Medical specialists are vital for India’s march towards the Sustainable Development Goals

The health workforce is a vital piece in the health system jigsaw. It is the building block which is important not just in planning and delivering health services, but also for operationalizing all the other building blocks in the WHO Health Systems Framework. The health workforce supports all other blocks and provides the all-important face as well as the skeletal frame for any functioning health system. However, this building block is one of the most challenging to create and sustain. Hiring the right people, with the right skills, for the right role and at the right time are often challenging within the contours of the public system. It is equally difficult to provide them with the appropriate incentives and retain them within the public system. From a systems perspective, mere availability of health workers is not sufficient; health workers need to be equitably distributed and accessible, possess the required competency, and are motivated and empowered to deliver quality care translating into effective service coverage [1].

The health workforce is a deficient resource at the global level. An analysis conducted by the Global Health Workforce Alliance and World Health Organization estimated a gap of 7.2 million professional health workers in 2012, which is set to rise to 12.9 million over the next decades. This shortage is starkly visible in developing countries. India too has a health workforce which is deficient in overall numbers and is inequitably distributed across geographies and across the urban and rural areas [2]. While an adequately staffed health department with the right skill-mix is essential to deliver services, the public system in India is plagued by a shortage of medical specialists. Medical specialists are trained to deliver specialized care and have a distinct advantage in managing cases that require specialized care. The public system envisions their presence at the secondary and the tertiary level of care which are delivered through the Community Health Centres and the District Hospitals/ Medical Colleges respectively. The Community Health Centres are typically at the Block level and cater to a population that exceeds 100,000.

The Government of India is committed in its efforts to strengthen the health system through policy decisions: One to strengthen care at first contact through Health and Wellness Centres; and second, to expand service provision and access through Ayushman Bharat. These very well align with the concept of Universal Health Coverage³ (UHC) where ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’. This definition highlights the importance of equity, quality of care and financial risk protection in the provisioning of UHC. In this context it is relevant to note that the provision of health services needs the presence of appropriate numbers of medical specialists.

Medical specialists, particularly paediatricians and obstetricians are vital to India meeting the targets of the Sustainable Development Goals by 2030. Medical specialists are scarce in India, and the numbers are disproportionately lower in the public sector, at the Community Health Centre (CHC) level and above. Even district hospitals in several states have an acute shortage of medical specialists. At the country level, we continue to face a shortage of specialists even when we consider the total number of specialists in the country. Ballpark figures suggest that India is about 40 per cent short of gynaecologists/ obstetricians (FOGSI estimates) and has approximately half of the 1.21 lakh paediatricians it needs (IAP estimates). A similar shortage plagues other specialties including medicine and general surgery. As per the data from the 2018 Rural Health Statistics,⁴ out of the 5,624 Community Health Centres at the Block level, only 325 (5.7%) were staffed with all four specialists. At the country level, against a requirement of 22,496 specialists required at the Community Health Centre level; 13,635 positions were sanctioned with only 4,074 (29.8%) in position.

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a pioneering initiative to provide health cover to the poor and vulnerable population with universal access to good quality hospital services without facing financial hardship as a consequence of using health services.⁵ This is one of the largest health insurance scheme globally where eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empanelled private hospitals.⁵ As on 22^nd December 2019, 20,752 hospitals were empanelled, 64,94,347 beneficiaries admitted and 6,67,60,406 e-cards issued. This is a laudable achievement in expanding the access to services and it has justifiably received the whole-hearted support of the citizens.

However, it is important to adequately equip facilities with specialized staff in order to cope with the rising demand for services and for maintaining the quality of care. The supply side of medical specialists (current models) in India is facing several impediments, involving limited number of post graduate medical seats, high ratio of under graduate to post-graduate seats and a limited number of medical colleges and specialty faculty. There have been recent initiatives to expand the post-graduate medical education across the country. There have been efforts to increase post-graduate medical seats in medical colleges through relaxing the teacher-student ratio, tapping DNB specialization through hospitals owned by the railways and other organizations, upgrading select District Hospitals in states to offer DNB and CPS qualifications as well as opening up new AIIMS in states. The participating District Hospitals where DNB/ CPS programs will be offered as a part of District Hospital Strengthening, will witness improvements in their capital infrastructure as well as the staffing of specialists. The presence of Post-Graduate trainees around the year will have a domino effect that may lead to higher utilization/ access of services. State Governments will directly benefit from the availability of a larger specialist pool. The population served by the District Hospital will have 24x7 accesses to medical specialists. These efforts stem from recognition to keep pace with the growing need of medical specialists within the country are in sync with the vision and spirit of the National Health Policy 2017 document.

In this context, public health experts will have to continue working with the health ministry and health systems to answer several important questions such as: How many medical specialists does the country need to achieve SDG targets? How do we improve timely and affordable access to specialist services? What is the optimal mix of specialists at all levels in the health system? What are the alternate models for creating specialists? How do we maintain the quality of specialist training while expanding access? The recent governance changes in medical education can be viewed as an opportunity to closely examine these issues. The Post-Graduate Medical Education Board under the National Medical Commission can work closely with NITI Aayog and other experts to create a blueprint for the country. It must be remembered that the latent time for training a medical specialist can be long process. We can anticipate a time-lag of at least five years from a policy decision to the actual recruitment of a trained specialist. The next five years will be crucial for India’s efforts towards planning and deploying the medical specialists for attaining the SDGs by 2030.

References

1. Global strategy on human resources for health: Workforce 2030 [Internet]. [cited 2019 Nov 24]. Available from: https://www.who.int/hrh/resources/16059_Global_strategyWorkforce2030.pdf?ua=1
2. Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data | BMJ Open [Internet]. [cited 2019 Nov 24]. Available from: https://bmjopen.bmj.com/content/9/4/e025979
3. World Health Organization. What is universal coverage? [Internet]. WHO. [cited 2019 Nov 25]. Available from: http://www.who.int/health_financing/universal_coverage_definition/en/
4. Ministry of Health and Family Welfare. Rural Health Statistics - 2018 [Internet]. [cited 2019 Nov 24]. Available from: https://data.gov.in/catalog/rural-health-statistics-2018?filters%5Bfield_catalog_reference%5D=6680151&format=json&offset=0&limit=6&sort%5Bcreated%5D=desc
5. National Health Authority. Ayushman Bharat [Internet]. [cited 2019 Nov 24]. Available from: https://pmjay.gov.in/