Sunday, May 20, 2007

Medical Education in Maharashtra - 1

Creating a robust Medical Education is a strategic imperative for India – healthcare is a critical sector of the economy in any nation. In a growing nation like India – with an absolute deficit of doctors, -- establishing a robust "pipeline" of medical talent is a critical element of development. After all, you cannot create economic surplus if you're sick.

Stewards of state are therefore expected to create an environment where talent is allowed to nurture and bloom.

Sadly, stewards of state in India -- and in Maharashtra in particular -- have done exceedingly well at destroying talent by establishing a deadening centralised license raj.

This is the story of what has happened in Maharashtra -- and what to expect as a result.

To begin with, starting a medical college in India is tough. You have to jump through multiple governmental hoops to get a green signal: from the number of beds you have/need, to the sizes of lecture rooms... even the fees you can charge!

However, the government worries very little about what quality of doctors you produce (in stark contrast, virtually all nations tightly regulate the quality of doctors produced; important, since a drop in educational standards can directly cost human lives).

As a result, many freshly graduated doctors in India are, to put it midly, incompetent. I had colleagues in my class who could not read a chest X-ray. This in a country where the first, second and third diagnosis for chronic cough is tuberculosis, tuberculosis and tuberculosis.

As a result, even after nearly 6 years of schooling, employment opportunities for a Doctor are slim (in stark contrast to graduates from engineering or management colleges).

No one comes to medical schools in India to recruit the next generation of Naresh Trehans or Nitu Mandkes: the cost associated with separating the wheat from the chaff is just not worth it. The best hospitals, in fact, simply do not entertain candidates until they earn credentials overseas – a simpler way (but more effective, at least from the Hospital’s perspective) of ensuring quality of supply.

Despite these flaws, the system was getting by: many doctors were starting out on their own, others were earning overseas qualifications and either returning or emigrating.

Somewhat predictably, the Maharashtra government began facing a crippling shortage of medical officers -- particularly in her rural areas.

Instead of freeing up the supply of doctors to address this shortage, the Government actually strengthened its stranglehold over supply and brough every aspect of medical education under direct governmental control.

All students were forced into mandatory rural service (girls from my class have served their bonds in Gadchiroli – a naxal infested area). Bonds were signed to make sure no student ‘slipped the dragnet’. Since the government could not "afford" to pay her resident doctors (doctors in teaching hospitals working to earn their MD/MS degrees), salaries were reduced. In fact, several resident doctors working to earn their DNB, do so gratis! Imagine a 27 year, unpaid neurosurgery resident!

Education delivery was next. Medicine programs that had run for perhaps longer than a 100 years at Mumbai and Pune University (among others) were dismantled and centralised to a no-name university operating out of a shed in Nasik. Centralised because the state found it easier to control one puppet university, Nasik because that was the health minister’s constituency.

To complete the picture, private medical schools in Maharasthra were also told by the government whom they must admit and what fees to charge!

As respected programs were demolished and replaced with an unknown and unwanted one, examination standards dropped; the new degree was even invalid internationally for several years. Doctors’ employability levels dropped further.

The result has been predictable. Lines to join medical school have been getting thinner. Growth in seats has stalled -- not one medical seat has been added in Mumbai in the past decade. Those already stuck in the system are leaving: fully half my graduating class has either migrated overseas, moved out of the clinical sciences or both.

Over a short span of ten years, vibrancy in medical education in Maharashtra was decimated, replaced by a deadening License Raj. A Raj of unmet demand, insufficient supply and poor quality.

But the divine law of supply and demand -- hated by the dirigiste state -- has caught up with Maharashtra. Over the next 20 years, Maharashtra will face a catastrophic shortage of medical doctors. This shortage will hit where it hurts most: public healthcare.

This catastrophe will not be easy to fix: it takes years to create a medical college of any standing (infrastructure, teachers, a working hospital) and nearly a decade to make a doctor (longer, if you include complex specialities).

By acting cynically to perpetuate their personal control over the sector, Maharashtra’s political leaders have virtually wiped out an entire generation of physicians, exposing her citizens to medical risk of institutional proportions.

They must be tried for criminal malpractice.

And yet, it is possible for Maharashtra to reverse the decay; i shall cover the topic in a separate post.


Varishna said...

Hi Adheetam, interesting piece. Especially since the best doctors in the US...are Indian. How can that be explained? Have they studied overseas?

Looking forward to your bit on the possible solutions. Take care, V.

iamfordemocracy said...

The link from Rajeev2004 blog took me here. I would just like to add one bit. Loads of money offered to Siddhivinayaka temple have provided the seed capital for many of those private colleges that will ultimately paralyse and maim the Hindu society.

Soniya said...

Great analysis Adheet. Please also comment on how the reservation policy further cripples the system. Also, i am not sure if this is such a bad thing: "You have to jump through multiple governmental hoops to get a green signal: from the number of beds you have/need, to the sizes of lecture rooms... even the fees you can charge!"
I know private college that paid people to be "patients" for a few hours and lie in their rented hospital beds when it was inspection time. On the one hand we want to increase accountability of private institutions, and on the other we don't want government regulations. What it a better way to do this?

Ekal Bangalore said...

I am from Karnataka. Some years ago the govt gave license for a large number of medical colleges. People cribbed that the standard would come down. But looking back the good thing was that market forces took over and all the bad colleges were forced to close down as students didnt go to them. Now only the good ones are still standing. So I guess the best solution is for the govt to deregulate the higher education and give it an industry status and encourage Pvt growth like in the US. Lets face it.. higher education is expensive.

Mukul said...
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