National Health Policy Must Address Shortage of Specialists, Regional Imbalances

21/03/2015 8:08 AM IST | Updated 15/07/2016 8:25 AM IST
In this Monday, Feb. 3, 2014 photo, a tuberculosis patient Manjeet Mishra, 18, sits outside a ward at Lal Bahadur Shastri Government Hospital at Ram Nagar in Varanasi, India. India has the highest incidence of TB in the world, according to the World Health Organization's Global Tuberculosis Report 2013, with as many as 2.4 million cases. India saw the greatest increase in multidrug-resistant TB between 2011 and 2012. The disease kills about 300,000 people every year in the country. (AP Photo/Rajesh Kumar Singh)

The draft National Health Policy 2015 lacks a federal approach and leaves much to be desired in terms of addressing regional imbalances. I will present an evidence-based prescription from the Northeast - which is relevant to every region in the country - to address the inadequacies of a centrally formulated, nationally imposed and regionally irrelevant policy formulation and implementation process.

Let us first consider the evidence illuminating the nation's state of health and what the Draft National Health Policy 2015 attempts to address. Life expectancy in India has risen by five years in the past decade due to better immunisation and nutrition, along with prevention and treatment of infectious diseases. Though India will remain a young country overall, the population of the elderly will touch 17% by 2050, according to the World Health Organization (WHO).

The longer lives of our people today, however, are often being led under the debilitating shadow of health conditions resulting from our present lifestyles. Section 2.7 of the draft Policy explicitly acknowledges that non-communicable diseases and injuries now account for 50.9% of the nation's burden of disease and that National Health Programmes offer very limited coverage and scope of treatment for non-communicable diseases. A prosperous nation cannot be built by unfit, unproductive people. Apart from primary, preventive and promotive healthcare, India must cater well for secondary and tertiary healthcare.

Where are the specialists?

To address this emerging burden, the nation must be prepared to provide affordable, accessible specialist care to our population. Let us allow statistics to further illuminate how inadequately prepared we are to provide care in the present situation, leave alone the future, due to lack of skilled manpower - the foremost requirement for healthcare. The statistical construct below also highlights how acute the regional imbalance is.

"There are just 12 neurologists catering to the entire population of 50 million in Northeast India. But at the current rate of addition of skilled manpower - one specialist per year - it will take 138 years to bridge the gap."

Let us take a condition, say, epilepsy and the specialists who treat it - neurologists. If diagnosed early and treated, 80% of epilepsy patients can lead a productive life. Lack of treatment, however, results in arrested intellectual growth, rendering individuals incapable of contributing significantly to society.

The population of approximately 50 million people in Northeast India carries a burden of prevalence of epilepsy greater than 300,000 individuals and annual new incidences numbering over 27,500. Now, nearly 99% of these individuals do not receive proper medical attention. This is not surprising, considering that there are just 12 (yes, 12!) neurologists catering to the entire population of 50 million in Northeast India - a ratio of 1:45,83,333. In developed nations, this ratio is around 1:18,000 - more than 255 times higher! The situation is similar for other specialisations. Considering that our population-to-doctor ratio or patients-to-bed ratio is typically one-fourth those found in the developed world, the situation in specialisations is literally more than 60 times worse!

Even if we accept a ratio far lower than the developed countries, the gap remains formidable. For example, if we wish to have, say, three specialists for 25-odd key specialisations for every 1-million unit of population, this would mean a requirement of around 3,750 specialists, of whom 150-odd would be neurologists. Given that we have 12 neurologists at present in the Northeast, this means a required increase of 138 neurologists - almost 12 times over what is available at present.

But here is the catch: the entire country today is producing just 50 neurologists, approximately, annually - of which only two are produced in the Northeast. Typically, at least one of them is from outside the Northeast and will not be available to serve the people of the region once he or she qualifies. This means that at this rate of addition of skilled manpower - one specialist per year - it will take 138 years to bridge the gap (on the basis of the entirely unrealistic assumption that there is no further growth of the population!). Do note that neurologists are required to not only treat epilepsy but several other conditions. The above situation repeats itself in specialty after specialty. Policy to deliver healthcare to the country must address this tragic situation.

Need for region-focused policies

The situation has manifested itself in such an acute form due to lack of region-focused, innovative, visionary, locally relevant health policies for creation of skilled manpower pools in different regions. This is hindering the process of creating a resource pool comprising adequately trained manpower - without which availability, accessibility and affordability of necessary healthcare for the people will forever remain a mirage.

"The federal method of policy formulation and implementation would entail providing adequate roles for state governments, state universities, state-specific social entrepreneurs and public-private partnerships."

While the National Health Policy has expressed the intent to address the issue of creation of qualified manpower pool, it fails to acknowledge the scale of the gap, the consequent dimensions of the challenge and the urgency to respond. Regional realities, requirements and methods to cater to these requirements can best be understood and addressed by regional drivers of innovation in public interest. In the absence of such platforms and mechanisms, a centrally driven agenda will only perpetuate the scarcity of skilled manpower, continuing the economic benefits enjoyed by some vested interests today, from the shortage of skilled manpower.

More power to states

Considering the scale of the challenge as demonstrated by the statistical formulation above, the speed with which the challenge must be addressed is significantly higher than possible through the methods outlined in the draft National Health Policy - which ascribes no role to the states in the creation of a pool of skilled manpower. The challenge can only be addressed by adopting what may be termed as the federal method of formulation of policy to create a skilled pool of resources, as well as the implementation and regulation of such policy. The federal method of policy formulation and implementation would entail providing adequate roles for state governments, state universities, state-specific social entrepreneurs and public-private partnerships. State representatives - public and private - should be given their seats and their say at the policy-making table - specifically regarding creation of the pool of trained manpower, and provided the freedom and authority to formulate state-specific policies in pursuit of locally relevant objectives - in accordance with the federal mode of transforming India espoused by our Prime Minister Narendra Modi.

The state governments, universities and other stakeholders should be empowered to design and develop curriculums and mechanisms to monitor their quality. This is necessary to create the required number of specialist clinicians who can take care of the conditions that are responsible for 50.9% of the healthcare burden - as identified by the draft policy itself.

In the absence of the above, we Indians from the Northeast and every other region will need several lifetimes before we can benefit from the outcomes that the policy proposes to deliver.

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