|Year : 2017 | Volume
| Issue : 3 | Page : 182-187
Aggregate availability of doctors in India: 2014–2030
Associate Professor, Economics and Business Policy, FORE School of Management, New Delhi, India
|Date of Web Publication||15-Sep-2017|
FORE School of Management, B-18, Qutab Institutional Area, New Delhi - 110 016
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The current belief of availability of doctors in India is based on the registration stock of doctors accumulated since the early 20th century. This has not been adjusted to attrition of the strength occurring due to retirement, emigration, etc. Objectives: To estimate the number of practicing doctors currently available in India and will be available in 2030 after adjustments made for attrition of the stock. Methods: The paper used Medical Council of India's historical data (1960–2015) on registration stock of doctors obtained from the Indian medical registers available on its website and other data on emigration of doctors accessed from Organization for Economic Cooperation and Development and destination country sources. Results: The paper found that there were only 4.8 practicing doctors per 10,000 population available in India in 2014, in contrast to the belief of having 7 doctors per 10,000 people. Rest of the registered doctors have either retired or emigrated from the country to practice abroad. It is estimated that the country would be able to achieve a ratio of about 6.9 practicing doctors per 10,000 people only by 2030. Conclusion: Given these findings of the current availability of doctors per 10,000 people and their growth prospects over the next 15-year period, it looks like an impossible task to achieve even a moderate doctor-population ratio of 1:1000 by 2030. Therefore, a genuine commitment to provide equitable healthcare to the rural population must innovate and experiment a special cadre of practitioners for rural areas on a pan-India basis.
Keywords: Availability, doctors, India, migration and health
|How to cite this article:|
Potnuru B. Aggregate availability of doctors in India: 2014–2030. Indian J Public Health 2017;61:182-7
| Introduction|| |
The achievements of India on basic health indicators such as life expectancy at birth (66 years in 2013), infant mortality rate (41.4 per 1000 live births in 2013), maternal mortality (190 per 100,000 live births in 2013), and births attended by skilled health personnel (67% in 2007–2014) are less and disappointing compared to those in the similarly advanced Southeast Asian nations such as Indonesia, Philippines, and Sri Lanka, and even more disappointing compared to the other emerging group of BRICS nations, such as Brazil, Russia, China, and South Africa [Table 1]. The relative inaccessibility of primary healthcare and undernourishment among children in India is among the most important causes of backwardness of Indian health status. It is clear from the fact that the percentage of childbirths attended by the skilled health personnel in India is only 67 (2007–2014), compared to 73 in Philippines, 83 in Indonesia, 94 in South Africa, 99 in Brazil and Sri Lanka, and 100% in China and Russia [Table 1].
Capacity of production of doctors
There were only 19 medical colleges and universities imparting medical education in India at the time of independence. Their number increased to 86 by 1965 and 143 by 1990. In the postreform period, due to the rapid privatization of medical education, the total number of medical colleges increased much rapidly to 287 by 2009 and further to 412 by 2015. In 1990, 33% of the medical colleges were privately owned, which increased to 57% in 2011. The annual first-year graduate enrollment capacity in these colleges accounted for about 51,825 in 2015–2016 academic year. The number of doctors entered into Indian medical registers annually increased from about 4,066 in 1961, to 14,023 in 1991, 21,263 in 2001, and 33,927 in 2011. This number however decreased to 26,342 in 2014. Consequently, the accumulated stock of registered doctors expanded from about 75,594 in 1960, to 393,424 in 1990, 566,102 in 2000, 824,673 by 2010, and further to 943,529 by 2014 [Figure 1].
|Figure 1: Number of doctors registered (stock) and available for practice (active) by select years, 1961–2030. Data on registered stock of doctors for select years 1961–2014 are actuals and the same projected for 2020 and 2030 based on past decennial growth rates. |
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The rapid growth of medical doctors through recent expansion of private medical education could not transform the basic health outcomes of the population in a significant way, as evident from [Table 1]. The major reasons are: one, recent increase in the number of medical practitioners is not adequate to match the much rapid increase in aggregate health-care needs of the rising population; two, the higher capabilities and expectations of the medical practitioners, especially specialist doctors, do not match with the primary health-care requirements and affordability of the majority of people in rural areas; and three, increase in the number of registered doctors (stock) do not reflect the actual availability of doctors in the country, i.e., the stock is erroneously perceived as the availability of doctors in the country ignoring the attritions occur due to retirement, emigration, switching of profession, etc.
