Mapping the rapid expansion of India’s medical education sector: planning for the future.

Author(s) Yogesh Sabde1, Vishal Diwan2, Ayesha De-Costa3, V Mahadik 4
Affiliation(s) 1Community Medicine, R.D.Gardi Medical College, Ujjain, India, 2Golbal Health, R.D.Gardi Medical College, Ujjain, India, 3Community Medicine, R.D.Gardi Medical College, Ujjain, India, 4Community Medicine, R.D.Gardi Medical College, Ujjain, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary India is in the midst of rapid expansion in the medical education particularly in private sector. We tracked the growth of medical schools over the last 7 decades in the context of geographic distribution across the country. The number of medical schools rose from 23 in 1947 to 355 in 2012. The poor performing provinces with a population of 620 million had only 94 (26.5%) medical schools. Private sector owned 195 (54.9) schools of which 38 (40.4%) were in poor performing provinces. Thus rapid expansion of private sector in medical education in the country was located primarily in the better off provinces. This paper also does an allocation analysis to find optimum location for new medical schools.
Background Medical schools are a vital component of any health care system as they produce the necessary human resources. In India medical schools as academic institutions connected to large hospitals have the potential to influence the local health care system, the health of the local population as well as local economy. The number of medical schools in India has expanded during the six post independence decades and the country now has the largest medical education system in the world. India stands at the top of a list of countries with the largest numbers of privately owned medical schools. Given the role that medical schools play in supporting the health care and general development of the local community, it is important to ensure that all regions (particularly underserved ones) in a large country benefit from the opportunities that medical schools in the area would create. India’s National Rural Health Mission plans to further expand the medical education system to cater for the country’s human resources health needs. At this point in time, it is relevant to historically trace and map the development of medical education in India, to locate where this growth has occurred, trace the changing role of the public and private sectors and importantly to enable strategic planning for the future.
Objectives This paper supports planning for this expansion by identifying districts that would benefit most from the location of new medical schools. The present paper studies (i) the growth of the medical education sector in the country since independence, and the relative contributions of the public and private sectors (ii) the distribution of medical schools in the public and private sectors of India (ii) the current geographic distribution of medical schools (public and private) across the country, and identifies ‘underserved ‘areas to support locational planning of new medical schools in the future.Setting: India is a union of 28 provinces with 833 million (68.8% of the 1210 million) of the population living in rural areas. India’s provinces have widely varying socio-economic and health indicators. Eighteen provinces, which account for about 51% of India's population, have been designated ‘high focus provinces’ under India’s ongoing National Rural Health Mission. These provinces have relatively poor socioeconomic indicators; 25-50% of their populations live below poverty line (based on a defined degree of deprivation) as per national surveys carried out by the Indian government. These provinces have relatively higher MMRs, infant mortality rates (IMR) and higher birth rates than the national averages of 212/100,000 live births, 50/1000 births and 22.5/1000 population respectively. The government of India has designated these provinces as ‘high focus provinces’ implying more focussed attention to and greater allocation of resources towards strengthening the health systems in these provinces [14]. In this study, high focus provinces as a group are referred to as “poor performing provinces” to differentiate them from the group of other provinces which are referred to as “better performing provinces”Provinces in India are divided into administrative units called districts, each with a population of between 0.5-5 million (1.5 million approximately). As per official records there are 640 districts in India that show wide variation in health and economic indicators. Districts have been used as a unit in the location-allocation analysis.
Methodology Information on the medical schools was obtained from the online database maintained by the Medical Council of India (MCI) as of 30th January 2013. The proportions of medical schools in public and private sector were compared for poor and better performing provinces in the country using OR (95% CI). The cumulative total numbers of medical schools and their annual intake capacity each decade were calculated since 1950 till 2010 and plotted using line diagrams.
A digital map of the medical schools was prepared based on their locations indicated in the MCI database. The map was superimposed on a digital map of India purchased from the office of Survey of India and subjected to further analysis using geographic information system (GIS) as follows;
1)Thematic maps: The distribution of public and private medical schools across the districts in poor performing and better performing provinces of India was shown using thematic maps.
