 65 per cent of medical seats are in government colleges, even today.
India’s high infant mortality rate (IMR) and maternal mortality rate (MMR) are also cited to argue for a rapid expansion of medical education. But that’s just not logical. Most maternal deaths happen among poor and illiterate women, who do not avail hospital facilities anyway. Research unambiguously shows that the bulk of maternal deaths can be avoided by improving socio-economic status, level of education; nutrition, antenatal care, early referral, and quick and well equipped transport facilities. None of these are dependent on doctors.  More than half of IMR is neonatal mortality or death within the first 28 days of life. Prematurity, low birth weight and neonatal infections account for the bulk of these. Breastfeeding, safe water and increased immunization coverage can help more than doctors in bringing down IMR. Incidentally, Delhi, with its high concentration of doctors, also has the highest IMR of 40 among metros  while Manipur, Meghalaya, Sikkim and Tripura, where doctors are scarce, have IMR ranging from 30 to 22.
A global study on a range of health indicators has ranked India 143rd among 188 countries, citing various challenges, including high mortality rates, malaria, and hygiene and air pollution. India was placed just ahead of Pakistan and Bangladesh which were ranked 149th and 151st respectively. India’s poor performance on Swachhata and air pollution was among the factors that placed it lower than countries like Bhutan, Botswana, Syria and Sri Lanka. “For malaria, which was one of the health indicators assessed, India merely scored 10 points and remained in the red zone. Similarly for hygiene, the study gave India just eight points, while for PM 2.5 levels it scored just 18 points. For under-five mortality India scored 39 points while for Maternal Mortality Rate (MMR) it scored 28 points. India, however, scored above 80 points for performing well in areas like Tropical Diseases, which are a diverse group of communicable diseases, overweight and alcohol consumption. There have been only minimal improvements in Hepatitis B incidence rates, while childhood obesity, intimate partner violence and harmful alcohol consumption have worsened.

In short, there’s a lot more to tackling India’s biggest health issues than simply increasing the output of doctors. The quality of practical training to medical students also requires a sea change. Improving doctors’ skill and empathy is more important than their numbers. The experience of Sri Lanka, Thailand and Iran also shows that much better health outcomes are possible even in developing countries with less than one doctor for every 1,000 people.

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