According to the WHO and the Ministry of Health and Family Welfare, Government of India has 7 doctors per 10,000 population. However, this ratio is derived based on the registration stock of doctors in India accumulated including those doctors who have qualified and registered ever since the early 20th century. This has not been adjusted to attrition of the strength due to retirement, discontinuation of practice, emigration and death of doctors. Therefore, this paper attempts to provide a reliable estimation of the availability of practicing doctors in the country taking into consideration current and future levels of production and attritions due to retirement and emigration. It also estimates the availability of practicing doctors in 2030; the year earmarked to achieve “health for all” by the UN's Sustainable Development Goals (SDGs).
| Materials and Methods|| |
The paper depended on the Medical Council of India's historical data (1960–2015) on registration stock of doctors obtained from the Indian medical registers available on its website and other data on emigration of doctors accessed from destination country sources. The paper also used information from secondary sources such as published articles and reports.
In the absence of official data on the retirement of doctors, to make a reliable estimate of the number of doctors practicing in the country, it is assumed that all those doctors who have registered 35 years before must have retired by now. This assumption is made based on the following two facts: (a) To qualify as a doctor and start medical practice, it needs 10–12 years of medical training at the tertiary education level, and (b) normal life expectancy in India is 63–65 years in 2014. This implies that a doctor normally starts medical practice at the age of 28–30 years and serves for 35 years before attaining the age of 65 years. Those who live and practice the profession beyond 65 years of age are considered to be practicing only part-time, and therefore, are excluded from full-time workforce count. In addition to this, significant number of Indian doctors who have registered with the Indian Medical Council also migrated from the country to practice abroad. Apart from these two reasons, there is also a possibility of doctors voluntarily stop medical practice, switch to another profession, etc., Taking into consideration of all these possibilities of attrition of the strength of doctors, the availability of practicing doctors at any point of time may be derived using the following formula:
- Where, ADt is availability of doctors in year “t”
- SDt is stock of doctors registered in year “t”
- SDt-35 is stock of doctors registered in year “t − 35”
- ESt is emigrated stock of doctors practicing abroad in year “t”
- is sum of the number of doctors who stopped practicing medicine for various other reasons during the past 35 years at period t (that is, t − i where i is 1, 2,…, 35).
Registered stock and retirement of doctors
[Figure 1] shows the number of doctors registered (stock) and the estimated number of doctors available (active) for full-time practice in the country after deductions made for retirement. Accordingly, it is found that there were only 690,568 doctors constituting 73.2% of the registered stock of doctors (943,529) available for medical practice in the country in 2014 [Figure 1]. In other words, 27% of the current registered stock of doctors have already retired. As per the national population data, there were 1239 million population living in 2014, the doctor-population ratio based on this availability turned out to be 5.57 per 10,000 people [Figure 2].
|Figure 2: Number of doctors registered and active per 10,000 population by select years, 1961–2030. Population data and projections taken into account for 1961:438 million (mn), 1971:548 mn, 1981:683 mn, 1991:846 mn, 2001:1028 mn, 2010:1186 mn, 2014:1239 mn, 2020:1353 mn, 2030:1476 mn.|
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[Figure 1] and [Figure 2] also show projections of an increase in the number of registered doctors (stock) for 2020 and 2030 based on the past decennial growth rates. That is, if the number of registered stock of doctors in India continue to increase at the pace it had increased in the past (i.e., roughly at 45% decennial growth), India will have 1,195,775 stock of doctors registered in 2020 and 1,733,873 in 2030 [Figure 1]. Taking into account the retirement of doctors alone (attrition by all other causes if assumed nil) by then, the available doctor-population ratio will improve to only 6.41 and 8.54 per 10,000 population, respectively by 2020 and 2030 [Figure 2].
