Doctors are the unknown faces of the vast Indian healthcare system and must be better recognised by Government and society. Doctor's Day is one such opportunity
Medicine is considered to be the ‘art and science' of healing; however, with increasing attention on specialist (and super-specialist) doctors and the race to adopt high-end medical technology, the art of healing seems to have been disappearing from the Indian healthcare system. This trend, if it continues, may result in reduced access and increased cost of healthcare in the country.
In India, the focus on medical care by specialist doctors is partly market-driven and partly originates in perceived and reported low quality of medical teaching, where graduate medical doctors often feel not to have learnt enough clinical skills. Young graduate students enter a medical college with an ‘over-sold' notion that graduate degree in medicine is not enough to become a good clinician. Following this, by second or third year of studies, future doctors already start preparing for post-graduate entrance examination, at the cost of spending time in hospital settings to learn clinical skills required for a doctor.
The one-year long mandatory internship required to receive a license to practise medicine, in a majority of medical colleges in India, is also spent to prepare for highly competitive post-graduate medical entrance examination. Essentially, the five and half years of graduate medical degree period is spent in the preparation to become specialist in one of the fields of medicine. Possibly, the overzealous attempt of the Government to address shortage of doctors for public health facilities, by giving permission to new medical colleges (both in public and private sector), has also backfired, in many if not all instances.
It has resulted in many institutions which reportedly have insufficient teaching facilities, infrastructure and patient attendance to provide clinical trainings to graduate students, even those who wish to learn. In this background, it should not be surprising that a number of research studies have reported that clinical skills of graduate doctors in India are not much superior to those of the unqualified practitioners.
The other trend of excessive importance and attention on high cost medical technology, even for conditions manageable by basic medical knowledge, is growing on the pretext of providing world class healthcare and to promote medical tourism in India. For one, there is need for expansion of already available low cost appropriate technology which can address most health conditions (the focus on high-end technology would consume a large part of future Government funding).
Second, such attention would increase the cost of healthcare and not necessarily with improved outcomes. Most countries with focus on use of advanced technologies spend in the range of 10 per cent to 18 per cent of Gross Domestic Product (GDP) on healthcare. The total health expenditure in OECD countries is around 10 per cent (of the GDP) on average and in the United States, 18 per cent of GDP. This is anything but desirable for Indian public healthcare system which is traditionally under-funded by Government; people bear two-third of total cost of healthcare and an estimated 63 million people annually fall below poverty line because of health related expenditures.
India has to explore its option to deliver better health outcomes without choosing expensive, unaffordable and unsustainable approaches of specialist care and high-end technologies. In fact, the country needs more of non-specialist, graduate level medical doctors and can focus on improving quality of medical education and training through better regulatory mechanisms. In fact, of nearly 80 to 90,000 medical doctor's Government system in India, 60 per cent to 70 per cent are non-specialist doctors. They are the ones who serve in distant villages in rural and tribal parts of country, enduring all types of challenges, and delivers the primary healthcare services to those most in need. These doctors are the backbone of public healthcare system in the country.
On the contrary, a large proportion of positions of specialists in the public system are vacant, which is not entirely due to shortage of specialists in the country but also because the specialist doctors choose not to join public system. Therefore, the approach of the Government to create more post-graduate seats for specialist doctors, at the cost of public exchequer, is very unlikely to address the problem (though, it would increase the availability of specialist doctors for private sector).
Bringing specialist doctors against existing vacancies in public system require other policy options in addition to creation of post-graduation seats. In spite all this, specialist doctors get a lot of attention in public policy and all Government recognition. For example, between 2000-2010, a total of 137 doctors were given Padma awards in India, all 137 were either specialists or super-specialist, and not even a single non-specialist doctor had received any of these awards in entire decade.
The immense contribution of graduate medical doctors without specialisation to the public health system of India largely goes unrecognised by both Union and State Governments. They also do not get respectable salaries in Government job and have limited career progression opportunities. They remain the unsung hero of Indian healthcare system and no surprise doctors desire to be specialist and super-specialists.
Potential solutions are in existing system: The new national health policy (2017) of India proposes (i) to increase Government spending on health to 2.5 per cent of the GDP by 2025 and (ii) to spend 70 per cent of Government funding on primary health care. These two proposals should be used for improving health outcome in India.
One, the proposal to invest 70 per cent of Government funding to primary healthcare should have mechanisms to attract and retain more non-specialist medical doctors to public system, give them respectable financial and non-financial incentives, including career progression and recognition. Strengthening primary healthcare requires well-trained and motivated doctors, and not the focus only on advanced technology and specialist care.
Two, the Government has to develop and strengthen mechanisms to improve quality of medical education and training starting from the graduate level. The proposed Indian Medical Council Act needs to give detailed consideration to this and should be given stronger legislative teeth to revoke the permission of medical colleges which fails to fulfil the laid down standards and criteria. The proposal of setting up medical colleges in district hospitals has to be traded cautiously and should not contribute to further deterioration in quality of clinical training of doctors. Rather than opening up new medical colleges, innovative approaches like training large number of students in already reputed medical colleges can also be explored. Cuba and China had adopted these models which produce more doctors per medical school per year than many parts of the world.
To conclude, non-specialist doctors are the pillars of primary healthcare system in the country and still are the flag bearers of art and science of healing. As India aims to advance universal health coverage, on this doctor's day, it would be fitting that the Government commits to recognise and celebrate the unsung heroes of the Indian healthcare system.
(The writer is a leading public policy expert, based in New Delhi)