Why India needs Incentivising Doctors working at Government Hospitals Now?

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Shortage of doctors at government isn’t new, and it’s time to deal with it — A HE report.


India is facing a critical shortage of doctors that could seriously jeopardize the ability of a patient to get medical care at government hospitals. Perhaps one of the most disheartening sights while travelling around the country is long queues of patients outside government hospitals, waiting to meet a doctor. In fact, it’s depressing that 398 medical colleges are unable to provide relief to people.

So what are the reasons for the shortage?

When it comes to careers, Indians have known to prefer medicine and engineering, but that’s changing now.

Take the case of *Aswathy. “Earlier high performers always chose engineering or medicine. However, today there are many career avenues available for students in India. Even though my mother is a doctor, she always told me not to pursue medicine, as it’s a tough job and the public has a terrible impression about the doctors,” explains the IT professional.

Clearly. Shortage of doctors has never been so evident. Take the case of proposed AAP model clinics, named Aapla Dawa Khana in Maharashtra. According to news reports, private doctors would be roped in at Rs 40 per patient for these clinics.

Rugged life style has its appeal, but not for physicians

Data from the Central Bureau of Health Intelligence shows that only 1.1 lakh, i.e. 10% of the 10.8 lakh registered allopathic doctors work with the government. Also, the issue equally affects both states which don’t churn out doctors as much as those which produces many doctors. As against the 10% national average, only 4.8 % of the registered doctors joined government hospitals in Karnataka. For Tamil Nadu, the number is  5.6%, and Maharashtra is 4.3 %.

Also, interventions of state governments are not helping. Eleven states namely Assam, Arunachal Pradesh, Chhattisgarh, Gujarat, Kerala, Manipur, Meghalaya, Nagaland, Orissa, Tamil Nadu and West Bengal have made it compulsory for all the medical graduates to serve in rural areas for a duration varying from 1 - 5 years. However, according to a TOI report, even though the MBBS graduates are supposed to put in a year of compulsory government service, it has not been implemented by the Karnataka state government due to bureaucratic hurdles.

A fall out of this shortage is an increased workload on those who have joined the government-run hospitals. A government allopathic doctor, therefore, ends up serving an average population of 11,082, 11 times the WHO recommended 1:1,000 doctor-population ratio. The situation is worse in poorer states like Bihar where one doctor has to suffice for as many as 28,391 people.

The exodus of doctors got attention several decades ago with regular coverage in several prominent publications. Between 2001 and 2005, almost 41% of doctors quit from the Central Health Service. Several doctors moved from public to private hospitals due to attractive pay offered by corporate hospitals, poor working condition, lack of transparency, career stagnation and lack of funding for research.

“There is a shortage of doctors working in public healthcare facilities. Factors might vary depending on the context: for example, it is difficult to get doctors to practice or to retain them in primary and community health centres. This can be related to the quality of life for the doctor and their families, as well as the availability of support services, and perceived (lack of) professional and personal gains to working at that level. In secondary level facilities, salaries and availability of infrastructure or support staff for specialists can be lacunae. Those working in tertiary facilities are susceptible to poaching by better pay in the private sector, however shortages at this level (given government jobs at this level are often preferred) can be a function of poor or delayed recruitment by the government. It’s possible however to have encouraging alternatives—for example, Tamil Nadu has done pretty well with being able to recruit and retain doctors for their public healthcare facilities. They have done this by ensuring supportive infrastructure (equipment, drugs/devices as well as staff), and by also building in incentives (for example reservations for in-service government doctors for post-graduation and super-specialization), says Anant Bhan, a public health researcher.

Eleven states have also made it mandatory for all the graduates to complete two to three years of rural service for admission to the PG degree programs.

What if doctors made more money?

Dr. Harish Pillai, Chief Executive Officer, Aster Hospitals and Clinics have a few suggestions to solve this issue. “For an excellent clinician, the private hospitals go all out to give you whatever you need to build a good department and will help you to encourage you for academic enhancements. The private sector is a much more independent sector compared to a highly regulated government sector. If you search for similar success stories in the public sector, organisations like ISRO provides an excellent case study of how a public sector enterprise should be run.

“ISRO attracts good talent at the very junior level and has also built a career pathway for them. Moreover, due to autonomy is given to its various Research and Engineering groups, they have produced several achievements for the country. AIIMS also has a certain degree of autonomy; therefore it does well. Sree Chitra Tirunal Institute for Medical Science and Technology is another example. Sree Chitra started as an autonomous institution focusing on Clinical Excellence in neuro and cardiac and also the bioengineering unit, thanks to the vision of the founding director, Dr.M S Valiathan. To sum it up, if you want to attract doctors, you need to create an ecosystem by building world-class infrastructure, have proper medical equipment, focused on sub-specialisation, promote academic activity and also incentivise doctors,” he says.

A Survival Plan

Pillai also points out that the doctors need to be paid on par with other comparable government services across India. “Doctors in government services should be paid on par with other similar government services. For instance, if the doctor wants to go for conferences especially prestigious international conferences, they should be funded. Also if you do all these things, you will be able to attract doctors.  One significant administrative reform which I  strongly advocate is, unfortunately, the principal secretary of health in India is always an IAS officer. An IAS officer is more of a generalist than a specialist.

Creation of Indian Health Service

Pillai also strongly demands the creation of an Indian Health Service, like the Indian Postal Service or Indian Revenue Service. “We need to have a separate cadre for running of government hospitals. Government hospitals across India are not well managed. Typically in state government-run institutions,  senior doctors who are outstanding clinicians become medical directors of the organisation. However, he doesn't have any qualification in management. He doesn't have an MBA or Masters in Hospital Management, so he may not understand how to run the hospitals. Management of hospitals is essential in the context of government hospitals. Take the example of France, even though it is an OECD country with large public hospital having the capacity of 1500 to 3000, but the CEO of the public hospitals and always come from the French Health Service. It is a competitive exam by which people can join the course. It is like an IAS. They have to go through a structured program, and then they are appointed as heads of large hospitals. They are highly professional, and they can manage limitations of the system, in spite of limitations in funding and other resource constraints. We need to have that kind of soul searching and reformation from a structural point of view order to rewire our institutions which are currently crumbling. The current model is not sustainable where the private sector only provides the healthcare needs of the majority of the population. It would help if you had an excellent public sector as well as a private sector to complement each other, only then healthcare outcomes in the country will be better,” he concludes.