There is a shortage of approximately over six lakh doctors and two million nurses in India. This brings to the fore the glaring fact that Indian healthcare system is facing big challenge on front of skilled medical professionals who play a vital role in enabling masses to avail accessible and affordable medical facilities to their doorsteps. Mukul Kumar Mishra of Elets News Network (ENN) explores various facets of the health workforce and steps undertaken by the Government to bridge the skewed ratio in the distribution of doctors, nurses and technicians working in the urban and rural areas.
Indian healthcare is evolving in unprecedented rate with digital technology, modern-day applications and innovative practices are driving delivery of healthcare services as never before. Though the technology as an enabler have proven its worth, it alone can’t execute things as skilled medical professionals are the one who leverage the modern-day tools to bridge the multifarious gaps pertaining to patient care.
On the scale of importance, skilled workforce is being placed at top of the pyramid of healthcare delivery system. But sad part is India doesn’t have enough expert doctors, nurses and technicians to sustain the dream to create an accessible, affordable and quality healthcare model to enable every strata of society to avail better medical care in India.
‘India has a little over one million modern medicine doctors to treat its 1.3 billion people. As per the data from National health profile 2017 we have one government allopathic doctor for every 10,189 people, one govt hospital bed for every 2,046 people and one State hospital for every 90,343 people. In these kinds of situation one can easily predict the collapse of the healthcare system when patients are sharing beds and doctors are over worked,” believes Praveshh Gaur, Founder and Director, Srauta Wellness.
Meena Ganesh, Co-Founder, MD & CEO, Portea Medical says, “The Indian healthcare sector is facing crisis of qualified healthcare professionals, and the situation is worse in the rural areas. Although recent statistics indicate that there is an improvement in the doctor-to-patient ratio or the skilled-healthcare-workers ratio to population, there is still lack of access to timely healthcare. This is one of the major factors hampering the critical goal of providing universal healthcare to everyone irrespective of where they are.”
Taking cognisance of the glaring issue engulfing the Indian healthcare sector, the government is toying with all possible options to improve the skewed ratio of human resources including doctor patient ratio. Dr Vinod K Paul, Member, NITI Aayog, Government of India has reiterated the importance of human resources adding that India lacks on experts in primary to tertiary care.
“The most difficult journey that we face today is about having the right mix, the right numbers, right quality, right skills and the right distribution of human resources in the healthcare sector,” Paul said recently delivering speech at Ficci Heal 2019.
GAPS BETWEEN URBAN AND RURAL CARE
As urban people have become more health conscious nowadays, they want best quality care from private healthcare providers in order to experience enhanced personalised care. A section of people in metro cities can afford quality care from top private hospitals which make them available immediate medical help for their patients suffering with deadly non-communicable diseases including heart issues, cancer, and stoke. This becomes possible as doctors and nurses are easily available in urban areas and people can afford costly facilities.
Unfortunately, this is not the case in tier three and four cities, and in rural areas which are grappling with shortage of health workforce. Primary health centres are devoid of doctors and other required medical staff.
“India has a world class private hospitals infrastructure but that only caters the one third of the total population. A report released by KPMG and the Organisation of Pharmaceutical Producers of India in 2016 stated that 75% of dispensaries, 60% of the hospitals and 80% of the doctors are located in the urban area and serving only 28% of the total population. On a comparison rural areas have only 39.8 physician per 100,000 people where as Urban area has around 55 physicians for the same number of residents,” Gaur said.
Satish Kannan, Co-Founder & CEO, DocsApp believes, “With more than 70% of the population living in rural areas and a low level of health facilities, mortality rates are high due to diseases. Health care for the rural population is expensive, often unregulated and variable in quality. Besides being unreliable for the illiterate, it is also unaffordable for low-income rural patients,” says Satish Kannan, Co-Founder & CEO, DocsApp.
“Retention of doctors in rural India is the biggest challenge. Due to lack of proper infrastructure & amenities, doctors prefer settling in urban cities. Remote areas barely get timely help unless they visit a nearby city which is equally difficult for Individuals in rural areas,” Kannan further said.
At a time when India is facing triple burden of diseases including lifestyle diseases, maternal & child health and infectious diseases, and the emerging infections like Nipah, trained workforce including doctors, nurses and technicians are needed to provide accessible and affordable care to masses.
Situation is same in case of government hospitals, which are facing human resources crunch. Issues like overworked doctors, and unavailability of beds, technicians and nurses explains the story of India’s public healthcare sector.
UPGRADING DISTRICT HOSPITALS INTO MEDICAL COLLEGES
The Government is working on every front to increase number of skilled professionals in healthcare. It aims to reach one doctor for 1,000 people by 2024.
As part of the Centre-sponsored programme Human Resources for Health and Medical Education, the Government has decided to convert district hospitals into medical colleges in phased-manner.
In the first phase, the Centre had given approval to convert 58 district hospitals into medical colleges while in the second phase, 24 hospitals were selected. Of the 58 medical colleges approved under the first phase of the scheme, 39 have already started functioning.
In order to boost availability of human resource for the health sector, the government gave nod to setting up of 75 government medical colleges, to be attached with existing district or referral hospitals, by 2021-22. The establishment of these medical colleges will add at least 15,700 MBBS seats in the country.
