By Sandra Albert
In the recently concluded Meghalaya Medical Services Association (MMSA) conference, the less than ideal doctor-patient ratio in Meghalaya was a topic of discussion. It was stated that the public/government sector has over 600 doctors, and when this number was extrapolated to the population the gap was considerable. And indeed, we need to improve the health care personnel to people ratio. But perhaps it is worth spending some time to unpack this issue and look at the when, where, who, what, why and how questions facing the health system. The truth is we probably have adequate doctor numbers in Shillong city, if one takes into account for instance the over 200 doctors employed at NEIGRIHMS, about 100 at charitable empanelled hospitals like Nazareth Hospital and more at other private facilities. The private sector is concentrated in Shillong city with many doctors and specialists. But the Primary Health Centres (PHC) and the Community Health Centres (CHC) of the government remain the main recourse for people in the rest of the 10 districts.
Considerable gaps exist in our rural areas in the government sector. So how many additional MBBS doctors does Meghalaya’s health system need? If you pose this question to senior health authorities, they will likely tell you, ‘We don’t really need more MBBS doctors in our PHCs’ i.e. most positions are filled and there are hardly any vacancies in our PHCs. But change the question to what is the deficit of specialist doctors at the CHCs and the answer will be a significant number! This deficit in specialist doctors holds true for most states in India.
When policy makers are asked how this problem could be solved, the answer often is ‘start medical colleges’. Sadly, that approach has not really worked even in states that have multiple medical colleges. In India a medical college could take anywhere between 15-20 years of existence before the first specialist doctor is produced.
Let’s look at NEIGRIHMS as a case study: this centrally funded tertiary care hospital in Shillong is rather well resourced – costs are subsidised by the central government and both capital costs and operational costs are provided for. It started functioning in 1998 and was able to start its first MD/MS postgraduate (PG) course for doctors in 2009-2010. So, PG courses were initiated after regulatory approvals over a decade after it started functioning and the first few specialist doctors would have passed out about15 years after the institute started seeing patients. NEIGRIHMS currently offers PG courses (2-3 seats) per speciality in the following 12 specialities: Anaesthesiology, Obstetrics & Gynaecology, Microbiology, Pathology, Radiodiagnosis, Surgery, Anatomy, General Medicine, ENT, Skin, Forensics and Ophthalmology. Annually a total of 27 seats are available based on marks secured in the screening NEET exams. Of the 27 seats 7 are reserved under ‘open northeast’ category. At the CHC the key specialist doctors needed are in Obstetrics, Anaesthesia and Paediatrics. Even if we open a few medical colleges, clearly this approach is not going to address our deficit in specialist doctors in the next 30 years. Hence, we need alternative models to be looked at. A possible solution was to make our large district hospitals as PG teaching institutes of the National Board (DNB) of the Ministry of Health & Family Welfare (MoHFW). Way back in 2015 this option was presented to the Health Dept. GoM, but after initial interest not much happened.
Recognizing that alternate models were desperately needed to be looked into, the Public Health Foundation of India (PHFI) took this up and initiated a programme in select states through the ‘Design and Adoption of Alternate models for Responding to address Shortage of Medical Specialists’(ADARSH project). The Orissa government was one of the first to adopt this scheme. In fact, the Orissa government went a step further and insisted that they would prefer to offer only the two year Diploma courses (DCH, DGO, DA etc) rather than the three year MS/MD courses. The rationale being that as soon as the three-year degrees are completed, doctors will tend to move out into tertiary care hospitals and AIIMS like institutes thus defeating the purpose. It may be noted that the clinical training in a Diploma (2 year) or a MD/MS (3 year) is essentially the same – the difference being that MD/MS candidates get an additional year to complete a research study. This is expected to prepare them for a teaching/research career as well. In the primary healthcare system, clinical competencies are paramount and hence doctors with Diploma qualifications are able to provide services quite well.
The degree granting bodies for the alternate models are the National Board of the MOHFW and the College of Physicians & Surgeons of India (CPS); an examination body with power to confer qualifications to practice Medicine and Surgery by the Indian Medical Degree Act 1916. In Orissa two batches of 39 specialist doctors have graduated through the scheme and the third batch of 27 are awaiting results.
In Meghalaya an MoU was signed with the state government on Dec 8, 2018. Through the ADARSH project the Indian Institute of Public Health Shillong (IIPH) with IIPH Delhi have been supporting the Government of Meghalaya to get approval for PG courses in the public sector hospitals. First a gap analysis of eight districts was done. The number of doctors available, specialist doctor shortages, potential faculty, equipment and infrastructure requirements as per guidelines were mapped out and gaps identified. There were 145 vacancies (53%) against the 276 sanctioned posts for specialist doctors. Subsequently three hospitals namely Civil Hospital Shillong, Ganesh Das and Tura Civil Hospital were identified for upgradation to PG teaching institutes. Following cabinet approval, filing of applications, back and forth correspondences with the NBE and CPS offices and much problem solving things culminated in site inspections by the National Board and CPS teams. In 2022 accreditation of Diploma courses with approval of a total of 22 seats in Obstetrics, Paediatrics, Anaesthesia and Radiology was obtained. Meghalaya is now poised to start specialist doctors training!
(Dr Sandra Albert is MD, DNB, DrPH and the Director, IIPH Shillong)