The Hindu Business Line : Ills in health management: Prescription for the malaise

Despite its credible achievements on the economic front, progress in science and technology and scaling new heights in information technology, India remains a laggard in providing universal health and sanitation to its teeming population.

The long, hot and humid summer over the Indian sub-continent is set to trigger another spell of disease outbreaks, water shortages and recurrent power failures. The season of chikungunya and dengue fever, kala azar, measles and malaria is likely to re-visit Indian homes, both rural and urban. A season when poverty stalks the rural countryside and diseases debilitate its people.

More alarming is that while the country is becoming increasingly vulnerable to this seasonal misery, it is even less prepared to confront this pestilence. The World Health Organisation has noted that India fares unfavourably with even low-income countries with regard to medical human resources.

The number of physicians per 10,000 of the population is seven, which is on a par with low-income countries. Physicians employed in the public sector are a paltry two per 10,000 people. The number of nurses per 10,000 people in India is eight, while for the world it is 33 and 16 for the low-income countries.

Shortage of medical resources

Speaking at the National Florence Nightingale awards presentation recently, the President of India, Ms Pratibha Patil, observed that it was a matter of pride that the quality and commitment of Indian nurses was getting recognition. However, they are in high demand in India and the world, there remains an acute shortage:

The demand for nurses is expected to surge to 10.5 lakh in 2012 from the current availability of 3.7 lakh. And the shortage of medical professionals is expected to accentuate further, despite 250 medical colleges under the modern system of medicine and over 400 colleges under the Indian system of medicine and homeopathy.

The country produces over 25,000 doctors annually in the modern system of medicine and a similar number of homeopathy practitioners, as well as nurses and other paramedical professionals. Despite these numbers, the country continues to face an acute shortage of manpower on the health front. The WHO has noted that a serious issue in human resource management has cropped up, leaving huge gaps in critical resources management in health, especially in government institutions. This is all the more so in rural areas that provide healthcare to the poorer segments of the population.

A large number of vacant posts are left unfilled in rural health centres and paucity of doctors is reported at the primary level in government hospitals. The positions for specialists in government hospitals in the rural areas are a lot worse.

The situation at the secondary and tertiary level is somewhat better, as doctors generally reside in urban areas.

Similarly, vacancies continue for the posts of laboratory technicians, radiographers and other paramedical professionals, which have serious service implications, particularly for programmes such as malaria and tuberculosis, the WHO observed. Low priority given to in-service training, inadequate staffing in training institutions and poor quality of trainers are other causes of concern.

Measures to fight the malaise

For its part, the Government has taken several initiatives for effective management of human resources, although certain systemic issues such as remuneration and seniority-based promotion disregarding suitability and merit have contributed to low morale and reduced the commitment of medical professionals across the States. Several measures were initiated to contain absenteeism and to fill the posts of medical officers in remote areas.

Measures include recruiting doctors on contract basis, compulsory rural posting for certain period, earmarking certain percentage of post-graduate seats for doctors who have served in rural areas, and provision of rural service allowance etc.

Proposals for medical practitioners to undergo knowledge and skill up-gradation and re-certification every five years were proposed in the Five-Year Plans. But none of these measures is able to redress the malaise inherent in the system.

And the situation is expected to get worse before it gets better. With the strident rise in the prices of food, agricultural commodities and basic raw materials, the terms of trade are becoming favourable to agriculture as against industry. This coupled with the new-found efforts of financial and economic inclusion of Rural India has begun to yield results. A resurgent demand is beginning to manifest itself for health, educational and other social services from Rural India. And this time the demand is being increasingly matched by improved purchasing power. If the economic momentum persists, the demand for medical health facilities from Rural India would far exceed supply.

Exodus of medical professionals

There has also been a growing exodus of medical professionals from India. April 30, 2008 would have been a momentous day for thousands of Indian doctors working abroad.

On that day, the British House of Lords ruled that the state was wrong in issuing guidelines discriminating against overseas medical graduates, mostly Indians, for employment in the British Health Services.

The ruling came on top of four-to-one judgment by Britain’s highest judiciary in favour of the British Association of Physicians of Indian Origin (BAPIO) and the 7,000-8,000 international medical graduates, mainly of Indian origin.

But what is even more noteworthy is that this ruling would not only sustain the emigration of Indian graduate doctors to Britain, but could accelerate the exodus in the years to come. Is this a cause for concern?

Being mainly fresh graduate doctors after completing the preliminary stint at the Indian medical colleges, it might be safe to assume that they emigrated out of the country during the past five-six years.

The annual migration out of India would be of the order of 1,400 per year — almost five per cent of the annual output from Indian medical colleges to just one country alone.

Migration to other rich countries of Europe and the US, Australia, New Zealand, Dubai and West Asia have also been on the rise. And it takes years of dedicated training and several lakhs of rupees to transform a lay student into a budding medical professional.

However, restrictions on professional migration need not provide the solution to India’s emerging crisis on the medical front.

On the other hand, migration has historical roots and has helped reduce unemployment, enhance remittances, brought greater equity and social development to the country, and has helped bolster foreign exchange reserves. Should we then enforce regulations on emigration of medical professionals?

Rural havens

The solution lies in economic logic: There is a huge mismatch between the demand for medical professionals and the numbers available in India. The answer lies in creating more medical colleges, nursing schools and professional training institutes. As more students pass out of these institutions, the best would obviously seek greener and richer dividends abroad, the good would find gainful employment in the booming health services of Urban India. As the terms of trade between agriculture and industry shift, the rural boom would create new and bustling towns in Rural India, demanding better medical facilities and attracting medical professionals to these new havens of prosperity.

During the last two decades, India has garnered fame for its human resources in IT. We are one of the biggest exporters of IT, medical professionals, engineers and other professionally qualified personnel. And this export of human resources has helped bring in huge riches. Let India’s health not be at the cost of migration of its professionals and let migration not be at the cost of its health services.