On disease and its cure
The Indian Union ranks extremely low in the level of healthcare that most of its citizens have access to. Beyond the swanky places that cater to the Indian elites and also increasingly to others in the name of ‘medical tourism’, much of the healthcare that is available is of low quality or is unaffordable. This reality is the disease that needs to be cured, if one is serious about health in India. The revamping of medical education and research is an important part of the cure.
The doctor-patient ratio is very low in India. This number becomes even lower when one separately looks at the numbers for rural and urban India. Indeed, as far as the geographical location of specialists goes, the difference is even staggering. Also, private healthcare is unaffordable for most people and public healthcare infrastructure is in shambles. Medical insurance that is paid by the government is simply a way to transfer public money to private health-care companies. The people are the real losers. There is the issue of emigration of doctors primarily to USA, UK and the gulf-countries. Often the émigré doctors are among the better doctors of their batch. This loss is another problem. Finally, medical research in the Indian Union has languished due to lack of commitment to Indian realities when doing medical research and a near total divorce of medical research from medical education and practice. Reforming medical education means reforming all of these things, as far as possible.
We need to go the root. Why does society decide to produce a doctor: so that the trained person can attend to the medical needs of society at large. Medical colleges are places to produce such trained personnel. They are not places to reward rote-learning science students after Class XII with a financially lucrative career or a boost in their ‘value’ in the marriage or dowry market. There is nothing wrong in being a careerist, but as a society, we need to decide exactly what sort of careerists are we training in our medical colleges. I present below three concrete proposals that might go a long way in achieving the goal of having better doctors for a healthier India.
One of the biggest problems that state governments face is that many doctors simply refuse to take up a position in rural areas. Most doctors come from urban backgrounds due to the better entrance-examination training systems available in cities. Rural healthcare cannot suffer due to this urban bias. I have a three-fold proposal. A significant proportion of seats in medical colleges have to be reserved for students from rural backgrounds. This can be in addition to the caste based quotas or the quotas can work within this rural quota. When the government sets up any new medical college, it should make sure that it comes up in a rural area. Additionally, such a college should have special reservations for students from that district. These two proposals will produce doctors who are more likely to serve in rural areas or even their home areas than urban careerists. There is no dearth of opportunities for urbanites. Healthcare for rural India cannot be a scapegoat of their ambitions. Finally, postings in rural areas have to be heavily incentivised, both in terms of salaries and post-graduate training opportunities. In fact, a single step of making three years of rural service mandatory for all post-graduate courses will go a long way in solving the dearth of doctors in rural India.
Of course, whether the posted doctors actually attend clinics and do their duties is a different
question for which the gram sabha and other representative bodies (and not individuals) can be utilised. Social auditing as well as grassroots monitoring along with a push for producing village-friendly doctors will be a boon to millions. Every year, the statutory bodies of the Indian government give ‘no objection certificates’ to young doctors who train in India and then serve in affluent countries. The same government sheds tears about dearth of doctors. This duplicity has to stop. One can of course go abroad to train, but at the end of training, if one choses to remain abroad, then the people have a right to extract their price in the form of large monetary penalties or other methods as may be deemed fit.
Medical research is as important as medical services. In very few medical colleges in India, hardly any research work happens. Promotions of medical faculty have to be tied to objective criteria of which research should be an important. In doing so, citation metrics have to be given due importance. Undergraduate students who have publications should be given priority in post-graduate training. Additionally, medical colleges should account for research time for faculty and not use them simply as clinical staff. One has to monitor the potential misuse of this. Again, citation based publication metrics will come in handy.
Finally, I have a wild suggestion about revamping healthcare and not just medical education. All elected representatives and higher-level bureaucrats would have to go to the geographically nearest government healthcare facility when they are ill or meet with an accident or any such eventuality. This single rule that might change everything in this age when cameras follow netas and bureaucrats around most of the time. Only when VIPs are forced into getting the aam aadmi treatment, will the aam aadmi have some hope. IPA