CONTROVERSIES IN MEDICINE
Year : 2021 | Volume
: 2 | Issue : 1 | Page : 71--72
Do we need more All India Institute of Medical Sciences - Type institutions?
Formerly Secretary, Department of Health & Family Welfare, Government of, India
Formerly Secretary, Department of Health & Family Welfare, Government of India
|How to cite this article:|
Desiraju K. Do we need more All India Institute of Medical Sciences - Type institutions?.J Med Evid 2021;2:71-72
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Desiraju K. Do we need more All India Institute of Medical Sciences - Type institutions?. J Med Evid [serial online] 2021 [cited 2022 Sep 30 ];2:71-72
Available from: http://www.journaljme.org/text.asp?2021/2/1/71/314627
The All India Institute of Medical Sciences (AIIMS) New Delhi, set up under the AIIMS Act, 1956, has a well-earned reputation as a medical centre which aspires and often attains the highest standards of treatment, teaching and research. Even a quick reading of the Act makes it clear that its primary focus is medical education and teaching. It was believed that well-trained graduates and post-graduates from AIIMS would, in their turn, help in staffing and running government medical colleges across India. Significantly, the AIIMS was kept out of the purview of the Medical Council of India (MCI), set up around the same time through the Indian Medical Council Act, 1956, a prescient move given the baleful influence the MCI came to exercise on medical education in India in later years.
Not everything worked out quite as expected. The AIIMS is certainly regarded as one of the best medical colleges in India, but very many of its graduates, after handsomely availing of its highly subsidised facilities, far from helping to set up medical colleges across the country, have fled its shores. A 2006 report found that 52.81% of AIIMS graduates over 1956–2003 were working abroad, mainly in the USA, and within the USA, mainly in New York and California. A later study of graduates over 1989–2000 found over 54% of them settled abroad. If AIIMS graduates had actually fanned out over the country and contributed to medical education in the states, the question of new 'AIIMS type institutions' would never have arisen 50 years later. In another development, the reputation of AIIMS has grown not only as a premier teaching institution but as possibly the country's best treatment facility, with the result that huge numbers of patients who ought, in any sensible public health system, to have accessed quality secondary and tertiary care at their district hospitals or at the state capitals, find themselves in the hopelessly overcrowded outpatient wards of the AIIMS, if not on the pavements outside. A daily load of 8000 was cited in 2019. AIIMS, New Delhi, is not alone in this. Safdarjung Hospital, New Delhi, and the Rajiv Gandhi Government General Hospital, Chennai, probably draw larger numbers.
The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) of 2006 established the framework under which the AIIMS model would be repeated across the country with new 'AIIMS-type' institutions in Rishikesh, Patna, Bhopal, Raipur, Jodhpur and Bhubaneswar. The selection of the locations of the new institutions was made even earlier, during the time of the NDA government (1999–2004), even if the scheme was finalised during the time of UPA 1 (2004-2009) and fund flow only began in UPA 2 (2009–2014). It is important to note that the key determinant of where a new 'AIIMS-type institution' would be set up was whether the proposed location already had passable hospital care facilities. Since the bulk of the patients crowding the wards of AIIMS, New Delhi, were from the relatively underserved states of North India, the selection of locations, where the state governments provided substantial parcels of land, was unexceptionable. The PMSSY recognised the need to correct 'the imbalances in the availability of affordable healthcare facilities in different parts of the country in general, and augmenting facilities for quality medical education in the underserved States in particular'.
Funds were made plentifully available. Each of the six new AIIMS had a revised approved budget of Rs. 820 crores in 2010, which amounts had not yet been fully spent as of 2018. Of the total of 5760 beds in all, with 960 beds in each of the institutions, a total of 4802 have been set up. MBBS education began in 2012 with an annual admission of 100 in each institution. Sixty students per year are also admitted to the B.Sc. Nursing course at each of these institutions.
There have been issues with the establishment of the new AIIMS institutions, not least to do with construction and time and cost overruns, but it is believed that these issues have been largely resolved. A more serious problem is to do with the availability of qualified teaching faculty, though even this is expected to improve with time, as also the commencement of a high standard of post-graduate teaching and medical research. As per the most recent information, AIIMS Rishikesh, has 238 faculty in position as against 331 sanctioned positions. We may presume a similar shortfall in the other AIIMS. It is for the medical profession to assess whether clinical, academic and research standards at the new AIIMS institutions are on a par with those at AIIMS, New Delhi. Subject to this caveat, we may reasonably say that the broad intentions of the PMSSY have been served, at least for now, and may hope that the institutions will continue to receive the same support that AIIMS, New Delhi receives.
