Corruption in India’s health sector: Begin with the reform of medical education

by Radha Viswanathan

Dr. David Berger, a Public Health specialist from Australia, served as volunteer in a charitable hospital in the Himalayas in northern India in 2012-2013. His essay titled ‘Corruption ruins the doctor-patient relationship in India[1]’ which appeared in the British Medical Journal in May 2014 once again brings the spotlight back to the systemic rot in all spheres of public and private healthcare in India and calls for urgent intervention from national and international agencies.

At the highest echelons, the Medical Council of India (MCI) with the collusion of officials of the health ministry, epitomises corruption.  Berger writes about ‘kickbacks’ in private and institutional practice which drive up costs and subject patients to needless investigations; he refers to the offensive doctor-pharma nexus –  all of which stem from the largely unregulated nature of the healthcare sector in India.

At the lowest rung of this monumental ladder of corruption is the system of admissions to the private medical colleges that currently train doctors in 190 out of 350 medical colleges all over India. The ‘capitation’ fee or bribe as a precondition for admission is an astronomical sum which far exceeds the earning capacity of fresh passouts from such colleges.  The quest for ‘return on investment’ in medical education begins early and serves as a strong disincentive to fresh graduate doctors working as generalists in rural areas,  and paves the way for the practice of “medicine for maximum profit” in urban areas. The acute shortage of institutions that produce health workers at all levels – doctors, post-graduates, nurses, para-medics, community health workers – puts an unnecessary premium on the seats, setting in motion the vicious cycle of corruption.

It is well documented that India faces an acute shortage of human resources in health and that the medical education system is not responsive to India’s health needs.  It is widely accepted that many issues facing India’s health sector are attributable to distortions in the supply and quality of human resources in health. In a scathing comment, the report of the Task Force for the National Rural Health Mission, Ministry of Health and Family Welfare (MoHFW), 2005, states: 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.

The news that India plans to establish 200 new medical colleges in the next 10 years to meet the projected huge shortage of 600,000 doctors[2], should bring cheer and renewed hope. However, some reports claim that the estimates of shortage of doctors for primary health care in rural areas have been “hyped”. According to one such report of April 2013, ‘Doctor population ratio for India – The reality’ by Madhav G. Deo[3], Pune Member, Medical Council of India, Academic Council, in the past sixty years all health parameters have shown “remarkable progressive improvement even in rural India”, proving that the issue of acute shortage of doctors has been exaggerated. The author makes the erroneous claim that having more colleges would dilute the quality of medical education[4].

Some medical practitioners opine that opening several new medical colleges to ease the supply is a rational solution, though it will be an uphill task to meet the stringent standards set by MCI, or to find a way to deal with the already existing faculty shortage.  Nevertheless the move to open new medical colleges will have to be accompanied by the reform of medical education to produce quality human resources who can uphold globally accepted standards of treatment and care.

To help in the creation of world class human resource, the National Council for Human Resources in Health, envisaged as an umbrella body incorporating all the different administrative and regulatory bodies in health – medical, nursing, dental, pharmaceutical, paramedical – including those for the Indian systems of healthcare, needs to become a reality. As the highest policy making body, the NCHRH can bring in coordination among different councils and ensure that the  disconnect between medical education and India’s healthcare challenges is ended[5].

There are different levels of healthcare and human resources for each of these levels must be trained accordingly. For example, from auxiliary nursing and midwifery to general nursing, a well researched curriculum needs to be conceived, that would link nursing courses to specific local needs and professionalise each of these services. The role of paramedic workers should be expanded. Paramedics, such as compounders, dressers, and laboratory technicians can also perform public health functions, such as dissemination of health information, providing immunisation, and first aid. Training programs for multi-skill and specialty technicians must ensure their quality and delivery. Pharmacy education should be popularised and the number of seats for pharmacy education should be increased substantially.

The MBBS curriculum ought to be less theoretical and the internship period provided for  more hands-on experience, should cease to be misused as a period of preparation for post-graduate studies.

The curricula of medical schools, both public and private, should be designed for producing ‘social physicians’. Medical education in India focusses excessively on imparting technical competence; dimensions such as empathy and sensitivity towards patients and handling ethical challenges need to be covered in the curriculum under Medical Humanities.

Teacher training for medical education needs to be revamped to orient teachers towards a less didactic and more interactive approach. The issue of shortage of teachers should be dealt with by having flexible and innovative approaches to involving doctors from the private sector, employing ICT, deploying non-MBBS professionals for teaching certain subjects.

The accreditation system for recognising colleges and courses needs to function autonomously and in a transparent fashion. The conduct of exams and evaluation processes must be above board and transparent. Something akin to the Washington Accord – an agreement among accreditation bodies of signatory nations for engineering degrees for achieving some manner of parity – needs to be envisaged for degrees in medicine as well.

In this connection, David Berger’s comment is relevant: “Medicine has globally accepted standards of conduct. The Indian profession should want to adhere and be held accountable to these. Currently, however, it seems to be failing in this regard. This is not only bad for India but bad for other countries that take doctors trained in India.”

For this the entrenched system of paying astronomical bribes to MCI to start medical colleges, or using dubious means including paying bribes to pass MCI inspections, or paying bribes to admit students and for securing pass marks in the exams must be put an end to.

“If prompt reform is not forthcoming from within the country (and the will seems to be lacking), then the spotlight needs to turn global.” Is the health ministry listening?

****

Radha Viswanathan, Senior Fellow, Observer Research Foundation Mumbai

Radha.v@orfonline.org

[1] (http://www.bmj.com/content/348/bmj.g3169.full.pdf+html)

[2] Human Resources for Health: Overcoming the Crisis. Boston: Global Equity Initiative, Harvard University; 2004. Joint Learning Initiative

[3] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724242/, http://www.icmr.nic.in/ijmr/2013/april/perspective.pdf

[4] The proposed massive expansion, which would reduce the medical colleges to pathshalas (primary schools), is

ill advised. It will not solve India’s woes of poor health services, but only downgrade country’s standing in the

medical world.

[5] Leena Chandran Wadia et al, Reforms in Medical Education to Promote Accessible and Affordable Healthcare for All, Observer Research Foundation Mumbai, 2012