Out of the crisis: breathing new life into medical education in India

Abhishek Yadav Program Manager, Healthbridge Advisors

Dr Adheet Gogate MD, Healthbridge Advisors

Everyone has high expectations from healthcare in India. In addition to providing care for 1.25 billion Indians, the industry is expected to be an engine of economic growth in itself, adding investment and creating millions of jobs that enables people to do well while doing good. But the ability of our educational system to provide the required talent is deeply deficient.

Other than massive quantitative shortages, the quality of education and the skill levels of the medical workforce are highly variable and unpredictable. Even at the current pace of reform, the situation is not likely to ease or improve for the next decade. Indeed, worsening, before any real improvement is highly likely.

Left unaddressed, the shortage will materially affect health and hence the overall economy and economic outcomes, a cost India cannot afford to bear.

India needs bold and dramatic reforms to address this issue. First, India needs to move from an input driven license raj to a competence based practice certification system. Second, it needs to remove barriers that thwart innovation and obstruct the entry of more players into this space. Finally, and perhaps most importantly, it needs to thoroughly redesign incentives for becoming a medical teacher and make it an accessible, rewarding and impactful career choice.

A grim diagnosis

Over the past decade, rapid and resilient growth in India’s healthcare industry has seen this sector attract significant interest. Exuberant estimates note that in under a decade, the country’s hospital industry may well triple in size and create over 15 million direct jobs as a result. Several observers also note that India’s so-called demographic dividend – her youth – are an ideal base to create this world-class talent pool.

However, a closer look at our health education system reveals that India is ill prepared to produce adequate talent of reasonable quality. India’s overall healthcare talent canvas has massive gaps, with several critical talent pools virtually non-existent. But even in the core pool of doctors – an area where India’s talent has earned worldwide acclaim – there is cause for alarm.

Exhibit 1

The doctor isn’t in

India has a severe doctor shortage; according to 2011 World Health Organization (WHO) data, India needs over 450,000 additional doctors to meet basic WHO norms. When compared to G20 nations – an appropriate comparison for a nation with global aspirations – the shortage is even more alarming: India comes out over a million doctors short.

From general practitioners to cardiac surgeons, there are simply too few. In an industry where care is largely paid for out-of-pocket, physicians choose to set up practices only where it is economically viable and where reasonable amenities (such as schools) exist. As a result, barely 26 per cent of doctors live and work in rural areas – home to over 70 per cent of the country.

A shortage of this severity also creates another problem: it leaves little to no talent available for the training of future doctors. (Exhibit 1)

Exhibit 2

Primum non nocere

But the problem is not merely about quantity. The quality of physicians being produced by medical schools in the country is also a concern. Direct, rigorous studies of the quality of medical education are few but emerging evidence indicates that trouble is indeed brewing. Educational studies have shown that the quality of education is overwhelmingly dependent on the quality of teaching and tutelage – both factors directly dependent upon teachers.

Against this background, the 25-30 per cent faculty vacancy rates reported at Indian medical schools is alarming. With every fourth teacher missing, it is obvious that Indian medical students are simply not getting enough teaching with significant implications for overall skill levels (Exhibit 2).

Further, the quality of faculty is also questionable. A milestone study demonstrated that India’s medical research performance – a critical indicator of teaching quality – is extremely poor. Despite having the largest number of medical schools and the second largest patient population in the world, India’s medical academia produces barely two per cent of all academic research. Over a thirty year period, India’s participation in global research has fallen far behind that of China’s, which has grown ten-fold. Further, nearly half of all research was done in just 10 medical schools (out of over 300). The implication: the education imparted to our doctors is of a significantly lower standard than across the world. Outside of the elite institutions, a further drop may be calamitous.

Poorly trained physicians extract a terrible price: they increase the cost of care, risk of errors and are causally linked to poorer outcomes. A poor doctor today also means more poor doctors tomorrow: tomorrow’s doctors are the teachers to tomorrow’s doctors.

Further, India’s practitioner licensing system – the bedrock of managing workforce quality – is also broken. Unlike in several countries, India does not have a graduating licensing exam: passing the final MBBS exam constitutes a de facto license. With over 300 schools, each with their own teaching and evaluation, there is little control over the quality of physicians entering the workforce.

As a result, the quality of clinical acumen (when it is available at all) is extremely variable and unpredictable. One World Bank study revealed that even in the National Capital Area (New Delhi and its exurbs – India’s largest and wealthiest urban agglomeration), barely half the doctors were able to clinically diagnose a heart attack. In poorer rural areas, this number dropped to barely one out of five (20 per cent) with 80 per cent of physicians in the sample being unable to clinically diagnose a heart attack.

As always, the burden of absent or poor quality physicians is borne almost entirely by the poor.

