Why Adding Medical Colleges Isn’t Enough To Improve India’s Healthcare

Yet, both public and private institutions continue to face a range of issues including faculty shortages and infrastructure issues, revealed a study on medical education by the Center for Social Economic Progress (CSEP), a Delhi-based think-tank. The study also highlighted regulatory complexities and budget constraints which impede private-sector involvement in medical education.

India has 0.9 doctors for every 1,000 people, close to the World Health Organization standard of 1:1,000. Yet, the country’s secondary care institutions in the public sector have an acute shortage of specialists, data show. Experts call for more investment on medical education, ensuring availability of infrastructure and faculty, and increased participation from the private sector to improve postgraduate medical education in the country, thereby increasing the number of specialists.

Telangana added 31 colleges, Kerala shut one college

During this period, Telangana added 31 medical colleges--highest among all states--followed by Tamil Nadu, with 25 colleges, and Uttar Pradesh, which added 21 colleges. Jammu and Kashmir and Jharkhand tripled the number of colleges, while Assam, Manipur, Rajasthan and Telangana doubled the number of medical institutions, data show.

Kerala, which has among the best primary healthcare systems in India, had 33 colleges as of 2023-24, down from 34 in 2017-18.

The top five states--Tamil Nadu, Karnataka, Uttar Pradesh, Maharashtra and Telangana--have 47% of all medical colleges, data show. The distribution of medical colleges across states can impact the availability of healthcare services and the quality of medical education in different regions, said the CSEP study.

The number of seats rose 60.6%, with 4,890 seats added in Telangana--the highest of any Indian state. This was followed by 4,750 more seats in Tamil Nadu and 3,475 in Maharashtra. Six states--Assam, Jammu & Kashmir, Jharkhand, Manipur, Rajasthan and Telangana--have more than double the number of seats as they did five years ago, data show.

Over the last decade, the number of medical colleges and seats has increased primarily due to the growth of government medical colleges and the relaxation of norms for setting up new medical colleges, according to the CSEP study.

Further, the increase in seats in both public and private colleges at the undergraduate level was higher than the rate of expansion of medical colleges, the study noted, indicating “that at least part of this expansion was on account of the relaxation of existing norms, thus enabling higher student intake, without any real augmenting of accompanying physical and human infrastructure”.

Despite the increase in medical seats, availability of medical seats remains a key concern in India, as per the CSEP study. In 2022, 1.76 million aspirants appeared for the National Eligibility cum Entrance Test exam, a national pre-medical entrance examination. While 56.3% candidates qualified, according to data from the National Testing Agency responsible for conducting NEET, only 12% secured a seat in a medical college, the study noted.

Further, availability of specialists remains a key concern. Non-communicable diseases (NCDs), which often require specialist care, account for two-thirds of India's deaths. The estimated deaths due to NCDs increased from 37.9% in 1990 to 61.8% in 2016, as per data from the health ministry, emphasising the need for specialists.

From 2005 to 2021, specialist shortfalls at community health centres--the secondary level of healthcare which tend to patients referred from primary health centres--increased from 46% to 80%, the study noted. Specialist production depends on factors like medical colleges, teaching faculty, and available seats, but detailed data are lacking, it said. Government data show that the number of postgraduate seats in the country doubled--from 25,850 in 2015-16 to 52,935 in 2023-24.

Most of this increase has been in the government medical colleges. Public colleges contribute more to PG seat expansion, with private colleges favouring Diplomate of National Board (DNB) seats. The government introduced the DNB course in 1975 to address the shortage of doctors and teaching faculty. DNB focuses on practical training, and currently contributes 19.7% of the all PG seat pool, with 67% of the DNB seats in the private sector.

The PG-to-UG seat ratio in India is 0.67:1, which is low in comparison with other countries such as China (1.01), the United States (1.85) and the United Kingdom (5.98), the study noted. This is coupled with a rise in vacant seats at the postgraduate level.

These vacant seats are often in fields with historically low demand and limited student interest, and typically include non-clinical and pre-clinical fields such as pharmacology, anatomy, physiology, biochemistry and microbiology, the study noted. “While most MBBS seats are occupied, a sizable number of seats remain vacant at the PG level,” said Khushboo Balani, a research associate with CSEP and one of the authors of the study. “Demand plays a crucial role, and low-demand PG seats may remain unfilled or even be given away at a reduced cost, while high-demand seats remain inadequate."

IndiaSpend has reached out to the offices of Mansukh Mandaviya, India’s health minister, Amit Biswas, undersecretary for medical education, and Chandan Kumar, under secretary for medical education for comment on the faculty shortages in indian medical colleges and how the government plans to address specialist shortage in the public health system in India. We will update the story when we receive a response.

