India has little more than a million allopathic doctors for her 1.3 billion citizens. According to World Health Organisation (WHO), India has been improving its doctor-population ratio from 1:1900 in 2000 to 1:1319 in 2016 as against the ideal of 1:1000 people (WHO, 2017). Among the existing doctors, the urban to rural ratio is 3.8:1 making rural presence of doctors a serious concern (Rajya Sabha, 2018). Despite increase in overall density of physicians, shortage of doctors and specialists remains an important bottleneck in India’s public healthcare system. According to National Health Profile (NHP) 2017, only around 11 per cent of all allopathic doctors were in the government services (CBHI, 2017). This brings the government doctor-population ratio to 1:11097. This ratio is as good as 1:2203 in city-state like Delhi and as bad as 1:28391 in the predominantly rural Bihar. The situation of government healthcare, served through primary health centers (PHC) and community health centers (CHC) in rural areas is particularly poor.
Fewer doctors in government
According to the NHP 2017, the proportion of vacant positions of doctors at PHCs was 24 per cent although only 8 per cent PHCs were without a doctor nationally. This is because existing doctors are given additional charge of a ‘PHC without a doctor’. Among the ten states with zero PHCs without doctors, Telangana (27 per cent), Gujarat (31 per cent) and Uttarakhand (44 per cent) reported very high proportions of vacant positions of doctors at their PHCs (CBHI, 2017).
The situation of CHCs is worse. There are fewer sanctioned positions of specialists at CHCs than what is required. Even then, at a national level, more than two-third of sanctioned positions (68 per cent) of specialists at all CHCs are vacant. The shortfall (i.e. proportion of vacant positions against need) is as high as 82 per cent. In a state-level comparison, the proportion of vacant position is as high as 85 per cent in Gujarat and Madhya Pradesh, and 90 per cent in Chhattisgarh. The shortfall in case of Gujarat is very high at 94 per cent (CBHI, 2017).
This shortage of physicians has increased over time in India. At an all India level, the proportion of vacant seats has increased from 11 per cent in 2005 to 24 per cent in 2017. The vacant positions and shortfall of CHC specialists have doubled from 37 per cent and 41 per cent in 2005 to 68 per cent and 81 per cent in 2017 respectively.
In Gujarat, for example, against sanctioned seats of 1070 PHC doctors, only 15 per cent were vacant in 2005. Over more than a decade, the proportion of vacant positions has increased to 31 per cent for 1769 sanctioned seats. The vacant positions and shortfall of CHC specialists have also worsened from 2005 (MoHFW, 2005). Clearly as the need for doctors and specialists expanded, the sanctioned posts increased; however, these posts remained vacant at many PHCs and CHCs.
More medical colleges—is it a solution for shortage of doctors?
A shortage of medical seats, owing to fewer medical colleges, has been cited as a common argument for the shortfall. Opening new medical colleges, therefore, remains a common chorus. Let us understand how expanding medical education can change the scenario for shortage of doctors. An examination of Gujarat’s new policy to encourage public private partnership for establishment of newer medical colleges to increase the supply of doctors in rural areas will be interesting.
Gujarat has better overall doctor-population ratio (1:944) as compared to the national average. However, with only 9 per cent of all registered doctors in government, it has poor government doctor-population ratio at 1:11475 (CBHI, 2017).According to Medical Council of India (MCI), Gujarat has 24 medical colleges with 3780 MBBS seats. Of these, 13 medical colleges and 1950 seats came up only during the last decade. Despite doubling of MBBS seats since 2008, shortage of MBBS doctors has only worsened in the PHCs of Gujarat. For specialists, there are 1634 seats of various MD and MS courses in various medical colleges of Gujarat as against only 92 working at various CHCs in the states. The recent CAG report (CAG, 2016) as well as recently released report from NITI Aayog (NITI, 2018) indicated that not only rural CHCs have shortage of specialists, the district and civil hospitals of urban Gujarat also have shortage of doctors and specialists of various kinds.
