SICOT

Editorial

Health Training in the Private Sector

Saumitra Goyal   SICOT Associate Member – Agra, India

Availability of human resource is a critical factor for effective provision and delivery of quality health care to the growing needs of the growing global population.

WHO’s Global Atlas of Health Workforce (2010) recognised that the vast majority of states are facing a crisis in healthcare workforce due to increasing costs and demands, uneven distribution and skill imbalance. The private sector is emerging as a major partner in health systems at the primary, secondary and tertiary levels all over the world. Although the importance of training health professionals like medical officers, nurses, pharmacists and other paramedical staff providing basic health facilities at the grass root level cannot be overemphasised, the role of the private sector in the training of doctors and development of skills will be the focus of discussion here.

In India, ranking 67th in the list of developing countries with a doctor-population ratio of 1:1700 compared to the world average of 1.5:1000, the government is unable to meet the overwhelming demand for basic medical education. In the United Kingdom, although the NHS invests more than 5 billion pounds annually for central funding in the training of the public health workforce, the Royal College of Surgeons (RCS) recognises that the independent sector is ‘not contributing as fully as it should’ and has called for private organisations to play a prominent role in surgical education and training.

Increased private funding for medical education, relaxed regulations and permissions by the Medical Council of India, along with large scale medical tourism and the migration of doctors and nurses to other countries is correlated with the fact that India has the greatest number of private medical colleges. India today has close to 400 medical schools. In the last two and half decades alone (1980-2014), private medical colleges have increased 405% (41 to 209) as compared to an increase of 72% (102 to176) of government run medical colleges.

As per the yearly survey and assessment, one-third of the top 25 medical colleges in India are private-run organisations, with the Christian Medical College, Vellore, and Kasturba Medical College, Manipal, consistently ranked among the top 10 having global recognition for providing quality health care and excellence in teaching. Semi-autonomous boards for medicine, nursing and other health professions ensure high-quality care to patients and set up controls against negligence along with accreditation from the regulatory body for both providers and facilities at all levels.

Maintaining demand and quality of treatment for paying patients has to be balanced with the opportunity and adequacy of training in the independent sector. At the Christian Medical College, many churches and missionary organisations support the cost of treatment allowing the opportunity for educating medical students. Public-private partnership and corporate social responsibility permits these institutes to receive funding and have parallel-run subsidised health care along with paying private patients. USAID, WHO and other international organisations have identified the potential of the private institutes providing support to fund quality of health care as well as training. Government health schemes for treatment in private hospitals and subsidised wards provide quality resources for care of patients and also permits trainees to learn in a quality assured supervised environment without corporate pressure.

However, conflict arises when the paying patients in private institutes are involved in education and training. For surgical patients this is compensated by constant supervision of senior consultants and the role of trainees limited to being first assistants with limited hands-on experience. A greater patient load and variety of routine and complex procedures provide trainees with more exposure. In the field of orthopaedics, the division of subspecialties into hand & microsurgery, paediatric orthopaedics, spine surgery, arthroscopy & sports injuries, joint replacement, and trauma with a compulsory six monthly rotation during residency provides an environment for comprehensive learning, for example at CMC Vellore, KMC Manipal Medical College and Ganga Hospital, Coimbatore. Being trained at both these medical colleges, I have noted through my personal experience that private patients also permit to learn from them as we maintained strong protocols of consent and quality, although the direct surgical opportunities were few.

Residents have an opportunity of learning and honing surgical skills through regular dissection of anatomical specimens, skills labs, video demonstration of surgeries and live surgery conferences. Dedicated cadaveric labs at Bangalore, Ahmedabad, Chennai and many other places hold trainee programmes in advanced procedures like arthroplasty, pelvis surgery, shoulder arthroscopy and so on, to name a few. They also have the opportunity and funding to attend such programmes in other parts of the world with partial funding borne by institutes for merit students.

Areas like general surgery, trauma and orthopaedics, urology, paediatric surgery, thoracic surgery and plastic surgery are surgical specialties where residency training could potentially be delivered by the independent sector. An example of this in India is identification of private institutes of excellence by an independent National Board of Education to provide a DNB (Diplomate National Board) degree in parallel to the Master’s Degree by educational institutes. After a basic medical degree, on a similar pattern of merit-based entrance exam, several private institutes provide the opportunity to take postgraduate training in medical and surgical training. Delhi, Mumbai, Pune, Hyderabad, Kolkata, Chennai, Bangalore, Ahmedabad and Coimbatore are some popular cities where corporate institutes are recruiting DNB candidates for higher training. Many of these are recognised at national and international level as centres of excellence, Ganga Hospital in Coimbatore being one such institute for orthopaedics.

Opportunity to train and learn from the best in the world is also available through accredited fellowships at many institutes. International organisations, such as SICOT and AO, and many regional bodies invite local and international surgeons and fund their training which encourages utilisation of private sector resources. 

Even though I might say I performed far fewer operations than my counterpart trained in the public sector, emphasis on guidelines, stringent follow of protocols, learning the correct methods, availability of better facilities at a private medical college has given me confidence to be a better doctor with good skills and also to share my experiences.

References:

1. Pradeep K Choudhury. Role of Private Sector in Medical Education and Human Resource Development for Health in India. ISID-PHFI Collaborative Research Programme Working paper 169, October 2014.
2. Royal College of Surgeons. Position statement on the role of independent sector in education and training. August 2013.
3. Clamp JA, Baiju D Sr, Copas DP, Hutchinson JW, Rowles JM. Do independent sector treatment centres (ISTCs) impact on specialist registrar training in primary hip and knee arthroplasty? Ann R Coll Surg Engl 2008;90:492-496.
4. Davey S, Davey A, Srivastava A, Sharma P. Privatization of medical education in India: A health system dilemma. Int J Med Public Health. 2014;4:17-22.