INDIAN infant mortality and maternal mortality indicators are worse than in most sub-Saharan African countries. Every ten minutes somewhere in India a young woman dies during child birth, 300,000 children die the day they are born, and 1.2 million children die even before celebrating their first birthday. Unfortunately, our policy makers continue to think that merely by increasing the budgetary allocation on health care, we would be able to address the crisis. Little do they realize that even if we increase our budgetary allocation for health care from the current 1.1% to 10% of the plan outlay, maternal mortality and infant mortality in India will not come down, simply because we do not have the needed skilled manpower to address the crisis.

According to information from the Ministry of Health, the shortage of medical specialists in community health centres – where a vast majority of the children in rural India are born – is close to 75%. To present the data in brief, 26 million babies are born in India every year. At least 20% of them require cesarean section; that means about 5.2 million cesarean sections per year. To perform 5.2 million cesarean sections, we need at least 200,000 gynecologists. However, at present we only have 30,000 gynecologists, nearly half of whom do not practice obstetrics. We need 200,000 anesthetists for these pregnant women while we have less than 20,000, most of them in cities.

To take care of these babies, we also need at least 200,000 paediatricians, while we only have 20,000, who again are mostly living in cities. No surgery can, however, be done on our 1.2 billion people without the right diagnosis and images. We need at least 150,000 radiologists, but have only 10,000. This is primarily because even though we produce 50,000 doctors a year, we only have 14,000 postgraduate seats for these doctors to become specialists. In contrast, the United States has only 20,000 undergraduate seats and 38,000 PG seats in medical schools.

Because of the acute shortage of PG seats, young MBBS students spend two to five years in coaching classes mugging MCQ in Kerala and Kota and not taking care of the patients. Why is a postgraduate degree so important in India? This is because we have very rigid Medical Council of India regulations specifying as to who can perform what procedure. For instance, I am a heart surgeon, but if I perform a cesarean section, I can lose my license.

For the time being, let us put aside maternal mortality and infant mortality problems, which do not affect the privileged living in cities. Let us instead look at the top ten causes of death in India starting from heart disease to liver failure, psychiatric illness, accidents, pneumonia, TB, and so on. None of these top ten causes of death can legally be treated by an MBBS doctor without a postgraduate qualification. In this scenario, how do we expect the death rate to come down without having the needed number of licensed practitioners to address it? This is the irony of the situation.

Today it costs somewhere between Rs 400 to 500 crore to start a medical college. As a result even state governments are reluctant to start a medical college. At the moment thus, from among the private sector, only not for profit trusts can build medical colleges. I cannot think of a single trust in India intending to start a medical college which would spend this amount and expect nothing in return. In the process, it is primarily, if not only, people with ill-gotten wealth who end up establishing new medical colleges. As a result, medical education has become extremely expensive.

 

Children from poor families in India cannot therefore dream of becoming doctors. The evidence is that by and large outstanding doctors across the world with magic in their fingers generally come from deprived backgrounds, in part because they are children with fire in the belly who are willing to work 24 hours a day, change the rules of the game and, in the process, become expert doctors. If such gifted children are today not keen or able to become doctors, we will soon be left only with incompetent doctors and the country will have to pay a heavy price for letting that happen.

With the stroke of a pen, India can equalize the member of undergraduate and postgraduate medical seats in medical colleges. This can happen without billions of dollars of investment, or waiting for a long period. For a start, we should dispel the myth that higher medical education can only be imparted in the premises of medical colleges. Across the world, quality higher medical education is provided in non-medical college hospitals, which happen to be centres of excellence.

One of the commonest questions raised by various medical councils when seeking permission to open a new medical college, or to increase the number of postgraduate seats, is about the shortage of faculty members. For a meaningful response, we first need to ask a simple question: Who is a teacher? Who is qualified to teach medicine?

 

Naresh Trehan of Medanta Hospital and Ramakant Panda of the Asian Heart Institute in Bombay are recognized as pioneers of cardiac surgery, and not just in India. Unfortunately, according to the qualification guidelines prescribed by the Medical Council of India, neither of them can teach cardiac surgery in India. Clearly, this means that there is something fundamentally wrong with the way we conduct medical education. Take for instance, in India on average it takes 140 faculty members to start a medical college with an intake of 100 students per year. However, some of the best British medical universities function with just 40 faculty members for a student intake of over 150 per year.

Health care cannot be dissociated from medical education. Across the world medical education is an integral part of health care delivery, especially in under-served and difficult to access parts of the country. By making the jobs available in rural India an integral part of the training programme, we can attract talented doctors to these under-served areas by enabling them to simultaneously increase their qualifications. These doctors are more likely to work without complaining, if only because at the end of three years they will acquire both a precious degree and valuable experience. But, we have consciously avoided using medical education as a tool to address maternal mortality, infant mortality and health care problems of rural India.

