The demand for doctors exceeds supply in large parts of India. At the same time, the demand for medical education also exceeds the number (supply) of seats. Reducing the demand-supply gap in medical education has been an elusive goal. This can impact the gaps in doctor availability to some extent.
Over the last decade, the country has made rapid strides in expanding medical colleges and seats at the postgraduate (PG) and undergraduate (UG) levels. Between 2010-11 to now, UG seats have nearly tripled, PG seats have almost quadrupled, while medical colleges have doubled. Despite this expansion, in 2021, the number of medical graduates per lakh population was 4.1, well below 6.2 in China (2018), 6.9 in Israel (2020), 8.5 in US (2021), and 13.1 in UK (2021).
Two drivers of the increase in medical graduates are the number and size of medical colleges. While the number has increased rapidly, the size of medical colleges remains a critical barrier to increasing the supply of doctors. The average number of UG seats per college is 153 in India as against 220 in Eastern Europe and 930 in China. The small size is an outcome of regulatory and financial constraints. For instance, a seat expansion in a public medical college from 150 to 200 required an expansion of books in the library from 11,000 to 15,000, daily OPD footfalls from 1,200 to 2,000 and a doubling in the number of nursing staff required, as per the draft guidelines for establishment of new medical colleges by upgrading district/referral hospitals (2015). Some of these have been relaxed, but seats per college have not risen proportionately. They have improved from 122 in 2010-11 to 153 now.
Scaling up might be a riskier proposition for private medical colleges. Investments in physical infrastructure, hiring teaching faculty and other staff may raise feasibility questions when seats remain vacant and costs are not recovered, often leading to price distortions with high capitation fees.
Scalability constraints hold for both public and private colleges, with teaching faculty shortages across both, despite a better remuneration structure in the former. Government colleges are only able to provide medical education at lower prices, but their costs continue to remain high, with the gap between the two being bridged by subsidies. The lowering of costs will entail regulatory reform to further rationalise some of the human and physical infrastructure requirements and a greater integration to innovation and technology in curriculum design and pedagogy.
So far, the argument by the government has been that the competency-based curriculum design in the country is focused on maintaining the quality of Indian doctors. Any attempts to scale disproportionately will impact the quality of the pedagogy and, in turn, the doctors produced. There cannot be more than 15 students surrounding a bed or in any other practical class. Small-group teaching, even though resource-intensive, is the key to maintaining the quality of the workforce. Thus, the nature of curriculum in turn dictates the constraints to scalability and has implications for the future pipeline of doctors.
The competency-based curriculum being implemented by India is similar to the one implemented in the US. The US has innovated in resource utilisation to scale the production of doctors. Besides its focus on mainstreaming technology and providing better financial incentives to teachers, it employs other innovations. The use of practising MD doctors who observe and mentor medical students in a clinical setting; integrating interprofessional education (IPE) into the curriculum, where doctors, nurses and pharmacists are taught together, improves quality, reduces teaching faculty requirements and enables optimal utilisation of resources.
While there is a perceived trade-off between quality and scale, there are also concerns about equity. The argument for increased productivity and scale needs to be viewed in the context of the overarching policy goal. While scale is needed, the National Medical Commission has currently prioritised equity. The previous cap of 250 UG seats has been revised to 150 for new medical colleges from 2024-25. Read alongside the requirement of 100 seats per 10 lakh population and restrictions on locating new medical colleges within 15 km of an existing college reveal the government’s focus on evenly distributed, localised production of doctors. But, this will not lead to efficient production due to inter-state migration of doctors from high-producing states like Karnataka and Andhra Pradesh.
Thus, the goal of equity requires attention to incentives and encouraging migration to low-availability areas rather than restricting production. The policy focus, therefore, should be on addressing the barriers to scale.
Agarwal is visiting Fellow, Balani is Research Associate and Venkateswaran is Senior Fellow, Centre for Social and Economic Progress
Two drivers of the increase in medical graduates are the number and size of medical colleges. (Express File Photo)
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