Guest column : Doctor ‘scarcity’ a crisis of numbers or leadership? #UHC

27 Apr

Dr Raman KumarA recent article in the Indian Express reported statistics from India’s National Health Mission to highlight what it called “a debilitating shortage” of health specialists in the country. In doing so, it only reaffirmed what several experts, committees, and policy wonks have said all along: India needs more doctors.

For the longest time, India’s healthcare problem has been defined as one of numbers. Doctor demand outstrips supply, we are told. The accent has been on creating supply (predominantly in the private sector) to address this perceived shortage. I use the word “perceived” because the problem does not lie in numbers alone. What India faces is a full-blown leadership crisis caused by the systematic undermining of primary care physicians and the disproportionate clout wielded by super specialists in medical regulation against the backdrop of a lacklustre public health system.

The wasted years

By 2030, India will have one million additional MBBS doctors at the rate of 50,000 a year. At 380, India has the largest number of medical colleges in the world. Ideally, with the right sort of training, a good number of them should be deployed at the frontline of healthcare – swelling the depleted ranks of primary care physicians who are the first port of call for patients.

Yet, this country of 1.3bn seems to not know what to do with them. A large section of newly-qualified physicians spend several years being unemployed or under-employed.

Just consider. What does the average MBBS doctor face at the other end of five gruelling years of study, and, in many cases, the expenditure of lakhs of rupees?

Contrary to the perception that newly-minted doctors shun the public system, the fact is that resource-starved, inefficient public healthcare does not have the capacity to absorb the workforce. In under-developed states such as Bihar, government statistics show that there are hundreds of applications for every post of “medical officer” with a salary of just $400 per month!

In parallel, private employers appear to ascribe little value to the MBBS degree. As it is, there is no campus interview for any level of medical qualification at any medical institution in India including the All India Institute of Medical Sciences (AIIMS). Worse, the average salary of a fresh medical graduate with an MBBS degree in ‘sizzling’ cities such as Bangalore, Hyderabad, Chennai and Mumbai is lower than that of an entry-level call centre employee.

So where do these doctors disappear to? A majority of India’s medical graduates are engaged in clearing post-graduate entrance tests for the first five to ten years of their career instead of fruitfully engaging with the health system. This keeps them away from communities where they could be delivering crucial primary healthcare, creating a high level of morbidity and an environment where people are compelled to visit hospitals populated with specialists for the industry-style consumption of medical goods.

Strengthen the backbone

It has been acknowledged time and again that primary healthcare is the backbone of the healthcare system. And at its core, stands the family physician. According to a Planning Commission paper, India needs to produce 15,000 family doctors (family medicine specialists) per year by 2030.

The theme of family medicine has been supported by a variety of stakeholders such as the Prime Minister’s National Knowledge Commission, the National Rural Health Mission task force on human resource development, and the Planning Commission’s Steering Committee on Health in India’s 12th -and latest – National Plan.

In 2013, the then health secretary K Desiraju wrote to states highlighting the need to strengthen primary and secondary healthcare to work towards “the long-term objective of universal health coverage.” He asked them to start post-graduate courses in family medicine in colleges to overcome the shortage of specialists at the sub-district and community health centres (CHCs). “A single post-graduate in Family Medicine can meet the requirement of a Surgeon, Obstetrician & Gynaecologist, Physician and Paediatrian in a CHC, besides taking care of the Public Health needs of the community,” he wrote.

But why would medical colleges – preoccupied with meeting existing regulations – do so? After all, the Medical Council of India (MCI) does not list a Department in Family Medicine as a prerequisite to start a medical college. Nor does it have a definition or a curriculum for it at the under-graduate or post-graduate level.

Palpable indifference

And why would it when it is dominated by specialists and super specialists many of whom seem to have insulated themselves from the grassroots. Primary care physicians have no representation in the MCI.

Vocational training and long-term career paths for primary care doctors have been blocked at the regulatory level. Primary care physicians who are best-placed to train medical students in the discipline of family medicine are, for all purposes, barred from teaching positions in medical colleges. CHCs and family physician clinics that are ideal training centres, are not recognised as such.

Two birds, one stone

Imagine a situation where these clinics were accredited to do so. Residency positions in family medicine could then be created at CHCs, primary healthcare centres and district hospitals. Primary care physicians would also lecture here. These centres would be sought after as a means to get a post-graduate degree in Family Medicine and the government could eventually do away with the compulsory rural postings of all medical interns.

But the fact is that a majority of Indian doctors (general practitioners, family physicians, medical officers, resident medical officers, and recently qualified medical graduates) are disenfranchised from academic and professional leadership positions.

Unfortunately, while India has its share of giants in healthcare, there appears to be a paucity of leaders. Celebrity physicians would rather represent the healthcare industry than lead the profession. So-called professional organisations have been hijacked by hospital owners. The deans and principals of our most illustrious institutions occupy themselves with routine regulatory deficiencies rather than focus on a national vision.

