1950, the year India became a republic, was also the year when several nations acknowledged the need to join forces on issues of health. Since then, 7 April has been celebrated as World Health Day, also the anniversary of the World Health Organization (WHO).

WHO’s theme for this year’s World Health Day is universal healthcare, an exact match with Indian government’s vision of Ayushman Bharat, powered by the National Health Protection Scheme (NHPS) announcement by the Union finance minister in his 2018 budget speech. NHPS has faced a mix of admiration and criticism from policy makers, politicians, healthcare workers and academics. Skeptics have raised questions on its contours, assumptions and implementation. Earlier, this author too had pointed out NHPS’s limitation towards achieving its objective of “health for all" as it excludes coverage for outpatient services availed in the private sector by its intended beneficiaries, the largest chunk of their out-of-pocket expenditure on health.

As a thought experiment, if all sceptics and supporters agree on the design principles and execution plan of the NHPS, this alone will not take India any closer to achieving universal healthcare unless the two-headed devil of severe shortage of healthcare personnel, and outdated infrastructure is tamed. The magnitude of just one of these problems, that of short supply of trained medical personnel, is large enough to push the feasible deadline of reaching this vision outside of the lifetime of a 2018-born.

Today, 1.3 billion plus Indians are served by 10,00,000 registered doctors instead of 15,00,000, if one were to comply to WHO’s recommendation for optimum access to health and quality care for all. Shortage of 5,00,000 doctors is a herculean supply gap to catch-up with, when the number of new doctors made in India per year is merely 65,000 (total MBBS and BDS enrollments in public and private medical colleges). 2500-3000 leave for foreign shores every year for post-graduate education or for work.

Little wonder, sanctioned posts for allopathic doctors in public sector health institutions remain vacant for years, especially in the primary healthcare centers (PHCs) in rural and remote areas. When the country is facing a severe job creation crisis, it is a shame that 26,800 posts for doctors have no takers, of which 18,500 are for specialists in community healthcare centres (CHCs) in urban and semi-urban parts. Once rated the most prestigious and sought-after, faculty positions at the newly set-up All Indian Institute of Medical Sciences (AIIMS)-like institutions are facing similar challenge. Only 38.5% posts have been filled. Last week, the Union ministry of health and family welfare confirmed in a letter to the Rajya Sabha that 6.7% PHCs do not have even a single doctor. 61% have at least one, against Indian public health standards-recommended staff of at least 2 doctors, 3 nurses, 1 technician and 1 pharmacist. 36% PHCs are short of a lab technician, breaking the crucial link between timely diagnosis and treatment. There is a 15% shortage of nursing staff too in the public sector. With an under-staffed public health system, there is no choice but to seek service from the private sector, which often faces massive trust issues related to over-charging and service negligence.

Quality of healthcare delivery is another concern. In public healthcare organisations, one finds well-qualified, over-worked, under-rested junior doctors and residents, who tirelessly work in order to eventually land up a more organized and better-paying job within India or abroad. The pitiable and unhygienic conditions in which they work and live is giving rise to another devil in the making—doctors who themselves need medical help for depression and psychological conditions. The Resident Doctors Association of AIIMS, Delhi, reported that at least half-a-dozen doctors checked themselves into the psychiatric ward since January this year. Depression is also rampant in the nursing community due to taxing work hours, emotional stress, and more recently, cases of verbal abuse and manhandling by patients and their kin. It is well-established that the hostility and distrust of patients towards health workers is a result of strong-rooted frustration built up over years of dealing with a crippled and exhausting public health system. In the private sector, finding access to a trained physician is a matter of luck and economic status. For a city-dweller seeking consultation from a private practitioner, say in Delhi, there is a 40% chance that one’s doctor may not hold a medical degree. The odds of meeting a degree-less, allopathic-doctor-by-experience go up to as much as 70-80% in states of Uttarakhand, UP, Bihar and Jharkhand.

Unless the delivery machinery in healthcare is extensively overhauled, even the skeptics-approved, tightened version of NHPS will remain a strategy on paper that will hit implementation crisis from the word go. India urgently needs a robust policy to expand and standardize production of trained health workers. This will entail creating more jobs, and ensuring consistent supply to fill these jobs. Opening new centers of medical excellence, and increasing seats for admission is not enough. The incentive structure of public health workers must be reframed to become competitive, to retain them within public institutes, and within India. The prestige and respect attached with the profession must be replenished to attract students to choose healthcare over other career options that promise a faster and more reliable route to job satisfaction.

Sheetal Ranganathan is vice-president of life sciences and healthcare operations at a research and consulting firm, and a commentator and columnist covering global health and science. She can be reached on Twitter at @_SheetalR.

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