By Sandhya Venkateswaran & Khushboo Balani
India’s reported doctor-population ratio stood at 0.9 per 1,000 in 2019, but once adjusted for infrequently updated data and duplicate registrations, estimates are closer to 0.6 to 0.7 per 1,000. The inter-state variance is wide, from 2.53 per 1,000 in Goa to 0.06 per 1,000 in Nagaland. The pace of expansion across states has been uneven over the last 40 years. In the last decade alone, some states (Andhra Pradesh, Delhi, Uttarakhand, Arunachal Pradesh, Haryana, Himachal Pradesh, Chhattisgarh) have seen rates of expansion above 8%, while others (Punjab, Maharashtra, West Bengal, Assam, Bihar) below 2%.
The obvious question is: What drives the availability of doctors across states?
At the national level, the debate on the brain drain seems misplaced now. In a reversal from previous decades, the last decade witnessed higher inflow and annual production of doctors than the outflow. Though there has been a systematic loss of highly qualified doctors from the country, recent statistics suggest that at an aggregate level, brain drain is not India’s biggest challenge.
The challenge is the production and distribution of doctors. The doctor availability across states is very variable, and there are numerous factors driving this: state’s economic status, public health expenditure, expenditure on medical education.
While the first variable has a positive association with doctor availability, some states (particularly the hilly ones) have a low density of doctors despite high per capita income. The other two variables have, at best, a weak association.
Looking beyond economic factors, two key variables stand out—the availability of seats and inter-state migration of doctors. In the case of public medical colleges, investments in local production of seats have driven increased availability of doctors. This association is further mediated by other factors: seat structure where 85% of seats are for state residents, bonds (variable across states) requiring compulsory service in government hospitals, and incentives for preferential treatment during post graduate seat allotment.
The inter-state migration of doctors is linked with seat structure (public versus private seats), policy incentives or disincentives and structural factors. Based on comparison of ratio of total seats in a state, and newly registered doctors in that state, two broad groups of states emerge—net exporters or next importers, depending on doctor outflow or inflow from other states. States can also be classified by availability of doctors—high or low availability, depending on the doctor-population ratio being greater or less than the WHO norm of 1: 1,000.
Combining the two, states can be classified into one of the four categories: 1) High availability of doctors and net exporters to other states—Andhra Pradesh, Karnataka, Jammu & Kashmir; 2) High availability of doctors and net importers from other states—Delhi, Maharashtra and Tamil Nadu; 3) Low availability of doctors and net importers from other states Rajasthan, Jharkhand, Haryana and Odisha; and 4) Low availability of doctors and net exporters to other states—Uttar Pradesh, Bihar and West Bengal.
There are several factors placing states in one or the other category: State policies and incentives for retaining doctors, availability of general and medical infrastructure, ratio of availability of public and private medical colleges.
Policies such as state-specific bond conditions (bond duration after completion of MBBS from government medical college ranges from 20 years in Assam to zero in Andhra Pradesh, Delhi) and penalty in case of breach of bond; market forces driving the potential return on investment; living and practising infrastructure are factors influencing decisions to study and practice in a particular state.
A combination of such policies and structural factors have led to Rajasthan and Jharkhand, low availability EAG states, attracting doctors, while Bihar and UP witnessing the exit of even locally produced doctors from the state. Thus, it is not merely the local production of doctors, but in-state retention policies that also influence the net availability of doctors across states.
Private sector seats are not combined with bond conditions, and states with higher availability of private sector seats are invariably net exporters of doctors. Karnataka and Andhra Pradesh, have among the highest number of private seats per million population, have the highest outflow of doctors. Over the last decade, private sector growth has largely been concentrated in the developed southern states (barring Uttar Pradesh).
Based on the above analysis, it emerges that the relationship between local production and local net availability of doctors is not straightforward. States with high availability of seats and yet a low availability of doctors suggests that the role of state’s incentives and disincentive mix and structural constraints, is equally important in influencing the equity in availability of doctors.
The analysis shows that NMC’s proposed norms of linking setting up of colleges to population norms (100 seats per million population) and distance norms (no new medical college within 10 km of an existing college) may run counter to the efficient production of doctors. While the current policy focus on addressing equity through increasing public medical seats in underserved areas is necessary, it may not be sufficient in improving the local availability of doctors. A singular focus on regulating the production of doctors may bypass the market dynamics underlying the functioning of medical colleges, especially private medical colleges.
Co-authored with Amrita Agarwal, visiting fellow, Centre for Social and Economic Progress
Respectively, senior fellow, and research associate, Centre for Social and Economic Progress. Views are personal.