The question before us is whether we need any more of these AIIMS institutions. This is now only of academic interest as in addition to New Delhi and the six we have discussed, another 11 (Rae Bareli, UP; Mangalagiri, AP; Nagpur, Maharashtra; Kalyani, WB; Bathinda, Punjab; Deoghar, Bihar; Bibinagar, Telangana; Rajkot, Gujarat; Vijaypur, Jammu and Kashmir; Bilaspur, HP and Guwahati, Assam) have been established and have commenced functioning. Another four (Madurai, TN; Darbhanga, Bihar; Awantipore, Jammu and Kashmir and Manethi, Haryana) are approved.
Three points are stand out. One, the principle of supporting underserved states has clearly been abandoned. Second, obviously, political considerations have outweighed every other criterion in the selection. And third, and this is not necessarily a bad thing, the centre seems quite willing, at least in principle, to fund activities in the states.
Health care is a subject on the state list under the constitution and medical education on the concurrent list; states are, however, always glad to accept central money. Large sums have been approved under the PMSSY. Where the first six AIIMS were sanctioned Rs. 820 crores each, the newly sanctioned AIIMS have twice as much, with Mangalagiri, Nagpur, and Kalyani kicking in at Rs. 1618 crores, Rs. 1577 crores and Rs. 1754 crores, respectively. These are huge expenditures in a situation where there are other priorities. It is undeniable that the centre has a responsibility to contribute to the states' resources, but states need money for primary care, for well-equipped and well-staffed primary health centres, for quality training of nurses, midwives, ASHAs and allied health staff, for upgrading the standard of district hospitals, trauma centres, blood banks and for drug purchases throughout the public health system. Huge expenditures on construction and land-related works will only encourage rent seeking and corruption and for precisely this reason, are extremely popular with all governments. More importantly, establishing AIIMS institutions in every state only serves to reinforce the point that the only treatment of any standard is to be found high-infrastructure tertiary care centres. The emphasis should rather be on proving that PHCs and district hospitals can between them cater to a wide range of complaints with only those cases actually needing tertiary care being referred elsewhere.
There is a related issue. The AIIMS are central institutions and are funded by the centre. AIIMS, New Delhi, receives annual support through the central budget and, in due course, if the newly established institutions begin to perform at capacity, a similar order of central funding will be necessary and on a permanent basis. The signs at present are that these massive commitments will not be met. The recently announced union budget for 2021–2022 provides a BE of Rs. 3800 crores (a small increase over the RE 2020–2021 of Rs. 3489.96 crores) for AIIMS New Delhi. However, for all the other 17 functioning AIIMS and the four under construction, the BE is Rs. 7000 crores (a small decrease against the RE 2020–2021 of Rs. 7517.25 crores). The break up across institutions is unclear, but what is clear is that there is no sense in establishing institutions to pacify immediate political interests and then letting them starve.
A case could yet be made for new 'AIIMS-type institutions' if it could be established that the new graduates from these new institutions are actually joining the faculty of medical colleges and hospitals in the states, though it is possibly too soon to establish this.
There is no denying that health infrastructure needs major overhaul, not to mention the need to strengthen and revitalise health systems. Pouring resources into mega-building activities is not the answer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Chauhan C. More AIIMS Pass-Outs Work Abroad. The Hindustan Times; December 26, 2006.|
|2||Kaushik M, Jaiswal A, Shah N, Mahal A. High-end physician migration from India. Bull World Health Organ 2008;86:40-5.|
|3||Perappadan BS. AIIMS to Shift Its OPD to More Spacious Accommodation. The Hindu; January 14, 2019.|
|4||PMSSY Annual Report 2019-20, MInistry of Health & Family Welfare.|
|5||Lok Sabha Unstarred Question N. 1750 Answered on July 27, 2018.|
|6||E-mail from AIIMS Rishikesh; February 19, 2021.|
|7||Expenditure Budget 2021-22, Ministry of Finance.|