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Healthcare Manpower Economics
Providing accessibility, affordability and assurance in healthcare
of world’s disease burden. Producing over 50,000 doctors and nurses a year, the supply of healthcare manpower is woefully inadequate, although India has the largest number of medical and nursing colleges in the world! For the last 10 years or more, the industry has been crying out loud for a major reform of the way medical education and supply side constraints of talent in India has been governed. The major constraints in the implementation of government’s health programmes and schemes have been in the realm of physical infrastructure, manpower and other support facilities for an effective healthcare delivery system. Infrastructure where available had not been fully operational due to critical gaps in availability of healthcare manpower. Hence the importance of developing a skilled, motivated and supported health manpower is now largely realised to achieve the national health goals.

By: Kapil Khandelwal

A

n adequate manpower supply is important for the effective and efficient delivery of health care services and, therefore, for Indian population health and the cost and quality of health care. There are various groups, industry and regulatory bodies that have been putting up the estimates of the supply and demand and the gaps for healthcare workforce in India and that for doctors, nurses, paramedics, etc and we can

keep arguing as to which one is right and which one is wrong. At a broad level, lets look at it from what we have relative to the world, rather than benchmark with developed healthcare systems or emerging healthcare systems of the world as India is unique in the way it is innovating healthcare delivery and it would be wrong to make comparisons on doctors/nurses/paramedics per 1000 population, etc. As the graph depicts, India has 18 per cent of world’s population (fairly young) with 20 per cent

Indian Government Policy Interventions
Assessments of the adequacy of healthcare supply often focus on three dimensions of the healthcare worker population: its size; its composition (e.g., the mix

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What is the future of Medical Education?
As per the Milbanks Report on the Future of Academic Medicine 2025, there are 3 key trends that are impacting medical education 1. Digitalisation of Healhcare • New science and technology, particularly genetics and IT • Speed of internet and digitalisation • 24/7 society • Lack of agreement on where healthcare begins and ends 2. Personalisation of Healthcare • Rich and poor gap • Seeking “wellness” and rise of self-care & sophistication • Increasing anxiety about security and ethical issues • Emergent diseases 3. Globalisation of Healthcare • Gap between what can be done and what can be afforded • Increasing accountability of all institutions • Loss of respect for experts •Economic and political rise of India and China

between primary care and secondary and tertiary care); and its geographic distribution. For the first-time in India, a national-level healthcare skill survey is being undertaken by National Skill Development Council (NSDC) that will inform us on some of the three dimensions mentioned. Last week, the Cabinet Committee on Economic Affairs (CCEA) on cleared a Ministry of Health and Family

Welfare’s proposal to add 10,000 seats in state and central government medical colleges for the undergraduate (MBBS) level in a move aimed at reducing the nation’s disease burden. The decision comes a week after CCEA cleared a proposal to set up 58 government medical colleges with 100 seats each. While as doctors provide health care services that, with some exceptions, cannot be

provided by non-doctors, the size, composition and geographic distribution of the doctors in India affects the amount and type of health care services available. I am a bit surprised at the nature and the timing of all this. There is also a question on whether we are taking the right policy decisions in addressing India’s health manpower economics through various medical and nursing Councils that exists today in India and work in tandem.

Opportunity Lost for Affordability, Acessability and Assurance in Healthcare
Affordability: The Cost and Benefits of Developing Careers in Healthcare in India It costs approximately `2 crores per seat to set up a medical college for 100 seats in India. While this may be economical, investments in medical colleges and doctor training is a lengthy