As a result, primary healthcare is in the emergency room.

Dr Raman Kumar is the Founder President of the Academy of Family Physicians of India (AFPI), a New Delhi-based society which is spearheading a movement for the return of the trusted family doctor in India. AFPI has a country-wide membership base and operates through several state chapters. Dr Raman Kumar is also Editor-in-Chief of the Journal of Family Medicine and Primary Care. He is the winner of the Montegut Global Scholar Award 2013 awarded by the American Board of Family Medicine. This post is an iteration of an Editorial by Dr Kumar in a recent issue of the JFMPC.

 

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8 Responses to “Guest column : Doctor ‘scarcity’ a crisis of numbers or leadership? #UHC”

  1. Soumyadeep B April 28, 2015 at 9:56 am #

    Reblogged this on SoumyadeepB.

    Like

  2. Anup Soans (@anupsoans) April 28, 2015 at 10:19 am #

    Excellent article. I agree with Dr. Raman’s observations and the reasons for India’s healthcare problems. These perspectives need to be given wider circulation and change perceptions about the numbers game. The status of the primary care physician needs dramatic upgradation.

    Like

  3. Dr. Jaya Bajaj (@FamilyDoc_India) April 28, 2015 at 10:38 am #

    Kudos Dr. Raman! A strong Primary healthcare is not just cost-effective but has better outcomes as well. The countries with strong primary healthcare have better population health measures as have been demonstrated. The perspectives need to be changed at the policy levels. It’s about time primary care physicians start believing in themselves and engage patients as well as policy-makers in a campaign towards a better healthcare system.

    Liked by 1 person

  4. Col(Dr) Mohan Kubendra April 28, 2015 at 12:03 pm #

    A wonderful blog by friend Dr Raman Kumar- reflection of the decaying health care system in our country. Dr Raman is a dynamic young leader who has initiated a national movement to bring back concept of family doctor, primary care and Family Medicine- a clinical specialty which could change the health care scenario of our country.

    Like

  5. Dr Jithesh P M April 28, 2015 at 6:10 pm #

    I too agree with every word in Dr Raman’s article.He has simply stated the plain facts.There is an overwhelming indifference towards primary care which is going to be disastrous in the long run for a developing country like India with one sixth the world population.To add to it a good chunk of the population will be elderly by 2030-2040.So I think it’s absolutely imperative that adequate measure be initiated to solve this issue in a time bound manner.

    Like

  6. Dr Dinesh Agarwal April 29, 2015 at 10:38 am #

    Given that we have nearly 250 pvt medical colleges in country, do we have any information as where are these doctors?? Considering that most pvt medical colleges just give degress in lieu of money, quality is big question mark. Why cant our MBBS doctors work as primary care physicians?? One more specialty of FM is not going to be an answer unless you improve quality of undergrad medical education substantially.

    Like

    • Dr Raman Kumar April 29, 2015 at 1:08 pm #

      @ Dr Dinesh Agarwal Family medicine is not just one more or a new specialty. From practice perspective it is the first/ancient discipline of medicine. Within regulatory frame this specialty has existed within the documents of MCI for decades (Please check serial no 8 of MCI PG regulation 2000) and not being implemented due to conflict of interest. Family medicine is the knowledge discipline, specialty and vocational training of primary care physicians including all practicing MBBS doctors.

      The notion that the specialists should teach MBBS (Generalist) on how to deliver primary health care is the biggest is misconception or flaw. An A primary care physician can not do orthopaedic surgery and same is true vice versa. How can primary care/family practice be taught when there is no department or faculty practicing the same discipline at medical colleges. Family medicine is the practicing discipline of the largest number of medical doctors (Medical officers/ GPs/ GDMOs/ Family Physicians) in India – irrespective of qualification and training. Yet it has been blocked by the vested interests. Interestingly many experts from medical public health are also opposing family medicine (will address this issue in a separate article).

      Yes you are right that the quality of undergraduate medical education needs improvement but still due to systemic designs; MBBS will remain a minimum eligibility qualification only towards entrance tests for specialist training course nothing else. Taught exclusively by specialist teachers/doctors only at tertiary centre, MBBS is a mini specialist course but not at all a vocational training for producing primary care doctors.

      In case within the unfolding scheme of design of Universal Health Coverage MBBS doctors are likely to be edged out and will have no place/position to deliver primary care. Products of both private and government medical colleges will have to look for alternative non medical career options.

      Like

  7. Dr Rajesh Kumar August 6, 2015 at 6:18 am #

    Yes. Family Medicine Residency should be started in CHCs & Sub-District Hospitals by National Health Mission. MD (Family Medicine) Course has been planned in PGI

    Like

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