This is my compilation on medical and paramedic education in India, presented in the All India Educaion Congress Ahemadabad dt 20th Nov 2012

1. MEDICAL AND PARAMEDIC
EDUCATION IN INDIA: NEED FOR
MAJOR REFORMS
Dr Shyam Ashtekar
AISSC. Ahmadabad, 22 Nov 2012

2. OVERVIEW : HEALTH HUMAN
RESOURCES AND RELATED ISSUES
Some Ground Realities

3. HHR IN VARIOUS COUNTRIES

4. HHR DENSITY IN INDIA

5. DOCTORS IN A DISTRICT STUDY (1: 634P)
11/21/2012 5

6. DOCTORS IN NASHIK CITY
Super specialty 25
Skin specialist 25
ENT sp 26
Psychiatrists 50
Anesthetists 65
Pathologists 65
gen Physician 75
Eye specialists 80
Radiologists 83
General Surgeons 85
Orthopedic sp 87
MD Ayurveda 100
Child sp 140
Ob-Gynec 200
C) Specialists 1106
B) Dentists 350
BUMS Yunani 7
degree not Avialble 91
MBBS 121
Homeopaths# 153
BAMS 1250
A) Gen Practitoners 1622
0 200 400 600 800 1000 1200 1400 1600 1800
11/21/2012 6

7. DOCTORS IN NASHIK DISTRICT
1400 U-Pub
1200
1000 U-Pvt
800
R-Pub
600
400
R-Pvt
200
0

8. OVERVIEW OF MEDICAL INSTITUTIONS IN INDIA
 355 MBBS colleges, nearly UG 43890 seats
 161 belong to Govt, with about 20000 UG seats
 194 are Pvt colleges, with 23900 UG seats
 National Eligibility-cum-Entrance Test for MBBS
Course (NEET-UG ) will be held from 2013
 NEET should take care of entry level
corruption, multiple tests etc.

9. URBAN-RURAL HHR GAP
 28% of the country’s population is urban (Census of India
2001)".
 Going by density of health workers per 10,000 pop, urban
HHR density is 4 times that in rural areas.
 Post graduate doctors are mostly in urban Pvt sector, so
also the dentists and Ayurveda GPs. (My study of Nashik
district the distribution of doctors)
 One can not expect an equal HHR proportion in Urban-
Rural since most specialists are city-bound. BUT basic
doctors/Family Physicians need to be well distributed.

10. HHR- THE 70:30 PRIVATE-PUBLIC DIVIDE
 Majority (70%) of HHR is in the private sector in
both urban and rural areas.
 In my study of Nashik district barely 10% doctors
are in the public sector. (Staggering 90% in Pvt
Sector including unregistered doctors)
 Around 50% of the nurses & midwifes are in public
sector.

11. EROSION OF PRIMARY CARE IS NOT GOOD
 In the medically advanced states and metros, we
see specialists occupy the apex of medical
care, and GPs are being pushed out.
 Primary care, in the GP domain, may get reduced
to simply coughs n colds, diarrhea n
dysentery, aches and fevers!
 The ultimate erosion of primary care will escalate
medical interventions, raise unit costs of
care, worsen availability of physicians and overload
hospitals

12. RISE OF THE SPECIALIST
 About 45 specialties are now listed by MCI : diploma
(DNB), MD (29) MS (5), DM(12), MCh(10)
 Nearly 50% (20000+) MBBS graduates can get PG seats.
Another 30% can get CPS diplomas..leaving 20% at grad
level!
 The role and share of specialists in outpatients and hospitals
is ever increasing, the generalists are losing ground (The
grand old Gen Surgeon is on the last leg)
 Even in super-specialists, we have both physician and
surgeons. Decision making is increasingly complex for
‘clients’!
 Costs are rising, but outcomes are also generally better!
 Therefore the medical pyramid is becoming top heavy!

