Medical Manpower in India: An Overview

 

 

Kasturi Mandal

 

 

Medical education occupies a crucial position as it involves a close and deep study of life itself and its vital processes. In India, there is a growing awareness of the role of health development as a vital component of socio-economic development. Various committees of experts like the Bhore Committee (1946), Mudaliar Committee (1962), Chadah Committee (1963), Mukherjee Committee, (1965 &1966), Jungalwalla Committee (1967), Kartar Singh Committee (1973), Shrivastav Committee, (1975) have been appointed by the Government of India from time to time to render advice on different health problems. The reports of these committees have formed an important basis for health planning in India. An “Expert Committee for Health Manpower Planning, Production and Management” was constituted in 1985 under Dr. J.S. Bajaj, then professor at AIIMS. Major recommendations of this committee were:-

The Indian medical education sector is broadly classified into:

 

1.   The modern system of medicine [allopathy, or non-Indian system of medicine (NISM)]

2.   Indian systems of medicine and homeopathy (ISMH) that include Ayurveda, Unani, Siddha and homeopathy.

 

 

 

Fig1. State-wise Enrolment (in numbers) of Students, in Medical Education (Medicine, Dentistry, Nursing, Pharmacy, Ayurvedic, Unani and Homeopathy), in India over the years.

Source: Ministry of Human Resource Development, Govt of India

.

The governance of Medical Education in India is routed through various councils in respective systems. Every year the respective councils primarily monitor and timely inspect all universities or colleges that give medical education. They allow colleges or universities to grant various degree or diploma provided they are strictly adhering to the standards set by the respective councils. In a nutshell the councils prescribe and recognize all standards of education in Modern and Indian Systems of Medicine. Fig 2 gives a snapshot of the existing structure of governance in medical education respectively. All these councils are autonomous bodies under the Ministry of Health and Family Welfare

 

 

Fig 2: Schematic representation of respective councils governing  Medical Education in India

 

NISM training for doctors in India is provided at several levels. The undergraduate degree, referred to as MBBS (Bachelor of Medicine and Bachelor of Surgery), provides basic training in clinical medicine over 5.5 years. The MBBS course is of four and a half years and is followed by one year of Compulsory Rotating Residential Internship. The course is offered in three phases, with a short foundation course which introduces the basic principles of Communication, Ethics and Problem Based Learning. The first phase is for 12 months and covers the basics of Anatomy, Physiology and Biochemistry. The following phase is for 18 months and covers Pharmacology, Pathology, Microbiology and Forensic Medicine.The last phase is for 24 months and covers Ophthalmology, Otorhinolaryngology, Community Medicine, General Medicine, Pediatrics, Surgery, Orthopedic Surgery and Obstetrics & Gynecology. Post-graduate training includes 3-year residency programmes and diploma training programmes. M.D. (Doctor of Medicine) and M.S. (Master of Surgery) are 3-year postgraduate degree programs in medicine and surgery respectively. Doctors possessing M.B.B.S. degree are eligible for these courses. There are super-specialty residency programmes for those completing postgraduate education. D.M. and M.Ch. are super-specialty programs in medicine. These programs duration vary from 2 to 3 years. Doctors possessing M.D. or M.S. degrees are eligible for the courses. Figure 3 provides a state-wise distribution of medical colleges and their annual intake in 2008.

 

 

 

Fig 3: State-wise distribution of Medical colleges  and their annual intake in 2008

Source:  http://www.mciindia.org/apps/search/show_colleges.asp

 

Dental Education in India starts with the Bachelor of Dental Surgery (BDS) which is a four year course with one year of compulsory rotary internship, thus making it a five year course. Post Graduate training includes Master of Dental Surgery (MDS). In India, there are 215 dental colleges offering BDS and 121 dental colleges offering MDS. Figure 4 gives an indication of the number of colleges offering BDS and MDS courses in India in 2007.

 

 

Fig 4: Share of Public and Private dental colleges offering BDS and MDS course in India in 2007

Source: http://www.dciindia.org/search.aspx

 

 

Table 1 , figure 5 and 6 gives an idea of nursing education; the various nursing and midwifery programs, number of institutes offering such programs in India, trend of PhD student registration in Nursing over the last three years

 

Table 1: Nursing and Mid-Wifery Programs

Program

Entry Requirement

Training

Duration

Examination

ANM

10 years

1½ years 

State nursing council/ DME

GNM

10+2 (arts or science)

3½ years

State nursing council/State examination board/DME

B. Sc (Basic)

10+2 (science)

4 years

University

B. Sc (Post Basic)

10+2,

2 years (regular)

