India ranks as the lowest performing country among the BRICS nations in all categories of the Human Development indices (HDI), with the exception of life expectancy. The country ranks among the worst in the world, too. According to a UNDP study conducted in 187 countries in the world, India ranks 135. The low rank reflects the poor state of public health - a critical component of the HDI - which in turn reflects the poor state of healthcare available to the public.
It is no state secret that India's public healthcare set-up is grossly underfunded, under-staffed, and poorly equipped. The 2011 report of the high level expert group of the Planning Commission headed by Dr K S Reddy noted that 1.37 million hospital beds were available in the country, for its population of roughly 1.25 billion individuals. This is far below the world average of 30 hospital beds per 10,000 population. Of these, 8,33,000 were in the private sector, and largely unaffordable to the masses.
"Hospital beds or healthcare equipment are irrelevant if skilled manpower is not available to provide the services."
With approximately 5% of GDP expenditure on healthcare, India ranks among the bottom five countries globally on public health spending. The bulk of expenditure on healthcare in India - over 65% - comprises out-of-pocket expenditure by individuals, and is, in turn, responsible for pushing an estimated 6% of the population below poverty every year, as they are forced to sell literally every possession to fund critical healthcare needs.
Indians encounter extreme disparity in the availability of healthcare, both in terms of quantity and quality. The urban, affluent population can access quality medical care, albeit at a high cost. The rural masses and less affluent sections in urban areas are extremely underserved. Physicians are highly concentrated in urban areas as compared to rural areas (13.3 and 3.3 per 10,000 population, respectively), as are nurses and midwives (15.9 and 4.1 per 10,000 population). For most parts of the country, formal primary care is virtually non-existent and is manned by a lone physician whose clinical diagnosis is reduced to spending anywhere between 10 seconds to a minute per patient.
To understand this sad state of affairs, it is important to recognise the role and importance of skilled manpower, the most critical component of healthcare delivery.
WHAT AILS OUR MEDICAL EDUCATION SYSTEM
Hospital beds or healthcare equipment are irrelevant if skilled manpower is not available to provide the services. The rate of skilling of manpower, presently, itself is grossly below requirement. According to my calculations in this article, at the present rate of skilling, we will not meet the requirements of the country for more than a century.
"The existing medical education system... churns out practitioners of the science of medicine, not those versed in the art of healing."
However, another set of factors are responsible for skilled healthcare professionals - the few that there are - preferring to serve the urban affluent and not the masses.
No assessment for soft skills: The first factor is our flawed method of choosing a potential healthcare professional. Providing healthcare is primarily about one human being serving another human being. Yet, at present, entrance exams for medical and para-medical courses primarily assess individuals' knowledge of science, but not their soft skills - especially their service-orientation and communication skills.
Focus on training clinicians rather than carers: The next stage of the journey of a healthcare professional is the training that he or she receives. The existing medical education system trains doctors only to be clinicians, rather than social servants with healthcare skills. It churns out practitioners of the science of medicine, not those versed in the art of healing. A successful doctor must be an empathetic, service-oriented individual and not merely a technically competent clinician.
Sir William Osler, one of the founding fathers of Johns Hopkins Hospital, once remarked: "The good physician treats the disease; the great physician treats the patient who has the disease."
In India, unfortunately, the healthcare training and delivery system is devoid of this notion. No component of our curricula trains medical students in ethics, behavioural science, communication and managerial skills - all necessary to win the patients' trust, which is half the battle won in the process of healing.
High costs: The third factor is the exorbitant cost of medical education. A student in a private institution has to spend between Rs 9-11 lakh annually only for tuition. After spending a fortune and devoting almost 10 years to education, doctors consider it unjustified to work in rural areas or government hospitals at low salaries. Only serving the urban affluent can earn them the money required for livelihood and loan repayment. Compounding the injustice, conditions are pitiable in most rural areas. Doctors often live in quarters devoid of even basic amenities, such as a fan. The situation is worsened by professional and social isolation.
"After spending a fortune and devoting almost 10 years to education, doctors consider it unjustified to work in rural areas or government hospitals at low salaries."
Private healthcare providers in urban affluent cities take care of the doctors' financial needs, causing a dearth of specialists in rural and backward areas, thus increasing the burden of diseases. Attempt to recover the exorbitant training expenses also leads to rampant malpractices (both illegal and unethical) in the entire healthcare supply chain further eroding patients' trust.
Regional imbalances: Another factor that is affecting healthcare is the mal-distribution of medical education facilities and a "one-size-fits-all" approach to curricula and training of the resource pool. A report by the National Knowledge Commission (NKC) highlighted in 2005 that 63% of medical colleges were concentrated in only six states of India - Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, Kerala, and Gujarat. In contrast, only 3% of training facilities were located in Northeastern sates.
THE WAY FORWARD: THE "A2S" APPROACH
India faces an urgent need to fix its basic health concerns in the areas of communicable diseases, maternal and infant mortality. In addition, the nation faces the burden of chronic non-communicable diseases (NCDs).
The panacea could be a three-dimensional talent funneling process, resulting in the availability of an adequate resource pool for healthcare and, finally, better health for the nation's populace.
Let me term this the A2S System.
The talent-funneling process prongs would be ensuring three things:
* The Attitude to Serve
* Attachment to Soil
* Attention to Scale.
This will enable Affordability to Serve for those chosen for training as healthcare professionals, and finally result in universal Access to (healthcare) Service for the country's masses.
Attitude to Serve: To ensure this, the entrance examination criteria for aspirants should be revised from being mere assessments of scientific aptitude to assessing individuals' psychological make-up, especially service-orientation.
"Local curriculum, local students, local training will result in lowering the cost of medical education for those being trained, leading to fulfillment of the Affordability to Serve criterion..."
Attachment to Soil: To enhance this factor, the medical education policy must allow the curriculum to be formulated and delivered locally to those who qualify locally. Adequate role, freedom and authority for state governments, state universities, state-specific social entrepreneurs and public-private partnerships are needed to formulate policy to create skilled, locally relevant manpower pools. These bodies must also implement and regulate such policy; design curricula and the quality-monitoring mechanism necessary for producing skilled clinicians who can ameliorate the local conditions. Medical professionals who are trained in the region they belong to will understand the culture of an area and serve people better than a professional from another region. Social bonds will be an additional motivator.
Attention to Scale: To enable this, the intake policy must ensure that 50% of seats in government medical colleges are reserved for those aspirants who cannot afford medical education but meet all other criteria. Providing free medical education, in lieu of a commitment to practice where needed, would enable aspirants from regions such as Jammu and Kashmir, Northeast and Andaman & Nicobar Islands to access quality medical education and serve the people in their region.
Local curriculum, local students, local training will result in lowering the cost of medical education for those being trained, leading to fulfillment of the Affordability to Serve criterion, as medical professionals will not be compelled by their financial burden to extract disproportionately from those that they are meant to serve. In addition, the obligation to the society which provided them the training - free of cost - will result in even distribution of doctors - the last mile that results in masses receiving Access to (healthcare) Services.
Only then will healthcare serve the masses, instead of being their cause for sorrow.