Tackling doctor crunch in public health

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Despite several efforts, India still struggles with a severe shortage of doctors, especially in the rural areas. An analysis of the current situation and ways to solve the issue By Raelene Kambli

In 2013, Andrea D’souza a 35-year-old woman  living in Mumbai was pregnant with her second child and required a domestic help to look after the household chores. She approached a well-known agency located in her vicinity and hired Malati (a 20-year-old girl from a tribal village in Pakur district of Jharkhand), who had just come to Mumbai in search of a job.

In a matter of few days, Malati adjusted to city life and Andrea’s family. She managed the household job efficiently; however, often complained of an acute stomach ache and frequent indigestion. Initially, Andrea sought help from her family doctor. But when Malati’s condition worsened, she got her admitted at Holy Family Hospital, Mumbai, where a slew of medical examinations brought to light that Malati was suffering from stage 1 stomach cancer. Thereafter, Malati underwent a surgery and currently leads a normal life. She still continues to work with Andrea and does not wish to go back home.

When Malati narrated her story to Express Healthcare, she pointed out that her village has a primary health centre where she often visited with her mother, but most of the time the centre remained nonfunctional due to lack of doctors and other medical staff. It takes almost one to two hours to get to the district hospital in Pakur and thereto, the situation remains the same. She informed that doctors don’t stay in the village for more than two months and often at intervals there are no doctors or nurses at all. In fact, one reason why her parents decided to send her to Mumbai was that she could work and save money to treat her stomach ache.

Malati’s story is certainly not one-of-its-kind in this country. It is a stark reality of the healthcare services available in the hinterlands of India. An irony of our healthcare system is such, where the country with more than 400 medical schools that produce about 50,000 MBBS doctors every year, yet there is only one government doctor for every 11,528 people in rural areas as per the National Health Profile 2015 report by IndiaSpend in November 2016.

Similarly, data from across the country, corroborated by an array of reports from several government agencies, NGOs working in public health, research institutes etc., have indicated that India still struggles with rural doctor shortages.

A report published by The Lancet highlighted that although the number of health facilities has risen in the past decade, workforce shortages are substantial in our country. According to the report, as of March 31, 2015, more than 8 per cent of 25,300 primary health centres in the country were without a doctor, 38 per cent were without a laboratory technician, and 22 per cent had no pharmacist. Nearly 50 per cent of posts for female health assistants and 61 per cent for male health assistants remain vacant. In community health centres, the shortfall is huge—surgeons (83 per cent), obstetricians and gynaecologists (76 per cent), physicians (83 per cent), and paediatricians (82 per cent). Again, the density of doctors and other healthcare workforce working in rural areas differs for state to state which was also reported by WHO is a research paper published in June 2016.

Researchers, Sudhir Anand, University of Oxford and Harvard University and Victoria Fan, University of Hawaii at Manoa and Harvard TH Chan School of Public Health in this research paper pointed out that among the lowest 30 districts ranked by density of allopathic doctors, half are in the north-eastern states and the remainder are in central states. The lowest 30 districts ranked by density of allopathic doctors with a medical qualification are found mainly in the states of Uttar Pradesh, Bihar and Madhya Pradesh.

More so, this deficit adds to the workload in district hospitals, in turn hampering the quality of care as well as contributing to increased mortality among the rural population due to lack of healthcare services.

Experts attribute this shortage to the unwillingness of medical students and specialised doctors to work in rural areas as they have better opportunities overseas. India-trained doctors account for nearly five per cent of American physicians and 11 per cent of British physicians, according to a 2005 study in the New England Journal of Medicine. Additionally, Organisation for Economic Co-operation and Development (OECD) figures reveal that nearly 86,000 doctors from India were working in the OECD’s 35 member countries. In second place were Chinese doctors, who numbered 26,000. According to Medical Council of  India between April 2013 to March 2016, 4,701 graduates from Indian medical schools moved abroad to study or work.

So what are the reasons behind this rural reluctance?

Is it lack of healthcare infrastructure, poor working conditions for doctors in rural areas, a medical education system that lacks focus on public health, lack of government investment in public health service or is it lack of a political will to address India’s most pressing public health issue?

Experts give a clear picture…

Harrowing chokehold

Dr Keshav Desiraju, Former Union Health Secretary, Government of India, explains, “Firstly, conditions in rural areas, especially where primary healthcare centres (PHCs) are located, are not easy. Secondly, most medical colleges are in urban areas and young doctors, even if they are from a rural background have lived in the cities for a long time and are reluctant to go back. This is especially true among women doctors who need to also balance their family lives especially when their husbands are based elsewhere. In India this is still the way it works. Thirdly, school facilities are generally very poor in rural areas. Most doctors would, legitimately, seek schools for their children that are at least as good as the ones they went to. Fourthly, government service is no longer an attraction. There is much more money in private practice and as long as conditions in government facilities continue to be poor, private clinics will flourish. Government cadres are mismanaged, promises are not kept, favouritism and bias in postings are common, all doctors are encouraged to bring political pressure to bear on postings, etc. Moreover, in our highly hospital based system, the value is only on specialists and super specialists. A PHC needs only a doctor with an MBBS but that doctor is not content and is obsessed with getting a PG qualification because that is what the system seems to prize.”

