If you live in a medium-sized or larger town in India, chances are that you have a private medical clinic or hospital not too far from your home. Chances are that it will describe itself as a “multi-speciality clinic” and the reception area will have a long list of specialists who you could consult. Even the smallest clinics in my neighbourhood in Bengaluru have around a dozen specialists on their roster. Every conceivable specialisation — from neurosurgery to psychiatry, interventional cardiology to maxillofacial surgery — is available within a 5-kilometre radius from my home.
The only problem is that if a person has, say a bad headache, he or she would not know where to start and which of these specialists to consult. In the best case, it is quite possible that they would see one of the specialists, do the lab investigations or scans she recommends, only to find out that the ailment belongs in the domain of another specialist. This, at once, is inefficient, stressful for the patient, undermines trust in the system, affects health-seeking behaviour and impacts overall health outcomes.
Missing family ‘doctors’
We have a lot of specialists, but too few “doctors”. The shortage of general practitioners or family physicians has become one of the weakest links in India’s medical system: there are too few of them both in urban and rural areas, although for different reasons. The trend towards specialisation is likely to continue. Of the 54,000 new doctors who will graduate this year, at least 44,000 will become specialists after the expansion in the number of post-graduate seats. Worse, as Dr Raman Kumar, president of the Academy of Family Physicians of India has written, the Medical Council of India (MCI)’s new 890-page MBBS curriculum “does not even mention the words “General Practice” or “Family Medicine” or “Family Physicians” throughout the voluminous document (sic)”, leaving ”students in the road of no return of specialist and tertiary level hospitalist care.”
As Dr Kumar points out, almost all the training that an MBBS student gets is at tertiary hospitals, depriving them of valuable working experience in clinics and primary health centres. In other words, of the 80,000-odd students who will enter medical colleges after the NEET exams this year, very few will study family medicine as a subject and very few will have any experience of “general practice” as part of their practical training. Political economic factors are likely to continue to push governments to increase the number of post-graduate seats, such that most of the 80,000 will be able to become specialists a few years from now.
To be sure, India needs the specialists. But it needs general practitioners even more. There are a number of reasons why the composition of medical practitioners is skewed in favour of specialists: competitive pressures of over-concentration in urban areas, greater income potential, higher status among peers, greater prestige in society and patients’ demand, among others, drive the preference for specialisation. As the changes in syllabus and expansion of post-graduate capacity show, the medical education system is more sensitive to the preferences of medical graduates, than the overall needs of the health system. Clearly, the connect between the health ministry’s national goals and the MCI’s medical education priorities must become stronger. One simple way is to increase the MBBS intake — India needs a lot more doctors anyway — and simultaneously increase seats for family medicine at the post-graduate level.
Up-skilling the nurses
Such policy changes are necessary, but even if they were implemented tomorrow — and we are very far from that — it will take close to a decade before we see changes on the ground. What do we do in the meantime? We should upgrade nurses and qualified ASHA workers to “chartered nurses”, equipping them with higher skills and technology that will enable them to become the citizens’ first port of call. In addition to basic medical services, their primary function would be to act as health advisors, guiding anxious patients to the appropriate healthcare facility. Indeed, one of the most effective healthcare interventions is to advise the person to “go and see the doctor”.
With greater smartphone ownership, internet connections and inexpensive diagnostic equipment, it is possible for chartered nurses to “check” the patient using a basic technology kit, transfer the data to analysis hubs for interpretation, and advise the patient what to do next. With just over 2 million chartered nurses, every 100 families can have a designated chartered nurse. There are around 900,000 ASHA workers and 3.07 million registered nurses in India who can be trained, up-skilled and supported by a technological backbone to become chartered nurses.
In movies of a bygone era, doctors would be fetched when someone fell sick. For those of us fortunate to have access to them, house calls by the family doctor were common during my own childhood. While the world has moved forward and it might not be practical to design a national healthcare system based on doctors doing house calls, raising a force of 2 million chartered nurses is something that can be done in a few years. If the nurse can tell — using inexpensive, reliable, prompt diagnostics and analytics — whether the headache is nothing to worry about, or that the patient must immediately rush to the appropriate hospital, we will be able to reap the benefits of having so many specialists around.
Nitin Pai is the director of the Takshashila Institution, an independent centre for research and education in public policy. Views are personal.