On the lines of All India Institute of Medical Sciences (AIIMS) in New Delhi, our government, and one has to commend them for it, wants to build an AIIMS in every state. This model of central government medical institutes with direct funding from the centre has been enormously successful and generally, these institutes command a much higher level of respect and recognition amongst the medical fraternity. No surprise hence that, young doctors used to aspire to work in these institutes. Not only this, even state medical colleges’ faculty position used to be held in high regard. Yes, you weren’t paid a lot of money but the salaries were comparatively decent enough and the respect you got in the society more than made up for the lower wages. However, this is all changing very-very rapidly and if media reports are anything to go by even the AIIMS (the old and the new ones) are now struggling to recruit faculty. One has to wonder if this is the situation for AIIMS, what is happening to our state medical colleges and of course the private ones? Are medical students in India really getting the education they deserve or are we just giving them the degrees?
Traditionally our government has never struggled to recruit and retain. After all, there has never been a shortage of people in India and governments have always had too many seeking too few jobs. But these dynamics are changing. With a growing and vibrant private sector that has the resources to recruit and retain the best with world-class facilities for patient care, much better remuneration, and more responsive management, many doctors are choosing to work for them rather than the public sector. The tag of an Assistant Professor or Professor is no longer sufficient to entice them to our medical colleges and seems to be too high a price to spend the whole life working in substandard (at times sub-human) facilities where the opportunities for career progression are few and far between and red tapes every step of the way.
Remuneration lies at the heart of all human endeavours. If you pay well enough, it is more likely that you will be able to get the best and the brightest to work for you. Why would you want to waste your life in a medical college when you know that if you devoted some of your earlier years to the private sector and made a name for yourself, you will be earning many times that amount for the rest of your life? Not only that, there is no retirement age in private sector; so once you have built a name for yourself, you can continue to work for as long as you like.
The gap in remuneration between the private and the state hospitals in India has over the years widened significantly. If this imbalance was not corrected, the day is not far when we will not have any faculty in our medical colleges. A typical faculty in a medical college has spent between 10-12 years, often longer, studying and learning. On top of it, they work unsocial hours, weekends, and generally have a more stressful life. Their offices are what you’d describe as very basic compared to other working environments for senior professionals in the country and generally they deal with the most deprived and the most vulnerable in the society. On top of it, they have the responsibility to train the future generation of doctors and move the science forward by engaging in research. This is a demanding job and the current remunerations are simply not enough to recruit and retain high-quality professionals in these roles. I would say provide them what they need and in lieu hold them accountable for patient care, training, and research. The fact that nobody wants these jobs in the first place doesn’t leave us with much of a bargaining chip when we wish to raise the standards of services that we should expect from senior medical faculty.
Sooner or later, we will have to devolve the management and indeed the finances of our government (both central and state government run) hospitals and medical colleges to people on the ground. Our institutes struggle because they are controlled by bureaucrats sitting remotely. The local authorities have little power to change the basic framework and hence, unsurprisingly, don’t feel any sense of accountability when systems fail. After all, we can only hold a local hospital director or superintendent accountable if s/he has some powers to change something. The United Kingdom has attempted to encourage local decision making by giving individual hospital trusts “Foundation” status, which means they can take local decisions free of bureaucratic influences. We need to devolve and empower our educational institutes in India if we wish to see them compete at the global level. Give them some independence to control their administrative and financial affairs, including the freedom to use innovative methods to generate revenue, and then, by all means, hold the higher management accountable for lapses. I think we need to have a national discussion on this topic and it probably needs to go beyond the medical colleges and hospitals to include universities and other educational establishments.
The government recognises that it needs to increase the pool of eligible faculty who can provide these services and recent move to increase the retirement age of faculty in AIIMS was aimed precisely at that. Though on the face of it, this seems to be a relatively easy fix, increasing retirement age may have its own problems. In addition to being more costly as these senior faculty members are likely to be at the top salary brackets, it can discourage younger professionals if the opportunities for career progressions decrease further. In my opinion, senior professionals should be asked to relinquish positions of authority within departments when they are permitted to work beyond the retirement age. But on the whole, increasing retirement age is a short-term fix and we need to think about expanding the pool even wider. Let us not forget there are tens of thousands of NRI/OCI/PIO doctors who may be willing to return for the right package. Many of them also have Indian qualifications already recognised by the Medical Council of India (MCI) but we should think of expanding the qualifications recognised by MCI further to include many foreign ones even if the countries in question do not recognise ours. Let us face it, the bar is much higher in many advanced economies and to say that we will only recognise American or British qualifications if they reciprocate in equal measure will only prevent us from recruiting the finest talent out there.
Even in 2017, the way most government jobs, including the medical ones, are advertised is archaic. You will almost have to know in advance that they are looking for people to be able to find such notices hidden in the middle pages of our newspapers. It can hardly be described as a meaningful attempt to reach out to the widest section of the potential candidates. One does wonder why in this day and age, we can’t create websites like NHS Jobs or BMJ Careers where all the medical jobs in every single remotes part of the country are listed to make it easier for doctors and nurses to find out about them. After all, we have some of the best software companies in the world and if we start paying them properly and on time, they might even be willing to work for the Indian government and not just the Americans, who it would appear don’t want them anymore. If we had all the jobs listed in one place, the whole process will become much more transparent and people anywhere in the country (and even abroad) will be able to apply for them.
Academic doctors want adequate facilities to look after their patients in. They want latest medical advances available to them so that they can practise cutting edge medicine. They want facilities and funding to carry out high-quality research and they want remunerations that are equivalent to the private sector. If we aspire our government hospitals to achieve and maintain highest standards, we will have to provide these facilities to the doctors there. Failure to make our government jobs attractive to the young professionals will only mean continued emigration of talent to the private sector and countries that value them more. It is a simple matter of market dynamics and can’t be too difficult to understand for a government really serious about improving the situation.
Following his graduation from Calcutta Medical College and post graduation from Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Dr Kamal Mahawar is now a Consultant General and Bariatric Surgeon with Sunderland Royal Hospital in the United Kingdom. He is also an Associate Clinical Lecturer with Newcastle University and editor of renowned scientific journals. His recent book ‘The Ethical Doctor’ published by Harper Collins India examines some of the serious issues affecting Indian healthcare.