Comments by Dr.J.V.Dixit

God, save this country from BOG!Due to charges of corruption, the president of Medical Council of India (MCI), Dr. Ketan Desai was sacked from his office and the executive committee was also dissolved. By government's order new board of governors (BOG) was appointed under the chairmanship of Dr. Sarin. Recently the care taker BOG has taken certain decisions that may create a suspicion about their intentions. In a news published in an English daily chairman Dr. Sarin has announced that there is shortage of 7,50,000 doctors in our country. Furthermore the BOG has shown its willingness to facilitate production of more doctors by relaxing various norms required to be fulfilled for opening new medical colleges. Now a medical college with admission capacity of 250 can be opened with 10 acre land instead of 25 acres. Such college will require a hospital with 900 beds instead of the existing norm of 1500 beds. The hostels of students can be located in the radius of 5 Km from the college. The medical teacher shall be recognized as teacher till 70 years of age in place of earlier limit of 65 years. The BOG aims at starting 100 medical colleges every year for the next five years. In addition it also wants to increase intake capacity of existing medical colleges by 100 each. To my surprise the BOG has acted fast and many of these decisions are made available on the website of MCI as amendments to existing regulations.
The decisions taken by the BOG have far reaching impact on medical education in this country. These decisions are also going to affect health and social life of this country. It goes without saying that such decisions should be taken after due brain storming in all the stake holders of this country. I wish to put forth some issues in this regard in this article.
Hon. Panabakka Laxmi, the then health minister, informed the parliament in July 2005 that as per available data there was one allopathic doctor for 1722 people in the country. After considering the Ayurved and Homeopathy doctors in the country the ratio comes to 128 doctors per 100,000 populations. This means that for 781 people there is one doctor in the country as per 2005 data. As per this statistics there are 6,38,792 allopathic doctors in the country. Every year around 32000 allopathic doctors pass out from medical colleges. Hence in 2010 there are around 8,00,000 allopathic doctors and the doctor population ratio is 1:1400 to 1500. 
World Health Organization in its course book on "Health Manpower Planning" of 1980 describes four methods to decide number of doctors required by a country. The "Health Needs" method takes into account the biological needs of the society for deciding the requirement of doctors. The other two methods include "Service Target" and "Health or Economic Demands" methods. In all these methods one has to collect information regarding the disease load, existing number of doctors as well as the economic and social milieu of the country. The last method, the simplest one is to decide required number of doctors on the basis of population. In this method one should know population of the country. Here the number of doctors required by the country is decided by taking into account international comparison, suggested norms, the statistics available from countries with better health care and study of past trends. Though simple this method is crude.
Dr.Sarin's conclusion that India needs 7.5 lakh allopathic doctors is based on this fourth method. It makes no sense to decide doctors required by India on the basis of statistics that Cuba has one doctor for 250 people or USA has one for 500 people. Before coming to this magic figure, Dr.Sarin should have done some serious homework. 
Firstly let us accept that more doctors do not necessarily mean better health. Healthy society will require lesser doctors! Secondly we must undertake the studies to find out workload for the doctors. The census can be used to find out the age and sex wise disease load in the country. Many of the services such as bandaging, giving injections, dispensing medicines etc are actually provided by nurses and pharmacists. Preventive and rehabilitative services are provided through paramedical workers. Doctors are required for curative services. The work of health promotion and protection is better done by farmers, teachers, environmentalists, engineers and scientists than the doctors. The curative services are on out patient or inpatient level. To calculate requirement of doctors for this purpose we should have data about various diseases. Then we can decide on the number of general practitioners, cardiothoracic surgeons, psychiatrists and pathologists. Of course this is a tough task involving collection of data at national level and its analysis. I wonder why after 60 years of independence this should not be possible!
In 1950 the WHO expert committee suggested a norm of one general practitioner for 1500 people. While suggesting this WHO had considered that a doctor will work for 2000 hours in a year (6.75 hours everyday for 300 days). In India the role of general practitioners is mostly taken by Ayurved or Homeopathy doctors. MBBS general practitioners are as an exception. If we consider the number of doctors of all pathies then the doctor population ratio comes to 1:781 far better than WHO expectations. Hence it is wrong to say that there is deficiency of general practitioners in India. India is unique country in the world which has almost equal number of doctors from other pathies. These doctors too learn medicine for 5 and half years. Without undue consideration to "Cross practice" it is logical to allow them to use a few modern medicines by giving adequate training. This will bring them under the regulatory net and also avoid misuse of medicines. The society will also get benefits of modern medicines. If we do not consider this peculiar situation of India and produce more allopathic doctors then we are encouraging mal practice and unethical competition amongst the doctors both of which damage the society ultimately.
It will be clear that India doesn't require more general practitioners. We require more of psychiatrists, anesthetists, cardiothoracic surgeons, neuro physicians and dermatologists. For this we will have to increase post graduation seats in medical colleges. In a college with intake capacity of 150 there should be 150 post graduate seats. MCI may relax norms to achieve these numbers. This will help our people. While giving attention to team leader of "Health Team", the doctor, are we thinking about nurses and technicians? The obstructed labor of "Paramedical Council" is an eye opener in this regard. 
The problem of India is not the number of doctors but it is the inequitable distribution of doctors in urban-rural as well as public-private sectors. Rather than increasing numbers we have to look into the reasons for why doctors are not willing to work in rural areas. One may have to develop a new model for providing health care to the community.
Dr. Sarin and BOG has to work for one year or till reconstitution of MCI. The BOG is appointed by ministry of health and family welfare. Without doubting their character and caliber one fact is clear that they do not democratically represent the medical students, teachers, managements of medical colleges as well as practitioners like their predecessors. Hence it is wrong for the BOG to take decisions that have far reaching impact on medical education and health of this country. In short they are care taker government and such excesses only show that they are going beyond their jurisdiction. This is actually defeating the very purpose of their appointment. In an attempt to increase the number of doctors in the country how MCI can afford to decrease their standard? Presently also there are serious doubts about quality of doctors produced in our medical colleges. It is an open secret to know the beneficiary of relaxed norms for starting new medical colleges! More than the society such decisions are going to benefit politicians interested in starting medical colleges and industrialists. 
Before attempting to improve doctor-population ratio in the country the BOG should study the editorial of December 1962 issue of Singapore Medical Journal. In an editorial "The doctor requirement" the editor writes- "All these go to show the danger of calculating medical needs on an arbitrary figure. The matured way of meeting a problem of this nature is to utilize available facilities efficiently and without waste, and not to plan a mansion with the possibilities of a flat to bemoan the inadequacy of resources. The former means healthy and economical planning and the latter a perpetual debt-like hire-purchase in an improvident family which must in the end come to grief with the Frankenstein it created. Medical need is a pressing item that all reasonable men must be interested in, but unless we cut our dress according to the cloth, such intent may not at all be a happy augury".
I hope Dr.Sarin's BOG looks seriously and sincerely into this number game before inflicting a long lasting injury to the health system of the country. The situation in the country is conducive to doubt the intentions of such move!

Dr.J.V.Dixit 
Public Health Specialist
drdixit1@rediffmail.com