Last month, tragedy struck Bhargavi and Laisan Kanhar in Sambalpur district of Odisha. The tribal couple’s only child Banita who was in Class III fell into a hot egg curry cauldron at her school in Girischandrapur village while she waited for the midday meal.

The eight-year-old suffered severe burns and was rushed to the nearby primary health centre (PHC), where the only doctor was absent. The hospital staff applied first aid and referred her to the VSS Medical College and Hospital at Burla. However, there was no ambulance to take her to the hospital 72 km away. She finally reached there in a private vehicle nearly four hours after the accident. The same evening, she was again referred to the SCB Medical College and Hospital in Cuttack, nearly 300 km away. By next morning, Banita was declared dead at the hospital in Cuttack.

The killer void – Vacant posts of doctors in PHCs and CHCs in 2012

In July, Delhi-based freelance filmmaker Anand Bhaskar met a similar fate despite being in the heart of the national capital. By the time he was rushed to Safdarjung Hospital, via a trip to the All India Institute of Medical Sciences (AIIMS), it was too late to save the 33-year-old who was electrocuted. He was not living in some back-of-beyond Odisha village, but in tony South Delhi.

For both, scarcity of doctors was an issue. Their lives couldn’t be saved because they could not get the right treatment at the right time. Healthcare in India, whether it is in the country’s capital or in the boondocks, is a nightmare. In fact, sufferers would say nightmare is an understatement.

There is only one doctor per 1,700 citizens in India; the World Health Organisation (WHO) stipulates a minimum ratio of 1:1,000. While the Union Health Ministry figures claim that there are about 6-6.5 lakh doctors available, India would need about four lakh more by 2020—50,000 for PHCs; 0.8 lakh for community health centres (CHC); 1.1 lakh for 5,642 sub-centres and another 0.5 lakh for medical college hospitals. By any reckoning, it’s a tall order, admits Union Health Minister Ghulam Nabi Azad.

THE RURAL RELUCTANCE

If shortage of doctors is one problem, their unwillingness to work in the rural hinterland is another, creating artificial scarcity in the area and high concentration in another, admit Union health ministry officials.

One of the first things that Azad tried to do after taking over as health minister was making rural posting for all government medical college pass-outs compulsory. But he failed to get the order implemented.

“Despite the efforts of the government and incentives offered, medical students or doctors are not showing interest in working in rural areas. I wonder what is wrong with the doctor fraternity,” says Azad, implying that it’s no longer a “service” but a “profession”.

But the doctors are not to blame either. Surveys of rural healthcare facilities have revealed poor infrastructure, non-availability of medicines, equipment and even the basics.

When asked about the doctors’ reluctance to serve in rural areas of Andhra Pradesh, Dr Abhilash, former president of Andhra Pradesh Junior Doctors Association (APJUDA), says a doctor, who has specialised in a particular medical field like cardiac or neuro, cannot be expected to treat normal medical cases, which is best left for MBBS doctors. “We are not saying we won’t serve in rural areas, but before asking us to serve there, government should ensure there is necessary infrastructure in place.”

Though the Andhra government had introduced compulsory rural service for PG doctors on completion of the course, APJUDA insists that the rule be uniform for all, as some private medical college students have gone legal to get exemption. Further, the bond of `20 lakh that a PG doctor has to sign is also being opposed.

In rural areas and semi-urban areas of the state, there is scarcity of doctors and specialists besides an acute shortage of well-trained paramedical staff, including nurses. In 1,709 PHCs and 186 CHCs in Andhra, there were 140 band 322 vacancies respectively.

The government admits the grim picture in the rural areas, despite the success of the National Rural Health Mission (NRHM). Shortage of human resources is a distressing feature of India’s healthcare services. Even the Planning Commission has conceded that availability of healthcare services is quantitatively inadequate.

The death of Rehima Bibi in Odisha’s Balasore district sums up how shortage of doctors takes its toll even in district headquarters. On June 2, Rehima was admitted to the district headquarters hospital (DHH) with complaints of acute diarrhoea. By evening, her condition began to worsen. The nurse on duty rushed an SOS call to the doctor on emergency duty but he did not turn up. And when he eventually did, the woman had already succumbed. 

