On 23 May, Maharashtra wrote to Kerala, requesting extra doctors and nurses for a new covid-19 treatment centre in Mumbai. The worst-hit state in the pandemic, Maharashtra is also one of the few that meet the World Health Organization’s bar of sufficient doctors. The request raised alarm bells, serving a troubling reminder of how covid-19 can disrupt health systems. The question that follows is: when could other states reach a similar stage?
With cases rising and the lockdown being relaxed significantly, at least 11 more states could reach this threshold point within a month, a Mint analysis shows. Nationally, the brink could be less than three weeks away, if cases rise at a similar pace as in May. States such as Haryana, Tamil Nadu, Bihar and Odisha are likely to be among the first major ones to reach there.
The day Maharashtra sought outside help, the ratio of active coronavirus cases to the number of doctors in the state had climbed to 0.17. Keeping that as the benchmark, this analysis looked at when other states would reach such a threshold, given their case trajectories and existing levels of health workforce. This threshold should not be seen as an indicator of complete collapse of the health system - Delhi, for example, has already crossed this threshold but has not sought external help. Rather, it should be considered an inflection point, after which it may be very difficult to attend to even critical cases in good time.
In this analysis, doctors refer to allopaths registered with the Medical Council of India or state medical councils - their number is 1,201,354 as of September 2019. To project future coronavirus tallies for states, the analysis uses the compound daily growth rate (CDGR) of active cases in May. But lockdown relaxations could lead to a sharper surge, and the threshold could come faster than what this analysis indicates.
The analysis suggests that Haryana, which has a poor doctors-to-population ratio, could begin to get stretched in 10 days, and Tamil Nadu, with a high case-load, in 12 days. Delhi is the only one to have crossed Maharashtra’s threshold, though it is not clear how it is managing the undeclared crisis, given the limited information the state government provides. A list of questions sent by Mint to the health department on Sunday afternoon had not elicited a response yet.
Some low-burden states such as Himachal Pradesh and Chhattisgarh appear to be even closer to the threshold, but that is because of the base effect. These states had very few active cases on 1 May and have seen a surge since then. States such as Bihar and Assam are also within three weeks of the brink. With migrant labourers returning from high-burden cities, cases have surged in these states.
The covid-19 pandemic may have brought about this tipping point but the real reason for the crisis lies in India’s historically low doctors-population ratio. Poor and populous states such as Bihar, Jharkhand, and Uttar Pradesh have among the worst doctor-population ratios, with nearly 3,000 or more people per doctor, as opposed to the World Health Organization’s standard of 1,000.
Overall, each Indian doctor caters to 1,134 people on average. However, this ratio could be even worse in reality. A study in the Indian Journal of Public Health found that just about two-thirds of the registered doctors are actually practising at a time. Most Indian states have dismal nurse density too. Long work shifts and possibility of infection among medical professionals have only increased the strain on the healthcare workforce.
One major reason for the low density of doctors is the delay in filling up vacant posts and the limited number of medical graduates. Around 45 percent districts do not have a medical college. Even in All India Institute of Medical Sciences (AIIMS), India’s apex medical institute, several faculty and health staff posts remain vacant. As of February, 30 percent faculty positions and 15 percent paramedical posts at AIIMS, Delhi were vacant.
India ranks 118th among all United Nations members in terms of doctors-people ratio, according to WHO data. Among the 12 countries with over 2,000 covid-19 deaths, India has the worst ratio. India also has the second worst ratio among G20 economies.
Unlike isolation beds and protective equipment, doctors cannot be produced in a month or a year. The pandemic is a grim reminder that India does not have enough doctors to fight a highly infectious disease. It is paying the price for neglecting a critical sector for many decades.