13. HEALTH VS MEDICALIZATION
 Are we giving up ‘health’ for medicine?
 For instance BP can be prevented and detected
early, and not just treated ! Is the
physician/cardiologist interested?
 Health promotion and prevention are taking back
seats or even getting medicalised (the great
vaccine boom is a proof)
 Increasing ‘deconstruction’ of specialties is losing
the holistic view if life and body

14. PUBLIC VS PRIVATE MEDICAL EDUCATION
 Medical education, once the pride of the Govt and local
bodies, is now equally shared between Pvt and public.
 In southern states, the expansion of care is mainly
because of pvt owners.
 The quality of medical education has suffered directly
and indirectly with rise of Pvt colleges, first because they
sucked teachers from public institutes and second
because they manipulated at many levels including the
MCI visits (the infamous Ketan Desai case)
 The student has to pay stiff prices esp for PG seats. This
has further tilted the elitist bias in medical education.

15. PATHY ISSUES: MODERN MED(MM) & AYURVEDA
 Ayurveda (also Siddha & Unani) has taken the shudhha option some
3 decades back, in order to protect the system from the MM
 However, most AYUSH graduates practice MM later
 For this they claim they have learnt MM in their ‘syllabus’ and college
hospitals; which they somewhat.
 But there is no subject examination for MM
medicine, pharmacology, pathology etc. So this claim is spurious.
 It is quite welcome that Governments employ them in PHC-CHCs.
But there is no formal training or assessment for MM use.
 The AYUSH board can not authorize them for MM use, nor MCI/state
council stop them (Police can lodge a case)
 So we now stand to lose both the scientific practice of AYUSH and
the legal cover for integrated practice. The issue can not be solved in
courts of law (SC has ruled against use of the ‘other’ pathy)
 The impasse has to be solved by a consensual central amendment.

16. THE PATHY ISSUE: MM & HOMEOPATHY
 Homeopathy is an entirely different approach based
on like cures like (symptoms in the patient need to
be matched to medicines that produce similar
symptoms in normal doses..the same medicine
works only in nano doses)
 Allopathy works on principles of diagnosis based on
symptom--How can then a homeopath use
allopathy, is it scientific?

17. THE CLASH OF PATHY INTERESTS
 But the major clash is for sharing the health care cake
 MM community wants to keep the right to use MM.
 AYUSH doctors want to use MM remedies to survive in
the health market
 The SC has rued against this ‘cross pathy’
 BRMS/BRHS courses seem to be a small way out . But
AYUSH doctors can not take even BRMS!

18. HHR NEED:30 LAKH POP DISTRICT AND INDIA
Table 3: HHR requirements for a 30 Lakh district and projection for India
The District Model India
HHR for 30L dist Rural Urban+ Total pop Country HLEG Actual shortfall
Med per need 2011** *
college unit
(A) Beds (public sector) 1500 1900 3400 882 1360000
(B) HHR-category-
doctors
SSP 0 50 50 60000 20000 209091 676756
Specialists 240 350 590 5085 236000 NA
MM-MO 280 200 480 6250 192000 417119
Ay MO/BRMS 410 410 820 3659 328000 314547 196488
Dentists 100 100 200 15000 80000 22962 74649
Admin MOs 10 10 20 150000 8000
Total doctors 1040 1120 2160 1389 864000 896206 +32206
(C) Other HWs
Nurses+Midwives 2120 1110 3230 929 1292000 11 Lakh 823588 468412
Other PM 820 800 1620 1852 648000 23276 624724
Ward Asst etc 1860 1800 3660 820 1464000
Support staff 660 600 1260 2381 504000
Total of other HWs 9770 307 3908000 20 Lakh 846864
All HWs 11930 251 4772000 1743070 3028930
ASHAs 3600 833 1440000 9000000 +7560000
(+ plus sign shows surplus HHR) ** HLEG makes different assumptions,. HHR is state bound-India pool is no help

19. NATIONAL HEALTH POLICY (NHP) 2002
RECOMMENDS
 Extending public health services(..) to AYUSH
doctors
 Expanding the pool of General Practitioners to
include a cadre of licentiates including Indian
systems of Medicine and Homoeopathy is
recommended in the policy in order to provide
trained manpower in underserved areas
 ..contract employment for such doctors.

