Numbers can be misleading…

While numbers can certainly make the decision-making easier, do they also tend to over-simplify a phenomenon and shift the focus away from important aspects that need to be addressed? The United States, Japan and Canada have the same doctor patient ration of 2.6. If access is a mere function of number of service providers, why are the health outcomes in respective countries different? 

A 2019 report by CDDEP in line with the standard doctor-patient ratio and nurse-patient ratio published by the WHO, estimates that India is facing a shortage of 6, 00, 000 doctors and 2 million nurses. Frequent reports hint at shortage of policemen, lawyers, teachers, etc. While it is true that many Indians cannot subscribe to quality healthcare services, police protection, basic education, etc., we should also be aware of the fact that access is not just a function of the number of service providers. Going by these ratios would mean increasing the numbers of doctors, nurses, policemen, lawyers, etc. However, such increase might not guarantee better outcomes because better outcomes are a function of various factors like access, skilfulness, affordability, standard infrastructure, public awareness, etc. Looking into few factors and their dependency on one another might help us understand that generalizing all these factors and proposing a standard ratio per population might not actually lead us anywhere further, despite making way for policy decisions that cost huge amounts of public money. 

Access: Access and Need for a certain more number of professionals, say ‘x’ will be indirectly proportional to each other. We seldom find great musicians, painters, and photographers, yet no report came to my notice claiming a shortage for these professionals. This phenomenon occurs because in this digital era, their respective works are easily accessible to millions across the globe. So, a greater access means a lower need felt for a certain more number of professionals. A research by KPMG and OPPI has identified that 80% of Indian doctors are located in urban areas. This could be due to various reasons ranging from the facilities that they get in urban areas to the lucrativeness of their service. So, in urban areas, the doctor patient ratio will be higher than the 1:1000 suggested by the WHO. Let us assume it to be at 3:1000, which means that there are 2 more doctors who can serve 1000 people each. It is a clear under-utilization. Increasing the number of doctors would only mean increasing their population in urban areas taking the ratio much beyond the standard and leaving many more doctors under-utilized. To strengthen the claim about under-utilization, we can look into a journal publication by Raman Kumar and Ranbir Pal in 2018, which states that as of 2017 India had 1.37 doctors for every 1000 population. Despite going past the standard ratio, according to global MPI released by UNDP for the year 2018 India has: second highest stunting rate, under-five mortality rate of 43/1000, and the highest vulnerability to malaria and tuberculosis amongst the middle-income countries. This could be due to the very fact that there are more than required number of doctors, but their concentrations are higher in only few areas making them inaccessible to many people. Making access possible depends on the infrastructure facilities.

Infrastructure: It is of two types. One that enables patients to reach the doctor: Roads, Ambulance, etc. The other which enables doctors to reach patients rural areas need: clean water, good transportation, hassle- free power supply, and quality housing, etc. Patients reaching the doctor miles away might not guarantee timely medicine. So, for doctors moving closer to patients and setting-up quality healthcare centres, they should receive incentives similar to those available while operating in an urban area. Clean water, quality housing and hassle-free power supply, hygienic food in major connecting villages will ensure a decent standard of living for practitioners. Incentives to set-up super-speciality hospitals and availability of necessary infrastructure will encourage practitioners to move from urban areas to remote areas. An added advantage of receiving more patients will also push them towards this path. However, this becomes an advantage to doctors only when patients are able to afford for the services. Government taking all the above said measures to make a doctor set-up their practice in rural India can only be justifiable if the factor of affordability is met.

Affordability: India’s out-of-pocket health expenditure is already close to 65% and this pushes several families into poverty. Unless the Income of people increases, it would be a terrible call to ask them to spend more. Either measures that rapidly increase the income of people must be undertaken or people need to be empowered through an insurance cover. Few initiatives have been taken in this direction by the Government of India but an increased budget allocation to healthcare sector could make better health cover for every individual a reality. Affordability if backed up by effective treatment will improve the health outcomes. Effective treatment depends on the skill of doctors.

Skill: An article in the ‘Indian Journal of Community Medicine’ claims that taken to a health care provider or not, under-five children die of preventable causes. While one reason for this could be due to delay in meeting the doctor (which again brings to the fore the question of access) the other could be the quality of service provided and the type of treatment rendered. If the patient is seen by a low-skilled doctor then the chances of survival go down. The challenge is two-fold, either practitioner is not skilled or the skilled practitioner is not motivated to do justice to his/her skills. If we do not have enough skilled people, it requires upping the game of skilling. Better curriculum, Top-notch professors, and World-class institutions could address the challenge. The practitioner not being motivated to deliver could be due to various reasons ranging from lack of supervision to lack of enough monetary incentive to justify his/her skills. This again moves the challenge towards ‘affordability’.

In such environments where multiple factors affect each other and affect the outcomes, simplification in terms of few ratios and numbers can be misleading. It would prompt the policy makers to increase the number of service providers while leaving the real challenges like access, infrastructure, affordability, and skills go unnoticed. If only numbers told the complete story the health outcomes in the US, Japan and Canada would have been similar. These countries have the same doctor patient ratio of 2.6/1000. The HAQ index based on amenable mortality gives US a score of 88.7 while Japan achieved a score of 94.1. The DALY’s are a measure of disease burden and the rate per 100,000 shows the total number of years lost to disability and premature death. In the United States this disease burden measure is at 24, 306 while in Canada it is only 19, 227. Therefore to make decisions, beyond the simple generalized ratios there are various other factors and their interconnectedness which need attention because numbers alone can be misleading. 

*Few contents in the article are inspired from the lectures of Mr. Manoj Mohanan (MBBS, MPH, SM, PhD, Associate Professor of Public Policy and Economics at the Sanford School of Public Policy at Duke University) at Ashoka University. All the opinions expressed in this article are of the author and do not reflect the opinions or views of Dr. Reddy’s Foundation or its members.