Address shortage of medical specialists

Jai Prakash Narain

Former Director, Communicable Diseases, WHO Regional Office for South-East Asia

SHARING the international border with Tibet in the Himalayas, the district of Lahaul & Spiti in Himachal Pradesh is characterised by geographic remoteness and harsh climatic conditions. While people living in this tribal district suffer from the double burden of disease — coexistence of communicable and non-communicable or chronic diseases — the health infrastructure is abysmally poor and people lack access to essential health services.

For example, of the seven specialist posts sanctioned at the Keylong district hospital, all but one are currently lying vacant. There is not even a single paediatrician, gynaecologist, surgeon, internal medicine specialist or an emergency care expert in the entire district. Nor is there an epidemiologist to prepare for or respond to emerging infection outbreaks, epidemics or a pandemic. It has been so for the past many years.

In the absence of specialist doctors, many patients from Lahaul & Spiti have to be taken to the neighbouring district of Kullu or other places, causing them considerable discomfort, delay in receiving appropriate medical care and economic hardships. Since there are no private hospitals or doctors, people are dependant entirely on the government system for healthcare and support.

The lack of specialists is of course not unique to Lahaul & Spiti. Many other geographical regions in India are struggling with this challenge. According to the Rural Health Statistics, 2021-22, released recently, there is an 80 per cent shortfall of specialists at community health centres. Against the requirement for the existing infrastructure, there is a shortfall of 83.2 per cent surgeons, 74.2 per cent obstetricians and gynaecologists, 79.1 per cent physicians and 81.6 per cent paediatricians. While Himachal Pradesh has one of the highest shortfalls, Kerala has the lowest.

There is a stark urban-rural divide, with specialised healthcare missing in rural areas, where the majority of the population lives. The scarce human resource for health in rural areas is the most common reason that the poor and those living in remote areas remain not only vulnerable to infectious disease outbreaks, but are also unable to access basic healthcare which people elsewhere take for granted.

This is ironical as India is committed to the United Nations’ sustainable development goals with the underlying theme of ‘no one should be left behind’. Enshrined within it is the concept of universal health coverage, which means that ‘everyone, everywhere should have equitable access to quality healthcare irrespective of their geographic location or ability to pay’.

As the G20 president, India is envisaging the creation of a fairer global health architecture with the premise that both rich and poor countries deserve good health. Under this architecture, priority is to be given to building a robust and resilient national health system with adequate health manpower — to prevent, prepare for and respond to major outbreaks, including the pandemics. The huge sacrifices made by health workers during the Covid-19 pandemic cannot be easily forgotten.

Faced with critical shortage of healthcare manpower, various states have adopted innovative approaches, including offering a variety of incentives in addition to salaries as a ‘pull’ factor to entice medical specialists to serve in their under-served areas.

The predominantly tribal district of Bijapur in Chhattisgarh, a forested and Naxal-affected area, is an excellent model where with support from the National Health Mission (NHM), the district hospital has since 2016 got transformed into a state-of-the-art facility. Increased salaries and other incentives such as free housing have attracted many specialists to work in this district hospital.

To meet the urgent requirement of specialist doctors to save lives, the Uttarakhand NHM recently launched a scheme “You quote, we pay” with offers of basic pay of Rs 2,25,000 per month, besides usual allowances.

In a specialist recruitment drive, Andhra Pradesh has fixed a salary of Rs 2,50,000 per month for specialists working in tribal areas. Interestingly, the state advertisement explicitly says, “Apart from this, the government is ready to provide remuneration as much as you want, depending on your qualification, experience and place of work.”

A few years ago, former Union Health Minister Harsh Vardhan urged the states — health is a state subject — to recruit health manpower, including medical specialists, while promising that the Central Government would pay their salaries.

Addressing effectively the scarcity of medical specialists, which is assuming alarming proportions, must be the country’s top priority. We must invest in health workforce and its development and distribution now and in future, catering to the need of new medical colleges and ensure that medical specialists are available to serve patients at the district level too.

Immediate steps must be taken to fill all vacant posts of medical specialist in the district hospitals and community health centres and those posted must report to their duty station without any political interference. Any politician found interfering in the posting of specialist doctors, thereby depriving the people in under-served areas of their genuine right to equitable healthcare, must be held accountable for unethical practices.

The incumbent doctor, on completion of his/her tenure in a difficult area, such as a tribal area, should be transferred out to a location of his/her choice. And he should not be required to arrange for his replacement, which can otherwise constitute a major disincentive for joining in the first place.

The specialists opting to serve at the district level should be offered incentives such as additional increments based on their qualifications. The Uttarakhand Government offers five increments to those with a postgraduate degree and seven increments to super-specialists. Simultaneously, the district administration must create an enabling environment and provide a decent accommodation or residential facility for the doctors and their families.

While there are not enough medical specialists in the government sector, the state governments must allow the districts to actively recruit them from the open market by offering attractive salaries under the NHM, as is being done in other states such as Chhattisgarh, Andhra Pradesh and Uttarakhand.

Finally, whether the states learn from the experience of each other remains to be seen. Clearly, the provision of essential healthcare in geographically remote and under-served areas is not only a systemic necessity, but also an ethical and moral imperative.

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