Raising similar concerns, Dr Sunil S Raj, Director Affordable Health Technologies, Public Health Foundation of India (PHFI), says, “The main reason for this shortage is the unwillingness of medical graduates to work in rural areas mainly due to lack of facilities and relatively poorer living conditions. Moreover, medical education in the country is focussed towards providing tertiary level care rather than primary level care which is the primary need of people living in  rural areas. A significant focus on specialised care during training reduces the value of primary medical care in the eyes of a new medical graduate. Further, the government has not provided enough incentives to make rural postings more attractive to them.”

Dr Raj further quotes some insights shared by Vikram Patel, Professor of International Mental Health, London School of Hygiene & Tropical Medicine, UK, “Working in the public health sector is often a demoralising experience for doctors because their professional lives are blighted by lack of professional development opportunities, accountability, and access to even basic medical resources necessary to perform an effective role.”

“Although some steps have been taken by the government such as compulsory rural postings, linking rural postings to postgraduate admissions and monetary incentives, there is a need for more structural changes and innovative solutions,” he adds.

Dr Dileep Mavalankar, Director Indian Institute of Public Health, Gandhinagar, criticises the current health system in India that is clouded by bureaucracy. He is of the opinion that lack of political will is the biggest barrier to solve this issue.

“India is way behind in health indicators not because we have shortage of doctors or hospitals, but because we do not have the needed political will, which translates in not having a well-developed national and state level public health service and public health cadre. Can we imagine Indian government without Indian Administrative Service, or Indian Army without army officers trained in military skills? But as a nation, we do not bother to have a public health service, except in Tamil Nadu and partially in Maharashtra and Gujarat. India produces one of the largest number of doctors in the world every year – about 50,000 MBBS graduates, most set up private practice as government has not invested adequately in the public health services and not created enough posts of doctors in rural and remote areas.  The current norm is one PHC Medical Officer for 30,000 population. In most developed countries there is one GP or medical officer for 1000 to 2000 people. How can one medical officer look after health of 30,000 people? This norm of density of medical officer was developed by the Planning Commission in 1980s which has not been since revised,” he avers.

Certainly, Dr Mavalankar has a point. One of the major put offs for doctors posted in rural areas is the work load that they are faced with, and to add to their agony, their PHCs and community centres have poor healthcare infrastructure and at times do not even have appropriate medicines to provide to their patients.

While researching on this subject, I came across some blogs posted by doctors who have worked in rural areas and have now moved to urban cities for better prospects. I read around five to six blog posts and they all had one point in common: poor working conditions and inadequate supply of medicine. One of the doctors shared her experience working in rural village of Assam. She said that her PHC pharmacy didn’t even have paracetamol. She often was harassed by Naxalite groups and lived in constant fear.

With this current state, attaining universal heath access will remain a farfetched dream for India. Not that the government hasn’t taken any steps to bridge this gap; however, the measures taken so far are temporary.

Stop gap measures

As per experts, in the past few decades the Ministry of Health and Family Welfare and state governments have attempted various strategies to attract doctors to rural areas, such as compulsory rural postings, linking rural postings to admission into postgraduate courses, and offering monetary incentives. Doctors trained in Indian systems of medicine such as Ayurveda, Siddha, and Unani are also being posted to government health facilities. Yet, the problem continues to exist. As a long-term measure, the health ministry in 2010 also proposed a new BSc course in community health; to train primary healthcare practitioners which was later reportedly opposed by MCI. Their point was that only MBBS doctors should be permitted to prescribe medicines under Indian law.

The proposed course was the subject of a public interest petition in the Delhi High Court in September, 2015. Later, the court suggested that the IMC Act should be amended or a new law be enacted to facilitate rural healthcare course.

In such circumstances, how can we figure out a solution?

Public health experts recommend some measures that can address this issue.

