India has long been short of doctors, nurses and hospital beds. And a recent working paper by Shruti Rajagopalan and Abishek Choutagunta of George Mason University’s Mercatus Center reminds us of that. Compared to the world average of 150 doctors per 100,000 people, India has only 86 doctors registered for practice. The actual number of doctors available for practice, as Basant Potnuru shows, is even lower: we probably have only around 64 doctors per 100,000 people, well below half the world average. Of course, the national average does not tell the whole story: southern states and urban areas are vastly better served than other parts of India. The picture with regard to nurses is relatively better, but there is still a shortage, regional variation and differences in skill levels.
We could take any indicator of healthcare capacity and find that as a country, we are short of it. Public expenditure on healthcare is low — our Union and state governments together spend around 1.5 per cent of GDP on health — and most of India relies on private, mostly out-of-pocket healthcare. Even as we point fingers at the government for spending too little on health, consider that only 20 per cent of the population has medical insurance. Perhaps it is yatha praja, tatha raja, and we have been collectively casual about our health.
This won’t do anymore.
Increase intake on a war footing
If the coronavirus pandemic reminds us of anything, it is of the importance of adequate healthcare capacity and the need for a hawkish approach to public health. India needs to build this capacity on a war footing. Creating more doctors, nurses, hospitals and medical equipment stock is not only necessary for our health, but also for our economic health. A manifold public investment in healthcare infrastructure is an effective, efficient and equitable way to stimulate economic growth in the short and medium-terms.
India needs to double the number of doctors to meet the world average, which means, we need at least 10 lakh more. This cannot be done overnight. If we plan to fix the shortage over a 10-year period, we need to produce at least one lakh additional doctors every year. Although the intake has improved over the past few years, the total annual intake is still around 70,000 per year. In other words, we need at least 30,000 additional medical seats to be added every year. While the government has plans to increase intake, those plans need to be accelerated and addressed on a war footing now: double the intake and reduce the shortage in five years, instead of 10.
Learn from Manipal
There has been considerable debate on how to produce more doctors: do we need more government medical colleges or should we allow more private ones to be set up? We need to get beyond this debate. The correct answer is we need more government medical colleges and we need more private ones. In the short term, it should be possible to increase numbers by authorising a 10 per cent increase in the number of seats in established government and private medical colleges. Just like how military academies expand intake during war, medical colleges should train more students during a health crisis.
Manipal, the small town in coastal Karnataka, has become a global healthcare hub, and offers a good model for other states to emulate. Even as the government build more AIIMS across the country, it should incentivise the private sector to create a Manipal in every state.
As importantly, we need to find better ways to finance medical education: a government-backed student loan scheme along with CSR-financed scholarships can help ensure every deserving student can study medicine. One reason we have only a few high quality private medical colleges is because of the overall restrictions on foreign investment in our university system. These restrictions have to make way for a more sophisticated approach: if a top university wishes to invest in an Indian campus and set up business, engineering and law schools, it could be obliged to set up a medical school too.
Incentives for rural areas
This still does not address the question of how do we ensure doctors serve in rural areas. Rural service bonds and obligations do not work. Better pay packages will not work in themselves. What might work better is if the government creates high quality health centres and hospitals in rural areas. This will not only serve the rural population but, at the margin, encourage doctors to practice outside big cities. In other words, ‘build the infrastructure first, and they will come’.
The trend towards specialisation means that even in urban areas it has become difficult to find adequate numbers of general practitioners and duty doctors in hospitals. The Modi government has sought to address this by emphasising Ayush practitioners and bridging some of them to practice modern medicine. Attractive as this might appear, the risks of this approach have been underestimated. Another way is to upgrade the nursing profession and create “chartered nurses” who are authorised to perform many routine functions of a general practitioner, including prescribing a subset of medications. As the coronavirus pandemic has so clearly shown, we need to celebrate and raise the social status of our nurses.
If Covid-19 urges us to what has long been necessary, India would still extract some good out of the tragedy.
The author is the director of the Takshashila Institution, an independent centre for research and education in public policy. Views are personal.