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Sunday, October 26, 2003

A few days ago, the government of AP declared their goal of starting 40 medical colleges in the state. Certainly society does need more and better health personnel. But mere increase in doctors’ strength does not help.

The fact of the matter is we already have more medical colleges than are necessary. A study published by the UNDP, way back in the late 1970’s, titled ‘Determinants of Migration” considered various factors like the country’s GDP per capita, and the number of doctors that any given society can absorb. The report indicated that by that time itself, India had more doctors than it could gainfully employ. Since then, the number of doctors in the country has roughly doubled, and more physicians are unemployed now. The real problems in health care are more complex and require larger systemic reforms. Mere increase in medical schools will not help. Let me focus on three key issues.

First, we have an “inverted pyramid” structure of availability of health care professionals. As Dr Arole’s Comprehensive Health Care Project, in Jamkhed, Maharashtra proved, fully 80% of cases can be competently handled by a well-trained paramedical professional and only 20% need the attention of a medical doctor. While the country requires more well-trained nurses, paramedical professionals, general practitioners and public health experts, we remain deficient in all those areas. Instead, we have umpteen numbers of super specialists who are needed by only a small percentage of the population. In fact, you have to search really hard to find a decent family physician, while super specialists in every conceivable category can be found at practically every street corner. Hyderabad boasts of more MRIs, CT scans and other fancy high tech medical equipment than the city of London! And yet at the same time, the majority of the poor don’t even have access to basic health care.

Second, the quality of training for our health care professionals has deteriorated tremendously over the past 20-25 years. Medicine, is a demanding profession and it calls for a higher degree of professionalism, competence, dedication and discipline than most other walks of life. In most parts of the world, one can get into a medical school only after the completion of a basic four-year degree. In countries like United States, one has to go through rigorous training ranging from 4-7 years after medical school before you are allowed to practice. In India, we allow 16 year olds to get into medical school, even before they fully understand what they would like to do. And the quality of training that is imparted is woefully inadequate. Most medical colleges in the country don’t have competent faculty to teach. There were instances of some colleges hiring local doctors for a fee, to pose as faculty members during Medical Council inspections!

Third, 60 % of the resource allocation in the health sector goes for curative services, which, largely favour the rich. Rs 3 is spent on the richest quintile for every Rs 1 spent on the poorest 20 percent! This figure has to be viewed in the light of the fact that hardly 0.9 % of the GDP is spent on public health, which is one of the lowest in the world. Hospitalized Indians spend more than half (58%) of their total annual expenditure on health care and 25 - 30 % of them end up below the poverty line as a result. There cannot be anything more disgraceful in a modern democracy.

Our policy makers should wake up and realize that what we need are more nurses and paramedics; we need more general physicians than super specialists; and more resource allocation towards preventive than curative services. A fundamental rethinking in health care delivery is vital to serve the needs of our people.