By Dr Sandra Albert & Prof Mayur Trivedi
On a recent visit to Mizoram, I happened to interact with senior faculty at the Zoram Medical College. The interaction made us all ponder on the challenges of maintaining a medical college in small northeastern states (especially the operational costs). Zoram medical college faces a deficit in operational costs and had asked the Centre to make it a centrally funded institute (declined). It is running with a fraction of mandated faculty. Not all are happy with the ramifications; when Mizoram set up a government medical college, the state lost its quota of reserved seats for MBBS in top medical institutions across the country.
According to the Medical Council of India, India has 780 medical colleges with 1,18,137 MBBS seats in 2024-25; the number of MBBS seats doubled from around 51,000 in 2014. A shortage of medical seats, owing to fewer medical colleges, has been cited as a common argument for the shortfall. Opening new medical colleges, therefore, remains a common response. Gujarat announced a policy to encourage public-private partnerships for the establishment of newer medical colleges to increase the supply of doctors in rural areas. Gujarat has a better overall doctor-population ratio (1:944) as compared to the national average. But ironically, only about 9% of all registered doctors serve in the public sector, resulting in a poor doctor-population ratio at 1:11475 in the government sector. The problem is not of production but of distribution.
Meghalaya has made remarkable progress in the past decade in addressing the shortage of doctors in the state. Our health personnel-to-population ratio has improved remarkably since a decade ago, when we were one of the lowest in the country. So how many additional MBBS doctors do Meghalaya’s health system need? If you pose this question to senior health authorities, they will tell you that there are hardly any vacancies for MBBS doctors in our health system. But the one area that has deficits are in specialist doctors for instance at the Community Health Centres (CHCs) and district hospitals; where we have a 92% shortage. It is not just Meghalaya, this deficit in specialist doctors holds true for several states in India.
When policymakers look into this problem, their answer often is ‘start medical colleges’. Sadly, that approach has not really worked even in states that have multiple medical colleges. In India, often the emphasis is on undergraduate training, and medical college could take anywhere between 10-15 years of existence before their first specialist doctor is produced. Zoram Medical College is yet to start MD and MS post graduate (PG) specialist training. At our CHCs, the key specialist doctors needed are in obstetrics, anaesthesia, surgery, family medicine and paediatrics. Even if we open three medical colleges, clearly, this approach will not 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 postgraduate (PG) teaching institutes of the National Board (Diplomate of National Board, DNB) of the Ministry of Health & Family Welfare (MoHFW).
Recognizing that alternate models were desperately needed, the Public Health Foundation of India (PHFI) initiated the ‘Design and Adoption of Alternate models for Responding to address Shortage of medical specialists’(ADARSH) project in select states. The Orissa government was one of the first adopters of the scheme. In fact, the Orissa government went a step further and preferred 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 tend to move to 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, with the intent to prepare them for a teaching/research career. In the primary healthcare system, clinical competencies are paramount and hence doctors with Diploma qualifications can provide services quite well. In Orissa, the first state to join the ADARSH project, to date 276 PG training seats have been created and over 137 specialist doctors have graduated at very little cost to the health system.
In Meghalaya, a MoU was signed with the state government on December 8, 2018. Through the ADARSH project, the Indian Institute of Public Health Shillong (IIPH) with PHFI Delhi has been supporting the Government of Meghalaya to get approval for PG courses in public sector hospitals. Following a gap analysis of eight districts, 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 Government Maternal and Child Health Hospital, Maternal and Child Health Hospital, Jowai and Tura MCH Hospital – were identified for upgradation to PG teaching institutes. Following cabinet approval, filing of applications, back-and-forth correspondences with accreditation agencies and much problem-solving, the process culminated in site inspections and approvals. To date, 52 specialist training seats have been created in obstetrics, paediatrics, anaesthesiology and radio diagnosis. The mental health institute MIMHANS is on the way to be approved for psychiatry speciality!
Medical colleges that train undergraduate (MBBS) can become white elephants that are not cost effective. The sheer costs of maintaining departments like anatomy, physiology, biochemistry and many other non-clinical departments merely for undergraduate training, that are statutory requirements, can be enormous. With the sudden spurt of increased medical seats across the country, including many AIIMS like institutes, there is likely to be an oversupply of MBBS doctors in a few years. Like the situation with dentists; last year when more than 500 dental seats across the country went unfilled.
A more cost-effective approach for the current needs would be to upgrade or set up medical colleges that focus on postgraduate specialty training so as to produce the needed specialist doctors for the state. This arrangement addresses deficits while simultaneously improving the quality of services at hospitals, as the presence of trainee specialist doctors in hospitals help in improving service provision considerably. It would be worthwhile for the government to commission a cost benefit/utility study before making more nuanced decisions as they consider establishing new medical colleges. From an ongoing economic analysis that IIPH Shillong is doing with the Institute of Economic Growth, it was estimated that the state’s health expenditure grew from around Rs. 300 crores in 2010-11 to Rs. 1650 crores in 2023-24. It is time we expect more allocative efficiency in our budget, as it would be unwise to spend approx. 300 crores annually to run an undergraduate medical course if projections demonstrate that scares resources can be better spent.
(Sandra Albert is the Director, Indian Institute of Public Health Shillong & Mayur Trivedi is Professor at Azim Premji University, Bhopal)