These medical colleges will be set up in under-served areas having no such institutes and attached with district hospitals having at least 200 beds. The exercise is aimed to increase the availability of qualified health professionals, improve tertiary care in government sector, utilise existing infrastructure of district hospitals and promote affordable medical education in the country.
NMC BILL TO REFORM MEDICAL EDUCATION
Medical education is the bedrock on which the needs of ‘human resources for health’, one of the major building blocks of any health system, are met. Today’s health professionals are required to have knowledge, skills, and professionalism to provide safe, effective, efficient, timely, and affordable care to people. With this objective, the Government came up with National Medical Commission Bill. Its objective is to create a transparent, accessible and affordable medical education system leading to better healthcare outcomes.
Through the bill the Centre will ensure transparency, accountability and quality in the governance of medical education in the country. With two dozen of new government medical colleges, the academic year 2019-20 saw the biggest addition of medical seats in government colleges in a single year.
India’s struggle on Human Resource
• As per Indian Journal of Public Health 2017 data, in India on an average, a government doctor attends to 11,082 people
• A total of 10,22,859 allopathic doctors are registered with MCI
• There is a shortage of over 600,000 doctors in the country and two million nurses • Currently urban to rural doctor density ratio is 3.8:1.
• There is one nurse per 483 patient in India
• 57.3% of personnel currently practising allopathic medicine do not have a medical qualification
• 65 per cent of health expenditure is out- of-pocket, and such expenditures push some 57 million people into poverty each year
• Primary health centres across the country are in want of at least 3,000 doctors with 1,974 such centres operating without a single doctor
• In community health centres, there is a shortfall of close to 5,000 surgeons
• If India has to achieve 1:1,000 ratio, it will need 2.07 million more doctors by 2030
PRIVATE AND PUBLIC SECTOR NEED TO WORK IN SYNC TO MEET THE GAP
Partnership between public and private sector is needed to meet the gap in the human resources. The Government has now allowed a consortium of private players to set up a medical college, unlike in the past when a medical college had to be established by a single entity. It also made a strong appeal from the private sector to contribute more to medical education and also to have more DNB (Diplomate of National Board) Seats.
TRAINED MID-LEVEL PROVIDERS TO BOLSTER PRIMARY CARE
Clause 32 in NMC bill is one among many issues in NMC Bill on which the Government is facing stiff protest from a section of medical fraternity. As per the provision, mid-level providers would be trained to practice medicine in order to bolster primary care. In a FAQ document on NMC Bill 2019 available on PIB website, the government justifies its decision.
“The ambitious Ayushman Bharat initiative announced by GoI in this year’s Budget Speech needs 1,50,000 mid-level providers within the next 3-5 years to provide comprehensive primary and preventive care. It will take 7-8 years to ramp up the supply of doctors, therefore, in the interim we have no option but to rely upon a cadre of specially trained mid-level providers who can lead the Health and Wellness Centres,” document states.
Refuting all misconceptions on the clause, Paul said: “It is proven facts across the globe that mid level providers augment doctor led team to boost care delivery system. In several European countries, mid level providers are a norm. We will be providing extra trainings to mid level providers thereby equipped them to provide first line of treatment for diabetes and other diseases.”
Chhattisgarh and Assam experimented with community health workers in past, but couldn’t implement the idea in full- fledged manner.
GLOBAL EXAMPLE WHERE CHPS PLAYING PIVOTAL ROLE
There are many countries–developing and developed which have deployed Community Health Workers under different names but with the same intent — providing basic health services at primary level. CHWs are providing healthcare services in Ethiopia, Rwanda, Bangladesh, and Thailand. They are called “health extension workers” in Ethiopia and Swasthya Sebikas & Swasthya Kormis in Bangladesh. Nurse practitioners are a well- defined category in the US, New Zealand and Australia. Apart from shortages of doctors in some regions, the rising costs of healthcare also catalysed the emergence of mid-level healthcare providers.
IDEA OF CHPs AS MID LEVEL PROVIDERS GETTING STIFF OPPOSITION
A section of medical fraternity is vehemently opposing the Bill, stating that it will encourage quacks to prescribe allopathic medicine. They have least idea who these ‘community health providers’ will be and how they would be trained by the Government.
“The government’s plan to provide training to community health workers to augment the primary care system in the country is a good decision policy- wise. It will help ensure delivery of basic healthcare to people residing in rural and far-flung areas. At the same time, it is the execution and the quality of training imparted that is going to be extremely crucial. They must be trained well in primary healthcare and sanitized on operating only in a supporting role and not acting as qualified doctors,” Kannan believes.
Experts who are opposing the move believe the Bill doesn’t clearly define “mid-level practitioner” and “limited license”. It seems that the Bill seeks to conflate all types of practitioners and allow all to prescrible modern medicine, something that was previously only allowed to those who had done an MBBS. Another concern this raises is on how these practitioners will be regulated as no clear solution has been offered so far.
It is proven fact that whenever some new initiative is undertaken by the Government, it bounds to face criticism from many quarters. Nonetheless, criticism encourages people at the helm to further fine- tune the step so that masses could be benefitted to the maximum.
Though the latest policy is little vague on many points, the Government’s intension is crystal clear that to improve skewed ratio of doctors, nurses, technicians, so that people at large could be catered with accessible and affordable medical facilities in every nook and corner of the country.
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