We don’t even know how many doctors currently practice in India

Dr. Robert Baid McClure has the registration number “1” in the Maharashtra Medical Council list, when you search the Indian Medical Registry on the National Medical Commission (NMC) site [1]. He died aged 90 in 1991 in Canada. He is part of the “stock” of 13.01 lakh (1.301 million) doctors listed in the Indian Medical Registry, mentioned in the Lok Sabha in December 2021 [3]. Dr. Ramchandra Shivaji Poredi is the first entry (No 100) in the Bombay Medical Council (now defunct) list in the same Registry. He was registered in 1913. He too is not alive.

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Both doctors are part of the arbitrary 20% who are considered to have died, retired, stopped practice, never practiced or migrated. This gives us an arbitrary number (80%) of 10.41 lakh doctors currently practicing in India, which is a doctor:patient (D:P) ratio of 0.74:1000, for a population of 1.40 billion (140 crores) as of December 2021. The WHO recommendation is a minimum D:P ratio of 1:1000. Qatar has the highest D:P ratio in the world of 7.7:1000, with Cuba at 6.7:1000, Spain at 4.9:1000, Switzerland at 4.0:1000, Australia at 3.2:1000, China at 1.5:1000 and Bangladesh at 0.3:1000.

In reality though, we have no clue. No one really knows how many doctors are actually practicing in India, i.e. are part of the “living/practicing” list of doctors. We have no tracking mechanism once a doctor has registered themselves in their respective State medical councils. We just use gross, inaccurate estimates.

Multiple papers over the last two decades have shown that the situation is much worse. The most recent is from Anup Karan and his colleagues from the Indian Institute of Public Health [4] that compares the National Health Workforce Account (NHWA) numbers (taken from the Indian Medical Registry) with the numbers from the census and the National Sample Survey Office (NSSO) of 2018. The article suggests that the number of living and practicing “qualified” doctors is likely 675000 (0.5:1,000), which is an availability of just 53% of those registered (another 148000 odd are “doctors” but unqualified and likely quacks).

You might turn around and say that the situation will improve significantly in the future. After all, we have the largest number of medical colleges in the world (595 as of Jan 2022) with an intake of 89395 students in the last year [5]. If 80% of these students complete their MBBS, and 75% of them remain in India to practice, we will add at least 53000 doctors per year.

But the population is also growing at 0.92% (1.3 crore) every year and will reach 1.52 billion or 152 crores in 2032. Let’s say we add an additional 500 practicing doctors a year (which would mean opening at least 5-10 new medical colleges a year) then we will add another 6.1 lakhs practicing doctors by 2032. If we assume that 20% of the current stock of 6.75 lakhs has further dropped out, we will get to a total of 11.6 lakh doctors in 2032, which will bring us to a ratio of 0.76/1000, which is still just not good enough, given the fact that the population is also aging considerably and would have aged even more in the next 10 years, requiring even more doctors and healthcare workers.

And we are not even considering the new WHO norms of 44 healthcare workers (doctors, nurses, technologists) per 10,000 population (4.4/1000) [6]. It is the same story with nurses (just double the doctor numbers) and technologists.

The chart below summarizes these doctor numbers.

We can add the 5 odd lakh Ayush doctors to the mix and say that it improves our doctor:patient ratio, but we don’t really know how Ayush doctors actually practice in India.

Your eyes may have likely glazed over all this data. If you read Rukmini S’s new book, “Whole Numbers and Half-Truths”, you will realize that this problem with data is a distinctive “Indian” problem. For some reason, our DNA is wired to be data averse. Given that most national policies are based on data, which is often just not good enough, you can imagine the problems this “data aversion” causes. Let’s take tuberculosis for example. India is the tuberculosis capital of the World and should be leading the World in tuberculosis research…but no path-breaking studies have emerged from our country, whether it be the basic sciences or epidemiology or treatment…we depend on Western multicentre trials or studies from South Korea, South Africa and sometimes even countries like Uganda and Mozambique for information and updates.

So you could turn around and ask, “but how does this affect me?” Perhaps you have enough money and resources to see the best doctors in the best clinics and hospitals in this country. So, what difference do these doctor numbers make?

Carlo Rovelli, echoing Nagarjuna’s philosophy, writes in one of his books, “I” is a ripple in a network of networks. None of us is an island and everything and everyone are interdependent. Just by virtue of living in India, you have an increased chance of contracting tuberculosis, dengue, malaria, typhoid, amebiasis, etc., whether you live on the 34th floor of a building facing the Arabian Sea or whether you are in the slums of Dharavi, the only difference being that if you are rich, your risk is lower and you have access to better treatment, compared to someone who is poor. And yet, it is not that straightforward. The richest person in Ranchi will still not get the same urgent treatment for acute stroke as a middle-class individual in Mumbai, because Ranchi lacks an acute stroke care unit, while Mumbai has at least three. Ranchi’s deficiencies are due to the lack of adequate, trained manpower and infrastructure, which no amount of individual money can surmount…and so on and so forth.

In our atmasvasth quest to live long, healthy, there is a lot that we can do ourselves to improve our healthspan and lifespan. But we are still dependent on the overall health infrastructure of the region and country we reside in. On the one hand, we are one of the few countries with a bluetooth based Covid-19 app that works, we have a digital Covid-19 vaccination certificate valid worldwide and we have recently launched a national HealthID, which will hopefully revolutionize patient care in the decades to come. And yet, we have no clue how many doctors (and nurses and technologists), who form the backbone of treatment delivery in India, actually work and practice in the country.

How difficult can it be to get the data? All the Health Ministry needs to do is to take a bunch of smart kids, give them access to income-tax data (find doctors who list professional medical income and cross-check with the Registry list), knock-off everyone above the age of 85, liaise with medical boards of the US, UK, Canada, Australia and similar countries where Indian doctors migrate to and find out how many first generation Indians are practicing there and cross reference them with the Registry list…it can be done. We may still have some gaps, but we will have a much better idea of the manpower situation.

Echoing Rukmini’s thoughts in her book…accurate data is the bedrock on which good policies are made. Our atmasvasth quest to live long, healthy is dependent on our country’s ability to provide optimum healthcare, which in turn depends on the healthcare workforce, especially doctors and nurses. To start with, we need to know how many are actually currently practicing in India.

Footnotes:
1. https://www.nmc.org.in/information-desk/indian-medical-register/
2. https://www.maharashtramedicalcouncil.in/frmRmpList.aspx
3. http://164.100.24.220/loksabhaquestions/qhindi/177/AU2299.pdf
4. Karan A et al. Hum Resour Health. 2021 Mar 22;19(1):39
5. https://www.nmc.org.in/information-desk/for-students-to-study-in-india/list-of-college-teaching-mbbs/
5. https://www.nmc.org.in/information-desk/for-students-to-study-in-india/list-of-college-teaching-mbbs
6. https://apps.who.int/iris/handle/10665/334226

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