India suffers from ‘over-medicalisation’—augment training for nurses, ANMs & rural doctors, rethink education
Given the small proportion of India’s GDP that is spent on health, the standard response for improving healthcare is increasing government spending. While that is a good thing, as leading health practioners like Devi Shetty of Narayana Hrudalaya and Srinath Reddy of Public Health Foundation of India argue, India’s bigger problem is ‘over-medicalisation’, and that is what needs to be fixed. Nurses in India, to give one example, spend the most time looking after patients but they have no real career path—they are not even allowed to prescribe a painkiller whereas, as Devi Shetty puts it, “even in litigation-happy US, 67% of anaesthesia is given by nurses, not doctors”; which is why, Shetty points out, while India has a shortage of 2.5 million nurses, admissions to nursing colleges have dropped and the number of nurses has fallen. Reddy, who talks of how mid-level health workers in Chhattisgarh have proved to be better than doctors in treating primary care conditions, especially malaria, emphasises the need to train nurses to become ‘nurse practioners’ and ‘nurse anaesthetists’—how, Shetty asked in a recent Idea Exchange of the Express Group, can we pay nurses more if their skills are not upgraded? Indeed, given the large shortage of doctors, if nurses and auxiliary nurses/midwives (ANM) are given adequate training, rural healthcare can improve and, for instance, neonatal and maternal mortality can be reduced dramatically.
While MBBS doctors are not allowed to deliver babies for instance, the Mumbai-based College of Physicians and Surgeons (CPS)—India’s first medical university, 105-years-old—converted them into diploma-holders in gynaecology, paediatrics, anaesthesia and radiology in just two years, but most states derecognised this due to pressure from the medical fraternity—luckily, Shetty says, the centre saw reason and has just recognized this diploma.
India has 50,000 gynaecologists/ paediatricians vs a need for 200,000 each, 10,500 radiologists vs 150,000 needed, 65,000 surgical specialists vs 600,000 needed … The problem here is that if a medical college costs Rs 400 crore, this limits how many can be set up and, to the extent the private sector puts them up, the fees are exorbitant and put a cap on the number of students. There are, Shetty says, 35 medical colleges in Cuba training doctors for the US in just 50,000 square feet of space. The over-engineered medical colleges in India, by contrast, require 140 teachers to train 100 students!
In a report for the Planning Commission in 2011, Reddy had recommended setting up of nursing schools/colleges in under-served states and also linking medical colleges to district hospitals—this would both lower costs of medical colleges dramatically as well as ensure greater supply of rural doctors. Shetty recalled how he worked in several remote areas in the UK where few doctors wanted to work since the hospitals he received his training in were located there. “This country”, Shetty said, “doesn’t require additional budgetary allocation … it requires the liberation of medical, nursing and para-medical education” (goo.gl/i5SmE6).
Equally important is the issue of private medical care, under fire recently after very high bills for patients who died and, in one case, the hospital declaring a neonate dead though it was alive. While it is easy to talk of the bills of private hospitals, if a recent Apollo Hospitals presentation is correct, the capital costs of a tertiary hospital bed is cheaper in the private sector, though opex is higher. The reason why no one talks of this, however, is that the costs of government hospitals are subsumed in the budget. If a genuine comparison is to be made of public and private costs, the government has to come out with actual capex/opex of public hospitals. There is little point demonising private hospitals since they provide more beds than government ones—$75 billion more is required by 2020 to set up hospitals and the government can’t possibly finance this. Also, in a huge shortage situation already, each private hospital closed—as the Delhi government did recently—means tremendous suffering for the public.
There is the issue of high taxes as well as huge land costs—in metros like Delhi—that need to be amortised, so it would be helpful for the government to put out data on how much of a patient’s high bills are due to land costs, to taxes, to expensive machinery. Issues like exceptionally high medical bills that have come to light recently need to be examined individually, but it is important to keep these factors in mind. Also, given the huge shortage of doctors in even private hospitals, charges of negligence need to be made more responsibly and examined by a panel of doctors rather than the media—an examination of deaths in public and private hospitals is a good idea after accounting for the fact that, in many cases, terminal patients are transferred to public hospitals.
So, if the government wants a healthy India, is has to completely revamp medical education and move away from ‘over-medicalisation’ that Reddy talks of and look at providing augmented degrees to doctors/nurses, create specialised degrees for rural doctors—Reddy talks of a 3-year Bachelor of Rural Health Care who, presumably, will be happy to work in villages—and find ways to lower costs for private hospitals and colleges. And if Karnataka’s Yeshasvini can provide cover for surgeries for as little as Rs 30 per month, the government needs to find a way to pay for this insurance if it can’t get the poor to pay themselves—indeed, once this is done, even private hospitals will have a better business case to expand in smaller towns. If India’s medical facilities are brought to par in the way just discussed, it can provide several million jobs—250 jobs for every `1 crore of hospital turnover—but for this to happen, the industry has to be allowed to develop.