20. NHP 2002 CONTEXT
 4.8 EDUCATION OF HEALTH CARE PROFESSIONALS
 4.8.1.1 In order to ameliorate the problems being faced on account
of the uneven spread of medical and dental colleges in various parts
of the country, this policy envisages the setting up of a Medical
Grants Commission for funding new Government Medical and Dental
Colleges in different parts of the country. Also, it is envisaged that the
Medical Grants Commission will fund the upgradation of the
infrastructure of the existing Government Medical and Dental
Colleges of the country, so as to ensure an improved standard of
medical education.
 4.8.1.2 To enable fresh graduates to contribute effectively to the
providing of primary health services as the physician of first
contact, this policy identifies a significant need to modify the existing
curriculum. A need-based, skill-oriented syllabus, with a more
significant component of practical training, would make fresh doctors
useful immediately after graduation. The Policy also recommends a
periodic skill-updating of working health professionals through a
system of continuing medical education.

21. NHP 2002 ON NURSING PERSONNEL..
4.10.1.1 In the interest of patient care, the policy
emphasizes the need for an improvement in the
ratio of nurses vis-à-vis doctors/beds. In order to
discharge their responsibility as model providers of
health services, the public health delivery centres
need to make a beginning by increasing the
number of nursing personnel.

22. MCI & NCHHR
 The proposed NCHHR has been returned by the
Cabinet for some reasons
 Was NCHHR only for Modern Medicine?
 Will it permanently outcaste AYUSH as a third rate
system?
 Will it encroach on rights of state to remodel their
medical education?

23. HLEG CONTEXT

24. 4 TIER HEALTH CARE: A DISTRICT MODEL
Tertiary
Hospitals
District & urban
ward Hospitals
(>100 beds)
30 bed Rural Hospitals
Primary Health Centers (30000
pop)
Sub-centers (3000 pop) with
paramedics or BRMS/AYUSH docs

25. THE CURRENT HHR
PYRAMID
Allopathic
doctors/
specialists
Nurses &
paramedics
Informal
providers AYUSH
(with due doctors
training)

26. THIS IS ALSO A STATE SUBJECT
 Medical & paramedic education is a state subject
 The states have to invest in and redesign the programs
for state needs, broadly keeping with national guidelines
and councils

27. A RADAR OF ISSUES AND REFORMS
1 Expanding Med Ed to
deficit states
12 Pvt medical 10 2 Courses for village
9
Education-cost… 8 doctors
7
11 Continuing Medical 6 3 Courses for
5
Education 4
paramedics
3
2
10 Integration of 1 4 District based
0
Health Services &… umbrella institutions
5 Common Platoform
9 Revisit NEET
for Healing systems
8 Syllabus & Learning 6 Mainstreaming
reforms incl ODL, PBL AYUSH doctors with…
7 Expanding Nursing
education

