Rajneesh K Aryan
With the commencement of MBBS classes in newly opened Medical colleges of the state and a proposal of opening two more new medical colleges in the state shows that the government’s priority is to produce more number of doctors. This move of opening new medical colleges is actually a part of the central government’s scheme to convert district hospitals with 200 beds in underserved areas to medical colleges to increase the MBBS seats. By definition, a medical college is an institution in which a person may undergo a course of study or training in order to qualify him/her for the award of any recognized graduate medical qualification. This simply means that in next 5 or so years we will have no dearth of doctors in the state. But before this, there is a need to introspect, if there is actually a shortage of doctors or their skewed distribution. With the current strength of all 9 medical colleges, a total of around 900 seats seem to be more than sufficient for the state. So the opening of two more medical colleges is not justified.
Currently, there are 749 Primary Health Centers, 135 Community Health Centers and around 31 district and sub-district hospitals in the state as per the latest figures from HMIS (Hospital Management Information system) portal. According to IPHS (Indian Public Health Standards) norms, the total requirement of medical officers (excluding specialist doctors) comes to be around 1684; with 749 medical officers one at each PHC, 4 medical officers at each CHC and 13 medical officers at each 200 bedded district hospital. However this is the bare minimum or the essential requirement.
According to the man power audit report of Health and Medical education department 2018, the total sanctioned strength of medical officers in state is 3317, off which 2256 were in place and 1061 posts were lying vacant at that time. 371 posts were filled shortly after this report leaving a deficiency of 560 posts. Subsequent to this government advertised 1000 new posts of medical officers and appointed nearly 921 medical officers. The government’s failure to retain the doctors at Primary health centers of the state is quite clear as more than half of these newly appointed medical officers did not join their place of postings in PHCs which resulted in the termination of their services. This demonstrates that there is no shortage of qualified medical graduates in the state. On the contrary, there is a shortage of specialist doctors. So increasing the number of medical colleges to produce more number of doctors is unlikely to solve the problem at present or even in near future and the focus, therefore, should be on measures to retain the medical officers at Peripheral health centers. The failure to retain doctors at peripheral health centers is a topic which is fairly researched and debated on throughout India. The reasons for their not joining should be introspected and the focus should be on what it takes to retain the doctors at PHCs.
The second concern & consequence of having more number of medical colleges would be the impact on the quality of medical education. It is easy to achieve the numbers but quality takes a lot to achieve. An example of this is the opening of new AIIMS (All India Institute of Medical Sciences) in the country. None has been able to achieve the status or functionality like AIIMs Delhi.
The current need is not opening of more new medical colleges but to strengthen the districts hospitals with all core specialties being functional. Medicine, Surgery, OBG & GYN, Pediatrics, Anesthesia, Orthopedics, Ophthalmology, ENT are the bare minimum specialties required at the DH. Radiology, Psychiatry and Pathology/Biochemistry/Microbiology are important complementary specialties. Establishing Specialist new born care facilities like SNCU (Special new born care) PICU (Pediatric intensive care unit) HDU (High dependency unit) are required at peripheral district hospitals to provide high quality care to sick and critical newborns to reduce the IMR further. Implementation of LaQshya (Labour room quality assurance) guidelines in labour room and labour room OT and NQAS (National Quality Assurance Standards) in all the departments of district hospitals can ensure the quality of healthcare services provided which in turn, will improve disease outcome and MMR. The amount which will be spent in raising the infrastructure and human resources of a medical college could actually, have been utilized on organizing services delivery and providing adequate human resources to strengthen these district hospitals and providing quality secondary and tertiary level care to the patients, thereby restoring the people’s faith in these district hospitals as quality care providing institutions. Starting of DNB courses at district hospitals is one such good move by the state government in this direction. This will ensure availability of the specialists at district hospitals who can provide quality healthcare. Such measures need to be more focused on.
Health indicators of J&K viz. IMR, MMR & TFR have shown continuous improvement over the years and are much better than the national average as per the latest SRS (Sample Registration System) data. Another positive point is the public health expenditure by J & K. According to National Health accounts 2015-16, J&K spends 1.7% (Rs 1533 per capita) of GSDP (Gross State Domestic Product) on Public health expenditure which is highest for any state in India, however out of pocket expenditure (OOPE- the direct burden of medical cost which a household bear for seeking medical care) still remains high. Nearly 56% (Rs 2138 per capita) of the total health expenditure is OOPE. To reduce OOPE there is a need to further increase public health expenditure as the national health policy of 2017 also envisages increasing the public health expenditure by states to 8% of GSDP by 2020. So increasing public health expenditure from the current level of 1.7% to 8% of GSDP is a daunting task and needs more attention by the state as nearly 90% of the population of the state relies on public health facilities for their healthcare needs.
With the epidemiological transition i.e. shifting of disease pattern from communicable to Non-communicable diseases (NCDs) the approach or responsiveness of the health system needs to be changed. As per disease burden report titled “Health of the Nation-states” 2017 by ICMR Non- communicable diseases like Ischaemic heart diseases, COPD, Road injuries, stroke, diabetes, chronic kidney disease contribute to the majority of disease burden ( measured in terms of DALYs i.e. Disability-adjusted life years) in the state. The approach to tackle this burden of NCDs should be a primary care approach to reduce morbidity, disability and premature deaths. The strategy or approach, therefore, has to be comprehensive by providing preventive and primary level care through primary health centers & Health and Wellness centers. Population-based screening for major NCDs, disease surveillance, strengthening HMIS and use of data along with the strengthening of district hospitals to provide a continuum of care is required to respond effectively to the growing burden of NCDs and will go a long way to address the issue.
(The views expressed are personal and in no way reflect the views of the Organisation I am currently associated with)
(The author is (MPH, BDS) Fellow-Public Health Administration Division, NHSRC Ministry of Health & Family Welfare, New Delhi)
Rajneesh K Aryan