Devi Shetty: No silver bullet for healthcare in India

India cannot improve its health care delivery systems without reforms in medical, nursing and paramedical education. Our biggest bottleneck is the extreme shortage of skilled manpower.

These changes are necessary for the government to develop a strategy to address the top ten causes of death. To treat these potentially fatal diseases, we require specialists with postgraduate degrees. That was not always the case; 20 years ago, a doctor with just an MBBS could administer anaesthesia, perform a Caesarean-section (C-section) or fix a broken bone. Unfortunately, today, without a postgraduate degree, an MBBS doctor is not allowed to perform these tasks.

The shortage is already being felt: India’s maternal and infant mortality rates (MMR and IMR) are equal to those of Sub-Saharan African countries. The government’s strategy should be to halve IMR and MMR in the next four years. This is an achievable goal. There are about 26 million childbirths every year in India, and conservatively, 20 percent of these births happen by way of C-sections. We need to perform at least 5.2 million procedures every year. For a successful child birth rate, we need over a lakh each of gynaecologists, anaesthetists, paediatricians and radiologists. That can be done only by equalising the number of undergraduate (UG) and postgraduate (PG) seats in medical educational institutions. (The US, for instance, has 20,000 UG and 37,900 PG seats whereas India has 50,000 UG and only 14,500 clinical PG seats.)
 
Build Schools
A 2015 PwC study reports that the country is short of three million doctors and six million nurses. One way to address this is to convert district headquarters hospitals into teaching hospitals attached to medical and nursing colleges and paramedical schools. If we create a hundred new medical colleges a year for the next five years, we will have an adequate number of doctors by 2025. With some changes in the medical education policy, these hospitals can be converted into medical colleges with a very modest investment of less than Rs 150 crore. For instance, we do not need a centrally air-conditioned auditorium or a dedicated hostel. When a medical college comes up, such services and infrastructure will grow through private enterprise, which will boost the local economy and encourage participation from the community.

The best way to revive the economy of a district is to start medical, nursing and paramedical schools there. The sheer number of students and related activities will change the economy of the district, pushing up the value of real estate and consumption of agricultural products grown in the region; that is, apart from offering better health care delivery.

The next step is to launch scholarships for children from rural India. Some examples are the Udayer Pathey scholarship programme in West Bengal and the Udaan scholarship programme in Karnataka. These Narayana Health initiatives help 13-year-old students from poor families in rural areas realise their dream of becoming doctors. They are mentored by doctors from Narayana Health. We also offer a scholarship of Rs 500 per month, which will prevent the parent from dragging the child away from school to work in the field. It is important to help such children become doctors as they have the fire in their bellies to change the way health care is being delivered. Currently, there are a few hundred students in various medical colleges across India under this scholarship programme. This model can easily be reproduced in north and east India.  

Health care is a regional service: If we need good doctors in Arunachal Pradesh to serve in rural areas there, we need local children to join medical colleges in their districts so that a small percentage of them will stay back after becoming doctors and serve the local population. If the same student comes to Bangalore and lives there for six years to become a doctor, the possibility of him or her returning to the home state is small.

Build Hospitals
The government should realise the potential of the health care industry: It is already a $7-trillion industry, the second largest in the world after agriculture. The health care sector can create a phenomenal number of jobs for highly-skilled, semi-skilled and unskilled people. For a turnover of Rs 1 crore per month in the information technology (IT) industry, we just need eight to 10 brilliant engineers. In health care, we will need 250 people to achieve the same turnover, and most of these employees will be nurses, technicians and support staff. A strong medical infrastructure will also help the government address one of its biggest challenges: Creating well-paid jobs for semi-skilled and unskilled people.

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Medical students attend an exhibition at Osmania Medical College, Hyderabad. A PwC study has shown that India is short of three million doctors and six million nurses

Today, only the health care industry can create millions of jobs and emerge as the largest employer, provided infrastructure is built and doctors and medical specialists are trained.  

India also needs to develop medical infrastructure in towns and villages. There are a hundred towns across the country with a population of 500,000-1 million each that have no super-specialty hospitals. Instead of building institutions like AIIMS in big cities, we need to create 300-bed super-specialty hospitals for heart diseases, cancer, joint replacement, advanced laparoscopic surgeries and organ transplants in these towns. Hospitals can be built and equipped for less than $10 million, a fraction of what is currently being spent by most states. In fact, state governments need only erect the building, and can then get private health care providers to equip and manage the hospital and take care of the underprivileged on a public-private partnership basis.  

Nurture Nurses & Support Staff
Health care is not just about doctors. Behind every doctor there are four nurses and four paramedics. But the nursing profession in India is on the verge of extinction because of lack of career progression.

Nurses rarely get the opportunity to learn additional skills that will make a difference to a patient, and so, their salaries do not change. They start as nurses and retire as nurses with a modest increase in income. Little wonder then, that admissions into nursing colleges have dropped by almost 50 percent in the last five years. This tide can be reversed if they are given the opportunity to become nurse practitioners, nurse intensivists or nurse anaesthetists. If career progression pathways are not provided, bright children will not opt for this profession.

It’s a similar situation at the country’s primary health centres (PHCs)—more than 25,000 in number—which are managed by doctors with MBBS degrees. But today’s professionals do not wish to work in PHCs and remain as ‘just MBBS’ doctors. As in the West, we need to create a parallel workforce to address the needs of primary health centres and rural clinics. One option the government can consider is to give the rights to prescribe 47 commonly used drugs in PHCs to AYUSH doctors (practitioners of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) after training and certification.  

We also cannot ignore the importance of paramedical care. Paramedics like physician assistants can contribute significantly to patient care and Indian universities should be empowered to start training programmes. But universities are stifled by regulations, and there is hardly any avenue for introducing innovative courses. Taxpayers’ money alone cannot pay for these initiatives as the country gets older. It is important to come out with innovative schemes like the Yeshasvini micro- health insurance scheme in Karnataka, which, since its inception in 2003-04, has performed over 7.10 lakh operations on farmers and 85,210 heart surgeries.

India has over 850 million mobile phone subscribers who spend, on an average, over Rs 150 a month just to talk over the phone. If we create a mechanism to collect Rs 20 a month from each subscriber as a contribution towards micro-health insurance, we will be able to cover the healthcare needs of this 850 million people. It will be possible for us to build the most robust health insurance scheme in the world.

I would like to congratulate our government for proposing the launch of the National e-Health Authority (NeHA). But insisting on a very high standard of medical data transfer in the name of privacy will scuttle the entire development; in such a scenario, millions of Indians will not have the option to access online health care remotely. If a patient consents and the doctor is willing, any social platform or electronic mode of communication of patient data should be allowed.

India can become the first country in the world to dissociate health care from affluence. We can prove to the world that the wealth of a nation has nothing to do with the quality of care its citizens enjoy. We can make this happen in less than a decade.