28. 1 MEETING THE DEFICIT OF MED
EDUCATION IN SOME STATES

29. DOCTOR
DENSITY
IN INDIAN
STATES
2001

30. HHR INSTITUTIONS IN INDIA
HHR Institutions & Availability (NHP 2008 NHSRC HHR Division)
Institute Numb Annual Availability of HHR HHR: pop ratio
er uptake
1. Medical Colleges 289* 32,815* MOs 2,15,199 1:1,667 Population-India
Spec. 1,52,437
2. Dental Colleges 282 22,650 Dentists 14,499 1:35 Lakh – Bihar; 1:18,812 -
Pondicherry
3. AYUSH Institutions 477 27,265 Drs. 70,202 1:798 Population - India
4. Nursing Schools 1,620 62,647 Nurses 6,90,564 1: 264 population – India; 1:
100-200 - Europe
5. ANM Schools 329 6,502 ANMs 5,24,283 1,42,655 - 2nd ANM;
43,966 - New SHCs
6. Health Worker - 102 5,334 2,28,946 No Registration from Council
Male
7. Pharmacy - Degree 241 13,400 1,25,915 India 1 : 1,840;
Phramacy: Diploma 523 31,543 Europe 1 : 2,300
9. Lab Technician 97 2,193 1,44,990 No Registration Council
10. Radiographers 33 410 36,628 No Registration Council
11. Ophthalmic Tech. 41 426 46547 No Registration Council
Total 4034 2,05,185 21,04,650
Curtsey: DR Thamma Rao & NHSRC, * based on older estimates (new figure is 355 & 43000)

31. DOCTORS: THE DISTRIBUTION GAP IN
STATES (CENSUS 2001 ESTIMATES)
 Punjab has a high density (8-23 / 10000) of doctors,
 J&K, Sikkim,Haryana, Maharashtra, Karnataka,WB,
Uttaranchal and Goa (6-8 docs/10000) are next.
 Then come MP, UP, Mizoram, TN (?), Kerala.
 The last group has (4-6 docs per 10000) has Orissa,
Bihar, Zarkhand, Chhattisgarh, Rajasthan, Assam,
Arunachal and surprisingly Gujarat.
 This picture nearly conforms to the number of medical
colleges in each state except Gujarat.
 Guj, Mah. AP, TN, Kar, Ker together have 60% MBBS
medical colleges and 62% of medical seats.

32. 2 COURSES FOR BASIC
DOCTORS/VILLAGE DOCTORS

33. THE FAMILY PHYSICIAN
 The irony is that Family medicine is also becoming
a PG course, to be done after MBBS. This will
escalate costs of care in primary sector
 A 3 year course could have fit in well, with CME and
supply of Essential Drug List
 The MCI/NCHHR (National Council of Health
Human Resources) is trying to distance itself from
realities of India by neglecting village needs and an
elisitist neglect of AYUSH.

34. THE RURAL PROBLEM
 Those who we call doctors , don’t like to go to
rural areas.
 Those who work as doctors in rural areas, we don’t
call them doctors, but quacks!
 In many states, this is the quintessential problem in
health care!

35. THE SHORT MEDICAL COURSE-BRMS
 BRMS (Bachelor of Rural Medicine & Surgery)
 Recently MCI has supported this
 Though now it is BRHS (H for Health)
 It will be launched in district hospitals.

36. THE QUACKS (INFORMAL PROVIDERS)
 The MCI estimate of quacks can be around 25 lakh (on
what basis is not known). They far outnumber the official
doctors.
 MCI lodges occasional complaints against quacks but
also admits that they are there because MBBS doctors
are unwilling for working in rural areas.
 Their practices are quasi-scientific they get some hands-
on-training and use some books.
 Viewed from the people's need angle, quacks have
served a crying need.

37. 3 COURSES FOR PARAMEDICS
India needs to train millions of health workers of
different types, accredit them and raise their working
standards and lives!

38. IT IS NOT JUST DOCTORS AND NURSES!
1. Allopathic physicians/surgeons -
2. Health Professional (except nursing)
3. Dental Specialists -
4. Ayurvedic physicians/surgeons;
5. Homeopathy physicians/surgeons ;
6. Unani physicians/surgeons -
7. Nursing Professionals -
8. Nursing Associate Professional -
9. Sanitarians -
10. Midwives -
11. Pharmaceutical Assistants-
12. Medical Assistants -
13. Medical Equipment Operators;
14. Life Science Technicians (Lab technicians);
15. Dieticians & Nutritionists -;
16. Optometrists -
17. Dental Assistants;
18. Modern Health Associate Professional (except nursing)
19. Health Professional except Nursing -
20. Traditional Medicine Practitioners -
21. Faith Healers -
22. ASHA and Anganwadi workers

