If India can initiate some radical changes in medical, nursing and paramedical education, dramatic changes will be visible in three years
India can become the first country in the world to dissociate health care from affluence. This can only happen by closely linking healthcare delivery with medical education.According to World Bank data, Cuba produces the larg est number doctors per capita in the world (6.7 per 1,000 against 2.5 per 1,000 in the US and 0.7 per 1,000 in India) and its health indices are better than that of the US, which spends the most on healthcare. India is short of 3 million doctors and 6 million nurses, as per a PwC study , and its paramedical training programme is virtually non-existent. It is unfortunate that in 65 years post-Independence, we have never even once studied our manpower requirement for healthcare.
CURBING MATERNAL AND INFANT MORTALITY
Every 10 minutes, a young woman dies during childbirth somewhere in India and 3 lakh children die the day they are born. India's infant mortality rate (42 per 1,000 live births) and maternal mortality rate (178 per 100,000 live births) almost matches that of sub-Saharan countries, and the situation will not improve simply because government spends more money . We simply don't have the number of medical specialists needed to reduce these rates.
For 26 million childbirths per year, we need to perform at least 5.2 million Caesarian sections. For successful childbirth following a Csection, we need over a lakh each of gynaecologists, anaesthetists, paediatricians and radiologists. We only have around 30,000 gynaecologists and 20,000 anaesthetists and radiologists.
NUMBING NEGLECT
No surgery on a human body can be done legally without an anesthetist.Only 30% of India's population has satisfactory access to proper anesthesia services, of which 80% are urban beneficiaries.
Top 10 causes of death like heart disease, resistant TB, brain stroke, mental illness leading suicide, liver disease, accidents and cancer cannot be legally retreated by a doctor without a postgraduate qualification. Consider our figures for just two specialties -India has only 4,000 gastroenterologists and 1,400 neurosurgeons. The US has 20,000 undergraduate seats and 37,900 postgraduate seats. In most developed countries, postgraduate seats are twice the number of undergraduate seats.However, in India we have close to 50,000 undergraduate seats and 14,000 postgraduate seats in clinical subjects.
EMPOWER NURSES
India runs MBBS-centric healthcare.Indian policies prevent anyone other than a doctor with an MBBS degree to touch a patient. Primary healthcare in most countries is taken care of by nurse practitioners or physician assistants. In India, a nurse with over 20 years of experience in a cardiac ICU is not allowed to prescribe basic drugs. But in the US, nurse anesthetists administer anesthesia in 67% of cases. The government should consider offering dispensing rights to nurse practitioners or AYUSH doctors working at the public health centre to dispense 47 basic drugs after rigorous training and certification.
The nursing profession in India is on the verge of extinction because career progression is limited in the field. Admissions to nursing colleges have come down by nearly 50%. Soon we may have to import nurses at exorbitant salaries from countries like the Philippines or Thailand.
TRAIN PARAMEDICS
Healthcare is not about just doctors and nurses. For holistic healthcare, there should be four nurses and four paramedics behind every doctor. Of the 20 fastest-growing occupations in US, 15 are in paramedical healthcare.Unfortunately in India, none of the 15 training programmes exist. Paramedics like physician's assistants can add significantly to very sick patient care.
Instead of only looking to increase the healthcare budget in India we should look at reforms in medical, nursing and paramedical education, which will have a big impact in less than three years. Pumping more money into a defunct system will only increase corruption.
THE PRESCRIPTION
The first step is to equalize undergraduate and postgraduate seats in India. This can be done without incurring any cost, by just increasing the number of postgraduate seats in medical colleges and giving the National Board of Examination the status of a statutory body and extending postgraduate medical education beyond medical colleges.
State-owned medical universities should be empowered to innovate and train adequate number of medical specialists, nursing and paramedics to meet the healthcare needs of the state.Today they are restrained and treated like examination conducting agencies.
The Mumbai-based College of Physicians and Surgeons (CPS), which was the first Indian medical university established 103 years ago, can convert the entire basic cadre of MBBS doctors from government hospitals into diploma degree holders in broad specialties like gynecology , pediatrics, anesthesia and radiology in just two years and with no additional investment. The CPS only requires state government recognition.
Unless community health centres are staffed with adequate number of medical specialists with postgraduate diplomas, infant and maternal mortality rates will not decline. The government's target should be to reduce both by 50% within five years.As a collateral benefit, the rest of healthcare delivery in India too will get transformed. Building more institutions like AIIMS will not create this effect. It is time to act now. Otherwise, we will end up reinforcing Einstein's definition of stupidity “doing the same thing over and over and expecting different results“.
