By Dhirendra Pratap Singh
India is scaling up economic activity, both on the demand and the supply side and a massive boom in healthcare services has changed the nation’s health delivery landscape beyond recognition in the last decade. Indian hospitals with the mantra of star facilities and bleeding-edge technology are writing a new chapter in India’s healthcare services. Despite this, India has 94 beds per lakh population compared to the WHO norm of 333. The density of doctors is also dismally low; there are only 43 doctors per 10,000 population compared to 249 doctors for every 10,000 people in Australia, 209 in Canada, 166 in the UK and 548 in the US. Estimates of doctor shortage is around 6, 00,000. This translates into an enormous opportunity to transform the medical education system, which should be opened up for private participation and companies should be allowed to establish medical and dental colleges.
All India Institute of Medical Sciences (AIIMS) has been at the forefront of providing medical education in the government sector. At AIIMS, everything is king-size,from the awe-inspiring campus with nearly 18 lakh patient footfalls a year, an array of 50 disciplines, 25 clinical departments and six super speciality centres managing every type of disease, to more than 54,000 wannabes who compete fiercely for one of its 77 MBBS seats. Research is what sets the AIIMS apart. AIIMS, which brings out more than 50 per cent of all the medical research from India, published over 1,500 original works in high-impact journals this year.
India has a health crisis exacerbated by the shortage of doctors and a mismatch between the need for basic medical services in rural areas and the congregation of specialists in urban centres. An abysmally low government spending on healthâ€”at US $ 32 per capita–, characterises the poor state of healthcare in India which is facing a ‘double burden’ of diseases afflicting both the poor and rich classes, recently published WHO report says.
While per capita health expenditure is about US $32 in poor countries, including India, it is around US $4590 in rich countries (more than 140 times). The high income countries consequently have 10 times more doctors, 12 times more nurses and midwifes and 30 times more dentists, the report said. With steep income disparities, India is also struggling to tackle a ‘double-burden’ of diseases, which include infectious diseases affecting the poor on the one hand and chronic lifestyle ailments typical of fast urbanisation on the other.
In 2005, the National Rural Health Mission was launched to provide accessible, affordable and accountable quality health services to the poor in the remotest of regions. In order to attract more doctors to the peripheral areas, incentives in terms of salaries and reservation in post graduate seats are on offer.
But there is a major roadblock, which most aspirants have to deal withâ€”the lack of postgraduate seats. According to the official estimates one in two graduates gets to do a postgraduate in medicine.
Post Liberalisation Era
In the 1990s, medical education was opened up to private investment without putting in place appropriate systems and institutional mechanisms for enforcing quality and standards. During 1995-2006, of the 106 medical colleges established, 84 were private. Today, there are 313 medical colleges, of which 163 are in the private sector and 31 are deemed universities. Considering the high premium on medical degrees in India, establishing a medical college has become a lucrative business opportunity, resulting in several players with political clout entering the area.
The Government is coming with six AIIMS-like institutes and upgradation of 13 existing Government Medical Colleges. The new AIIMS-like institutes will be completed by the end of 2012 at Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh. The upgradation components in Phase-I include government medical colleges at Trivandrum, Salem, Bangalore, Kolkata, Jammu and Srinagar, NIMS Hyderabad and B J Medical College, Ahmedabad.
The idea is to make affordable and reliable healthcare services available to the rural populace though these. Each hospital will have 960 beds and will provide undergraduate medical education to 100 students per year. Post-graduate and post-doctoral courses will also be offered.
The Pradhan Mantri Swasthya Suraksha Yojana PMSSY was initially started in March, 2006, with the object of correcting regional imbalances in availability of affordable or reliable tertiary health care services and also to augment facilities for quality medical education in the country.
While per capita health expenditure is about US $32 in poor countries, including India, it is around US $4590 in rich countries (more than 140 times). The high income countries consequently have 10 times more doctors, 12 times more nurses and midwifes and 30 times more dentists, recently published WHO report says
Research Focus and Challenges
India lacks a comprehensive policy to address the acute shortage of human resources in healthcare, which is a key driver of health costs and a huge constraint on scaling up public-health programmes. There is flawed public policy. Also, poor governance, with the result that there is no standardisation of health-care providers in a manner that is relevant to the country’s needs. Lastly, corruption, an outcome of unregulated privatisation of medical education that has severely compromised its quality.
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Faculty development is another important component in medical education. It is necessary to organise faculty development in a systematic manner. Steps are necessary at various levels, as the stakeholders are many, viz., the policy makers, the Government of India, Medical Council of India, teachers, students and private and government college managements.
New watchdog in medical education
Union Health Ministry has decided to seek Cabinet clearance for the proposed National Commission for Human Resources for Health (NCHRH) Bill, 2011. The Bill aims at creating a super medical authority by scrapping all other regulatory bodies. The proposed Bill aims to consolidate the law and promote human resources in the health sector.
