Specialist doctor crisis persists in rural India; no change in last five years despite rising seats in medical colleges

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The number of doctors at primary health centres (PHCs) in rural India has improved remarkably over the last five years, but the acute crisis of specialists in community health centres (CHCs) persists across the country, show government data.

There were 26,464 doctors in rural PHCs in 2015-16. This number grew to 31,716 in 2020-21, marking a rise of 20 percent. However, during the same period, the number of specialists at CHCs in rural areas grew from 4,192 to 4,405, an improvement of just about 5 percent.

The latest numbers come from the Rural Health Statistics 2020-21, which was released last week. The report highlighted that as of March 2021, there were just 4,405 specialists at rural CHCs against the requirement of 21,924. In other words, there is a shortfall of 17,519 specialists or a whopping 80 percent.

These numbers suggest that owing to the gradual rise of medical colleges in the country there may be more MBBS doctors now available to serve in the hinterlands, but a majority of those with Post-Graduate (MS, MD) degrees may still be shying away from serving in the government facilities in the countryside.

Dismal numbers

The RHS 2020-21 show that at rural CHCs, compared to the requirement for existing infrastructure, there is a shortfall of 83.2 percent surgeons, 74.2 percent obstetricians & gynaecologists, 82.2 percent physicians, and 80.6 percent paediatricians.

These four types of specialists are mandated at all CHCs, apart from a general duty medical officer.

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“Overall, there is a shortfall of 79.9 percent specialists at CHCs, compared to the requirements,” said the report.

According to experts, the lack of specialist doctors in CHCs often puts unnecessary burden on district hospitals, which are often stretched to capacity, thus depriving a large number of the rural population of the specialist care closer to their homes.

But sadly, this shortfall in specialists in government facilities has emerged over the long term.

There was, for instance, a shortfall of 17, 525 specialists at CHCs in 2014-15, 17,459 in 2018-19 and 17,519 in 2020-21.

This shortage, surprisingly, is continuing despite the remarkable rise in both undergraduate (UG) and post-graduate (PG) seats in medical colleges in the country.

Rising seats in medicine

Government figures show that while the number of UG seats has increased by 72 percent -- from 51,348 before 2014 to 88,120 seats for the ongoing academic session, the number of PG seats, which also include DNB and CPS (diploma courses after MBBS for students other than MS and MD courses), has increased by 78 percent -- from 31,185 seats before 2014 to 55,595 seats.

A government official in the medical education wing of the ministry conceded that while a lag between additional seats and filling of vacancies is expected, the lack of any change in the shortfall of specialists in CHCs over six years is “conspicuous”.

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Public health researcher Oommen John pointed out that in the absence of a robust gate keeping function and effective referral mechanism, a large number of citizens seek specialist services in secondary and tertiary care facilities.

“Therefore, the specialists seem to be concentrated at district headquarters or larger cities,” he pointed out.

‘A complex issue’

T Sundararaman, who previously headed the Union government’s National Health System Resource Centre and is now associated with Jan Swasthya Abhiyan, said that from the design of the health facility pyramid to a push towards privatisation, there may be a lot of reasons for the specialist crisis beyond cities.

“In my view, providing for the post of a single surgeon in a CHC is not helpful as they often find it difficult to operate,” he said, adding that creating more seats for specialists in district hospitals may be a better idea.

“Also, as more and more speciality and super-speciality seats are being offered in the private sector where doctors have to spend multiples of Rs 50 lakh to secure a degree, they are unlikely to see serving in a rural hospital as a lucrative prospect,” he added.

According to Sundararaman, as the unified test for entrance into medicine (National Eligibility-cum-Entrance Test UG and PG) does not take into account the local problems of a region or a state, many students end up studying in states with a large number of seats but not necessarily a great need for specialists.

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This was skewing the situation, he pointed out.

“I also feel that there is a major internal brain drain happening, with corporate hospitals spreading wings where all specialists and super specialists want to work. And therefore, ideally our entire medical education policy needs an overhaul,” he said.

Public health specialist Dr Antony K R too said that it is mostly CHCs or the sub district level hospitals that lack specialists while they prefer to work at district hospitals and medical colleges.

“Many doctors after PG do not get automatic appointment as specialist and continue as non-specialist grade and pay,” he said. “So when private sector hospitals attract them with higher pay why should they reject it and be loyal to government service?” he asked.