Dearth of Doctors in India: Curing the Med-Ed System
By Arunima Rajan
Healthcare is a complex system, and understanding how it operates is key to comprehending why it tends to produce problems that are resistant to improvement. Can we view the shortage of doctors as a "systems" issue, and can we effectively solve this issue?
Since the COVID-19 pandemic, the Indian healthcare system has faced many challenges, but the most glaring problem is the shortage of doctors.
Elements of the System
There are 619 medical colleges, out of which 340 are government medical colleges, and the rest 279 are private medical colleges with a total of 1,25,857 seats (Govt. Seats- 70008 and Private Seats- 55849) as per the data published by NMC in May 2021. The MOHFW in Jan 2020 stated that there had been a 47% increase in government medical colleges during 2014-19, compared to a 33% increase in the total number of medical colleges in the past five years.
India always had a shortage of doctors. There is only one registered doctor for every 1,456 individuals compared to WHO's recommended ratio of 1:1000 as per an article in The Strait Times. Therefore, since the onset of the COVID-19 pandemic, India has been grappling with a shortage of doctors and healthcare workers.
Although, doctors have responded very well to this global health crisis even with stretched resources to ensure patient safety and protect individuals, families, and communities. Still, there are only 12,55,786 registered allopathic medical doctors in India and 3,71,870 specialist doctors, as per a quote by Union Health Minister published in Medical Dialogues Sept 2020. In addition, as per a 2020 data, there are around 18,99,228 hospital beds (private sector >60%) i.e., 1.4 beds per 1,000 population. Therefore, the lack of essential human resources and infrastructure has created a complex problem and treatment uncertainty amid the pandemic.
During the pandemic, hospitals added infrastructure such as extra beds, ventilators, etc., to accommodate the increasing patient load, but the human resource to run these resources cannot be created in a day. Doctors are already stretched to capacity and overwhelmed by the pandemic's warlike conditions. Our country is in dire need of more doctors to handle the substantial increase made in medical infrastructure.
Interconnections
"We are presently witnessing a serious shortage of frontline primary care physicians who are prepared and able to care for patients. But if you ask me, the shortage is actually on account of unequal distribution of doctors across the country's geography. The real issue here is the poor access to healthcare in several 'un-doctored' regions.
This issue can be brought under control by authorising the existing doctors to do more than just the essential treatments and care that they are providing. Existing doctors and also fresh MBBS graduates need to be further trained in specific areas like paediatrics, general surgery, obstetrics & gynaecology, diabetes care so that they can take up more responsibilities in primary care like managing deliveries, treating malnutrition, conducting immunisation drives, draining abscesses, setting fractures right and also doing minor surgical procedures.
If adequate training and infrastructure are provided in these 'un-doctored' regions, there is absolutely no reason why graduating doctors will not be okay with being deputed to such areas. Also, these doctors who serve in these regions should not be weighed down by administrative, statistical and procurement responsibilities, and their focus should be purely on providing clinical care. Finally, on a more long-term basis, the number of medical colleges and the intake of students in these colleges can be increased till there are enough doctors in India," says Dr V Mohan, Chairman of Dr Mohan's Diabetes Specialties Centre.
Restructuring Primary Care and Telemedicine
As per an article published in The Indian Express, COVID-19 has accelerated the need to restructure primary care. It requires the identification of clinical care areas that can be delegated to health workers since it is impossible to create doctors in a short period.
Developing a telemedicine web model in close connection to primary health care centres operated under public health systems is another way to address this crunch of doctors.
Dr. K. Shweta, Medical Director, Nightingales Home Health Services, says that the Indian healthcare system has long struggled with the shortage of doctors. Still, the COVID-19 pandemic has brought this issue to the forefront. "We can continue to add more hospital beds and critical care centres, but there is little use if we don't have enough doctors to serve the patients.
With the concept of a family physician diminishing in India, individuals increasingly turn to specialists for help. Middle and high-income families prefer the quality of care that private and corporate hospitals offer. This increases the burden on hospitals because these hospitals also bear the load of essential interventions and surgeries, ICU care, and other medical interventions. After surgery and discharge, many patients visit hospitals for clinical interventions, and some of these can be easily managed at home through home healthcare. In contrast to India, other developed countries have many alternative healthcare facilities to provide long term support to patients after they have been discharged from the hospital but need help in transitioning from hospital to home, such as – LTACHs (Long-term acute care facilities), SNF (Skilled Nursing facilities) and IRF (Inpatient Rehabilitation Facility). Hence, there is a pressing need for a complementary healthcare delivery system in India.