University

GNMs

3 years (Distance)

M. Sc.

B. Sc

2 years

University

2 years experience

M. Phil

M. Sc.

1 year (Full time)

University

2years (part time)

Ph D

M. Sc./ M. Phil

3-5 years

University

Post-Basic Diploma Course

RN & RM

One Year

Council or

University

 

 

 

Fig 5: Number of Institutes offering the respective nursing programs in India in 2008, ANM: Auxiliary Nurse and Midwife, GNM: General Nursing and Midwifery, PB B.Sc.: Post Basic B.Sc

Source:http://www.indiannursingcouncil.org/Recognized-Nursing-Institution.asp

 

 

 

 

Fig 6: Trend of PhD student registration in Nursing over the last three years

Source: http://www.indiannursingcounil.org/phd-research-praposal-students.aspc

 

Indian systems of medicine and homeopathy (ISMH) that include Ayurveda, Unani, Siddha and homeopathy is provided by offering degrees like B. A. M. S. (Bachelor of Ayurvedic Medicine and Surgery) and B. H. M. S. (Bachelor of Homoeopathic Medicine & Surgery). The course duration is 5½ years including one year of compulsory internship. Post graduate courses include M.D. in Homeopathy. There are 98 ayurvedic colleges, 8 siddha colleges and 40 unani colleges in India offering different degree and diploma courses.

There was a National debate in 1983 on standards of Health Science Education.  It was resolved that there is a need to establish a separate Health Sciences Education Commission at National level at par with UGC and Unitary Health Sciences Universities in the States.

Accordingly, for the purposes of affiliating, teaching and ensuring proper and systematic instruction, training and research in Modern System of Medicine, Homoeopathic System of Medicine, Ayurvedic System of Medicine, Unani System of Medicine, Nursing Education, Pharmacy Education, Dental Education, Education on Laboratory Technology, Physiotherapy, Speech Therapy and Education on other paramedical courses several Universities of Health Sciences have come into existence since 1986 in different states of India. Attached in annexure is a list of Universities of Health Sciences with their year of inception.

 

Table 2: List of Universities of Health Sciences established in India over the years

Name of the University

State

Year of Inception

NTR University of Health Sciences

Andhra Pradesh

1986

Rajiv Gandhi University of Health Sciences

Karnataka

1994

MGR University of Health Sciences

Tamil Nadu

1997

Baba Farid University of Health Sciences

Punjab

1998

Maharashtra University of Health Sciences

Maharashtra

1998

West Bengal University of Health Sciences

West Bengal

2003

Rajasthan University of Health Sciences

Rajasthan

2005

Source: Websites of State Government

 

The universities take up the responsibility of undergraduate, postgraduate and post-doctoral courses including the Ph. D. programme in Modern System of Medicine, Homoeopathic System of Medicine, Ayurvedic System of Medicine, Unani System of Medicine, Nursing Education, Pharmacy Education, Dental Education, Physiotherapy, Speech Therapy and Education on other paramedical courses like Occupational Therapy and Prosthetics-Orthotics in the states.

Such universities hope to foster and develop an intellectual climate conducive to the pursuit of excellence, either independently or jointly with other centres of excellence of higher learning.

In recent years, India has been through an expansion in the number of medical colleges due to the growth of private colleges.  India, with a population in excess of 1.1 billion, has the largest number of medical schools within one country (274), with an admission capacity in undergraduate medical courses (MBBS) measuring 31,298 per year. In 1980, there were 112 medical schools in India, whereas in 1994–95 there were 152, admitting 12,249 students. Figures 7 and 8 are indicative of the fact.

 

 

 

Fig 7: Percentage share of public and private medical colleges offering M.B.B.S courses in India in 2008

Source: http://www.mciindia.org/apps/searchow_c/sholleges.asp

 

 

 

Fig 8: Trend of introduction of new medical colleges since 1998

Source: http://www.mciindia.org/apps/search/show_colleges.asp

 

Changes have been brought though not very speedily and effectively, as the main concern seem to be to make quantitative changes. There is a ten fold increase in the number of medical colleges and the output of doctors, resulting in a large number of specialists and an equally impressive number of super-specialists. This has been largely unplanned and has only resulted in a marked increase in output without any thought for finding rewarding careers for them. This leads to frustration and thus the westward flood. The promotion of medical colleges in the smaller cities in the districts has not made much of an impact on the distribution of medical manpower. The products of these colleges are more hard-hit and the result is brain drain within the country. The overflow from the cities has always been to the west and now the flow is towards the African and Gulf countries. It is time we made a close study of this problem which is basically a study of manpower requirements.


