The scenario of public healthcare in quite a large part of the country is in
shambles. This is no secret. There are powerful lobbies within the country that
are bent upon seeing off the remnants of public healthcare in whatever state
they are in now. Healthcare as of now has become a commodity which is much
beyond the reach of an average Indian in most of the states of the country.
There are questions being asked about the propriety of
healthcare being put in as a basic right of each of the citizens of the
country. The result has been quite gruesome.
Basic health indices like Maternal Mortality Rate, Infant
Mortality Rate etc. are so dismal in quite a many parts of the country that
both the care-givers and the cared are well versed in sweeping adverse health
events under the carpet. Latest reports say that we're in for real trouble with tuberculosis.
States like Kerala, Tamilnadu etc. have made major strides
in healthcare whereas states earlier known as the BIMARU states, and presently
designated as the Empowered Action Group states are a major blot for the
healthcare prestige of the nation.
The question remains on how serious we are about this?
One aspect to look at is the healthcare manpower of states
in general. I would like to start off with the availability of doctors in
various regions of the nation. I do not have numbers from the respective State
Medical Councils. However, there is readily available information about the
number of seats for MBBS in the different states of the country.
Of course, I would have critics tell me that the presence of
doctors alone is not enough to ensure that the nation is healthy. There are
countries like Sri Lanka who depend more on nurses for primary care than
doctors, thereby ensuring that healthcare indices are much better than even
places like Kerala or Tamil Nadu.
Going back to availability of medical graduate seats in
various states, I would like to draw your attention to the table below . .. …
Take a look at the below facts . . .
a. Kerala and Tamil Nadu which has got a combined population
which approximately totals the population of Bihar has 70 medical colleges with
a total of about 9000 MBBS seats whereas Bihar has a measly 13 medical colleges
with a total of 1200 seats.
b. I thought of looking at Gujarat as we have NaMo, the present
Chief Minister claiming all qualities to don the mantle of Prime Minister after
the next parliamentary elections. With a population which is almost double that
of Kerala, Gujarat does neither have the number of Medical Colleges nor the
MBBS seats that Kerala has. Poor marks for that, Mr. Modi!
c. You may be wondering on how I arrived on the calculation of
doctor per 100,000 population. I made the supposition that each medical
graduate would serve the nation for at least 40 years after graduation. However, there is a problem here too. For India, the calculation says that
there would be about 160 doctors per 100,000 population. However, on the
ground, we have only 62 doctors per 100,000 population. For comparison, Cuba
has 672 doctors per 100,000 population. I have not taken into account the major
brain drain in the field of healthcare which continues in the country.
d. I’ve not taken also into account doctors who are graduating
from other countries and coming back to India. Experience says that the numbers
of such doctors are also more from the better off states rather than the EAG
states. And of course, doctors who would have spent quite a lot for their
studies abroad will never be much inclined to serve the rural areas. However,
I’m sure that there is no point blaming them as our graduates too do not prefer
serving Bharat and instead preferring the shining India.
Now, I’m going to give another twist to this whole issue.
Recently, there was a major statement from a leading healthcare professional
about the need for more specialists in the country especially for the
specialities of cardiology, diabetes etc.
Of course, with only measly group of medical graduates
passing out each year in terms of requirement of the country, it becomes all
the more tough to make them specialists in various fields of medicine. And the
biggest question is whether we require specialists for each branch of medicine.
In one of my previous posts, I had explained quite in detail
about the realities about availability of specialists in remote areas of the
country, such as ours.
Here, I would like to look at how we would end faring if the
situation remains status quo.
One major concern is poor obstetric care. Why don’t we look
at the speciality of obstetrics?
Below is a very similar table to the one above. The only
difference being that, we’re looking at the number of obstetricians that
colleges in the same states churn out every year.
The number of obstetricians who pass out each year in Tamil
Nadu is more than twice that of Kerala. There is no point in looking at numbers
from the other states. Uttar Pradesh, which has almost 3 times the population
of Gujarat has almost the same number of obstetricians passing out each year.