Gopinath Parida, the doctor on duty, put forth his predicament: “I was the only doctor on evening duty and had to attend to nearly 100 patients. Still, I went to attend to Rehima. She was suffering from very serious complications and also renal failure for which she could not survive.”

Earlier last year, another woman from the same district almost lost her life soon after giving birth at a community health centre in Soro. With no obstetrician available at the CHC, a nurse conducted the delivery and in the process had allegedly cut the urinary tract of Jafiran Bibi and left it unstitched. The woman from a very poor family had to undergo a second operation to save her life.

Cases like this abound as the healthcare sector grapples with an acute shortage of doctors in the hospitals across Odisha. The state, apart from the three government medical college and hospitals, has around 1,162 PHCs, 351 CHCs, 324 area hospitals, 30 DHHs, 26 sub-divisional hospitals and two apex hospitals, one each in Bhubaneswar and Rourkela.

According to the Health and Family Welfare Department, more than 20 per cent of the posts of specialists and assistant surgeons in the peripheral hospitals from the PHCs, CHCs to the DHH level are lying vacant. Of the total 4,362 posts in the peripheral cadre for the primary and secondary level healthcare institutions, as many as 1,090 are vacant.

• There is only one doctor per 1,700 citizens in India; the World Health Organisation stipulates a minimum ratio of 1:1,000.

 

• There are 387 medical colleges in the country—181 in government and 206 in private sector. India produces 30,000 doctors, 18,000 specialists, 30,000 AYUSH graduates, 54,000 nurses, 15,000 ANMs and 36,000 pharmacists annually.

 

• Health ministry claims that there are about 6-6.5 lakh doctors available. But India would need about four lakh more by 2020 to maintain the required ratio of one doctor per 1,000 people.

Worse still, many doctors posted in the hospitals in the rural areas remain absent for long periods. And in the absence of doctors, patients visiting the healthcare centres are treated by stand-ins—pharmacists and even nurses.

The situation in the medical college hospitals is equally grim. Though the SCB Medical College and Hospital at Cuttack is better off, the two others—VSSMCH at Burla and the MKCGMCH at Berhampur—are beset with shortage of doctors at all levels.

While the shortage is attributed to low production of medical professionals in the state, with only six medical colleges till last year, there is a deep disinclination among the graduates to serve in rural areas even though they have to sign bonds with the government for mandatory three years service in the peripheral institutions.

Karnataka, however, produces 1,200-1,300 MBBS doctors every year. But they refuse to serve in rural areas. While more than 30 per cent of the posts for general physicians and primary caregivers are vacant in PHCs, CHCs and sub-centres across the state, the vacancies are as much as 65 per cent when it comes to specialists and super specialists, says Sharanaprakash P Patil, Minister of Medical Education. According to the state health department, 1,148 posts for specialist doctors and 2,727 posts for doctors in state hospitals are lying vacant.

“The issue is really serious as doctors are not willing to work in rural areas. There is no legislation in place to make it compulsory for them to work there. Last year, 90 per cent of the students who passed out bought their way out of the rural service,” he adds, referring to the penalty of `1 lakh for MBBS students and `5 lakh for postgraduates.

State Health Minister U T Khader recently announced in the Assembly that the penalty has been revised. He told The Sunday Standard that the MBBS doctors will now have to pay `10 lakh and postgraduates `25 lakh if they decide not to practice in rural areas for a stipulated period of time. “The decision is pending with the Central Government. Once the rule comes into place, students will have no choice but to work in rural areas,” he adds.

The decision seems to be a far cry considering the speed of our delivery. But the immediate fallout is alarming.

In Dakshina Kannada district, Yashoda, 23, who is suffering from a neurological disorder, attempts suicide if the monthly appointment with her psychiatrist is skipped even by a day. Imagine the ordeal the family undergoes in case the doctor is absent.