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(in `)
value within the healthcare manpower spectrum, when compared with other sectors, their respective attractiveness is low, resulting in relative enrolments in medical schools and also para medical schools remaining low and in some cases even the seats not being filled in. Accessibility: Providing trained staff in different parts of India Due to overpopulation and a tremendous disease burden, along with inadequate resources and policies, there has been a perpetual demandsupply gap of medical professionals as well as health care resources in most parts of the country, especially in rural India, with demand always exceeding supply. The majority of medical school and residency training occurs in hospital settings, where there are fewer primary care role models and a greater orientation toward specialty care. Role models and exposure are important factors in specialty choice; therefore, hospital-based training may influence medical students

process; therefore, changes implemented to alter supply do not have immediate effects on the supply of trained healthcare professionals. Hence the proposed investments made by the Government in medical college will require a couple of years for the impact to be visible in the healthcare system. While new medical colleges are being planned, investors in existing medical colleges are looking at exits as they expectation on their investment is not attractive due to the size of quota seats and capitation,

creating a revolving door phenomena. To better understand the attractiveness of medicine as a career in India, a couple of years ago, we had carried out an interesting exercise in trying to compare different careers in healthcare in India and their life time value to compare them on a common parameter in rupee terms. The chart below vividly compares them. It is interesting to note that although surgeons and medical adminstrators in India command a higher life-time

It is important to better understand the attractiveness of medicine as a career in India

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toward specialties. Hence there is pent up demand and premium for specialty MD seats in India with some specialties such as radiology commanding a premium of over crores of rupees. A recent estimate reveals that as many as 40 per cent of rural posting by trained medical graduates and post graduates in different states in India are not fulfilled. There is a huge shortage of gynaecologists, cardiologists and child specialists in rural hospitals in the government sectors. Hence the government announcement to increase the supply of medical graduates may still not address the accessibility issue. Assurance: Training to medical professionals meets global standards to perform in any healthcare system Medicine in globally is complex, and there is significant variability in training programs in India and elsewhere. Much of how medical care is provided in any part of the world is rooted in local and regional cultural standards, and mastering these standards can be achieved only by total immersion in that system of medical care over time and under strict supervision. Medical education are supposed to be overseen by the different Councils of India, which is responsible for ensuring the quality of both the infrastructure and the professors at India’s medical institutes and also provide assurance that they meet the global standards. Since demand is high, it is difficult for schools to retain faculty over the long term, which creates a lack of continuity
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in both the school’s practices and its policy. The plethora of new and underequipped medical schools will create more doctors and healthcare professionals on paper, but will lower the quality of the doctors produced, further exacerbating the preexisting shortage. So, while attempting to alleviate a shortage of doctors, India has managed to create a completely new crisis on top of the preexisting one - the shortage of teaching professionals in these medical collages. Various estimates put this somewhere between 75,000 to 100,000 trained teachers and professions currently. Another issue of assurance is that Indian trained doctors have to undergo additional training abroad or have to compromise with lower pay and status as a doctor abroad inspite of have similar degree as compared with doctors coming out from medical colleges abroad.

healthcare outcomes and meet the growing requirements of skilled and trained healthcare professionals in India that is meeting global standards, rather than a siloed approach to planning through various councils in India. My recommendation is a holistic approach from planning manpower and human resources actions to working on individuals objectives and assurance that the healthcare system delivers to the requirements of India’s population health outcomes. As many experts have postulated that the future of medical education will play on three key themes. It is necessary to prepare our healthcare manpower for the future.

Summing Up
Mere policy announcement for opening up more medical colleges in India is not the panacea for solving the shortages in the supply of healthcare professionals and the people to train healthcare professionals. It is time we look at the issues holistically and plan for the future!

Healthcare Manpower Economics – Where do we go from here?
In order to achieve our

About the Author: Kapil Khandelwal has earned recognition as an angel investor, venture capitalist and expert in health sciences, education, agri, clean tech and information communications and technology (ICT). His expertise positions him as one of the thought leaders in India, Asia Pacific and emerging markets. In his 25 years of his career, he has carried out over 30 transactions including cross-border and buyouts. He has chaired various committees at various industry bodies. Kapil runs an early stage investment fund and his own investment banking and advisory services company EquNev Capital Private Limited. He can be contacted at: kapil@ kapilkhandelwal.com

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