Private Sector in Medical Education and Human Resource Development for Health in India: Understanding the Regional Variations
Choudhury, Pradeep Kumar (2016). 'Private Sector in Medical Education and Human Resource Development for Health in India: Understanding the Regional Variations' Paper presented at the annual conference of the HDCA, Tokyo 2016.
topics: Education and Empowerment, Health and Disability, Inequality and Justice
abstract: Availability of human resource is considered as a critical factor for effective provision and delivery of quality health care to India’s vast population. It drives health outputs and outcomes, including immunisation levels, outreach of primary care, and, infant, child and maternal survival (WHO 2006; Anand and Barnighausen 2007; Mitchell et al 2008; Rao et al 2012). Also, India’s mandate for universal health coverage (UHC) — developing a framework for providing easily accessible and affordable health care to all Indians — depends, to a large extent, on adequate and effective health workforce providing care at primary, secondary and tertiary levels. However, even with the recognition of the importance of a health workforce for delivering better health care, the number of health workers in India today is quite inadequate. The World Health Statistics Report (WHO 2015) reveals that in India, between 2007 and 2013, there were 24 health workers per 10,000 population (seven doctors and 17 nurses and midwives)—almost half of the global average of 43 workers per 10,000 population (14 doctors and 29 nursing and midwifery personnel). The availability of human resources (doctors, nurses and midwives) in India is less than the threshold of 25 health workers per 10,000 population as established by the Joint Learning Initiative (JLI) of the World Health Organisation (WHO) in 2004. As per the WHO’s Global Atlas of the Health Workforce (WHO 2010) data, India ranked 52 of the 57 countries facing human resources for health (HRH) crisis. It is argued that states in India are struggling with the complexities of escalating human resource costs, additional demand for health workforce, uneven distribution, and skill-mix imbalances; and the intervention of private sector is suggested as a potential alternative in solving these issues (Jilani et al 2008; Davey et al 2014;). In the past several decades, there has been a growing participation of the private sector in building up health manpower in India, particularly by establishing a large number of medical and nursing colleges (Mahal and Mohanan 2006). However, there is lack of evidence on how the private sector has contributed to the health system by producing human resources in India and also in the understanding of the regional spread. It becomes important to examine the issue of the acute shortage of HRH and the role of private sector in its alleviation in the context of the Draft National Health Policy (NHP) 2015, which is largely silent on this issue. Though the draft policy document has highlighted some important aspects of human resources in the health sector (like the quality of medical education, locating doctors and other health professionals in rural areas), the role of private sector in the expansion of medical education in India and its consequences have been mostly ignored in both the research and policy domains (Government of India 2014). Though the health workforce includes all the clinical staff such as physicians, nurses, pharmacists, dentists, midwives, allied health professions, community health workers, and support staff engaged in providing health services, most of the studies (both in India and elsewhere) in this area have largely focused on examining the issues related to physicians, nurses, and midwives, as their role is quite significant in the overall healthcare delivery. Similarly, this study has focused on the allopathic physicians that is, the medical graduates who hold Bachelor's Degree in Medicine and Surgery (MBBS) from medical institutions recognised by the Medical Council of India (MCI). This paper discusses three important issues: (a) the role of private sector inmedical education, particularly its growth and regional distribution; (b) availability and distribution of doctors in India, with a special focus on inter-state variations and rural-urban disparity; (c) assessing quality of medical education, mainly looking at the role of MCI in implementing regulations and improving the quality of private medical education. The paper uses data from the MCI, National Health Profile and Rural Health Statistics published by the Ministry of Health and Family Welfare, and the WHO. The discussion on the quality aspect of medical education is based on evidences provided in the literature, major policy documents, and reports of various committees and commissions. This study finds that one of the most dominant features of Indian medical education is the rapid expansion of private sector (especially after the 1990s), which has led to regional inequality in the production and distribution of doctors. Interestingly, this growth has occurred primarily in the more developed states with better health outcomes, while the low-income states with poor health indicators have lagged behind. This unequal distribution of medical colleges has had an impact on the availability of medical services and has resulted in regional differences in access to doctors (some cases access to quality doctors) in the country. For example, there is considerable variation in the density of doctors between rural and urban areas, which indicates the difficulty rural Indians face in accessing healthcare. Due to a lack of qualified physicians, people in rural areas rely on unqualified health practitioners, who have either no training or have training in alternative system of medicine, but they still prescribe allopathic medicines. A majority of the qualified doctors available in the country serve in urban areas and are not interested in working in rural areas despite policies and guidelines laid out by the state in this regard. The other important issue highlighted in the paper relates to the existing deficiencies in the quality of training imparted at private medical colleges, leading to production of doctors who do not possess the requisite skills and competence. The focus of the MCI is mainly on availability of infrastructure and other facilities in these institutions and there is hardly any attempt to evaluate faculty engagement in academic achievements and quality of care. The need of the hour is to reorient the private sector for the production of quality medical graduates to meet domestic needs, particularly in the underserved areas.