We have tinkered long enough with the curriculum and contents of the course. But we have never considered the suitability of a single uniform course when it is known that the final evolution as a General Practitioner or a Specialist or a Scientist requires different courses at the undergraduate level itself. It is time to consider the feasibility of multi-channel courses to suit different groups. This would cover the big gap now seen between the undergraduate course and specialities.
Three such broad channels can be identified, say for a family doctor, the specialist and the health scientist. In this way, it may be possible to plan manpower supply to fulfil the needs of a region or a state (Deshpande, 1982).

There is a growing interaction of medical education with social sciences by introduction of Psychology and Psychiatry in teaching hospitals. The increasing use of sophisticated equipment has highlighted the need for close collaboration with engineering, electronic and computer sciences

In spite of all this change and expansion, we do find a lot of dissatisfaction expressed, both by the people and their representatives. The main criticism is that of neglect of rural and remote areas and overproduction of highly trained persons with no corresponding increase in gainful employment. There is a big gap in the distribution of health care personnel over rural and urban areas. And, equally important, there are serious questions about the training doctors receive in terms of its utility for different categories of diseases and, therefore, delivery to different categories of people.   Who’s World Health Report for 2006 shows there is a global shortage of health professionals. The greatest shortfall occurs in south and south-east Asia and India, Bangladesh and Indonesia top the list. The number of registered doctors in India has increased from 61,800 in 1951 to about 645,825 in 2005 — which is 0.60 doctors for 1,000 people. The Joint Learning Initiative, a global health network launched by the Rockefeller Foundation findings suggest that India has India has 0.59 doctors, 0.8 nurses and 0.47 midwives for 1,000 people, which adds up to 1.86 health workers for 1,000 people or if put in another way one doctor serves 1694 people, one nurse for 1250 people and one midwife for 2100 people. Tables on across-states distribution of government Doctors and Doctor-Population Ratio, Specialist doctors available in CHCs vis-à-vis doctors at PHCs, distribution of Paramedical Health Manpower working in rural areas in the section entitled ‘Science and Technology Mapping in States of India’in the theme on ‘S & T Structure, Infrastructure and Public Space’ can also be referred to for further details.

 

Apart from the fact that this figure falls considerably short of the desired figure, it also does not indicate the distribution of health professionals and does not, therefore, show how supply relates to demand. The statistics for the state sector reveals a pathetic scenario. According to the Union ministry of health and family welfare’s (mohfw’s) Health Information of India, 2004, the country had 67,576 government doctors: meaning one doctor was serving roughly 15,980 people.

The current availability of doctors does not meet the recommendations of several past committees. In 1946, a committee headed by Joseph Bhore, had suggested one doctor for 1,600 people; another committee in 1948 had recommended one doctor for 1,000; Research joint panel had recommended in 1980 that six general practitioners and three specialists should be available for 100,000 people. As far as specialists are concerned, the situation on the ground comes nowhere near meeting this figure. The government’s estimated requirement of specialist surgeons, obstetricians and gynaecologists, physicians and paediatricians in 2001 for community health centres in rural areas is 12,172, but only 6,617 positions have been sanctioned and 4,124 positions have been filled. An Escorts Heart Institute and Research Centre document prepared in 2005 said India would need at least one million more qualified nurses and 500,000 more doctors by 2012.

 

The root cause of our problem arises from a mistake. This was the blind imitation of the Western model, which perhaps suited the English situation. This obsession with the Western model and standards has made our products misfits in our own society and perhaps unwittingly promoted brain drain. The truth is that the medical graduate finds himself more at home outside the country than at home.

So, changes in the curriculum have to be brought about in a more rational way by assessing our own needs. Every country, and within each country, a geographical region has its own problems. In a way, the socio-economic groups, the rural-urban settings and other parameters differ from country to country and from state to state. There are broadly the medical needs of an individual and a community, and the mental health needs. The disease patterns and prevalence rates also determine the needs.

Changes and reorientation should be brought about to make the education relevant to the needs of the largest group. Proper vocational guidance should be made available to the medical graduate, so that reliable data and rationale thinking precede the choice of future career. Perhaps, we might even think of a larger share and inputs in public health so that such a career becomes attractive. To the traditional approach of how to provide clinical cure for individuals, we must provide and add care of well defined populations so that the medical student knows how to be useful to the community at large. 

Excellence in medical education should not mean merely vertical expansion and achievements. Maximum improvement of health and relief form suffering within available resources should be our goal. There is thus a clear need to set up innovative models and bring about qualitative changes.

 

 

 

References:

 

 

 

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