If 18-year-old M V Subrahmanya does not receive his psychiatric medication on time, he grows restless. If not engaged in some activity he explodes into a boiling rage and leaves a trail of destruction at his home. His father Mayya says while staring blankly at his son in his house in Hoovina Koppala near Kokkada in Dakshina Kannada. 

The nearest PHC in Kokkada does not have a psychiatrist, neither it stocks psychiatric drugs. Like Kunha Mugera, Yashoda’s father, nearly 60 to 70 people change buses to consult private psychiatrists in Puttur. Even the district’s 160-year-old hospital does not have specialist doctors to deal with crippling deformities seen in 439 endosulfan sufferers in Kokkada.

In a country where pizza reaches home before an ambulance, Nedungulam panchayat of Tamil Nadu is no exception. Nedungulam, under Vilathikulam Taluk, 50 km north of Thoothukudi, has nearly 7,000 inhabitants.

Leave aside doctors and hospital, the 108 emergency ambulance service takes nearly 75 minutes to reach the village, allege villagers. In the absence of basic healthcare facilities, people travel at least 20 km to reach the nearest PHC at Vembar. According to villagers, many lives could have been saved had there been minimum healthcare facilities in the panchayat. Even basic drugs like paracetamol are not available there.

Dr Bosko Raja, Deputy Director (Health), Kovilpatti Division, however, cites the norm of a population of 30,000 or more for setting up a PHC.

At the start of 11th Plan, the number of doctors per lakh population in the country was only 45, whereas the desirable number is 85 per lakh population. As per rural health statistics 2012, there were 1,48,366 sub-centres, 24,049 PHCs and 4,833 CHCs functioning in the country. Forget about sub-centres, doctors are not available even in CHCs.

Compared to requirement for existing infrastructure, there was a shortfall of 74.9 per cent of surgeons, 65.1 per cent of obstetricians and gynaecologists, 79.6 per cent of physicians and 79.8 per cent of paediatricians. Overall, there was a shortfall of 69.7 per cent specialists at the CHCs.

THE PATIENT RUSH

A trip to AIIMS in the national capital—the country’s top most referral hospital—at emergency hour could be heart-wrenching, if not scary. According to official data, around 7,000 patients visit the OPD everyday from various states and the number of serious cases has to be added. In the year 2008-09, the number of new cancer patients coming from Uttar Pradesh and Bihar stood at 2,403 and 1,072 which has now gone up to 2,666 and 1,243, respectively.

Little wonder that people in India now prefer to mortgage their land and gold to avail healthcare in the private sector. With the Government spending on healthcare woefully inadequate, there’s been a mushrooming of private sector hospitals, mostly high-end. It has not only put pressure on the common man’s medical healthcare bill, but also strained the supply of doctors. There’s a continuous flight of doctors to these better-paid and better-equipped private healthcare domains. This has led the private hospitals to cash in on the abysmal government health infrastructure.

In Andhra Pradesh, patients are often shifted to private hospitals from the government hospitals, though there is no necessity for it; ironically, this is justified by the government doctors. Some of them very often refer the cases to their own clinics to make money.

The condition is no different in neighbouring Odisha. The proliferation of private hospitals and nursing homes has, in fact, posed a major challenge for the government. With no restrictions on private practice, government doctors are being engaged by private hospitals as consultants. In the process, the government doctors posted in the rural areas, who also are consultants with private hospitals in towns and cities, are resorting to blatant absenteeism.

A worried state government has now decided to take drastic action against the delinquent doctors. “Instructions will soon be issued to all private hospitals and medical colleges to appoint doctors as consultants or faculty members on the basis of no objection certificate from the government. They will be subjected to scrutiny and any violations will be judged seriously,” state Health Secretary P K Mohapatra says.

FLIGHT OF RESOURCES

Today, India has the highest number of medical colleges in the world. This unprecedented growth has occurred in the past two decades in response to increasing health needs.