Take another example: Few may have heard of an institution called the College of Physicians and Surgeons (CPS) based in Mumbai. This is one of the oldest medical universities in our part of the world, established well over a century back. For years it awarded diploma degrees in gynaecology, anaesthesia, paediatrics and radiology, among others, to address the needs of rural India. Unfortunately, a few years back, its degree was de-recognized.

The training programme developed by the College of Physicians and Surgeons can be conducted at any of the government hospitals. Properly done, this would convert all the young MBBS doctors in government hospitals to medical specialists in two years, thereby addressing three-fourths of the shortage of medical specialists in the government sector across the country. All it requires is a simple instruction from the Ministry of Health.

 

I have travelled across the country meeting young medical students. Today, an overwhelming majority of young medical students or young doctors do not want to work in rural India. Across the world, meanwhile, primary health care is provided by nurse practitioners or physician assistants. Unfortunately, we in India have never created a legal framework for nurse practitioners or physician assistants to dispense basic medicines – that is 47 basic drugs – in primary health centres.

We have close to 600,000 AYUSH doctors who are graduates from the same universities which give all the medical doctors their MBBS degree. All they need is merely an additional six month bridge course to be certified as competent to legally prescribe the 47 basic drugs in primary health centres. This can address the seemingly intractable problem of absenteeism of MBBS doctors in primary health centres and thereby enhance the quality of health care to rural India. Unfortunately, in spite of several meetings and many expert recommendations, our policy makers have not seen fit to include the AYUSH doctors to the list of those who, post training, are legally allowed to prescribe the 47 basic drugs even though this simple policy change could easily address the rural health care problem; all we need is the political will to make it happen.

 

We need to tackle another crisis. The nursing profession in India is dying. In the next five years, we will not have the needed number of nurses to serve our patients in hospitals, resulting in the closure of several hospitals. This is a disaster waiting to happen and it is a known fact.

Admissions to nursing colleges have come down by over 50% and nursing colleges across the country are closing down, especially in southern India. The main reason is that the nursing profession offers no career progression. Today, when young people choose a profession, they want to know about their career prospects. In the United States, 67% of anesthesia is administered by nurse anesthetists. She can independently anesthetize a patient for a major heart surgery, whereas in India even a nurse who has worked in the Intensive Care Unit for over 20 years is legally not allowed to even prescribe a proxyvon tablet, leave alone administer an intravenous injection.

Because of the absence of career progression, hospitals are not able to give our nurses higher salaries; in the process the nursing profession has lost its shine. If we were to create the positions of nurse anesthetist, nurse intensivist and nurse practitioner, many of the current problems could be addressed by releasing doctors to do major clinical interventions and allowing the nurses to do the basic routine work. Health care is not about just MBBS doctors. Behind every doctor there are four nurses and four paramedics.

 

If one goes through the data from the US Bureau of Labour, 15 out of the 20 fastest growing occupations in the US, are related to health care. The top position is that of a home health care aide. Unfortunately, no training programmes for those occupations exist in India.

Our policy makers never tire of talking about creating millions of jobs. In the United States, the largest employment generator today is the health care industry; the same holds true of Europe. Unfortunately in India, even though there is an opportunity for the health sector to emerge as one of the largest employers, we are not willing to liberate medical education, nursing and paramedical training. By missing out on these opportunities, there is danger that India will soon become a country with over 200 million unemployed youth. It is unlikely that any democratic country can afford to have millions of youth without jobs. You do not need external aggression to ruin our country; our unemployed youth are sufficient.

Technology can bring about a massive shift in the way health care is delivered and funded. Eleven years ago we conceptualized a micro health insurance scheme called Yeshasvini, which was launched by the Department of Cooperation of Karnataka state. In the first year, 1.7 million farmers paid five rupees per month as a premium and the state government became the re-insurer. Today, we have over four million farmers who are paying ten rupees per month and in this period of ten years close to one million farmers received surgical treatment, of which close to 100,000 farmers were able to avail of heart surgery in one of the 476 network hospitals.

This is the power of India with its population of 1.2 billion. Today we have close to 900 million mobile phone subscribers who spend about Rs 150 per month just to talk on their phones. If we could come up with a regulation to charge Rs 20 from each mobile phone subscriber, we would cover the surgical costs of 900 million people. This is not rocket science and we can do it.

 

In the end, I would like to stress that we have a great opportunity of becoming the first country in the world to dissociate health care from affluence. We can prove to the world that the wealth of the nation has nothing to do with the quality of health care its citizen can enjoy.

India can easily become the health care provider for the world if only our medical education is liberated from the shackles which currently bind it. We could easily run the hospitals in US, Europe, Africa, Latin America and the rest of the world, but for this to happen we need to produce millions of doctors, nurses and medical technicians.

Every year we add 26 million babies to our population. We may not have petrol or other natural resources to make them rich, but surely we can give them education, which will enable them to create a better world, for themselves and for all of us. All we need to remember is that no unhealthy nation has ever achieved greatness.