The author is chairman, Narayana Health
India can become the first country in the world to dissociate health care from affluence. This can only happen by closely linking healthcare delivery with medical education.According to World Bank data, Cuba produces the larg est number doctors per capita in the world (6.7 per 1,000 against 2.5 per 1,000 in the US and 0.7 per 1,000 in India) and its health indices are better than that of the US, which spends the most on healthcare. India is short of 3 million doctors and 6 million nurses, as per a PwC study , and its paramedical training programme is virtually non-existent. It is unfortunate that in 65 years post-Independence, we have never even once studied our manpower requirement for healthcare.
CURBING MATERNAL AND INFANT MORTALITY
Every 10 minutes, a young woman dies during childbirth somewhere in India and 3 lakh children die the day they are born. India's infant mortality rate (42 per 1,000 live births) and maternal mortality rate (178 per 100,000 live births) almost matches that of sub-Saharan countries, and the situation will not improve simply because government spends more money . We simply don't have the number of medical specialists needed to reduce these rates.
For 26 million childbirths per year, we need to perform at least 5.2 million Caesarian sections. For successful childbirth following a Csection, we need over a lakh each of gynaecologists, anaesthetists, paediatricians and radiologists. We only have around 30,000 gynaecologists and 20,000 anaesthetists and radiologists.
NUMBING NEGLECT
No surgery on a human body can be done legally without an anesthetist.Only 30% of India's population has satisfactory access to proper anesthesia services, of which 80% are urban beneficiaries.
Top 10 causes of death like heart disease, resistant TB, brain stroke, mental illness leading suicide, liver disease, accidents and cancer cannot be legally retreated by a doctor without a postgraduate qualification. Consider our figures for just two specialties -India has only 4,000 gastroenterologists and 1,400 neurosurgeons. The US has 20,000 undergraduate seats and 37,900 postgraduate seats. In most developed countries, postgraduate seats are twice the number of undergraduate seats.However, in India we have close to 50,000 undergraduate seats and 14,000 postgraduate seats in clinical subjects.
EMPOWER NURSES
India runs MBBS-centric healthcare.Indian policies prevent anyone other than a doctor with an MBBS degree to touch a patient. Primary healthcare in most countries is taken care of by nurse practitioners or physician assistants. In India, a nurse with over 20 years of experience in a cardiac ICU is not allowed to prescribe basic drugs. But in the US, nurse anesthetists administer anesthesia in 67% of cases. The government should consider offering dispensing rights to nurse practitioners or AYUSH doctors working at the public health centre to dispense 47 basic drugs after rigorous training and certification.
The nursing profession in India is on the verge of extinction because career progression is limited in the field. Admissions to nursing colleges have come down by nearly 50%. Soon we may have to import nurses at exorbitant salaries from countries like the Philippines or Thailand.
TRAIN PARAMEDICS
Healthcare is not about just doctors and nurses. For holistic healthcare, there should be four nurses and four paramedics behind every doctor. Of the 20 fastest-growing occupations in US, 15 are in paramedical healthcare.Unfortunately in India, none of the 15 training programmes exist. Paramedics like physician's assistants can add significantly to very sick patient care.
Instead of only looking to increase the healthcare budget in India we should look at reforms in medical, nursing and paramedical education, which will have a big impact in less than three years. Pumping more money into a defunct system will only increase corruption.
THE PRESCRIPTION
The first step is to equalize undergraduate and postgraduate seats in India. This can be done without incurring any cost, by just increasing the number of postgraduate seats in medical colleges and giving the National Board of Examination the status of a statutory body and extending postgraduate medical education beyond medical colleges.
State-owned medical universities should be empowered to innovate and train adequate number of medical specialists, nursing and paramedics to meet the healthcare needs of the state.Today they are restrained and treated like examination conducting agencies.
The Mumbai-based College of Physicians and Surgeons (CPS), which was the first Indian medical university established 103 years ago, can convert the entire basic cadre of MBBS doctors from government hospitals into diploma degree holders in broad specialties like gynecology , pediatrics, anesthesia and radiology in just two years and with no additional investment. The CPS only requires state government recognition.
Unless community health centres are staffed with adequate number of medical specialists with postgraduate diplomas, infant and maternal mortality rates will not decline. The government's target should be to reduce both by 50% within five years.As a collateral benefit, the rest of healthcare delivery in India too will get transformed. Building more institutions like AIIMS will not create this effect. It is time to act now. Otherwise, we will end up reinforcing Einstein's definition of stupidity “doing the same thing over and over and expecting different results“.
The author is chairman, Narayana Health
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