Doctor population ratio remains an issue

At 0.92 doctors per 1,000 population, the number of MBBS doctor supply is close to the World Health Organization guideline of 1 doctor per 1,000 people, as per the National Health Profile 2021. This ratio varies significantly across states. Goa has the highest doctor-population ratio at 2.53 doctors per 1,000 people, followed by Sikkim at 2.13. Karnataka and Tamil Nadu had ratios of 1.92 and 1.91, respectively. In contrast, states such as Bihar and Uttar Pradesh had lower ratios of 0.38 and 0.37, respectively.

“While government colleges do improve local availability, due to their bond requirements, the larger problem of overall doctor availability remains unaddressed. In essence, establishing a medical college in an under-resourced area doesn't assure enhanced local availability," said Balani.

The doctor-population ratio in India improved from 0.66 in 2010 to 0.9 in 2019, but much of this increase is driven by select states, the study noted. Factors like per capita income, state-specific policies, and retention incentives for doctors play substantial roles and state-specific incentives and disincentives further influence doctor availability, the study noted.

Experts also point to the fact that doctors refuse to move to rural areas due to bad living conditions and expensive education. The rural doctor shortage is not primarily about supply; we are producing enough doctors, said Rakhal Gaitonde, professor of public health at the Sree Chitra Tirunal Institute for Medical Sciences and Technology. “The core problem is that many doctors opt against practising in rural areas for various reasons. These encompass concerns about the quality of education for their children (and the quality of education in general), limited professional networks, feelings of isolation, and inadequate preparation during their education," said Gaitonde.

Reasons for shortages

a. Funding for medical education

The expenditure on medical education, training, and research as a percentage of total health expenditure varied significantly across Indian states between 2015-16 and 2020-21, the study found, based on data from the Combined Finances reports of the Comptroller and Auditor General.

For instance, Andhra Pradesh saw fluctuations from 8.28% to 12.23%, while Arunachal Pradesh experienced a wide range from 0.96% to 16.76%. States like Karnataka consistently invested a significant proportion, increasing from 27.04% to 30.59%. These figures reflect the diverse priorities and resource allocations for medical education across the country, as IndiaSpend reported in May 2022.

The health sector budget has been growing slowly, said Sandhya Venkateswaran, senior fellow at CSEP. “It is important to consider not only the overall health budget but also how it is allocated, including the budget for medical education. The persistent gaps in the healthcare workforce have been a concern for years, yet the budget for medical education hasn't seen any substantial increase.”

The study found a strong and linear correlation between state-level spending on medical education and seats at government medical colleges. Assuming that the impact of spending will be seen with a lag, the authors looked at spending in 2014-15 and available seats in 2018-19. States like Nagaland and Sikkim did not have government medical college seats despite spending on medical education, the study found. In contrast, Goa, spending Rs 606 per capita (4.6 times the national average), had one medical college with 0.1 seats per 1,000 population.

There is high investment, low returns and long gestation period because medical colleges are resource-intensive and require substantial infrastructure, said Gaitonde. “Larger states with fiscal capacity are better equipped to make such investments since it takes several years to produce the first doctors and see returns on investment. The interplay of supply and demand, along with fiscal capacity, drives the growth of medical colleges.”

Lack of teachers, faculty and patients

Despite expansion efforts, both old and new medical institutions, including 11 of 18 operational AIIMS, grapple with severe teaching faculty shortages, resulting in high teacher-student ratios exceeding the recommended 1:2 or 1:3, the study found.

Additionally, there has been a reduction in sanctioned teaching posts and increased vacancy rates. These faculty shortages are more pronounced in public institutions compared to private ones. Newly established AIIMS-like institutions also face resource overburdening due to high student-teacher ratios, the study found. Student-teacher ratios vary from 2:1 in Bilaspur to 5.4:1 in Gorakhpur, the government told Lok Sabha in December 2022.

Gaitonde stressed the need for a more holistic approach instead of looking to build a medical college to solve the problems of medical education. He stressed on the need for well-qualified faculty, support staff, and comprehensive planning, and financial incentives in drawing doctors from the private sector, and suggested that to retain quality medical professionals in public sector medical colleges, appropriate incentives should be provided.

The study identified complex hiring processes and administrative issues as the main reasons for these vacancies. In contrast, private colleges tend to have lower vacancy rates due to the risks associated with derecognition. “A fundamental structural problem is the opportunity cost of teaching compared to practising. This factor often discourages doctors from transitioning to teaching roles, demanding attention to find innovative solutions to incentives for teaching faculty," said Venkateswaran of CSEP.

Public vs private

Private colleges have more undergraduate medical seats than government colleges, as we said above. However, experts believe that private colleges can also help bridge the demand-supply gaps when it comes to specialists, which requires high investments.

Amrita Agrawal, visiting fellow at CSEP, stressed that the challenge becomes more prominent when dealing with specialist training, which demands more elaborate infrastructure. She also pointed out that "localising production does not necessarily equate to an increase in the local availability of specialists due to inter-state migration".

“Most private sector seat capacity is concentrated in developed Southern states, highlighting the supply and demand dynamics that drive private sector expansion. However, we have seen doctors graduating from some southern states with large private medical seats migrating to other parts of India,” said Agrawal.

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