Ideas and Action for a Better India
The most telling commentary on the state of the healthcare delivery system is contained in the report of the Task Force for the National Rural Health Mission, created by the Ministry of Health and Family Welfare (MoHFW) in 2005: The health system has created an impasse where no health services of any acceptable quality can reach a vast number of the citizenry. By insisting on health services through graduate doctors, or nothing, the medical fraternity has created a situation in which vast numbers get nothing.
Much of the challenge in the health sector has been the lack of capacity building in human resources arising out of a lack of enunciation of the concept of “Health for all”. The problem has been exacerbated with the policy makers’ inability to distinguish between different levels of medical care and plan for manpower innovatively. By aligning curriculum with local health needs, placing learners in community clinical settings, focusing on training large numbers of basic healthcare workers rather than tertiary care specialists and by making changes at policy level, a direct linkage can be demonstrated between medical education and improved health. The crucial questions to be answered are: Will those who are at the helm of policy making have the vision to implement these changes? Will the leaders of the health profession willingly accept these changes?
The vision of ensuring a well designed world class health and medical education system in the country for providing accessible and affordable healthcare for all is stated in the draft document of the proposed overarching regulatory body in medical regulation, the National Council for Human Resources in Health (NCHRH 2009). This is as noble as it is daunting; especially in the context of the present state of health care in India. India’s health risks straddle the worlds of the very poor and the very rich. Traditional hazards related to poverty and under development, such as lack of safe water, inadequate sanitation and waste disposal, indoor air pollution and vector borne diseases, and modern hazards caused by development that lacks environmental safeguards, such as urban air pollution, lifestyle changes and exposure to agro-industrial chemicals and waste go hand in hand. Consequently India has to battle third world, infectious and parasitic diseases such as tuberculosis, AIDS, and malaria as well as, heart disease, diabetes, psychiatric ailments and chronic respiratory diseases associated with the developed world. Low birth weight, malnourishment, anemia, iodine deficiency, night blindness, are other preventable ailments that plague sections of the rural populace and poor in India.
Despite an extensive network of government funded clinics and hospitals ( 137311 Sub centre, 22000 PHCs, 28000 dispensaries, 3000 CHCs, 3500 UFWC 12000 secondary and tertiary hospitals in the public sector) providing low cost care, curative health services in India are largely provided by the private sector. The private sector provides 58% of the hospitals, 29% of the beds in the hospitals and 81% of the doctors. Another relevant aspect borne out by several field studies is that private health services are significantly more expensive than public health services – in a series of studies, outpatient services have been found to be 20-54% higher and inpatient services 107- 740% higher. But health services in the country, whether public or private, are largely uneven, unsupervised and unregulated.
As per 2005 statistics, the total annual expenditure in the national health sector is of the order of 5.1% of the GDP, but, public health expenditure barely reached 17% of the total health expenditure (i.e. 0.9% of GDP or Rs. 220 per capita); and the more regressive fact is that 68.8% of the total health expenditure was ‘out-of-pocket’ expenditure (OOP). In 2009, the government’s expenditure on Health was 1.45% of GDP. It is seen that the private sector share of outpatient services rose and that for inpatient care continues to grow.
The neglect of nursing and auxiliary services has severely impacted delivery of healthcare at the primary and secondary levels. To make matters worse, public health qualified physicians, who were available in larger numbers in the first decade after Independence, have progressively disappeared from the system. In contrast, in China, following severe shortage of doctors after the Cultural Revolution in 1977, more than 2 million `barefoot doctors’ (now known as `countryside doctors’) were trained and about half of them have passed an examination comparable to that required of graduates in the secondary medical school. All the graduates and countryside doctors have contributed greatly to the medical and health care delivery system in China.
As per the WHO report of 2005, India, with 1.5 doctors to a population of 10000 is at par with low income countries, as against the world average of 7. In 2009, the number of registered allopathic doctors numbered 757377. The number of nurses to a population of 10000 is as low as 8 in India, as against a world average of 33 and low income countries average of 16 per 10000! 80% of Indian healthcare is provided by the unorganized sector many of whom are from the AYUSH sector. Such providers are able to attract clientele for two reasons: firstly, there is no reliable graduate allopathic doctor in the proximate distance to whom they can turn, if allopathy is the discipline of their choice; and, secondly, because most of the medical conditions for which they require services are of the common type, for which the quasi-trained practitioners can often offer some relief. These systems of medicine need to be integrated with modern medicine.
Only 30 per cent of the population lives in urban areas but 70 per cent of the medical professionals have concentrated their services only in urban areas. Only 30 per cent of medical professionals have been serving 70 per cent of the population in rural areas. Most graduates aspire to spend their career in the urban ambience that they are familiar with, and for reasons explained below, most graduates see urban practice as providing better opportunities for return on investment.
Training infrastructure: There are 273 recognised medical colleges with the capacity to train 32000 doctors and 444 colleges teaching AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathic) medicine at the graduate and post graduate levels2. Overall, the production capacity of doctors (and nurses) is much higher in states with better health indicators and this reflects the distorted distribution of the country’s production capacity of health workers. Private medical colleges also place a heavy burden of fees on students and their admission procedures are not transparent. At present there is a huge disparity in tuition fees between Government (Rs. 9,000 per term) and private institutions (Rs. 175,000 or higher per term), which needs to be considered. The high cost of medical education keeps out the less affluent but deserving candidates from seriously considering a career in the medicine.
The curricula of medical schools, both public and private, are not designed for producing ‘social physicians’. The MBBS curriculum is too theoretical in its content and after 4 ½ years of the main course and I year of internship, the finished graduate has very little ‘hands-on’ experience and confidence to even provide primary healthcare services independently. Teacher training is perhaps the most neglected of issues in medical education. Teaching is viewed as being authoritarian and passed down from ‘God Professors’ rather than a problem-based and interactive approach.
32 Years ago at Alma Ata the World Health Organization came up with a broad definition of health as a state of physical, mental, social and economic well being – a positive state and not merely an absence of disease and infirmity.While no society, however advanced, can lay claims to having achieved this overarching state of good health for its citizens, it is essential that through fulfillment of short term objectives, a society can aspire to move closer to the long term vision. Many issues need to be tackled simultaneously: redefining and shifting the health goalposts keeping in mind the broad parameters of the WHO Declaration of 1978, policy level interventions to achieve this, encouragement of local initiatives and restructuring medical and health instruction system from ‘KG to PG’.