Extent of emigration of doctors
Since 1960s, India has been one of the most important source country of medical doctors for the advanced countries. [Figure 3] shows annual outflow of Indian medical graduates to the four major destination countries such as US, UK, Canada, and New Zealand for the period 2002–2013. It shows that annual entry of Indian medical graduates to the UK has declined considerably from the peak of 3641 doctors in 2004 to merely 342 in 2013. This is due to the reason that the aggressive recruitment practices of the National Health Service Plan 2000, which set ambitious targets to achieve staff expansion of an additional 7500 consultants, 2000 general practitioners, and 20,000 nurses by 2004., These targets were in fact overshot leading to recruitment freezes which led to dramatic decline in the entry of Indian medical graduates to the UK after 2005. However, owing to the changing demographic trends with rapidly ageing population that would need increased health care and the future retirement patterns of the baby boom generation doctors in large numbers in the UK are expected to revive the demand for international doctors.
|Figure 3: Outflow of Indian medical graduates to select destination countries, 2002–2013.|
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There has been a gradual increase in the annual entry of Indian medical graduates to the US from 1526 in 2002 to 1868 in 2009. Thereafter, however, it has declined sharply to 966 by 2013 [Figure 3]. This decline is perhaps because of the effects of 2008 recession in the US. However, projections of future supply and demand for physicians in the US suggest a shortfall of 46,100–90,400 physicians by 2025. Owing to these emerging shortages, American Medical Association has been recommending the government to increase Graduate Medical Education positions across the board to meet the needs of US-trained students, as well as to make it easier for international medical students to enter the US. Thus, it is anticipated that as economies recover from recession completely, the demand for international doctors would increase both in the UK and the USA.
Despite the recent decline in the entry of Indian medical graduates to the US and UK [Figure 3], their accumulated stocks in these countries were staggeringly high in 2013–2014. According to the General Medical Council, UK, there were 25,116 Indian medical graduates registered with it in 2013. Of them, 23,420 were given license to practice. Similarly, Federation of State Medical Boards, USA reported that 48,337 Indian medical graduates were given licenses to practice in the US as on 2014., There are also about 3981 Indian medical graduates practicing in Australia, 1943 in Canada, 468 in New Zealand, 177 in Germany and 36 in Norway in 2013 [Table 2]. Gulf countries also host significant number of Indian doctors. Although no reliable data are available on the number of foreign doctors working in the Gulf, media reports indicate Gulf countries employ large number of doctors from South Asia region. In Oman, there were about 2000 Indian doctors. The Indian doctors in Kuwait formed an Indian Doctors Forum, which had about 500 members of Indian origin in 2007. An estimate suggests that about 20,000 doctors from South Asia region with the majority from India alone present in the Gulf. In the absence of accurate data, even if we safely assume that about half of them were from India, the total stock of Indian doctors present outside the country (all over the world) accumulate to about 90,537 [Table 2]. This constituted around 13% of the active doctors (after deductions made for retirement) in the country in 2014.
|Table 2: Stock of Indian medical doctors practicing abroad by host country, 2013-2014|
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As discussed above, keeping in mind rapid aging of population in the Western countries with negative implications on the size of their health workforce and increasing elderly population, it is pertinent to anticipate that the outflow of Indian doctors to overseas destinations would increase further in future. Recently, during the boom period of 2004–2011, India has witnessed return flow of Indian doctors from abroad especially to work in the private corporate hospitals. Nevertheless, these flows were very much limited to make any significant impact on pan India estimation of the availability of doctors in India. However, considering both emigration and return migration of doctors, Indian planners may anticipate a net-emigration of at least 120,000–130,000 doctors (assuming the current emigration rate of 13% of the available doctors prevail) from the country to immigration abroad in 2030.
| Results|| |
Estimation of the availability of practicing doctors
To estimate the availability of practicing doctors in India for 2014, the latest year for which data are available, recall equation (1) and compute the data:
Thus, there were 600,031 doctors available for practice in India in 2014 to serve its 1239 million population with a doctor-population ratio of just 4.84 per 10,000 people. This ratio is significantly lower than what has been published in the World Health Statistics 2015 as 7 per 10,000 population for 2007–2013. It may be noted that due to unavailability of data, the leakage of doctors for reasons such as those who discontinued medical practice due to change in profession, death or for any other reason during 1979–2014 (35-year period) is assumed to be zero. Thus, taking into account of only two important causes of attrition of doctors such as retirement and emigration, the strength of practicing doctors reduced by 36.5% of the stock and the doctor-population ratio slipped from 7 to 4.8 per 10,000 population.
Similarly, the availability of practicing doctors in 2030 based on the estimation of the stock and attrition due to retirement and emigration by then will be as follows:
Thus, if the registration stock of doctors continues to increase at the rate it has increased in the last two decades, the availability of practicing doctors in 2030 will be 1,018,008, after deductions made for retirement and emigration of doctors. This would give a ratio of only 6.9 practicing doctors per 10,000 people in 2030, given Indian population estimation of 1476 million in 2030.