The World Health Organization (WHO) recommends a doctor-to-population ratio of 1:1000. In India, the doctor-to-patient ratio is 1:1500, and the patient-to-hospital-bed ratio is much worse. We need to continue to build effective delivery models that are non-hospital based. One of the best ways to reduce the burden on hospitals and doctors is to encourage home healthcare actively. In the ongoing pandemic, we have seen that many common medical issues and interventions can be managed at home. For example, during the earlier waves of the pandemic, Nightingales was the choice of over 20 leading corporations to serve the COVID care needs of 300,000+ employees across India and delivered 100,000+ COVID-related consultations to them. Home healthcare that can provide remote monitoring and teleconsultations has a critical role in out-of-hospital care delivery. Common ailments can be treated at home by clinical consultations, investigations, nursing care or physiotherapy. If quality clinical services can be provided at home, it is a win-win situation for doctors and the patients," she concludes.
Balancing Inflow and Outflow of Resources
Another way to overcome the shortage of medical professionals due to COVID-19 is to hire retired doctors. "The government must hire female doctors and train them for COVID care and critical care," says Omana Rajan, who has worked at a PHC for a short time in Kottayam. She also adds that many doctors leave government hospitals for lack of infrastructure, and the poor infrastructure affects female doctors more than male doctors.
Fixing Escalation
Another method to overcome the shortage of doctors is to conduct examinations on time. As per an article published in The Strait Times, many students are just waiting for exams to graduate and work as doctors. Even the delay in NEET PG Counselling 2021 is one of the reasons behind the shortage of doctors. As per The Print, several doctors said the primary reason behind the shortage of doctors is the delay in NEET PG 2021 Counselling. It has severely affected doctors struggling to fill in for sick doctors while awaiting the new batch of PG trainee doctors.
Moreover, conducting exams on time will enable these students to complete their degrees within the stipulated time.
Need to make the system more “Resilient"
Sanjith Saseedharan, Head-Critical Care, SL Raheja Hospital, Mahim, says that India's need of the hour is to have quality medical professionals at all levels. "Head-to-head, USA has at least ten times the number of doctors per 1,00,000 patients compared to India. Ramping up these numbers cannot be done without the help of private sectors partners establishing a medical college, thus churning out more doctors. Private sectors should also be given all means of help to set up large hospitals which can serve as training grounds for graduated doctors from medical colleges. Training the doctors is just one side of the story; getting them to remain in the country and work in the rural areas is another story altogether. Most of the brilliant homegrown talent would either want to go abroad or work in the major cities, which again leads to the acute shortage in the rural areas, which bears the brunt of the lack of doctors in all fields. A gross difference in the salary is the most important reason this occurs. Doctors in a city would earn at least twice, if not thrice, of doctors in rural areas. The other reason is that the community health structure, infrastructure, equipment, and workforce allocation (paramedical and technical) are not conducive for a highly trained professional to work in such areas. It also seems that the paying capacity of people of the rural areas is largely responsible for this. To cover this lacuna, good government community health insurance schemes are required. All this would be possible only if the government would hike the percentage of GDP spending on healthcare. To put matters into perspective, our federal government's spending on health is dismal, to say the least, when compared to even much smaller and less developed nations," he concludes.
The Better Approach
We all have our assumptions about how to fix the healthcare system and shortage of doctors.
Unfortunately, increased ICU beds and other infrastructure will not treat patients. The challenge is the shortage of doctors, and India needs more doctors and healthcare workers to win this battle. There is a need for short-term and long-term solutions to overcome the shortage of doctors. Solutions like the telemedicine web model and tele-ICU can ease pressure on over-stretched doctors and provide proper medical consultation to more patients. It is impossible to overcome the shortage of doctors quickly, but the solutions mentioned above can help ease pressures and help combat the pandemic. Lastly, the healthcare system is dynamic, so diligent, flexible policies that can function non-linearly over various situations and are open to alterations should be considered.