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India's Doctor Shortage Reflects Problems
in Medical Education
Low salaries and red tape have
limited the appeal of medicine as a profession
By
Shailaja Neelakantan
Issue
cover-dated June 13, 2008
New Delhi
On a hot Tuesday morning, more than 300 patients and anxious
relatives cram themselves inside the waiting room of the outpatient
department of radiation oncology here at the All India Institute
of Medical Sciences, one of the country's top medical schools.
"I see about 100 patients, sometimes
more, in a single day," says Kumar Harsh, 31, a senior
resident at the institute, sitting in his small cubicle as he
takes a brief rest between consultations. "Some of my colleagues
who have moved to the U.S. write to me saying how hard they
work and how tired they are seeing just 15-20 patients,"
he says, chuckling.
Dr. Harsh's sense of humor is one of
the few outlets he has for a seemingly untenable situation.
India's medical profession is in a crisis. For every 10,000
people in India there are only six doctors, compared with nearly
55 in the United States and nearly 21 in Canada.
The problem is likely to get worse
before it gets better. Professors are leaving medical schools
for better-paying jobs in private hospitals and in the pharmaceutical
industry, forcing the schools to cut the size of their programs.
And students who would have studied medicine a generation ago
are pursuing more-lucrative careers in the technical sector.
The doctor shortage illustrates how
government regulation and bureaucracy sometimes make it more
difficult for India to meet the challenges that come with rapid
economic growth. Regulatory hurdles to the establishment of
private medical schools have limited the opportunities to train
for careers in medicine, prompting would-be doctors to go abroad,
despite a boom in private health care.
Some students opt out of the field entirely.
"In our institute some years ago,
we had five classrooms of medical aspirants, and now we just
have eight to 10 students," says Satish Kumar Suri, founder
of New Delhi's Sahil Study Circle, a coaching center for students
taking India's highly competitive medical and engineering entrance
examinations. "It is a materialistic world, and the child
can see that the remuneration a doctor gets is nowhere close
to what an engineer gets. And a doctor has to struggle for more
than 10 years."
Better Options
Shruti Kharbanda wanted to be a doctor
for as long as she could remember. But after graduating from
high school last year and winning admission to medical school
(in India, medical education begins in the undergraduate years),
she decided to become an engineer instead.
"Initially I didn't really like
it, because I was interested in biology," says Ms. Kharbanda,
a freshman at Manipal University, in Karnataka state. "But
I thought careerwise it is a better option." Ms. Kharbanda's
parents, both doctors, were the ones who discouraged her from
entering medicine, noting that she would need to spend years
pursuing an advanced degree with little reward to show for her
hard work."Compared to that, getting a bachelor's degree
in engineering is the end of the struggle," she says.
Ms. Kharbanda's parents were not exaggerating.
Since thousands of students with bachelor's in medicine may
be competing for a single slot in graduate school, some retake
the entrance exams for several years. That means an education
that is supposed to take about 11 years often takes much longer.
Once in graduate school, students become residents at overburdened
government hospitals, where salaries are only a third of entry-level
pay for a top engineering graduate.
A senior resident at the All India
Institute of Medical Sciences earns $7,200 a year. By comparison,
the average salary offered this year to graduates of the Indian
Institute of Management in Ahmedabad was $49,000.
"Society has changed," says Dr. Harsh, the medical
resident. "Earlier, when I was a kid, a doctor was treated
like a god. Nowadays the person who has maximum money has power
and acceptance. Sometimes I regret getting into this line."
Following the Money
Many high-school graduates are doing
the math and, like Ms. Kharbanda, opting for engineering or
technological fields.
This year, 160,000 applicants took
the medical-school entrance exam, 25 percent fewer than last
year. By comparison, the number of applicants for entrance into
the elite Indian Institutes of Technology rose by 28 percent,
to 320,000.
Many Indians still want to become doctors,
but they choose to do so abroad, where it is often easier to
gain admission into specialized programs, and salaries are higher.
