Doctors For The World: Indian Physician Emigration

Fitzhugh Mullan

Health Affairs. 2006;25(2):380-393. 

In This Article

The Market Rules

India devotes 5.1 percent of its GDP to health, ahead of Pakistan (4.0 percent) and Sri Lanka (3.7 percent) but behind China (5.4 percent), Brazil (7.6 percent), and the United States (15.6 percent). The striking fact about Indian health expenditures is that they are heavily in the private sector. Only 0.9 percent of the country's GDP is spent on public-sector health programs, whereas 4.2 percent is private. India ranks 171st out of 175 countries in percentage of GDP spent in the public sector on health and 17th in private-sector spending.[5] Interviewees reported time and again that the system of publicly administered health care dating back to the time of independence was "brilliant" on paper but was poorly funded and, as a result, dysfunctional in many aspects. The government system supports a series of tertiary and secondary hospitals in cities and larger towns and a nationwide network of primary health centers staffed, in theory, by a physician and four paramedics for every 35,000 people. With exceptions, the former are crowded, unattractive, and stressed, and the latter are disastrously short of funds, equipment, medications, and personnel.

Physician Supply

About 600,000 physicians are registered to practice in India, although the actual number is probably lower because of emigration and retirements.[6] With a population just above one billion people, the physician-to-population ratio in India is 50-60 per 100,000. The distribution of practitioners is heavily skewed toward urban areas. The Center for Enquiry into Health and Allied Themes estimates the urban physician-to-population ratio at almost six times the rural concentration of physicians.[7] India's allopathic physicians practice largely as private fee-for-service (FFS) practitioners among the urban middle class—some 250,000,000 people—meaning that the effective physician-to-population ratio among India's better-off citizens is about 200 per 100,000, approximately the physician concentration in the United Kingdom. This analytic perspective explains why some observers report that "India has enough physicians," while many Indians, in fact, never receive the services of allopathic physicians at all.

Physician Services for Poor or Rural People

The vacuum in service provision for poor and rural people is filled by nonallopathic FFS practitioners from a variety of indigenous systems of medicine (ISM), whose educations are also government-sponsored at the university level.[8] These are practitioners of Ayurvedic medicine (Hindu), Unani (Muslim), homeopathy, and Siddha (Tamil). In addition, there are numbers of "nonqualified" doctors in practice—people with no medical training of any sort. An allopathic physician reported to me that when he began a practice in a rural village, he discovered twenty-eight private "competitors" in the area—all practitioners of ISM. In the Mumbai slum of Jari Mari, I was told that the most popular practitioner was, in fact, a "nonqualified" doctor. In most cases, ISM practitioners use allopathic diagnoses and prescribe or sell allopathic medicines. Allopathic medicine predominates, even if its practitioners do not. The presence and influence of such a large overall number of doctors (allopathic and ISM) as well as a relative shortage of nurses has led to a generally nonreceptive environment to the development of new clinicians such as nurse practitioners and physician assistants.

Private-Sector Medicine

The private sector enjoys high levels of investment, enterprise, and energy. Private hospitals, many with national brand names such as Apollo, Escort, and Manipal, have opened in most large cities, providing excellent facilities and cutting-edge technical care to those who can pay. In addition, these hospitals have begun to draw patients for high-cost elective procedures, such as transplants and bypass surgery, from the Persian Gulf states and countries in Asia, Africa, and Europe—a development referred to as "medical tourism." Many of these hospitals are specialty institutions, and many have recruited Indian specialists back to India from the United States and the United Kingdom, contributing to their technical capabilities and market prowess. Specialization and "super" specialization are predominant values among doctors and knowledgeable patients. There is no formal system or designated practitioners of primary care.

Small, private hospitals called "nursing homes" are ubiquitous in large cities. Mumbai has 1,150 hospitals, 90 percent of which are private and 70 percent of which have fewer than thirty beds.[9] "Nursing homes" all have operating theatres and diagnostic equipment, which, if used regularly, make them extremely profitable institutions. Diagnostic and imaging centers are commonplace, and all respondents reported active commercial competition for patients and procedures.

In Chennai, for instance, twenty hospitals offer renal transplants.[10] Fee splitting (often called "follow-up payments") from laboratories and imaging centers is frequent, and multiple observers reported many instances of unwarranted surgical interventions. Numerous reports and a number of my respondents described an active, illegal trade in purchased organs (kidneys, in particular) that has developed in tandem with the growth in transplantation centers.[11]

"Interventionist" Medical Environment

The concentration of physicians in urban areas along with aggressive pharmaceutical and medical equipment sales strategies and physician-ownership of hospitals have created a highly commercialized and actively interventionist medical environment. Government regulations pertinent to areas such as hospital certification, prescriptive practices, and proscribed behavior are either not in place or rarely enforced.[12] The result is a culture in which supplier-induced demand is commonplace and ethical improprieties and unwarranted surgeries are widely acknowledged.