There are 387 medical colleges—181 in government and 206 in private sector. India produces 30,000 doctors, 18,000 specialists, 30,000 AYUSH graduates, 54,000 nurses, 15,000 ANMs and 36,000 pharmacists annually. According to Medical Council of India (MCI) data, 31,866 new MBBS doctors were registered during the year 2009-2010 and 34,595 students were admitted in 300 colleges for the academic year 2009-2010.

The number of allopathic doctors registered with the MCI has increased progressively since 1974, to 6.12 lakhs in 2011—which yields an adjusted ratio of one doctor for 1,953 persons.

The shortage of doctors in government hospitals is also attributed to the factors such as preference to work in private hospitals, and study and work abroad.

According to Union health ministry data, the present doctor-population ratio is 0.5 per 1,000 and the target by 2025 is 0.8 per 1,000. In the current scenario of doctor-population ratio, the number of doctors required in the rural areas was enormous and target of one-doctor-for-1,000 population cannot be met before 2020. After detailed inputs from various working groups, the MCI came to a consensus that the targeted doctor-population ratio of 1: 1000 would be achievable by the year 2031. According to the 12th Plan document, 6,91,633 physicians are available during the 11th Plan and expected availability for the 12th Plan by 2017 is 8,48,616 at annual capacity of 42,570 doctors.

Ironically, cellphone reaches the tribals in Tamil Nadu’s hills, but not healthcare. At 1,800 metres in Siraikkadu forest of Western Ghats, mobile phones ring loud in the serene atmosphere but lack of access to healthcare facilities are taking a toll on the health of the inhabitants there. 

The worst-affected are women and children; most of them suffer from anaemia. Five-hundred metres down the hill, women of the 40 tribal families residing in the houses provided by the government also suffer from anaemia.

The tribal hamlet has no transport facilities. In case of any health emergency, the people need to walk at least eight km to reach the nearby government hospital in Bodinayakanur. “Even in the government hospital, only if we go before 11 pm, the doctors would treat us,” said women.

The situation is even worse in Kurangani village and Bodimettu, a hilly area where the government health sub-centre remained close for more than a year. “Our five tribal hamlets depend on this health centre for treatment, but nurses come here rarely,” bemoans women in Kurangani.

“We don’t even have a chemist shop here. The government hospital in Bodinayakanur is located nearly 25 km downhill,” says Ramar (35), a daily-wager. According to hospital sources, of the total 16 doctors, only nine were working at present.

“The doctors are supposed to come at 7.30 am, but they all come only around 8.30 am. Moreover, they don’t stay till 12.30 pm,” say the hospital staff. Several doctors of the Bodinayakanur Government Hospital run their  private clinics.

RIGHT PRESCRIPTION

Faced with huge supply and demand gaps in the availability of basic health human resources, the Union health ministry did initiate several reforms. In just over four years, the availability of MBBS seats has gone up from 33,567 to 45,629. Similarly, the number of PG seats has increased from 13,838 to 22,850. The medical colleges at the six new AIIMS have started functioning with admission of 50 students each and hospitals are going to be made functional this year. In order to strengthen tertiary healthcare delivery in the government sector, the health ministry also took up 19 state government-owned medical colleges for upgradation under the Pradhan Mantri Swasthya Surakasha Yojana.

To incentivise doctors for rural postings, the health ministry said that 50 per cent of seats in PG courses would be reserved for government medical officers who have served in designated rural areas for three consecutive years and a weightage of 10 per cent marks given for each year of rural posting for national entrance examinations to the postgraduate courses. However, the response was not encouraging for doctors.

Health ministry officials point out that based on 2001 Census adjusted for only qualified personnel, India has about 62 doctors, nurses or midwives per 1,00,000 today, and of these about 38 are doctors and 24 are nurses and nurse-midwives. In order to reach the international norm, we would, at the very least, require six lakh additional doctors and 12 lakh additional nurses.

