Guest Blog: Medical education and shortage of doctors in India-Dr Akshay Badakare, LVPEI

For all the progress, we have made as a country, medical education and availability of doctors for the increasing population has a gap that is struggling to be bridged. With roughly 80% of our population being in rural areas, less than 1/3 rd of the country's health force is available in rural areas. The skill gap is so vast that we are below what the World Health Organisation (WHO) defines as low doctor to patient ratio (low being 1 doctor per 1000
population).

Where does the problem lie?

It is a situation that has issues at multiple levels. Availability of quality medical and postgraduate medical education seats, distribution of medical resources, varying quality of medical education across the country, brain-drain are just some of them.

Every year India produces nearly 80,000 doctors (post MBBS). Majority of these doctors aim for acquiring a post-graduate seat in a specialization of their choice. Postgraduate seats pre- NEET (National Eligibility cum Entrance Test) era, was about 7000 per session. The discrepancy stands out. NEET has to some extent reduced this discrepancy since it includes not only those 7000 seats available through All India entrance exam but also other private colleges and Institutes which offer DNB courses. But simply increasing the seats available isn't the solution since new challenges comes up with varying training standards across the country in medical institutions. While there are some shining examples of institutions which offer robust training programs which would mean an ideal combination of clinical acumen, surgical training, and research there are those at the opposite end of the spectrum where a resident feels he or she has merely spent 3 years in post-graduation without acquiring any
of the above-mentioned skills.

To bring uniformity in medical education, there must be changes made right from how candidates gain entry into postgraduate courses to how they are trained during their 3-year, period. Currently, aspiring postgraduate students need to answer multiple-choice questions (MCQ) and are ranked by this. There is no way this alone can be used since the aptitude, the attitude and willingness to learn cannot be gauged by MCQs alone.

The training program should follow guidelines like those laid down by the ICO (International Council of Ophthalmology) which break down goals for each year of training. If guidelines like these are followed, there can be uniformity in the training curriculum, no means perfect but can definitely improve the current situation. Regular training programs for teachers in the form of refresher courses, credit points for attending and participating in teaching programs are important. Technology can play a role too. There are plenty of online learning platforms
where one can refine knowledge that can aid teaching skills.

Dr. Chua's website in ophthalmology is one such website. Telemedicine can play a vital role so can webcasting of teaching sessions from some of the premier institutions. Webcasting of teaching programs is one way to dispense knowledge to a large gathering and it does not require physical presence hence can be a convenient method to teach.

While these are ways to improve standards of medical education, what can be done about the shortage of medical personnel in rural areas? If we analyze India's rural health care set up, it is a tiered set up with primary health care centres (PHC), a secondary care centre or district hospital and a community health care centre (CHC). There is a common perception that doctors from cities or those educated in institutions in cities are more prone towards
postgraduate specialized practice rather than work in rural areas.

While this misconception is not entirely untrue, the doctors are often left to man centres ill-equipped and under-
staffed. Some states in India have made a rural posting mandatory and have attached incentives to a rural posting with regards to postgraduate seats but still the problem persists.

What can be done?

Do not make it mandatory, instead, have rural postings incorporated in late part of an internship in MBBS and latter half of post-graduation where a doctor would juggle between PHCs and CHCs for a fixed period and he or she can then be given a choice of practising in a PHC or CHC. The bureaucracy from their side must ensure that these centers are well funded and well equipped. This would be added motivation for doctors. Ensuring that rotations like this are done by not just Government institutions alone but also private colleges and Institutes will retain continuity and will ensure there is no shortage.

Promoting good quality medical education at both the MBBS and postgraduate level and enabling (and not forcing) young doctors to work in rural India, has benefits like making care accessible, equitable, safe, patient-centred, timely and effective. Incidentally, these happen to be the six requisites that need to be followed to ensure good quality health care. Education and empowering our young doctors are the first step.