2) Euclidean distances: The straight line distance of each district from the nearest medical school was used as an indicator of geographic access to the services of medical school. The Euclidean distances for the districts in poor and better performing provinces were compared using histogram and independent samples Mann-Whitney U test.
3) Ring Buffer analysis: Rings of radius 50 kilometers were plotted around the location of each medical school. The region outside these rings was considered remote region and the number of districts in this region was calculated.
4) Near analysis: The median distances between the adjacent schools in poor and better performing provinces were compared using independent samples Mann-Whitney U test.
5) Location-allocation analysis was performed to identify districts which are likely to benefit most from services provided by medical schools. Districts were the unit of analysis. This twofold analysis simultaneously located medical schools and allocated demand for them. The suitability of location of new institutions was based on following criteria;
a. Euclidean distances above 50 kilometers
b. Population over 1 million
c. Rural population above 80%
d. District rank was lower than 300 (as per National Population Stabilization Fund, Ministry of Health and Family Welfare in India that ranks the districts based on five maternal and child health indicators)
e. Proportion of population with low Standard of Living Index (SOLI) above 20% (as per a national district level household survey in 2007-08)
Results There were 355 medical schools in the country enrolling 44250 students into physician training annually in 2012. Private sector with its 195 (54.9%) medical schools trains more students than the public sector (24205, 54.7%). The 18 poor performing provinces with a population of 620 million (51.3%) had only 94 (26.5%) medical schools. The number of privately owned schools (38, 40.4%) was significantly lower in poor performing provinces compared to 157 (60.2%) schools in better performing provinces.
The geographic distribution of medical schools revealed the dominance of public sector institutions in the poor performing provinces, while the private sector is largely located in the better performing provinces. The maps of medical schools in each decade showed that the foci of private sector schools began in the south in the 1960s and then ‘spread’ to the north in 1970s. The number of public sector schools also grew during this time. By the 1990s there were many more private schools concentrated in the southern peninsula and the rich northern provinces. After the 1990s, the public sector (not expanding anymore) remained the major provider of medical education in the poor provinces. This trend continued into the last decade, with the establishment of private schools beginning in the poor provinces. Only in the last decade have we started to see some spill over of privately owned schools into the poor provinces.
The mean distance between districts and their nearest teaching hospitals in 2012 was 49.2 kilometers (median 45.5 kilometers). Of a total of 267 districts that were located outside 50 km buffer of a medical school, 215 (80.5%) were in poor performing provinces (p value)
Conclusion The number of medical schools has increased in all parts of world with increasing population, advances in technologies and increasing lifespan. Asia witnessed the largest part of this growth as it has 44% of the total medical schools in the world. Privatization of medical education over past several decades has substantially contributed to the growth of medical education in Asia. The entry of the private sector into medical education has been beset with controversy as to whether it has resulted in a dilution of standards in medical education, and on whether it makes medical education the purview of the rich.
The study used geographic information system (GIS) which is a comprehensive, graphical modeling of the distribution of medical schools and its relationship with other variables in Indian medical education system, the largest in the world. The present study highlighted important concerns i.e. differential growths of private sector in richer and poorer provinces in terms of the proportion of medical schools, distances of districts from medical schools and the distances between adjacent medical schools. Thus far, the existing regulations for opening of new medical schools mainly focuses on the infrastructure requirements, assets and financial capacities of the owners and no consideration is given to the existing health services in the local geographic area in the accreditation process of new medical schools. In such an environment, private medical schools are more likely to locate themselves in forward provinces, unless future expansion is planned for both public and private sector schools.
The National Rural Health Mission of India plans steps for the expansion of medical education to address the human resources health crisis in India. We have conducted a location-allocation analysis to identify districts that can benefit most by the services of medical school. The identified 94 districts had no medical schools within 50 kilometers of their main towns and they had reasonably large populations of over a million. The selection criteria applied in this study were chosen from an equity perspective, so that districts with poorer population in terms of economy, health and infrastructure were prioritized. Given that majority of these districts were located in poor performing provinces, the establishment of medical schools at these locations will help support the healthcare services to the district populations.

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