As many as 60,000 Indian physicians are estimated to be working
in the United States, Britain, Canada, and Australia. A recent
report published by the Planning Commission of India says the
country ranks at the top among nations whose physicians are
working in the major developed countries. India is second only
to the Philippines in the number of nurses working abroad.
Devi Shetty, a renowned cardiac surgeon
and philanthropist, is founder of Bangalore's Narayana Hrudayalaya,
one of the world's largest pediatric cardiac hospitals. He says
he is deeply worried about the lack of seats available for students
who want to become heart surgeons or other kinds of specialists.
As many as 1,000 applicants could compete for one seat, he says.
"In India only 80 doctors can become cardiologists"
in a given year, while "in the U.S. there are 800 positions
to train cardiologists." As for kidney specialists, the
United States has more nephrologists of Indian origin than India
has, Dr. Shetty says, noting that "India has only 60 seats
for nephrology."
Worse is yet to come. Because so many
professors are quitting for better-paying jobs in the private
sector, some Indian states will soon reduce the number of graduate
seats they offer in medical schools.
Medical schools in the state of Maharashtra,
for example, had 1,900 slots in 2001 for students seeking advanced
medical education. Today only 411 slots remain, says Shailesh
Mohite, head of the forensic-science department at the T.N.
Medical College in Mumbai (formerly Bombay), capital of Maharashtra.
"Inadequate pay scales, stagnant promotions, and poor working
conditions are frustrating and have caused many teachers to
leave and move to the private sector," says Dr. Mohite.
The decline in the number of graduate seats, he adds, has increased
the work load of full-time professors, frustrating them more.
The shortage of graduate seats also means fewer and overburdened
residents at hospitals.
In April students at Maharashtra's
medical colleges, supported by their professors, went on a weeklong
strike to demand more graduate openings. They called off the
strike after the government agreed to increase the number of
seats.
Private-Sector Solutions?
Many doctors and hospital administrators
believe that the only remedy to the national shortage of doctors
is for the government to loosen its stringent regulations on
private-sector participation. The few private medical schools
that exist in India are often of poor quality, and they charge
fees substantially higher than those of the state-run schools.
The government seems to agree that
such a step is called for.
The national health ministry is considering
modifications of some of the regulations under the Indian Medical
Council Act of 1956 to make it easier to establish medical colleges
in India, according to local news reports. The law requires
providers to own 25 contiguous acres of land on which to set
up a medical college, and at least a 300-bed hospital where
students would be trained.
The first condition may be relaxed
to allow two plots of lands a few miles apart, a health-ministry
official told a local newspaper. And any new medical college
may be allowed to link itself with a district hospital in the
neighborhood instead of having its own hospital. (Repeated calls
to the Ministry of Health & Family Welfare were not returned.)
'
The government is also trying to expand
the capacity of public medical schools to absorb more students.
One plan calls for setting up six new medical institutes, like
the one in New Delhi, and upgrading the country's 13 existing
ones. Another plan would establish 60 new medical colleges that
would be only for teaching, not for research.
Medical professionals, however, say
those plans are too little, too late.
"We are creating a crisis situation ourselves by not leveraging
private resources," says Vishal Bali, chief executive of
the private Wockhardt Hospitals Group, who says India needs
at least 600 more medical colleges. "Where will we get
these 600 colleges from? They won't come from the government.
They have to come from the privates," he says, adding that
Wockhardt itself would like to start a college. "It is
in our interest and also in the country's interest."
Dr. Mohite, the Mumbai medical professor,
fears that the situation is going to spiral out of control.
"Good government hospitals will become like primary health-care
centers," he says, providing only the most basic care.
"We are sitting on a bomb."
Only idealists, says Dr. Harsh, of
the All India Institute of Medical Sciences, will continue to
work in government hospitals, because that's where they are
able to serve so many patients. "Just look at the number
of people outside," he says, referring to the packed waiting
room. "If you are really interested in treating people,
this kind of satisfaction you can't get anywhere else."
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