The number game – how many doctors are enough?

An article by Samar Halarnkar in yesterday’s HT raised the issue of  the lack of doctors in our health care system. As I read the well written piece, that highlighted once again the many well known problems with health care in this country, I worked out some math in my head.

WHO, the accepted global benchmark for all things to do with health, recommends that a country should have 1 doctor per 600 population for effective health care. The population of India as per the 2011 census is 1,241 million and as of  2010, the Indian Medical Register has 8,193,00 allopathic doctors. This works out to a ratio of 1:1541 of population, a far cry from the WHO recommendations. How are these ideal figures worked out? I am sure there are robust algorithms for getting these figures and it is not my intent to question these.

The 12th Plan document of the Government of India cites that there were 45 doctors per 100,000 of population in 2007 (based on an assumed 5.5 lac doctors), which works out to 1 per 2,200 population.  Various other sources are quoting 1 per 1800 to 1 per 2000 (PMO), and it is difficult to say which is accurate. While the census figures cannot be disputed, it being one of the well done exercises in this country, the figures on the doctors has many fallacies.

Ideally every profession should have an idea of their strength and these are derived from the numbers registered with the official body of the Profession. The Indian Medical Registry was established in the early 1930s when the IMC Act was passed. Every name that has ever been registered still exists, as it is not a live register and there is no mechanism for deleting deceased and non-practicing doctors. Although the original Act of 1933 was modified in 1956, the large number of subsequent amendments have not addressed the issues related to registration. There is an urgent need to introduce compulsory re-registration (with or without CME credits) and bring a ‘dead’ register to ‘life’. Attempts to do this by State Medical Councils have met with great opposition, and has been successfully introduced only in Delhi and Maharashtra. So all in all, the actual figure may lie some where between 5.5 lacs(the XII Plan document) and the 8.32 lacs in the official register. Which ever it is, we are far from the desired numbers!!

The other major flaw in the Register is, that it is not essential for doctors to register post-graduate qualifications. So there is no way of knowing, how many specialists of any kind there are – all the figures that are floated around are at best educated guesses. This also has legal implications, as technically an MBBS doctor cannot be faulted for performing any specialized procedure!

And finally, what does the ‘x per 1000 population’ figure mean, except as a piece of statistics? If one looks into the geographical distribution, the disparities in supply are even more glaring. And this does not take into account the rapid decline in training standards which produce paper  qualified but incompetent doctors. There are many hundreds of thousands of our countrymen who will not meet a doctor in their entire life.

Just imagine that by 2025 if we are to be a country of 1.4 billion people, we would need 23 lac doctors to attain 1 per 600 WHO norm!! And 14 lacs to get to 1 per 1000. These are totally unachievable targets. And so we need to discuss this – work out long term strategies, develop alternative health care delivery systems, invest on the non-allopathic medical work force – in other words, do whatever needs to be done to ensure that all of  populations gets medical services. This dialogue should ideally be initiated within the medical fraternity, which occupies the premium position in the health system hierarchy. However, that is unlikely to happen, except in rare instances, as the medical profession has become insular and self-serving.

So, the annual call for increase in medical seats will continue, the media will highlight an occasional sensational case of misconduct or admission misdeed here or there, more young minds will be lured into the ‘charm’ of being a doctor. Ultimaltely, how many will be enough? If only we could stop and reflect…….

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