Joint Secretary in the health ministry Vishwas Mehta says, “We need huge number of doctors. Even if we are able to manage them in place, doctors will not work in rural areas. So we need to have mid-level healthcare professionals between Accredited Social Health Activist (ASHA) and doctor. There are already seven lakh ASHAs working in rural areas. That’s why we are going ahead with the introduction of BSc (Community Health) courses soon.”

Currently 1.4 lakh sub-centres are being manned by ANMs designated with the functions of prenatal and antenatal care; educating the mothers about basic child healthcare etc. The proposed scheme of BSc (Community Health), which is also called the Bachelor of Rural Health Care (BRHC), is under discussion by the ministry for the last three years and already got the support from the state governments and the Planning Commission.

Prof  K Srinath Reddy, President, Public Health Foundation of India, said that the positioning of well-trained mid-level healthcare providers (MHPs) in the health system to provide essential primary healthcare to underserved populations was now a growing trend, especially in Africa and Asia but also seen in some developed countries. In India, there was need for MHPs to strengthen primary healthcare in both rural and urban areas.

In fact, Assam has a three-year course to train a Rural Medical Practitioner for primary healthcare; the Assam Rural Health Authority Act governs this arrangement. Chhattisgarh had begun, and given up, a similar programme but over 950 Rural Health Assistants with such qualifications have been employed by the state government. West Bengal has begun the training of nurse-practitioners.

Maintaining that lack of doctors and trained specialists, even nurses, is a huge problem, Mission Director of NRHM in Assam Prateek Hajela said the  Assam government had introduced The Assam Rural Health Regulatory Authority Act, 2004 to provide for establishment of Assam Rural Health Regulatory Authority to regulate academic activities for imparting medical education and training at government as well as private sector.

Jharkhand Principal Secretary Health K Vidyasagar says, “There are no short-term solutions to meet the immediate shortage of doctors. However, to meet the challenge, the first step we have taken is to increase the age of retirement to 65 years for all doctors, teaching and non-teaching. We are making efforts to increase the number of MBBS seats in the medical colleges and planning to set up new colleges in 300-bed divisional-level hospitals.”

THE KERALA MODEL

In a country of pathetic healthcare facilities, Kerala shows the way. The state has the best coverage of medical care facilities in the rural sector. Even the remotest places and tribal hamlets have access to basic medical facilities, which makes the state different.

In the state, the doctor-patient ratio of 1:700 is on par with most of the European countries. Indian Medical Association, Kerala, secretary Dr A V Jayakrishnan said there was no need to worry about the manpower. “Doctors are even available in the tribal areas,” he says, adding that some doctors were reluctant to move to the rural areas. “It is not because the doctors are not willing to serve in rural areas. But it is only because of the want of basic facilities and amenities,” he says.

Jayakrishnan also claims that there are no vacancies for doctors both in the government and private sector. “Recently when applications were invited for 800 vacancies, about 5,000 candidates had applied for the post. But we have a shortage of specialist doctors in the state,” he says.

Kerala Government Medical Officers’ Association president O S Syam Sundar says though the state had the best medical facilities when compared to others, some issues were yet to be addressed. “All the panchayats have at least one PHC. But we have not increased the PHC with the increase in population. The main issue is that a single doctor might have to look after a larger population. There should be a scientific staff structure,” he says. In certain remote areas in Wayanad, Idukki and Kasaragod, the issue of non-availability of doctors can be seen, Dr Sundar says. This was only because the government has not addressed some of the genuine issues of the doctors working in the rural areas.

As an HRD ministry report says, there would have been fewer casualties in the Bihar midday meal tragedy, had the children been provided treatment on time. The hospital where the children were taken to—after consuming poisoned food in Dharmasati village, Saran district, on July 16—did not have even rudimentary facilities.

When the condition of the children deteriorated, parents and relatives desperately tried to move them to the district’s Sadar hospital but no ambulances were available. It took almost four hours to reach the hospital after snagging some private vehicles; meanwhile, more children died.

The situation in Sadar hospital was so bad that children continued to die. It was late in the night that the district administration decided to shift the affected children to Patna Medical College Hospital. Four died on the way. Life is so cheap here.