Signs of life

Cognisant of the challenge, state governments have begun the process of adding medical capacity – at least at the undergraduate level. Since 2005, capacity has nearly doubled with most of the new capacity being added in the private sector. Although this capacity addition is welcome, it is nowhere close to enough. Our analysis indicates that even at this rate of new capacity addition, quantitative shortages will not ease for the next 15-20 years; longer, if India aspires to G20 levels of physician availability (approximately 40 per cent higher than WHO’s norms).

Though more capacity is being added, the process of capacity creation remains a complex license raj of permissions, approvals, inspections and quotas that obsesses over minutiae such as the number of microscopes available for teaching. Approvals hence take years, delaying the addition of crucial talent.

Overall, current process of running and starting medical educational institutions continues to be hobbled by three deeply flawed mindsets:

Premise 1: Control inputs, ignore outcomes

India’s medical education system is governed by a strong bureaucratic mindset that controls every input into medical education. From syllabi, methods of teaching, methods of evaluation to even the fee structure, every aspect of a medical college’s functioning is defined and decided by central or regional decision-making authorities with little room for innovation outside a handful ‘autonomous’ institutions.

Several regulations, in fact, actively obstruct innovation in teaching. Licensing rules, for instance, mandate library sizes and presence of labs on all wards, as pre-requisites to approval. In addition to driving up costs, these requirements actively obstruct introduction of new technologies and methods that eliminate the need for such facilities. The impact of such requirements and regulations on teaching and learning quality has never really been audited or sought to be improved.

Similarly, controls over fee structures have moved several payments off the books, creating a ‘donation’ economy. In addition to being illegal,monies from this parallel economy can never be ploughed back into actually improving the quality of education.

But perhaps no other input focus has caused as much damage as the magnificent obsession over entrance examinations. Over the past two decades, the country as a whole — and several individual states — has toyed with myriad entrance examinations. Frequently ill conceived and hastily implemented, exams have come and gone, each with different goals.

From exams that are focused on ensuring equity to students across syllabi, equity to students across years (for a syllabus) and across regions to exams designed to replace other exams, the country has tried them all. The constant tinkering and experimentation has led to scores of court cases, costing crores and delaying hundreds of thousands of careers.

In contrast, regulators have been singularly disinterested in the mainstay of a strong talent pool: stringent, higher quality licensing standards. In the US for example, prospective doctors are required to clear the highly gruelling, formidable and expensive Board Certification exams in addition to their individual degree examinations. India has none (other than the DNB). Though the concept does find a mention in the MCI’s 2015 vision document, it is dismissed in a paragraph. More space is devoted, in contrast, to the fees to be charged for entrance examinations across different socio-economic groups!

The net result of this License Raj is a profound deadening of innovation and experimentation in every aspect of medical education. In response to these incentives, institutions focus merely on meeting real-estate and infrastructure criteria and are singularly disinterested in the quality of doctors they produce.

Premise 2: Teachers don’t matter

Research all over the world has shown that the quality of education – in each and every discipline – is exquisitely sensitive to the quality of faculty and teaching. Despite this knowledge, policy planners have made little effort in this area; teacher shortages are endemic. Though the shortage has existed for years, policy planners have made little effort to address the root causes of poor teacher availability.

Real issues – such as the extremely poor economic prospects of a life of teaching, the near total absence of meaningful research opportunities and the reduction of academia to a token meritocracy – remain unacknowledged and unaddressed. Little to no effort has been made in defining innovative ways to make teaching economically attractive legally and avenues to widen the pool of teachers have been systematically closed over time. As a consequence, the ‘practice to academia’ divide is widening, leaving students with increasingly limited exposure to goings on in the wider workplace.

Premise 3: India can only have quality or quantity, not both

Instead of charting out a roadmap to raise standards of teaching quality at the time of capacity expansion, policy planners in recent times have recommended (and approved) a steep dilution in teaching competence standards. In area after area, parameters of achievement and experience have been significantly diluted (see Exhibit 3).

Exhibit 3

At a time when capacity is being rapidly added, the dual impact of more doctors, with poorer tuition cannot be taken lightly. And yet, no formal research of these reforms has been conducted. Indeed, the basic question: is there a better way of growing quality and quantity has not even been asked.

In sum, left on the current trajectory, India will enter a vicious downward spiral where she will have more medical schools, with fewer skilled teachers, a far less diverse teaching faculty and no means to gauge and manage the quality of physicians being produced. The costs of this misadventure, and its impact on the poor, can only be imagined.

Way forward

Though the challenges facing medical education in India are significant, they are not insurmountable. Before any ‘reforms’ are undertaken, however, policy makers need to pause and establish clearer goals first. For a while, the job of creating healthcare professionals and doctors was seen as a necessity and a societal obligation towards nation building. Policy makers need to introspect and assess whether this goal remains true.

