In poor health

In a country like India, it seems that health has never been a matter of charity. Money has always played a critical role in availing better healthcare services as the condition of government–sponsored community healthcare centres is like the mobile charging points installed by telecom service providers for publicity, most out of which, stop functioning after a very short interval of time. The pertinent question is this: who should be held responsible for running healthcare centres in rural India or urban localities?  The government is leaving no stone unturned in building competitive infrastructures for providing up to the mark healthcare facilities to every section of the society, but the key issue which has crippled the health services is the shortage of quality doctors in the country.

In a country where doctor–patient ratio is worse than its neighbouring countries like Pakistan and China, the steps like introducing exit MBBS examination to weed out bogus doctors, allowing nurse practitioners to prescribe medicines in rural areas are in the better interest of general public as the sole objective of the government is to produce quality medical practitioners and make availability of trained hands at the disposal of common masses, who are still dependent on quacks, superstitious methods of treatments. The latest decision of the government to allow corporate giants to open their own medical college is considered as a major step initiated to address the dearth of doctors by producing quality doctors. The government has allowed private players in medical education by relaxing the ‘stringent’ norm of establishing a medical college as a non–profit entity through the means of Charitable Trusts. The literal meaning of this decision is this that medical education will now fall under the category of profit making institutions.

The government has its own reasons to defend the move. According to a senior official in the health ministry, who didn’t want to be named, the decision will help in producing quality and trained doctors as well helping in putting a check on ‘tax theft’. “We have a shortage of doctors as the country is not able to produce more doctors due to a lesser number of MBBS seats in limited colleges. Private entities in healthcare are keen to start their medical colleges, but clauses are so stringent that they take two steps back on moving a step in this direction,” the official said.

The Health Ministry official further said, “As per the clause, which has been a relaxed now, the interested party would have to first establish a Trust, then the process of establishing a college used to begin, which is actually a cumbersome process. It has become a hard reality that medical colleges have started mushrooming on ‘papers’ only, which is very unfortunate.”

Now corporate players like Tata, Reliance, Apollo, Max Healthcare, Medanta, etc can open their own medical colleges and high–class hospitals across the country. Not just this, the government has also allowed all medical colleges running as non–profit trusts to convert themselves into profit making entities. It appears very impressive that students studying in medical colleges run by either Tata Group, Reliance, Apollo, etc would be highly qualified as they would get all kind of supportive assistance such as better case studies, latest machines and equipment, etc. To be very precise, the students would get all those facilities that they are usually devoid of while studying in Divya Jyoti Medical College and Hospital, Ghaziabad, Mahaveer Institute of Medical Science and Research, Bhopal, etc which are operational on papers and websites.

The question that government should answer is that whether coming up of high–end medical colleges would really address the shortage of doctors particularly in rural areas, where availability of medical practitioners has never been a priority for the government. Would students, who shell out crores of rupees to get MBBS degrees from high–end private colleges, prefer to join government medical services or go for rural postings?

Possibly not, the reason being  this that the working culture of government hospitals and that of the private is very different. On top of that, public systems of health management would not match the remuneration or pay package in comparison to private hospitals. There are several cases where the doctors of All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, etc have left their institutes and parked themselves at private hospitals such as Fortis, Apollo, Max, Medanta, thereby, doubling their income by encashing the face value of these institutes.

The intention of the government behind the move has been questioned by many. “Will this move really bridge the widening doctor–patient gap? In my view, it won’t. Instead of opening doors for corporate, the government should have strengthened the existing infrastructure of public medical colleges. The number of postgraduate seats in government colleges should have been increased, but nothing much has been done on that part,” Madan Jaira,  a senior journalist covering health sector, said.

“It’s okay that the number of MBBS doctors would increase, but what will happen to health care of poor people living in rural pockets of the country? Why would a student who spent above Rs 1 crore for getting a medical degree, go for entrance test to get selected in government hospitals? There will be very few from this lot who would prefer to work in the government system, while most of them would look for opportunities at the global level,” he said.

Speaking in support of the move, noted gynaecologist Meenakshi T Sahu said, “It is not any secret that many private medical colleges take hefty capital fees, and yet run as trust–based, non–profit organisations. It is okay to create a system where profit making organisations will be invited.”

“The already existing private medical colleges are still not up to mark in terms of quality of education, as compared to training at government Institutions. On the brighter side, inviting corporate houses for setting up colleges that are profit–making ventures, may help in creating world class medical infrastructures, with hiring of top talents in field of medical education as well as medical research (all of which need financial investment),” Dr Shahu said, who is medical graduate from Banaras Hindu University.

“And if such institutions indeed are being crafted, the government also needs to ensure that students with good scholastic aptitude get entry and not just any student whose parents can pay the fees. Any steps to increase the number of doctors will help decrease the gap of doctor–patient ratio,” Sahu said. However, Sahu also stressed that it is bit hard to imagine a rich family’s child obtaining MBBS degree from an urban–based profit making corporate medical college, willingly, go for a rural posting.

Agreeing with the views of Sahu, Indian Medical Association (IMA) president–elect KK Aggarwal said, “It’s good in the interest of the country and doctors fraternity. The move will definitely help in addressing quality of doctors and increasing the strength of doctors. Medical education now, will be more transparent.”

On rural posting of doctors, Aggarwal said, “There is no dearth of doctors in rural India as well. We have an innumerable number of medical practitioners willing to go for rural posting, but it’s the government who is not encouraging our doctors for serving in district hospitals or any primary health care centre.”

However, Arvind K Chaturvedi, who is director of radiology at Rajiv Gandhi Cancer Institute & Research Centre, dubbed the decision as commercialisation of medical education. “It will make medical education more flourishing as a business. After the clause relaxation, corporate players would come in hoards to set up new institutions. The merit would also be compromised as all meritorious students can’t afford to go for a medical seat worth Rs 1 crore or above.”

Drawing the attention of the government to increase PG seats, Devi Prasad Shetty, noted cardiac surgeon, said, “If city doctors are not working in rural India, why not double the PG seats so that doctors from other Asian countries or Africa can do it for the degree?”

“In India, medical education has nothing to do with healthcare delivery. Postgraduate education happens only in city–based colleges. In the US, they have 21,000 undergraduate seats and 40,000 postgraduate seats. PG seats are double the UG seats in all developed countries, but in our country its opposite as we have 53,300 undergraduate seats and only 14,500 PG seats in clinical subjects,” said Shetty, who has pioneered lowest–cost, high–quality healthcare service provider by establishing Narayana Health, a chain of 21 medical centres across the country. “The Medical Council of India portal claims that there are 25,000 PG seats, but most of them are in subjects like anatomy, physiology and biochemistry, which no young doctor wants to take up. It is due to shortage of PG seats that the capitation fee for an MD in radiology is in the range of Rs 4–6 crore. Bring parity in PG and UG seats, and the premium on PG seats will disappear.”

It’s a hard fact that out of 10 lakh registered doctors from 450 colleges in India, thousands have got their degrees from institutes that function as little more than teaching shops. Today, colleges are set up almost immediately after hospitals are opened. They may have no patients for students to practise on. But if you have the money, a piece of paper certifying you as an MBBS awaits you at the end of five years.