The Bill aims to merge existing regulatory bodies such as the Medical Council of India, Dental Council of India, Pharmacy Council of India, Nursing Council of India and councils under the Department of AYUSH into a single body. The Bill also talks about constituting a separate board â€” the National Board for Health Education â€” to assist the commission to oversee health education. The board will facilitate and promote academic studies and research in emerging areas with focus on professional health education and ensure uniform augmentation of trained specialists and super specialists to achieve excellence in these connected areas.
Reform in medical education is urgently needed. There is acute shortage of doctors in India. India needs more than one lakh doctors per year. Or so to say, India can absorb one lakh doctors per year. And we only produce 30,000. So what we need to do is to scale up our medical infrastructure three times. Shortage of doctors affects the poor, who do not have easy access to healthcare services. Private sector must be stepped into medical education to bridge the existing gap and strict regulatory bodies must monitor this. Medical education should encompass infrastructure for training of Medical, Dental, Paramedical and Nursing students. These four pillars of health education should grow simultaneously to provide effective human resources for health.
The focus of approach paper to the 12th five-year Plan (2012-13 to 2016-17) is on restructuring public health schemes. Recently, the working group constituted for the Plan asked for massive expansion of medical education to improve primary healthcare. The working group comprises officials from the health ministry, representatives of business chambers and Planning Commission members.
A survey by the Organisation for Economic Co-operation and Development says that only seven countries in the world spend less money than India on public health
Dr Devi Shetty of Narayana Hrudayalaya said in his presentation that there was a shortage of one million doctors and the price of a seat in an MD course was `5 crore. He said doctors trained through the expensive private education route would never be available for primary healthcare needs. Hence, the only way to make healthcare affordable was to create a massive education network, at the rate of 100 medical colleges every year for five years. This, he said, was possible by turning each of the 625 district hospitals into medical colleges.
The idea is not just to allocate more funds as is being demanded but to ensure that whatever funds are allocated are used in a more effective manner.
The ministry of health is believed to be in favour of raising the allocation to the sector (excluding sanitation and portable water) to at least two percent of GDP by the end of the 12th Plan, which starts from 2012-2013. A survey by the Organisation for Economic Co-operation and Development says that only seven countries in the world spend less money than India on public health. Also, the Department of Health Research is projecting an ideal expenditure of around Rs9,000 crore during the 12th Plan period, it is learnt.
Role of Distance Education and ICT
There is need for creat ing new cadres of health professionals who are trained to address the needs of the rural population. IT skills and e-labs can be launched to reach out far and wide. Vision sharing by experts and Orientation to nation’s health system and policy is the need of the hour. Distance education is a boon as it can be pursued at leisure and helps enhance skills. This is equally true in the context of medical education.
Distance education in India is cheaper than a full time degree. It also provides high quality, well structured learning material. New communication technologies and electronic media have played an important role to improve the quality of education. A lot of universities in India have a section for distance education that present courses in various streams.
Open universities offer distance learning programs for students across the country. These universities are present in nearly every state and specialise in correspondence or distant learning courses. In the open system, the courses are open to any person who may not possess any formal qualifications. But in some institutions they should have attained the age of 18 years for undergraduate and diploma courses and 21 years for postgraduate courses. Enrolment in some courses is subject to qualifying in a written exam but the admission process and qualifying criteria is simpler than those offered by regular universities.
The Indira Gandhi National Open University (IGNOU) has redefined open and distance learning in medical education. The IGNOU School of Health Sciences offers a plethora of innovative and unique courses in this domain. These courses have been appropriately structured to fulfill the various needs of medical education in India and help in bridging the various gaps created due to lack of medical seats in India.
Leading universities in India are adapting to a constantly changing India and a newer generation entering its classrooms. Globalisation has led to greater demand from the industry for different types of jobs, which are being looked at by private players. The call of the hour is not to train students to do a job but to educate them in a particular field.
The emerging areas in medical education which are seeing maximum growth and ground-breaking research are reproductive medicine, plastic surgery, endocrinology, oncology and cardiology. Apart from this, newer specialisations are also in the pipeline. Emergency service has long been a recognised specialisation in the developed countries. Recently, the Medical Council of India (MCI) gave it thumbs up and colleges across India have been notified to offer it as a post graduate discipline. Geriatric medicine or the care of the elderly is another area to watch out for in the future.
The NKC recommends the implementation of an independent authority, the Regulatory Authority for Higher Education, which needs only a set of people to supervise the entry requirements, accreditation, licensing and rationalising the entry procedure. The Yashpal Committee has suggested an apex regulatory body, the National Commission for Higher Education and Research, which will bring within it the existing agencies and make entry easier for newer bodies.
There is a need to set up clear and transparent accreditation and assessment procedures that are fair to all universities. Four to five agencies should focus on assessing the institutions and bring out a public rating. Each body should be allowed to go to one of these agencies to get a rating that could be available on their websites. Public private partnerships can allow many more private players to start an institution if the government provides land. This will cover a diverse population and different needs of students.