39. THE GAP IN PARAMEDIC SECTOR
Category Required Available Additional
Required
Pharmacists 1,36,869 20,967 1,15,902
(Allopathy)
Lab. Technician 1,36,869 12,904 1,23,965
Radiographer / DRA 37,681 1,867 35,814
O T Technician 46,563 NA 46,563
Ophthalmic 66,478 NA 66,478
Technician
Physiotherapist 66,478 NA 66,478
Source: Dr. D. Thamma Rao, Public Health Foundation of
India, New Delhi

40. ALLIED HEALTH COUNCIL
 Paramedic councils will now be formed in states
and some system of paramedic education flow
 There are many contentious issues of law (can they
ues medicines?), education policies, professional
councils, and turf battles like between the eye
surgeon and ophthalmologist

41. 4 EXPANDING NURSING EDUCATION

42. NURSES IN INDIA
 Nurses follow the doctors' density map
 About 56% registered nurses & midwives are in the 5
southern states (Maharashtra, Karnataka, Kerala, TN and
AP).
 Goa and NE states except Assam also have high density
of nurses.
 50% Nurses are in the public sector, mainly because
nurses prefer Govt sector as a better employer! The
small size units are unwilling to pay and provide security
to nurses.

43. 5 COMMON PLATFORM FOR HEALING
SYSTEMS

44. COMMON PLATFORM FOR MODERN MEDICINE
& AYURVEDA
 The district hospital should serve as a common
meeting platform for 2-3 pathies
 The health subcenter can serve both MM &
Ayurveda services, with trained paramedics and
doctors of ‘basic’ category
 Meaningful research and conflict-resolution can
happen only on such platform.

45. A Homeopath in UP’s Rural Hospital-OPD 2012
6 MAINSTREAMING AYUSH DOCTORS
WITH BRIDGE COURSES

46. MAINSTREAMING AYUSH DOCTORS
 Many states have posted AYUSH doctors in public
health centers and hospitals-A welcome step
 But there is no formal induction of MM, no legal
cover for MM use
 We need bridge courses in flexi formats & rigorous
tests for use of select MM remedies before they are
posted
 This bridge requires legal cooperation of all
councils-calls for a political solution via
parliamentary

47. 7 RAISING A DISTRICT BASED
UMBRELLA INSTITUTION FOR
MEDICAL & PARAMEDIC EDUCATION

48. DISTRICT BASED UMBRELLA INSTITUTE FOR MED-
ED
 A unit of 30 lakh should be treated as a district
 Covert the district hospital (500 beds) into a UG
medical college (PG in select centers)
 Will also have a BAMS college & hospital unit, with
a Homeopathy OPD & institute
 Nursing college for ANM-GNM
 Institute for Paramedics for hospitals and
community
 Other allied health staff like sanitary inspectors

49. 8 SYLLABUS & LEARNING REFORMS
INCLUDING FLEXI LEARNING,
PROBLEM BASED LEARNING, EBM
ETC

50. REFORMS IN MEDICAL EDUCATION
 Med Ed is increasingly biased for PostGrad, didactic,
bookish and theoretical, rote based, exam oriented
this is counter productive!
 We need a layered education, ensuring we get
enough basic doctors at level1, rather than only PGs
who will only work at higher end.
 We need pedagogic reforms, use of Problem based
learning, flexi learning methods, strong practical
component
 Consider Bi-Lingual medium to ensure community
links, accountability, ethics,
 Promote preventive approaches, Evidence Based
Medicine and research orientation.

51. A PAST STUDENT OF MBBS SAYS ABOUT HIS
EDUCATION
 No student can straightway start medical work after this
course (he is from a renowned Mumbai Municipal
college). There is no such capacity building.
 The syllabus and books are huge, but students have
complied notes and this has replaced many biggish
books..Parks-PSM for instance
 The main task from 2nd MBBS is the Entrance test for
PG, run by pvt coaching classes. They offer combo packs
for two years, sponsor student gatherings etc.
 So last 6 semesters and internship are spent in
ET, internship is all managed..none is serious about it!