The maximum overall conversion rate from graduates to obstetricians is a measly
4%. For comparison, almost all developed countries has more than 10 obstetricians
per 100,000 population.
In a hospital setting where we have a sick baby, a mother
for antenatal care, an elderly man for diabetic control, a mother in labour
room who needs an emergency Cesarian section, we expect to have a Pediatrician,
Obstetrician, Internal Medicine Specialist, and an Anesthetist.
I was trying to do some calculations.
Suppose one obstetrician can supervise approximately 200
deliveries in a month, which amounts to about 2400 deliveries in a year. In
Jharkhand we have an approximate birth rate of 24 per 1000 population. Therefore, we would do well with one obstetrician for 100,000 population.
Unfortunately, although this looks good when we calculate availability
according to the number of post-graduate seats in obstetrics, it does not work
well. For example, the region of Palamu, Garhwa and Latehar districts which has
a total population of approximately 4 million has only about 10 obstetricians
on paper. It should have had 40 obstetricians. I understand that practically,
there are only 3-4 obstetricians in the region.
Now, according to rules, we need to have an anesthetist
wherever there is an obstetrician. Below is a table showing status of
anesthetists in the same states.
But, do remember that anaesthetists are not only required by
obstetricians, they are needed to work alongside any of the different surgical
specialities. So, the anaesthetists need to be much more than the number of
obstetricians.
Now, if we apply the same rule to other conditions, we shall
soon find out the enormous challenge that we have in our hands.
I’m sure that this is the case scenario for almost all
specialities. All of us know quite well that the number of post-graduate
training opportunities available to MBBS graduates is on the lower side. The
National Board has tried to offset this shortcoming by arranging DipNB courses
in private hospitals. There are challenges here which are beyond the scope of
this article.
To complicate issues, on the healthcare side, the burden of
non-communicable diseases is on the increase. There are calls for more
specialists in the areas of diabetes, cardiology, oncologists etc. However, do
remember that we still grapple with basic healthcare issues such as maternal
and child health care, infectious diseases such as malaria and tuberculosis. For
completion sake below is a table which shows the number of Internal Medicine
consultants and cardiologists who pass out from the same set of states.
Availability of clinical care in rural areas of the country is a major issue. Of course, there needs to be major inputs into infrastructure development of public health facilities in all tiers of clinical care. States such as Tamil Nadu and Kerala has already shown us the way in this realm.
If one closely looks into the Kerala model of healthcare,
one can very easily find out that the availability of graduate doctors in grass-root
public health facilities, namely the Primary Health Centre and Community Health
Centres has been one of the key reasons for healthcare equity. The challenge is
to replicate this model in this era of specialisation.
And in Kerala, I find the justification about equipping PHCs
and CHCs adequately. Because till about 5-10 years back, the total medical
graduate seats in Kerala was not more than 800 seats. And still with that
number, Kerala was successful in bringing to quite a certain extent in bringing
about healthcare equity.
In the present era, considering into fact the reality that
post-graduation is the norm in the field of healthcare, we are in a quandary.
In addition, there is a fall in standards of medical education all over the
country. It is not uncommon to find MBBS graduates who do not understand
anything about clinical medicine and finds it difficult to practice. In such a
scenario, a post-graduate speciality for training in general practice is very
much necessary.
And this is exactly where a Masters course in Family
Medicine would be of benefit.
For uncomplicated cases of pregnancy, do we need an
obstetrician around to supervise delivery? For a routine care of diabetes, can
we afford to have diabetologists all around the country? Even, for an acute
cardiac event, are we entertaining the possibility of only a cardiologist
managing the case? Of course, for the rich and the powerful, affording a
specialist would not be an issue. The question remains of the common Indian
citizen.
And this is where exactly a Family Physician would fit in.
In a situation where we can equip our Primary Health Centres
with couple of Family Physicians, the workload on our referral centres would
come down quite a lot. And the cost of healthcare would come down to quite a
large extent.
Would like to have feedbacks for this post . . .