To achieve a moderate doctor-population ratio of 1:1000 by 2030, the country would need to have a registered stock of 2,074,350 doctors by then, so as to make available 1,476,000 active doctors after deductions made on account of retired and emigrated doctors in 2030. This would require the registered stock to grow by 151% in the 20-year period over the stock of 2010. Given only 14.41% growth rate achieved in the stock over a 5-year period between 2010 and 2014, 151% looks like an impossible target to achieve in rest of the 15-year period.
| Discussion|| |
Apart from the aggregate shortfall of doctors in India, severe problems lie in their distribution and access across states and in the rural and remote areas. Based on the State Medical Councils' registration data, Maharashtra alone accounted for 14% of the total stock of doctors, while other populated and comparatively backward states such as Madhya Pradesh and Rajasthan accounted for a little more than 3% each in 2015. The current shortage of doctors in rural areas are mainly due to four reasons: (1) there is an aggregate shortfall of doctors in India, (2) there is greater demand for doctors and associated higher returns to them in the urban areas, (3) lack of adequate infrastructure, technology and facilities in the rural areas, and (4) unsuitable training standards of medical education to the rural needs.
The first reason is directly associated with inadequate production of doctors in the country to adequately meet the needs of its growing population. The analysis in this paper shows that current ratio of “practicing doctors” to population is merely 4.8 per 10,000. Since the gap between the registered stock of doctors and those available for practice is widening, doctor-population ratio derived based on the stock of registration data can no more be true. There is a need for about 1,476,000 practicing doctors in 2030 to meet a doctor-population ratio of 1:1000 people. This needs an impeccable growth rate of the registered stock of doctors by 151% in the 20-year period from 2010. Moreover, it may be noted that even 1 doctor per 1000 people in the aggregate may not necessarily ensure adequate access of doctors in rural areas.
Three other reasons stated above that cause unequal distribution of doctors in the country are structural in nature and would need a long-term plan to address them. Under the current inadequate conditions in rural areas in India and in a situation of continued aggregate shortfall of doctors in the country as we discussed in this paper, it may be illusory to expect large number of doctors and specialist to adequately serve in rural areas even by 2030. Therefore, a genuine commitment to provide adequate, equitable, and sustainable healthcare to the rural population is to innovate and mandatorily introduce a special cadre of practitioners for rural areas on a pan-India basis.
The infrastructural support provided by the Fore School of Management, New Delhi for undertaking this research is gratefully appreciated. The author has benefited from the feedback received on the presentation of an earlier version of this paper made at an International workshop-cum-seminar on “education, migration and global development agendas: MDGs and SDGs” organized by International Migration and Diaspora Studies Project, Zakir Husain Centre for Educational Studies, Jawaharlal Nehru University, New Delhi on February 18-19, 2016.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vallyamma P, Deshpande SR, Gayathree L. Mal-distribution of medical manpower resultant decay of the Indian medical education system: Existing problems and possible solutions. Br J Med Pract 2009;2:46-9.
Rao M, Rao KD, Kumar AK, Chatterji M, Sundararaman T. Human resources for health in India. Series: India: Towards Universal Health Coverage 5. Lancet 2011;377:587-98.
World Health Organization. World Health Statistics 2015. Part II: Global Health Indicators. Geneva: World Health Organization; 2015.
Khadria B. The Future of Health Worker Migration. Background Paper, World Migration Report 2010. International Organization for Migration, Geneva; 2010.
Organization for Economic Cooperation and Development. OECD Statistics. Available from: http://www.stats.oecd.org
. [Last accessed on 2015 Jan 05].
Potnuru, B. Indian Medical Education, Migration of Doctors and Sustainable Workforce. Working Paper No. 2016/12. FORE School of Management, New Delhi; 2016.
General Medical Council. United Kingdom. Available from: http://www.gmc-uk.org/
. [Last accessed on 2014 Dec 01].
Thakur A. One of Four Foreign Doctors in US has Graduated from India, The Times of India, New Delhi; 9 Jan 2016.
Indian Council of World Affairs. Report of the High Level Committee on Indian Diaspora. New Delhi: Indian Council of World Affairs; 2001.
Adkoli BV. Migration of health workers: Perspectives from Bangladesh, India, Nepal, Pakistan and Sri Lanka. Reg Health Forum 2006;10:49-58.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]