52. A PAST STUDENT OF BAMS SAYS ABOUT HER
EDUCATION
 The teachers ask us to read ‘pharmacology’
while they deal with dravyagunavidbyan..which
itself is quite huge
 But there is no pharmacology examination as
such.
 Hospital training is poor
 No counseling about what to do after BAMS
course
 Every one is going for PG program.

53. 9 REVISIT NEET
Is the PG entrance exam reducing the graduate
medical program to a formality before PG?

54. NEET FOR UG
 NEET (National Entrance Eligibility Test) for
undergraduates has helped to ‘optimize’ entry
process and level playing field across states, and
chastened the pvt medical colleges
 However 8 high-courts have stayed the NEET (UG
or PG)

55. COMMON ENTRANCE TEST PG
 PG CET/ PGNEET turned the entire medical
college training program into another
entrance exam.. this is the biggest problem.
 We need to detoxify the medical training
from mindless PG NEET competition. HOW
do we do this is a big problem!

56. 10 INTEGRATION OF HEALTH
SERVICES & MED EDUCATION
Segregation has caused unfavorable terms for doctors
in the services as compared to med-ed

57. INTEGRATE MED-ED AND HEALTH SERVICES
 The segregation of MedEd (DMER) and Public
Health dept has created a new varnashram in
health care sector, the former offers better
pays, better working conditions and urban life.
Health services dept is getting a bad deal!

58. 11 CONTINUING MEDICAL EDUCATION
(CME)

59. CME
 CME is just taking off, but it is not well organized
 The syllabus and implementation has to be planned
and learning resources widely available
 Evaluation/accreditation is a distant issue,
 CME for other pathies and nurses is also necessary

60. OPEN SOURCE FOR HEALTH INFO
 We need a source of authentic health info in All Indian
languages.
 This can be an open source for primary care,
paramedics, consumers and students.
 We need diagnostic algorithms to help decision
making, decide protocols
 More authors, institutes, and donors need to
contribute.
 Medical colleges, students, teachers, illustrators can
help!
 Wikipedia is not very strong movement in Indian
languages—for various reasons

61. OUR WEBSITES FOR PRIMARY HEALTH CARE
IN MARATHI AND HINDI
 http://www.arogyavidya  http://www.bharatswast
.net/arogyavi/ hya.net/#
 Already launched 20  Part-1 to be launched
months..clocked 1.4 in 2-3 weeks
million visits (2000  Need help by way of
daily) funds, contributors,
 Need support for videos, advsetisements
sustenance and etc
development

62. 12 PRIVATE MEDICAL EDUCATION-
COST CONTROL & TRANSPARENCY
ISSUES

63. ?
PVT MEDICAL COLLEGES
 A difficult customer, is it a solution or problem?
 Quality of med Ed herein is questionable, barring
some places.
 Costs to students are high and hence it is helping
only some rich families (PG premium is about 50
L+). This is perpetuating ‘dynasty’ hospitals
 NEET is only one way of regulating entrance
 Regulation in Pvt medical sector has proved to be
very difficult-given the money power and collusion
of MCI

64. SUMMARY
1 Expanding Med Ed to
deficit states
12 Pvt medical 10 2 Courses for village
9
Education-cost… 8 doctors
7
11 Continuing Medical 6 3 Courses for
5
Education 4
paramedics
3
2
10 Integration of 1 4 District based
0
Health Services &… umbrella institutions
5 Common Platoform
9 Revisit NEET
for Healing systems
8 Syllabus & Learning 6 Mainstreaming
reforms incl ODL, PBL AYUSH doctors with…
7 Expanding Nursing
education

65. THANKS
Dr Shyam Ashtekar
Bharat Vaidyaka sanstha
& Sadiccha Trust
21 Cherry Hills society, Anandwalli, Nashik 422013
Website: http://www.bharatswasthya.net/#
Cell 91-9422271544