‘Lack of adequate doctors’ has been argued by the central government as one of the primary reasons to initiate medical educational reforms. However, a close reading of the numbers would reveal that the issue of ‘shortage’ of doctors is overstated. As per the National Health Profile 2019, the total number of registered allopathic doctors in 2018 is more than 12 lakhs in India. This translates into 0.7 doctors of modern medicine per 1000 population (assuming that at least 80 percent of them are active), which is less than the WHO norm of 1:1000.
If the professionally trained and qualified AYUSH practitioners are taken into account, the doctor-population ratio rises to 1.2 per 1000 population at the national level.
Another critical insight emerging from the data is that the northern states including Bihar, Uttar Pradesh, Madhya Pradesh, Odisha and Rajasthan are far short of the required norm, while the southern states, barring Telangana, have enough doctors in possession.
Aside from the unequal inter-state distribution of doctors, the concentration of the physicians in major urban centres remains a key issue in a country where 65 percent of the country’s population still reside in rural areas.
Dilution of Basics for the Setting Up of Medical Schools
Quality and maldistribution of trained health workforce are two other pressing challenges that the health system is facing. Unfortunately, the policy thrust is on scaling up specialist training through expansion of medical colleges. In fact, the government aims to add around 10,000 postgraduate (PG) seats within the next four years, and to achieve that, it has altered the rules and made regulatory waivers.
For instance, the minimum qualifications for the PG teachers in medical institutions have been relaxed; in case of super-specialties, the minimum number of years of teaching experience as well as total teaching experience have been shortened (from 5 to 2 years and 8 to 6 years respectively).
Similarly, the requirement of number of research publications has also been relaxed for faculty positions at all levels. On the other hand, Professors and Associate Professors are now allowed to guide 3 and 2 MD/MS students respectively, an increase from the earlier ratio of 2:1 and 1:1.
Besides, the government has not only diluted the essential norms for establishing new medical colleges but also allowed all teaching institutions including private colleges to offer PG programmes, regardless of their infrastructural conditions. In conjunction with these new regulations, the pass criteria for PG students have also been eased from 50 percent to 40 percent in theory papers, to ramp up the production of specialist doctors. Understandably, the revised criteria would benefit students who sought admission in private medical colleges on ‘non-merit’ grounds.
How Quality of Teaching & Medical Learning Is Being Compromised
Clearly, in the name of producing more such professionals and addressing the shortage of teachers, academic standards, the quality of teaching and learning is being compromised. Sceptics warn that the lowering of the academic bar would make our ‘specialist’ doctors little better than the quacks, and in turn, endanger the lives of millions. A recent study on the quality of doctors in India, by Georgetown University, University of California, and the Global Health Bureau revealed that physicians without any formal medical training in Tamil Nadu and Karnataka possess better medical knowledge than the fully trained and qualified doctors in Bihar and Uttar Pradesh.
The government decided to ‘standardise’ medical education in India by imposing a National Exit Test (NEXT) for MBBS students across the country, marking a serious departure from the earlier system, when the final year MBBS students were to appear in exams conducted by universities of respective states.
Appealing as it may sound, the idea of setting a common standard in medical education through NEXT is quite flawed.
As mentioned above, there are glaring inter-state disparities in quality of medical education in India resulting from the differences in infrastructure, faculty and clinical opportunities. Hence, bypassing these structural shortcomings, the use of a uniform criteria to assess the medical knowledge of the graduating doctors spells a debacle.
Centralisation of Medical Exams & Its Grave Implications
NEXT has also been conceptualised to serve as a PG entrance test. Judging from recent experiences of centralisation in different contexts, such as National Eligibility-cum-Entrance Test (NEET) and Joint Entrance Examination (JEE), there are likely to be grave implications. It would help consolidate the growth of coaching centres, resulting in watering down the MBBS curriculum, institutional learning, acquisition of clinical expertise, and promote rote learning.
Studies suggest that coaching-based exams tend to disadvantage students from poor or marginalised backgrounds. Therefore, centralisation of medical education will make the medical profession further exclusionary and the monopoly of the better-endowed.
Also, the elimination of underprivileged students will greatly reduce the number of doctors in rural areas.
Another major reform is the new under-graduate medical curricula (Graduate Medical Education Regulations 2018). As the curriculum was revisited after two decades, it was expected that the new syllabus would respond to the healthcare needs of the Indians and address the existing inadequacies. It is worth noting that because of widespread poverty and insanitary living conditions, the prevalence of infectious diseases such as tuberculosis, pneumonia, hepatitis, ARI, malaria, and Japanese encephalitis continues to be unacceptably high in the country.
This demands that the Indian medical graduates understand the epidemiology of infectious diseases.
The partial findings of the National Family Health Survey 5 (2019-20) indicate that more than half of our children are severely malnourished in populous states. Furthermore, the maternal and child mortality in the disadvantaged castes and tribes are among the highest in the world. All these warrant that the medical graduates who would work in primary health centres should have the ability to understand the limits of ‘evidence-based medicine’, identify the underlying non-medical determinants of diseases, the reasons for the persistence of health inequalities and factors that affect access to healthcare.
In short, they should be able to address the social determinants of health. But the new curriculum seems to have provided only lip service to the inclusion of the above topics, far from ensuring that it builds social science perspectives to health among medical students. Instead, it introduced spiritual health whose causal relationship with physical health is hardly established.
How Reforms Failed to Address the Core Issue
None of this is to deny that there are serious issues with medical education. But the so-called competency-based syllabus, relaxation of the requirement of minimum qualifications for faculty and such other regulatory changes are not the solutions. The reforms have failed to address the core issues. What we need is not centralisation of medical education but inclusive ways that eliminate any advantage of coaching for the entrance exam, and, healthcare reforms designed to guarantee ‘health for all’.
What the country needs is a large pool of ‘public health’ and ‘family medicine’ professionals, but these broad specialties have not found a place in the curriculum.
The need for expertise in areas like public health, epidemiology and family medicine cannot be stressed enough, particularly when the country is facing the COVID-19 pandemic.
(Soumitra Ghosh, PhD, is an Associate Professor, Centre for Health Policy, Planning and Management, School of Health Systems Studies, Tata institute of Social Sciences, Mumbai. This is an opinion piece and the views expressed are the author’s own. The Quint neither endorses nor is responsible for the same.)
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