We believe that healthcare and medicine are not merely an obligation but a sector of the economy with tremendous potential to do well and do good.

Planners hence need to thoroughly redefine their view towards medical education and commit themselves to a far higher goal: to create a system of medical education that attracts the best and brightest individuals, teaches them the most relevant skills innovatively and grooms them into highly sought after healthcare leaders.

To embark on the journey of creating this system, India needs to usher in three sets of bold reforms:

Reform 1: Migrate from an input-based licensing system to a competence based one

With the sheer diversity of medical colleges and programmes, establishing a rigorous, comprehensivemandatory certification system that governs the entry and continuation of practitioners into the workforce based upon their talent and professional competence is imperative. This regulating system must be built to deliver the following:

• Ensuring mandatory, third party, independent certification at graduation as a practice requirement. India requires a national certification examination to ensure that all physicians meet universal, non-negotiable criteria of competence and professional aptitude independent of their school of graduation. Using a variety of testing methods (written, oral, practice simulation), this examination should ensure that prospective doctors have a) adequate medical knowledge, b) are skilled enough to apply their knowledge in making clinical decisions, c) have the right professional skills such as basic practice management, ethical concepts and legal principles to practice. The standard of examination also needs to be periodically studied, subject to evidence-based review and raise. Over time, newer skills and capabilities (e.g. ATLS stages, competence in basic intensive care, surgical skills) should be made mandatory for licensing. A professionally managed and appropriately incentivised independent institution should be created explicitly for ensuring enforcement of the licensing process (vide infra).
• Mandatory, competence-based practice certification renewal system. In addition to graduation testing, periodic testing to ensure competence to practice is essential and must be established. The system should issue renewals based upon direct competence and skill testing and not merely against participation in CMEs and seminars.
• Establish a licensing control system. In addition to practice certification checking and evaluation, a clear set of conditions for granting, suspending or permanently delicensing should be established. These should, as a means of policy, be linked to transparent criteria to reduce subjectivity in adjudicating these decisions that may get very politically charged.

The creation of such a regulatory system will require significant institutional reform of national and state medical councils. The biggest change will be one of mindset – from a machinery designed to scrutinise inputs and grant licenses to colleges to one that defines competence-based standards for ensuring talent quality (while continuing to set common minimum standards for infrastructure).

So-called ‘short term’ solutions to address the shortage may seriously affect teaching quality
From higher standards…	… to lower ones
Teaching eligibility; main specialities Professor: 4 research publications in national journal and 1 in international journal; 4 yrs experience as reader Associate Prof/ reader: 5 years experience as lecturer; 4 research publications Post graduate education Professor and 1:1 for other cadre Medical qualification granted by selected foreign medical institutes recognised	Professor: 4 research publication in national journal, 3 year experience as reader Associate Prof/ reader: 4 years experience as lecturer; 2 research publications PG teacher to student ratio 1:2 for Professor and 1:1 for other cadre For anaesthesiology, forensics and Radiotherapy, the ratio is 1:3 and 1:1 respectively More of the foreign medical institutes were included in the list of recognised institutes in subsequent schedules
Source: MCI website

The journey of creating this regulator will be a long and arduous one but is not without parallel and success stories – even in India itself. India would do well to consider the following principles in setting up the system:

• Restructure the MCI as a performance regulator and not a license issuer. This would include reconstituting the MCI as an independent body with its own Governing Board that sets clear five-year mandates and remains at arms’ length from management. It would also require to comprehensively re-structure the Council’s selection policies to attract appropriate talent to the role. For e.g. key management positions should be filled using global searches by emphasising right track record and achievements over qualifications and cadres.Selected individuals must be given specific, finite, measurable result areas and performance goals for their tenures. Financial autonomy, achieved through the levy of a fee (to teaching institutions) will also help ensure independence and mutual accountability.

• Decentralise the operation of regulatory governance into regional hubs, similar to that employed by the UK’s Royal Colleges. In addition to reducing administrative delays, regional (autonomous) hubs will also encourage innovation and competition among bureaux and accelerate the development of best practices.
• Establish a strong culture of review, audit and continuous improvement. The process of governing talent levels must itself be reviewed periodically. The correlation between methods, systems of evaluation and actual talent outcomes must continually be monitored. Standards of competence must periodically be reviewed and raised. Above this, new goals and targets must specifically be assigned to office bearers to ensure performance and accountability.
• Roll-out competence-based practice certification in a phased manner, including setting ‘lapse out’ clauses for older practitioners and so on. Several lessons in phasing in change may be learnt from other public agencies such as the Election Commission, pollution control boards and others.

