Continued investments in the area of human resources will reap great dividends not just for India’s healthcare system but for the overall economy as well.
The area of human resources for health (HRH) has been plagued with substantial challenges including shortage of skilled healthcare personnel, uneven distribution of HRH across multiple levels of care as well as education and training curricula not keeping pace with the dynamic health priorities and demographics in the country. While several institutions have mushroomed over the years especially in the private sector, the quality of training and education provided has been extremely variable.
During the last few years, several noteworthy steps have been taken by the government to address these challenges.
Improving Health Infrastructure And Manpower
A scheme for setting up 58 new medical colleges attached to district/referral hospitals by 2019-20 is being implemented by the government. The Union Cabinet has also approved the establishment of another 24 medical colleges, with a special focus on undeserved areas.
Together, these initiatives will result in the addition of 8,200 MBBS seats, while ensuring that there is at least one medical college for every three parliamentary constituencies in India. Moreover, the Union Cabinet has also approved an increase in MBBS seats by 10,000 and post-graduate seats by 8,058 to be achieved by the year 2020-21.
Including the most recent 2019-20 interim budget announcement, a total of 15 new AIIMS (All India Institute of Medical Sciences) have been initiated by the government during the last five years. It has also been proposed that 112 auxiliary nursing and midwifery (ANM) schools and 136 general nursing midwifery (GNM) schools will be established in the under-served parts of the country by 2019-20.
Further, the superannuation age of doctors other than doctors of the Central Health Services, has been increased to 65 years. This move will enable experienced doctors to provide services for a longer period of time thereby also improving patient satisfaction.
These initiatives are crucial because the current distribution of doctors and nurses in India is extremely uneven. A similar inequity is seen in the distribution of medical and nursing colleges, which are largely concentrated in a handful of states including Karnataka, Tamil Nadu, Andhra Pradesh, Maharashtra, Gujarat and Kerala. Moreover, beyond the shortage of MBBS doctors and nurses, there is also an estimated shortage of 0.5 million specialists resulting in several posts lying vacant across the country.
Of course, in the longer term, efforts should be made to ensure the presence of a medical college in every district that currently lacks one. Additionally, every district with a population of above 10 lakh should have a nursing college or school. Similarly, all districts with a population of above 5 lakh should have at least one ANM school.
Reforming Medical Education
The Medical Council of India (MCI) has often been in the news for all the wrong reasons. Recognising this long-standing challenge, the government drafted the National Medical Commission (NMC) Bill, 2017 based on the report of a parliamentary standing committee on health and family welfare as well as the recommendations of a group of experts constituted under the leadership of late Professor Ranjit Roy Chaudhary.
The bill seeks to radically revamp the regulatory framework for medical education in the country by making it more focused on quality and outcomes, selecting regulators on the basis of merit as well as rapidly expanding the number of undergraduate and postgraduate seats. The NMC Bill, 2017 is currently pending in the Lok Sabha.
Till such a time that the National Medical Commission comes into being, MCI has been superseded by a meritorious Board of Governors (BoG) chaired by Dr Vinod Paul, member, NITI Aayog. The BoG comprises persons of eminence in the medical field such as Dr Randeep Guleria, director, AIIMS, New Delhi; Dr Jagat Ram, director, PGIMER, Chandigarh; Dr B N Gangadhar, director, NIMHANS, Bangalore and Dr Nikhil Tandon, professor, department of endocrinology and metabolism, AIIMS.
The BoG has already announced some important measures for strengthening medical education in India. Firstly, the norms for Diplomate of National Board (DNB) degree-holders who want to teach in hospitals and state medical colleges have been relaxed. The previous guidelines put in place by the MCI had for all practical purposes barred DNB holders from getting recruited as faculty in established medical colleges.
The new guidelines could expand the pool of candidates eligible for appointment as faculty by approximately 3,700 per year. Secondly, the BoG has recently given a go ahead for offering AYUSH (ayurveda, yoga, Unani, Siddha and Homeopathy) as an elective subject for undergraduate medical students from the 2019-20 academic year. Such a step could play a key role in enabling the integration of different systems of medicine for promoting the holistic health and well-being of citizens in the country.
Strengthening The Regulatory Framework For Alternative Systems Of Medicine
To reform education for Indian Systems of Medicine and Homeopathy in line with the proposed reforms for allopathic medicine, the Union Cabinet has approved the draft National Commission for Indian System of Medicine Bill, 2018 as well as the National Commission for Homoeopathy, Bill, 2018.
The draft bills provide for the constitution of autonomous boards for regulating undergraduate and postgraduate education as well as handling issues pertaining to the rating and assessment of educational institutions, ethics and registration of practitioners. The bills also propose a common entrance and exit exam, which will need to be cleared by graduates in order to obtain a licence to practise. Further, a teacher eligibility test has been included for evaluating the standard of teachers prior to appointing or promoting them.
Boosting The Development Of Allied Healthcare Professionals
While allied healthcare professionals such a lab technologists, physiotherapists, optometrists, radiologists and phlebologists have existed in India for several decades, their impact has been hampered due to the absence of clear standards for education and training as well as the lack of a comprehensive regulatory framework.
In this context, the approval of the Allied and Healthcare Professions Bill, 2018 by the Union Cabinet is a significant move, which can pave the way for better regulation and greater standardisation of education and service delivery in the field. The bill provides for the establishment of an allied and healthcare council of India along with counterpart state allied and healthcare councils.
Allied healthcare professionals have an important role to play in the ‘team based’ model envisaged under Ayushman Bharat as opposed to one which is heavily doctor dependent. It is estimated that the bill and its provisions will directly benefit at least eight lakh allied healthcare professionals in India.
Going forward, there is a need for a well-defined policy on HRH in states as recommended in NITI Aayog’s ‘Strategy for New India @ 75’. For facilitating the development of sound HRH policies in states, the Centre needs to design model management systems covering improved methods for recruitment, retention, incentive structures and performance management.
Additionally, the quality of HRH education and training needs to be improved by introducing a competency-based curriculum. The curriculum needs to keep pace with changing needs (e.g. increasing burden of non-communicable diseases) and orient healthcare providers sufficiently with the social determinants of health, gender and equity issues by going beyond the tertiary care hospital setting.
Reforms are also needed in the nursing, pharmacy and dental councils to strengthen their governance capacity including the ability to ensure quality of training at par with global standards while keeping in view local requirements.
Finally, in order to move beyond a doctor-dependent health system, there needs to be an emphasis on creating a public health cadre in states for the efficient management of the health system at all levels beyond implementing vertical programmes. A cadre of primary health care practitioners should also be created by introducing a three-year competency-based dynamic course for primary, community and family medicine.
The healthcare industry, which is one of the largest employers in the world, has the potential to generate an additional 7.5 million direct job opportunities in India by 2022. A medical, nursing and paramedical college can change the entire economy of a district. A solid foundation has been laid during the last few years. Continued investments in the area of human resources will reap great dividends not just for India’s healthcare system but for the overall economy as well.
Disclaimer: The views expressed are personal.