By Glenn C. Kharkongor
A front page news items in the Shillong Times, Aug 26, 2023 indicates that the state cabinet has approved the setting up of three medical colleges in the state. The commitment of the state government is quite admirable. In the last couple of decades there have seemingly been sincere efforts to begin medical education in the state, but these attempts have been fraught with delays and failures.
There is good intent and political will power, but medical education is a specialized and demanding discipline and the creation of a medical college needs highly technical and human resource inputs and a detailed and nuanced approach. In other words, experience and expertise in setting up a medical college is indispensable. But such know-how is in short supply, and the government will need to obtain this expertise. Land and local approvals are the easy part. Money and good intentions alone will not achieve the desired result.
Expertise from outside the government can certainly be called upon. There are many self-styled consultants who claim expertise, but they are mostly corporate honchos for whom consultancy fees are the main priority. It is admirable that a few states in the Northeast have set up medical colleges, but there have been some noteworthy failures such as the ill-fated PPP medical college in Tripura.
These are the major hurdles.
Detailed Project Report
This may be the easiest part. A combination of insider inputs and external expertise would be able to put a DPR together. This would have to be a multi-dimensional document with at least ten years of operational and financial projections, with future plans for postgraduate medical, allied health and nursing. The two main components: medical college and clinical teaching hospital would present different levels of difficulty in forging the DPR. The medical college portion is straightforward because the National Medical Commission norms and guidelines are explicitly stipulated.
The teaching hospital projections would be a more complex task. The most difficult projections would be a plausible hospital occupancy and the feasible sufficiency of a wide variety of patients for undergraduate and postgraduate students to learn from.
Patients for the
teaching hospital
Meghalaya has a small population to draw from and the state would not be able to easily attract patients from outside. NEIGRIHMS has achieved this to some extent, but over the years it has established some strong departments that bring in patients from elsewhere. Faculty shortages and equipment maintenance are frequent bugbears, but even so NEIGRIHMS has laudable achievements. But this has taken over a quarter of a century to accomplish. A state medical college hospital will find it difficult to duplicate this feat. For three state medical colleges to draw enough patients is probably an unrealistic expectation.
The numbers of patients in government hospitals in Shillong may provide an adequate occupancy for the medical college in Shillong, but the numbers of patients in the civil hospital in Tura may not be enough. A private medical college situated near the Assam border will attract patients from there, but the teaching hospital will not benefit many patients from Meghalaya. A private medical college will keep most of the seats for itself, so it is uncertain how many local students will benefit.
There are several mission and private hospitals in the state and many families take patients to hospitals in Assam and elsewhere in the country. These mindsets and practices will not change easily. Even in densely-populated states, health-seeking behaviours are habituated. Some private medical colleges in the country arrange fleets of buses, pickup from stations and bus stands, and free treatment at their hospitals but continue to struggle to attract enough patients.
Faculty and staff
This mountain would be almost insurmountable. The number of needed faculty, with the right qualifications and teaching experience, simply do not exist in the country. Even the highly-vaunted new AIIMS institutions (19 have been opened, five more are planned for 2025) are struggling, some of them with barely thirty percent of the required faculty strength. NEIGRIHMS has recently seen an exodus of faculty.
Given these facts, how do we expect faculty from around the country to gravitate to Meghalaya. The number of doctors qualified to teach in Meghalaya at present is negligible. It would be a tough challenge to attract faculty to Meghalaya. What could be the incentives? There are hardly any reasons to work in Northeast India for someone from the mainland.
Across the country, there is a continuing exodus of specialists from teaching institutions to private hospitals. The Manipal group is the largest provider of private medical education in India, with five medical colleges, all of them are highly rated. Their hospitals, now the second largest network in the country, draw some of the best specialists from medical colleges. The remuneration packages at private hospitals and family conveniences of city life are unchallengeable.
Recently a friend of mine whose daughter secured a seat through NEET at Sikkim-Manipal Institute of Medical Sciences, Gangtok, instead chose to send his child to a lower ranked medical college in south India. Why? His reason was that Sikkim is close to strife-torn Manipur. Fears and misconceptions about the Northeast are widely prevalent in mainland India.
Other health professions
While the state government is so visibly focused on medical colleges, training in other much-needed health professions are neglected. MLCU is the only major training centre in the state for allied health professions such as medical lab technology, imaging technology, optometry, operation theatre technologists and other paramedical professionals. These graduates are grabbed by the job market all over the Northeast. There is only one public health institute, and hardly any training for mental health workers, except for MLCU. These priorities should be taken up also.
Rather than state-funded or conventional PPP arrangements, the government may consider locally possible innovations. The MLCU School of Allied Health Sciences provides classroom teaching and basic labs. The hands-on training is provided by local hospitals in Shillong and the capstone skills are polished by one-year internships, six months of which has to be outside the state at leading private and mission hospitals. These hospitals routinely offer jobs to our graduates after internship. While medical education is, of course, more demanding in its set-up, a convergence of local institutions, resources and efforts may be one way of climbing the mountain.
Yes, we should set up a medical college in Meghalaya and we can do this in tandem with other training priorities. But some of the statements in the Shillong Times news report and the “push for medical colleges” on page 3 by the UDP, are mostly wishful thinking.
Medical education is largely a private good, as its benefits mostly accrue to the graduate doctor. However the hospital services and the ancillary local development are a public good. This justifies its governmental priority. It is also true that the country needs more doctors, though when one takes foreign medical graduates such as from China or east European countries, AYUSH and traditional healers into the equation, this need is diminished. The data shows that even though medical colleges have mushroomed in south India, rural regions do not benefit much. The best medical graduates practice in the cities or go abroad.
For someone who has been a career academician and administrator in a medical college, insider insights and directions are clear. A deep dive into the complexities is a necessary exercise. When we go public with our plans and interact with outside players and local stakeholders, we should look credible, not just enthusiastic.
The author is a former professor of pediatrics at Kasturba Medical College, ex-Director of Planning and Development at Manipal University, and previous senior vice president of the Manipal Education and Medical Group. He is also the author of “Manipal and Beyond” (Penguin Books, 2016)