Clearly, the blame for shortage of doctors and specialists in government healthcare facilities cannot be squarely placed on the creation of fewer medical professionals. This cannot alone be solved by expanding medical education through self-financed medical colleges in private or trust owned institutes as against subsidised seats in government-funded colleges—that are in any case becoming a rarity. An expensive education would naturally result in doctors seeking high-remunerative employment in private sector in urban settings.
Opening up of new medical colleges may increase overall doctor-population ratio; howsoever necessary it seems, it is not sufficient to ensure improved equitable health workforce scenario. Under-production of doctors is not a big problem; getting them to stay and work in rural and remote areas and public facilities of all kinds needs a special attention and newer strategies.
How to attract and retain
doctors in the government
Government needs to look beyond recruitment, and focus on retention through incentives that evolve with rapidly changing private markets. Doctors opting to work in government seek better work environment, better remuneration, non-monetary incentives like quality stay for family and education facilities for children, and a clear career progression. Some states like Chhattisgarh, Maharashtra and Tamil Nadu have taken out-of-box approaches to incentivise and motivate young doctors to join public service. Chhattisgarh came up with a scheme that not only provided better remuneration to doctors who opt to work in difficult areas, but also offered incentives for career advancement, help with school admission for their children and job placement for their spouses. Tamil Nadu and Maharashtra have dedicated public health cadre that ensure entry, retention, and progression of doctors and other public health professionals from numerous functionaries from the grass-root to higher administrative levels.
Most other states, including Gujarat, still use punishment approach like ‘mandatory rural posting’ and ‘bonds’ for ensuring involuntary short-term association of doctors, who quit as soon as they can. Unless there are strong incentives to join and stay in the public systems, doctors and specialists would opt for a flourishing and lucrative private practice in urban and peri-urban centers.
More doctors, better doctors and looking beyond doctors
While we expand numbers of medical seats, we also need to make our medical education better, smarter, and nuanced for local needs. This needs shift in the outlook of medical education, beyond diseases and its treatment, towards health. It is also high time India look up to health beyond illness and injuries, healthcare beyond diagnosis and treatment, and health workforce beyond allopathic doctors and paramedical staffs. India’s health sector and its medical education needs to incorporate public health approach. It needs to respect, and if possible, incorporate specialties like social science and management that play important public health role before diagnosis and after treatment.
The Parliamentary Standing Committee on Health and Family Welfare recommended that the proposed bridge course in NMC 2017, one that allows practitioners of traditional medicine to practice modern medicine through a short-duration course, should not be a mandatory provision and the decision should be left to states. However, it also indicates that “State governments may implement measures to enhance the capacity of the existing healthcare professionals including AYUSH practitioners, B.Sc.(nursing), BDS, B.Pharma and many others to address their state specific primary healthcare issues in the rural areas”(Rajya Sabha, 2018). This is indeed a welcome step towards public health goals. Public health professionals, with medical, para-medical or non-medical backgrounds, can take a lot of ‘administrative’ burden away from doctors and help improve their medical efficiency.
Comptroller and Auditor General of India (CAG), 2016. Report of the Comptroller and Auditor General of India on General and Social Sector for the year ended March 2015. Government of Gujarat: CAG of India.
Central Bureau of Health Intelligence (CBHI), 2017. National Health Profile Page 233, 238, 107: Ministry. of Health and Family Welfare. Available at: http://cbhidghs.nic.in/
NITI Ayog, 2018. Healthy States, Progressive India: Report on the Ranks of States and Union Territories, Government of India: Niti Aayog.
Ministry of Health and Family Welfare (MoHFW), 2005. Bulletin on Rural Health Statistics in India. Department of Family Welfare: MOHFW.
Rajya Sabha, 2018. 109th report on The National Medical Commission Bill 2017. Parliament of India: Rajya Sabha.
World Health Organisation (WHO), 2017. Global Health Workforce Statistics: The 2017 Updates, Geneva: WHO.