Who wants to become a doctor?
Evidently, not too many people, as this ToI report notes.

It takes ten years of sustained, punishing, high-risk training of the finest minds to make a trained specialist (obstetrician, surgeon, pathologist); fourteen if you want a 'super' specialist (cardiologist, brain surgeon). The results these days, despite the risk, can be quite impressive.
The only known 'de-risker' we know? The calibre and training of the mind-hand holding the scalpel.

About 15 years ago, Maharashtra created a new 'super-risk': a line of mantris and babus of the command-and-control dispensation, for whom doctors were slave labour.
Clever policies and incentives ensued: mandatory rural postings, endless exams, shifting universities, disappearance of teaching seats, and, of course, increasing reservations.

The finest minds have voted with their feet. Should we be surprised?

Medical Education in Maharashtra – 2

A path to resolution.

Now that the stewards of state (of “commanding heights” fame) have completely botched things, how do we reform? Where do we begin? What do we do?

To answer that question, it may be useful to remember the Cheshire Cat from Alice in Wonderland, “[what you need to do] depends a good deal on where you want to go.”

To understand what we need to do, we need to have a suitable vision of where we want to go. We may, for instance, want to “Establish a system to produce world-class physicians and health care leaders to meet Maharashtra’s and India’s demand for talent, while creating economic value via high-quality patient care, research and accelerated job creation.”

Translated into plain English, this means more and better hospitals -- say three times as many, with vastly improved teaching skills and capabilities that directly meet India’s healthcare needs.

It is tempting – but wrong – to conclude that all it will take is more money. If that were the case, the thousands of crores of taxpayer money the government has spent in shoring up Air India and Indian Airlines again and again would not have been as completely wasted as they have been.

No – it’s not more money that is required. What is required is an entirely new system for channelling cash, most of it from private pockets, to create an all new educational system.

There are three big changes the government must drive to make this happen:

1.Create competition in the delivery of medical education by liberalising norms governing setting up of medical institutions

The only way we can have more medical schools is, well, by allowing more people to start medical schools.

Transparent, simple yet stringent norms should be established – and anyone meeting those norms should be allowed to start a medical school. The norms could well cover requirements such as financial stability, experience in running medical schools – perhaps even globally. This is a good way of getting schools like Harvard and Hopkins interested. Incidentally, Singapore adopted a similar strategy to attract Insead Business School and Duke Medical School to Singapore.

Going beyond the school itself, medical institutions should be allowed to select the university with which they choose to be affiliated. Ergo Medicine programs should be repatriated to their parent universities, completely reversing the current trend for sameness. Creating competition – where universities strive to be affiliated to the best schools – is a far more powerful means of creating quality than by obsessing over standardising curricula across the state.

2. Create payment security in Education to attract the best medical schools

While (1) will grab the interest of leading healthcare educational institutions, it is unlikely to keep them from having bouts of attention deficit. To make sure the Harvards of the world come – and stay – the Government will need to assure them of a good return on their investment.

Discussing “returns on investment” in education is typically considered inapplicable – heretical even.

I disagree.

An education – in particular, a degree from a reputed college – is highly monetisable. When an average IIM-A student gets a starting salary worth 10 lakh, the market deems the worth of that “student+degree” combination to be worth at least as much. So, if an IIM-A student is charged Rs. 5 for a degree, s/he should not really be bothered – s/he will still be, economically speaking, better off.

So, in a nutshell, the government must give full freedom to medical schools to charge market rates for their fees.

And, instead of controlling fees, mechanisms should be established whereby the poorest of the poor have access to the capital required to fund this education. A cornucopia of solutions – from student loans to vouchers as suggested by Friedman – are possible. The government can, in fact, “fund” the education of students from whichever caste/creed/demographic/electorally useful group of people it wishes to pamper by directly paying the school the full cost of their education.

Such a move will have an altogether salubrious effect on the schools themselves. Forced with having to compete for the student’s rupee, colleges will have to offer better facilities, higher teaching standards and resources to attract students and value –added services – like career counselling and placements. The motivation for becoming distinctive will also incentivise them to establish tie-ups and alliances for research and development.

Existing shackles that prevent these relationships from emerging should also be removed.

3. Ensure public safety by establishing an independent regulatory authority.

While (1) and (2) may be adequate in other sectors, it is certainly not enough in medical education. After all, is it safe to leave the licensing of physician to a bunch of colleges that is interested in a 100% pass rate?

This is a legitimate concern, but effectively solved by establishing an independent regulator.

In the United States for instance, all physicians – even those from the best schools –must pass stringent licensing examinations administered by an independent licensing authority.

India too has successfully established ombuds and regulators such as the TRAI, indicating the viability of the concept. This regulator should be kept independent of the government (which means the Ramadoss or Grand poobah of the time should not be allowed to meddle in its operations). It should also be made financially secure by providing it with ring-fenced government funding and “licensing fees” collected from students and medicall colleges.

This independence and financial stability is crucial to staff the regulator with high quality experts – and not some spineless lackeys beholden to the present Minister.

Details about how we can make this regulator – indeed any institution – at arms length from political vicissitudes is matter enough for a separate post.

So there we have it – a framework to pull Maharashtra back from its state of self-inflicted medical decline and place it firmly onto a growth trajectory.

Of course, several operational issues remain unanswered – such as how do we ensure that these medical colleges have the right kind of teaching hospitals available? This one is easy: allow hospitals to forge alliances with existing hospitals to upgrade them into teaching institutions. Give incentives for adopting and transforming poorly run government hospitals and so on.

Some questions are harder – such as how do we get the best here? How many medical schools are enough? How expensive is too much?

They are all valid and important.

However they are also amenable for resolution under the umbrella framework of the three shifts listed above: competition, payment security and outcome regulation.

So, why have we not started as yet?

Unfortunately, like most changes – this change too has to start from the government. Babus have to go from thinking of themselves as thekedaars and maay-baaps of the sector to facilitators and nurturers.

They have to realise that this sector is too important to be held ransom to their petty egos.

Alas, the recent fracas with Ramadoss and the AIIMS demonstrated how far the sarkar is from this realisation.

Einstein had once said that a problem can only be solved at a level of consciousness higher than at which it was caused.

Our netas and babus need to raise their levels of consciousness pretty significantly to embrace such radical change.

Cold comfort, that we need to wait for our Netas and Babus to think differently.

Perhaps they should begin their journey by reading Alice in Wonderland.

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.