How many medical graduates do we need to train to meet the healthcare needs of India’s 1.4 billion population?
While the Covid-19 pandemic brought the policy focus on health systems in general, the Ukraine war crisis brought the focus on the state of medical education in India. In India, nearly 90,000 allopathy medical students graduate every year from ~595 medical colleges and an additional 53,000 AYUSH medical students graduate from ~733 AYUSH colleges. As per a statement made in the Lok Sabha by Union Minister of State for Health & Family Welfare in July 2021, there are 12.68 registered allopathic and 5.65 lakh AYUSH doctors in India. In addition, students trained in foreign medical colleges are licensed to practice after clearing foreign medical graduate exam (FMGE) conducted by the National Board of Exams (NBE). The number of students appearing for the FMGE has been increasing over the years. In the light of this, many state governments have made recent announcements of setting up new medical colleges in each district.
The WHO recommends a minimum of 1 doctor per 1000 people. To meet this, India needs ~14 lakh doctors. The WHO does not specify whether formally qualified AYUSH doctors practicing alternate systems of medicine can be counted in this assessment. Given the above statistics, we seemingly are nearing the benchmark if we were to count only allopathic doctors. However, we do not have accurate data on yearly turnover due to retirement, migration, career change and deaths to estimate the number of new graduates needed to replace the loss. In addition, the revolution we are witnessing in digital health especially in the area of telemedicine, clinical decision support systems, selfcare apps and AI may change the equation further.
The problem is not in numbers. It is in the distribution of the doctors!
While we seem to be close to the desired numbers, they are not distributed as per the population needs in terms of geography and specialization. While two-thirds of the population still lives in villages, two thirds of doctors are living in towns and cities leading to demand-supply mismatches. As people seek specialists for their needs, their number is not commensurate with the disease burden of the population. Mobile clinics, telemedicine, increased road connectivity etc., are partly bridging the gap in villages. But telemedicine cannot substitute a real doctor talking to and physically examining a patient! There is a need for systematic assessment of the demand-supply gap of specialists to plan seats in specialty courses.
There is a great concern on the quality
While medical colleges adhere to the standards laid down by the National Medical Council on paper, the quality of graduating students in terms of their knowledge and skills is not uniform. Standards have been evolving in terms of simulation labs, teaching privileges to visiting faculty, online classes and teaching methods. Competency-based teaching curriculum are being designed. However, there continue to be challenges in exposure to an adequate range of clinical cases, diagnostic and therapeutic technologies. Flexibility in clinical rotations might address this.
Just as the current common medical entrance exam – National Eligibility cum Entrance Test (NEET), is designed to ensure common standards in the country, the proposed common exit exam called NEXT, may bring about uniformity in standards of exiting students across the country. However, some states have started objecting to NEET in the name of federalism and freedom of states. Given the fact that we do not have separate state-level licensing to practice medicine, it makes sense to have nation-level entrance and exit examinations. While the above ensures quality at exit level, how to maintain the competencies in the face of rapid advances in medical sciences, remains to be addressed. Unlike some of the developed countries, India doesn’t have a system of mandatory continuing medical education (CME) credits and re-licensing examination every 10 years to sustain the competencies.
Medical education is foundational for strong and resilient health systems.
Medical education shall prepare the student for the most complex and dynamic health systems. In addition to traditional focus on medical sciences, a student of today needs to be conversant in health systems, health management, public health, health informatics, health economics, health policy, health regulation, healthcare purchasing, behavioral sciences etc. Medical student should be groomed in professionalism of the highest order in terms of medical ethics, compassion, patient-centeredness, equity and human dignity.
In summary
The supply of medical professionals should be planned as per the emerging population healthcare needs, advances in medical and digital technologies, and ageing populations. The curricula have to be designed to prepare the student for complex health systems and patient-centered integrated value-based care. Standards should be in line with evolving learning methods and tools. Quality should be assured through high standards in entrance and exit examinations, licensing and relicensing methods. The proposed National Health Professionals Register will enable the supply side planning of medical graduates and postgraduates. In addition, growing demand-supply gap across the world makes a strong case for health workforce labor economics.
Dr Krishna Reddy Nallamalla
President, InOrder
Regional Director, South Asia, ACCESS Health International
Photo Credits: Shiksha