A 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.
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.