The world has been grappling with the deadly pandemic for the last two years. During this time, millions have fallen sick, so many lives are lost, the economies have crashed and the fear is rife among the people. Doctors at this time have been the angels for people by curing them, giving them hope, nursing them back to good health and guiding them to lead a healthier life ahead. Their importance has never been more apparent.
On this National Doctors Day, let us pay tribute to the superheroes of this pandemic and assess the state of India’s healthcare system.
Doctors per thousand in India
The World Health Organization (WHO) has recommended a standard ratio of 1:1000 (doctor to population ratio). According to the official data, only eleven states in India meet the WHO recommendation, while none in the public healthcare sector manage to make the cut.
While India has a booming private medical sector, the public healthcare system operates at a dismal ratio of 0.08 doctors for 1000 people. The states with the highest shortfall of doctors – Uttar Pradesh, Chhattisgarh, Odisha, and Madhya Pradesh – house a huge share of India’s rural population of more than 0.8 billion.
While Delhi has the highest number of doctors working in the public healthcare sector in India, Goa has the highest number of registered doctors, with a doctor to population ratio of almost 2: 1000.
Given that the Primary Healthcare Centres (PHCs) are the basic structural and functional unit of the public health services in the country, it is important to ensure that India starts by addressing the shortage of doctors in that area. As per the 2018 government data, 10 Indian states face a shortage of doctors at the PHC level. However surprisingly, in most Indian states, the government has sanctioned more than the required number of doctors and in many states, the PHCs have more doctors than needed! The need of the hour is to address this demand-supply mismatch in healthcare infrastructure.
Medical facilities in India – Urban vs. Rural areas
In India, 75% of the healthcare infrastructure is concentrated in urban areas where only 27% of the total Indian population is living. The remaining 73% of the country’s population is lacking proper primary healthcare facilities. Private healthcare has been witnessing steady growth whereas there is a serious degradation in the quality of infrastructure in the public healthcare sector. Rural healthcare in India is characterised by understaffed facilities with bad infrastructure and low availability of medicines. According to a KMPG report, “74% of Indian doctors are catering to the needs of the urban population.”
Most people in rural India opt for government healthcare facilities because of monetary issues and transport options to the urban centres are not very affordable. Despite that, only 11% of sub-centres, 13% Primary Health Centres (PHCs) and 16% of Community Health Centres (CHCs) in rural India meet the Indian Public Health Standards (IPHS). Only one allopathic doctor is available for every 10,000 people and one state-run hospital is available for 90,000 people.
Apart from these, there are certain other constraints that work impede the rural healthcare sector:
Infrastructure: The biggest concern for the rural healthcare system is the lack of adequate infrastructure. As per the sources, the existing healthcare centres in rural areas are under-financed, uses below quality equipment, are low in supply of medicines and lacks qualified and dedicated human resources. On top of it, underdeveloped roads, railway systems, poor power supply are some of the major disadvantages that make it difficult to set up a rural healthcare facility.
Doctors: Patient-doctor and Nurse-Doctor ratios contribute collectively to the inadequacy of the rural healthcare system. Every doctor needs a nurse to cater to their patients. The rural healthcare infrastructure is three-tiered and includes a sub-centre, a PHC and a CHC. PHCs are short of more than 3,000 doctors, with the shortage up by 200% over the last 10 years to 27,421 as per a report by India Spend. A patient is not always treated on time in rural India since the doctors are less in number.
Insurance: Insurance is something that is severely lacking in rural healthcare. India has one of the lowest per capita healthcare expenditures in the world. The government has only contributed to about 32% of the insurance in the healthcare sector in India which is sufficient.
Affordability: This is a constraint since people cannot afford the upmarket health services when they need to visit private hospitals. With the advancement of technology, healthcare is also becoming increasingly costly. The cost of diagnostic facilities is also going up. Along with that, there are commissioned charges that most people don’t understand.
Lack of Awareness: Awareness about proper healthcare is insufficient in India. The population needs to be educated appropriately on basic issues like the importance of sanitation, health, nutrition, hygiene and healthcare policies, the importance of medical services, their rights, financial support options, the need for proper waste disposal facilities.
Lack of Medical Stores: Medicines are often unavailable in rural areas. The fair price shops (PPP model) are mostly located in tertiary care and secondary care hospitals. These fair price shops charge differently in different locations. Discounts vary from 50% to 70% by the same provider on the same medicine. This makes it very difficult for people in rural areas to access medicines.
Brain Drain of Doctors from India
For several decades, India has been a major exporter of healthcare workers to developed nations particularly to the Gulf Cooperation Council countries, Europe and other English-speaking countries. And this is part of the reason for the shortage in nurses and doctors. As per OECD data, around 69,000 Indian trained doctors worked in the UK, US, Canada and Australia in 2017. There is also large-scale migration of health workers to the GCC countries but there is a lack of credible data on the stock of such workers in these nations. There is no real-time data on high-skilled migration from India.
With the onset of the COVID-19 pandemic, there has been a greater demand for healthcare workers across the world, especially in developed nations. Countries in dire need of retaining their healthcare workers have adopted migrant-friendly policies. At the beginning of the pandemic, OECD countries exempted health professionals with a job offer from the travel bans. Some countries processed visa applications of healthcare workers even during the lockdown period. The UK has granted free one-year visa extensions to eligible overseas healthcare workers and their dependents whose visas were due to expire before October this year. Similarly, France has offered citizenship to frontline immigrant healthcare workers during the pandemic.
While there are strong pull factors associated with the migration of healthcare workers, in terms of higher pay and better opportunities in the destination countries, one cannot deny the strong push factors that often drive these workers to migrate abroad. These factors include the lack of government investment in healthcare and delayed appointments to public health institutions. Also as the healthcare institutions face the burden of unprecedented numbers of admissions amid the pandemic, the doctors are overloaded with a large number of patients causing them stress, anxiety and many more health problems at insufficient pay. On top of that, the mob mentality among many people has put the safety of the doctors treating the kin of such people, in jeopardy.
Over the years, the government has taken measures to check the brain drain of healthcare workers with little or no success. In 2014, it stopped issuing No Objection to Return to India (NORI) certificates to doctors migrating to the US. The NORI certificate is a US government requirement for doctors who migrate to America on a J1 visa and seek to extend their stay beyond three years. The non-issuance of the NORI would ensure that the doctors will have to return to India at the end of the three-year period.
However, what is important to understand that the government’s policies to check brain drain are restrictive in nature and do not give us a real long-term solution to the problem. We require systematic changes that could range from increased investment in health infrastructure, ensuring decent pay to workers and building an overall environment that could prove to be beneficial for them and motivate them to stay in the country.
In order to achieve that, the government must focus on framing policies that promote circular migration and return migration. This means that the policies must incentivise healthcare workers to return home after the completion of their training or studies. It could also work towards framing bilateral agreements that could help shape a policy of “brain-share” between the sending and receiving countries in order to check brain drain from India. Such a brain share policy could have a clause wherein the destination countries of the migrants would be obliged to supply healthcare workers to their country of origin in times of need.