Reform 2: Liberalise the industry to raise participation and spur innovation

As the competence based evaluation and certification system establishes, India rapidly needs to dismantle the license raj in medical education. Colleges must be given more leeway and flexibility over time to shape their agenda and test, validate and replicate innovative ways of teaching. Specific areas for liberalisation include:

• Enable participation in medical education. India should not discriminate against agencies from delivering education-based upon their business model: public, not for profit, private not for profit, and private for profit entities must be allowed to compete for students. Colleges should also be allowed greater autonomy in selecting candidates to admit and, over time, in charging their fees. Rules that impose outdated or economically unviable real estate requirements on hospitals (with little known benefits) also need to be done away with.
• Liberalise syllabi and pedagogy. Across the world, tremendous innovations are being attempted to fundamentally change how medical education is being delivered. A variety of innovations are being attempted – from shorter educational programmes to more immersive methods of teaching and usage of technology. Notably, these innovations have been possible only when institutions have been given both the autonomy and the incentives to do so. By removing input controls and establishing a strong skill focused regulatory system, India will create a strong platform for innovative ways of teaching while also ensuring that all graduates conform to a national standard of competence. Calibrated approaches may be used to achieve these goals, such as giving higher level of autonomy to institutes with a solid track record in producing quality medical graduates. Fee structures and charging methods will also need to be liberalised to enable institutions to generate adequate surplus to invest in teaching and care innovation and reward performance.

• Incentivise patient-friendly education. Traditionally, most Indian medical colleges have been attached to free or nearly free public hospitals. This has been necessary to attract poor patients on whom medical students learn clinical skills, principally via experimentation and trial and error. It is not uncommon for students to learn CPR (and make mistakes) on an actual human being, an ethically questionable practice. Policy planners must create strong incentives to replace direct patient experimentation with technology-based learning tools such as endoscopic learning labs, computerised robotic dummies, among others. Appropriate policies to incentivise the local manufacture and local development of these techniques needs to be strongly encouraged.
• Re-define the MCI. Finally, the role of the MCI too needs to be redefined from an organisation that sets entry parameters to an organisation that sees itself as the custodian and regulator of health education (e.g. like the TRAI or IRDA). The MCI must be reformed to play a larger policy and direction setting role to steward rather than license the growth and transformation of medical education.

Reform 3: Reform academia to make teaching a competitive career choice

In addition to creating a stronger licensing system and more innovative, inclusive educational institutions, real change will not happen (and sustain) unless India can also attract and retain high quality physicians and other professionals to become teachers. India should aspire to create an inclusive academic environment that allows teachers to be economically successful even if they do not practice. To achieve these goals, two key shifts are essential:

• Enable participative teaching. Indian policy planners need to create a far more nuanced, participative framework for governing teaching activities. At present, most regulations in most states grant teaching status to physicians largely based upon whether they are ‘full time’ or not. As a result, several highly competent physicians, with a flair and passion for teaching, find themselves debarred from playing a teaching role. To enable this, policy makers need to make a fundamental mindset shift: granting of teaching privileges should be based upon the teacher possessing the required clinical competence (usually acquired through clinical practice) and a fundamental interest in teaching; it should be delinked from modes of employment or association. Modern technologies such as biometric checking may be used to ensure requisite participation and logging of hours in teaching activities.
• Enable monetisation of teaching skills. Finally, policy makers would do well to keep in mind a fundamental economic reality for physicians: choosing a life of teaching involves major income loss due to the reduction in clinical practice. In several specialties, the magnitude of foregone income is a barrier to attracting teachers. Only when choosing a life of teaching represents a viable career option to private practice, will India be in a position to sustainably solve its medical teacher problem. We believe that while higher salaries may help; their role is likely to be limited. Instead,policy planners must encourage physicians in academia to create synergies between their employment and other opportunities. In the leading business schools across the US, professors have successfully created a virtuous cycle of academic work that creates external advisory/ teaching opportunities that provide additional perspectives to further the teaching/ academic goals. In a similar vein, India too must allow medical school teachers to monetise their teaching skills. For instance, a highly sought after classroom teacher should be allowed to license out broadcasts of his or her lectures to other medical schools or teaching companies for a fee/royalty, similar to digital downloads of music.

Through these reforms, India will pave the way for creating a medical education system that is likely to be far more innovative, responsive to talent needs and sustainable than it is today. These reforms will also enable India to address the dual concerns of quality of teaching and quantity of physicians in a sustainable way.

Conclusion

Reforming medical education in India is likely to be challenging. With healthcare being a concurrent subject, it will be impossible for either the centre or an individual state to change the landscape of this sector holistically. The long lead times in medical education and the time duration between reforms and results (typically a decade or longer) will stress political systems and short-term incentives. Strong cross-party political support will be crucial to making any meaningful headway.

The road to a world-beating medical education system will hence be long, arduous and challenging. It will be a test of Indian politicians’ leadership to ensure that they stay the course.

But stay the course they must: nothing less than the lives of 1.25 billion Indians are at stake.