Paper short abstract:

The paper discusses three issues: (a) the role of the private sector in medical education, particularly its growth and regional distribution; (b) the availability and distribution of doctors in India, with a special focus on inter-state variations and rural-urban disparity; (c) mapping out the regional variations in the availability of doctors and COVID-19 death and infection rate.

Paper long abstract:

Human resource availability is critical for effectively providing and delivering quality health care to India’s vast population. It drives health outputs and outcomes, including immunisation levels, the outreach of primary care, and infant, child and maternal survival (WHO 2006; Anand and Barnighausen 2007; Mitchell et al. 2008; Rao et al. 2012). Also, India’s mandate for universal health coverage (UHC) — developing a framework for providing easily accessible and affordable health care to all Indians — depends, to a large extent, on an adequate and effective health workforce providing care at primary, secondary and tertiary levels. Likewise, to achieve the Sustainable Development Goal (SDG) 3, which aims to ensure health and well-being for all, India needs to improve the availability of human resources for health. More importantly, healthcare workers play a vital role in the fight against COVID-19 Pandemic. However, even with the recognition of the importance of the health workforce for delivering better health care, more so in the recent Pandemic, there is an acute shortage of health and care workers in India. The World Health Statistics Report (WHO 2022) reveals that in India, between 2012 and 2020, there were 24.9 health workers per 10,000 population (7.4 doctors and 17.5 nurses and midwives)—more than half of the global average of 55.9 workers per 10,000 population (16.4 doctors and 39.5 nursing and midwifery personnel). Even after two decades, the availability of human resources (doctors, nurses and midwives) in India is less than the threshold of 25 health workers per 10,000 population as established by the Joint Learning Initiative (JLI) of the World Health Organisation (WHO) in 2004.

Health and care workers (HCWs) are part of the frontline facing the Pandemic. The Pandemic has affected their physical, mental and social well-being (Nguyen, Drew, Graham, et al. 2020). There has been a significant death of health workers during COVID-19. In India, as per the Indian Medical Association (IMA) data, around 1342 doctors have died in the line of duty ever since the Pandemic began in March 2020, and this figure is likely at the lower bound. Many health workers continue to work in under-resourced and fragile health systems, with inadequate personal protective equipment, dealing with a situation that was unprecedented consequences (Essex & Weldon 2021). Health and care workers in India have faced grave concerns where their density is low, and they need to serve many patients, for instance, in rural and semi-urban areas.

How does India address the issue of human resources for health, a critical factor to the human development and well-being of the Indians? Mainly, what are the post-pandemic strategies to address this concern? It is argued that states in India are struggling with the complexities of escalating human resource costs, additional demand for the health workforce, uneven distribution, and skill-mix imbalances, and the intervention of the private sector is suggested as a potential alternative in solving these issues (Jilani et al 2008; Davey et al 2014). Thus, in the past several decades, the private sector has grown participation in building up the health workforce in India, particularly by establishing many medical and nursing colleges (Mahal and Mohanan 2006). For instance, in the last three decades (1990 to 2020), private medical colleges increased by 540%, whereas government-run medical colleges grew up only by 174% (Kumar, 2022).

In this context, the paper discusses three issues: (a) the role of the private sector in medical education, particularly its growth and regional distribution; (b) the availability and distribution of doctors in India, with a special focus on inter-state variations and rural-urban disparity; (c) mapping out the regional variations in the availability of doctors and COVID-19 death and infection rate. Specific questions raised in the paper are:

1. How has the private sector intervention in medical education resulted in regional inequality in the availability of health and care workers in India?

2. Is the availability of doctors in a specific state/region linked to patient infection and death in India?

3. How to improve the coping strategies and dynamic capabilities among doctors to serve patients during pandemics like COVID-19?

The paper uses data from the National Medical Commission, National Health Profile and Rural Health Statistics published by the Ministry of Health and Family Welfare, COVID-19 statistics of the Government of India, and the World Health Organisation. Descriptive statistics and multi-variate regression techniques are used to analyse the data.

This study finds that one of the most dominant features of Indian medical education is the rapid expansion of the private sector (especially after the 1990s), which has led to regional inequality in the production and distribution of doctors. Interestingly, this growth has occurred primarily in the more developed states with better health outcomes, while the low-income states with poor health indicators have lagged. This unequal distribution of medical colleges has impacted the availability of medical services and has also resulted in regional differences in access to doctors (in some cases, access to quality doctors) in the country. For example, there is considerable variation in the density of doctors between rural and urban areas, which indicates the difficulty rural Indians face in accessing healthcare. We find a robust negative relationship between the availability of doctors and COVID-19 death rate i.e. states with less availability of doctors have high COVID deaths, and vice versa. But we did not find a clear relationship between doctor availability and COVID infection rate. The findings of the study call for minimising regional inequality in the production and distribution of human resources for health in India and also suggest developing coping strategies and dynamic capabilities among doctors to serve patients during pandemics like COVID-19. This work is an initial effort to understand the role of private sector in producing doctors in India and connecting with the Pandemic context, which is extremely important for health workforce planning in India. The findings of this study underline some potential areas for future investigation.