Strategies to attract doctor to rural areas

Dr Prateek Rathi, Fellow Member Post Graduate Program In Public Policy Management, IIM Bangalore stresses upon providing better facilities to doctors and other public health workers as well as focus on developing PPPs for human resources development and training. “The government needs to provide better pay structure at least at par with medical education and in line with Central Government doctors. This includes time bound promotions and career progression as per recommendation by Tikku Commission, which was set up in 1992. Also, a PPP model for human resource can be a solution, wherein government finances healthcare in rural areas or is a purchaser of healthcare (by way of coupons, health insurance schemes) and the service can be provided by the public as well as private healthcare providers. The Rashtriya Swasthya Bima Yojana, a health insurance scheme for BPL population was one such step. The demand generation and financial incentives will help in laying infrastructure in rural areas. This will also help to march towards universal healthcare.” He further urges the government to revisit strategies for short-term medical courses in public health and says that India can take lessons from concepts such as bare foot doctor of China and convergence of the ASHA network which can help to create a comprehensive rural healthcare institutional delivery structure.

Dr Leila Caleb Varkey, Adviser RMNCH, Centre for Catalyzing Change, New Delhi suggests, “The rural professional services need to have a common HR system and more needs to be done in terms of assistance with – children’s education, banking, transportation, holidays and perks – similar to what is done for the armed forces, railways or central PSUs where the HR department does more that just manage leave and salary. Develop a professional cadre of  State Cadre of Health Officer – that can be recruited from any of the health/ life and Social sciences at Bachelors degree level and train them in clinical and community skills over a two year period (zoology, dentistry, AYUSH, nursing, pharmacy, life science, etc).”

Adding to this, Dr Desiraju advises, “A public health/ family medicine orientation must be brought back into the MBBS curriculum. The government should send its new recruits to exemplary institutions such as the Jan Swasthya Sahyog, Village Ganiyari, district Bilaspur, Chhatisgarh, to understand that it is possible to do high quality medicine and render great service even in a very poor area.”

Dr Raj too has some interesting solutions that can be applied in order to address this issue.  “The top down approach of building a new cadre which can work in rural areas is important, but this will take some time to be implemented. There is a need to focus on a bottom up approach, where existing ground level service providers can be empowered to provide some basic essential services. Under the National Health Mission, there has been a significant strengthening of health infrastructure and human resources including ASHAs and ANMs. However, the challenge with them has been a relative lack of training to the desired level, which hampers their ability to perform their task as envisaged,” he opines.

Expounding on how technology can help tide over, he cites some examples of PHFI’s technology platform which have been utilised in some rural areas of India in order to ensure quality healthcare services to people despite the shortage of medical staff.

“This is where technological innovations like PHFI’s Swasthya Slate are proving their worth. The project is being implemented in Jammu and Kashmir, where despite the effects of terrorism and internal turmoil, healthcare services have largely remained unaffected. Vulnerable populations like pregnant women and children often find it difficult to travel to a hospital to get antenatal checkups and diagnostic tests done. Thus, frontline ANM workers in the districts of Rajouri, Poonch, Doda, Ramban, Kishtwar and Leh, are now carrying a ‘Hospital on Back’ or PHFI’s Swasthya Slate kit, which is providing rural healthcare and diagnostic facilities at the doorsteps of the population in these areas”, he informs.

Recapitulating on how the slate is used, he says, “A range of 12 tests like blood sugar, blood pressure, urine, pregnancy test, foetal doppler, haemoglobin and HIV test are conducted within a span of less than 45 minutes. Based on this, beneficiaries are given treatment or referred to the nearest PHC hospitals for treatment. This tablet also sends patient records over the cloud, which means the health directorate can, at the tap of a finger, see the demographic health disease pattern in a particular area, act on an outbreak or if need be, send reinforcement. This technology is not only providing great benefit to the patients but also helping in many other ways like referring only a selected high-risk clients to the hospitals, who have initially been found to have an abnormal diagnostic test. It also helps to empower the ANMs who are not only learning to use technology but also to conduct diagnostic tests, identify high-risk patients and referring them to higher facilities in time, filling a critical gap in training. Another advantage with this is that it can be modified to provide any population-based health services which may be needed including telemedicine, referral transport information system, pharmaceutical management etc. Some other states are using another tablet-based software ‘Anmol’ which helps to register the beneficiary and upload the history but this does not have the facility to undertake diagnostic tests, which need to be performed in a hospital separately.”

Finally…

Measures mentioned above can help us cement the cracks in small ways or big. But, the government will need to take a bigger responsibility in solving this issue. Lack of a political will is the biggest hindrance in translating these solutions into positive results. Currently, our nation stands at a crossroad where some efforts have helped us to better our health indicators, yet there is a long way to go in order to achieve the dream of a healthy India, where every citizen will have equitable access to quality healthcare. In 2017, India will therefore need to solve every single problem that serves as an obstacle towards achieving our healthcare goals. This means that political leaders and healthcare decision makers will need to work towards ending corruption and focus more on making healthcare a right of every citizen.

Is this an ambitious request to ask of our leaders?

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