By Sandra Albert
If there was a correlation between medical colleges and good health of a state, Karnataka and Maharashtra should lead the league table of good health indices in the country, sadly they do not. It is almost a knee jerk response in the northeast region to attribute poor health indices to the absence of sufficient medical colleges. As the state of Meghalaya is considering setting up a couple of medical colleges one in Tura and the other in Shillong, perhaps it is a good time to look at the plans more closely. Ideally hugely expensive projects should be based on empirical evidence or at least on the best evidence available at the time. A key rationale offered for establishing medical colleges is to address doctor ‘shortage’. But as of now there is seemingly little shortage of MBBS doctors in Meghalaya; 534 of the sanctioned 544 posts in the State Health Dept. and 20 of the 24 contractual posts under the National Health Mission are filled. Dig a bit deeper and technocrats in the health department will tell you that the problem is not in the production of doctors but in getting them to stay where they are needed most. That is in remote rural areas of our state. Building more medical colleges will not solve this issue unless you build them in these remote regions.
Where we do have a gross deficit isof specialist doctors like obstetricians, surgeons, anaesthetists and paediatricians (over 50% of the sanctioned posts are lying unfilled). Setting up one or two medical colleges will not address the deficit of specialists even in the next two decades in this State. Instead we need to look at alternate models – one that has been suggested and is being explored by some states is converting large district hospitals into DNB (Diplomate of the National Board, a degree equivalent to MD) centres, where in-service doctors can practice and simultaneously be trained into becoming specialist doctors. Another one is an in-service degree model in Family Medicine with core specializations being offered by CMC Vellore. Of course we still need to address the issue of getting health care personnel to spend time where they are needed most. There are multiple underlying deterrents which need to be prioritised and attended to, that is beyond the scope of this article.
Considering the paucity of good tertiary care hospitals in many of our districts it makes sense to locate a medical college in the Garo hills. But do we need another one in Shillong? The city already has a good centrally funded, well equipped medical college and several tertiary care hospitals in addition. A rough calculation of doctor to population ratio indicates that East Khasi Hills has close to the recommended doctor population ratio. So if we must build one why not locate it in West Khasi Hills, Ri Bhoi or in the Jaintia Hills?
Of the two medical colleges being proposed one is to be set up by the state and the other on a PPP model. Setting up a medical college is an enormously expensive venture – it requires initial capital expenditure (infrastructure, equipment etc) which can vary anywhere between 250-500 crores, including the teaching hospital. This amount may not be too difficult to raise as there are banks willing to extend soft loans for such ventures. What we need to be more concerned about is the annual recurring or operational expenditure – the cost of sustaining the enterprise on a day to day basis. In states that have barely enough funds to sustain their health budgets, this is an issue worth dwelling on. Many of the north eastern states rely on the Centre for nearly 90% of their health budgets (NHM) and lack of funds for other initiatives is a common refrain within health departments. So where are we going to find the additional 80-100 crores annually to run the state funded medical college? One way is to charge students the true cost of their medical education i.e. minimum fees of 5-8 lakhs per year amounting to over 25 lakhs for the full course. But is our government going to charge these fees? Are tribal students going to pay these fees even if they have the wherewithal to do so? One suspects that they would be willing topay high fees outside the State or in a foreign county but may be reluctant to do so within the state. There will be protests and demands for subsidy across the board for tribal students – so who pays is the question?
As for the PPP model – there are two examples in the Northeast that this government can do well to examine closely as many lessons can be learnt from them. The first PPP model medical colleges was the one in Sikkim established by the Manipal group. Reliable sources inform that it is not a sustainable entity and the Manipal group is able to carry it forwards only because of their institutions elsewhere subsidizing the Sikkim-Manipal institution. The second is one established in Tripura, the short story is that the group responsible abandoned ship and slipped away after a few years, leaving the state to pick up the pieces. The state proceeded to set up a society which now runs the institution and charges around 25 lakhs fees – medical education is a costly affair. Just because institutions like NEIGHRIMS charge a pittance, it does not mean that it reflects actual costs. The cost is a lot higher, students and parents do not feel the pinch as tax payers of this country subsidize their higher education. Costs and pricing are often confused by people hereabouts and we would do well to discuss the difference between the two.
The decision to invest in expensive medical institutions should ideally be based on good quality evidence rather than well-meaning intentions and opinions. It is not as if the state does not have a yearly pool of new graduates available to replace those who are retiring form the workforce. Currently Meghalaya gets about 69 MBBS seats every year at almost no cost to the state. We need to figure ways to make use of them as efficiently as possible and also explore ways to provide them avenues for specialist training after say 3-5 years of service.
(The author is Director, Indian Institute of Public Health Shillong)