Indian EM: A System Overview

Published on January 13, 2015
The recent EMCON conference put on display the ambitious steps being taken to improve Indian emergency medicine. But with over 1 billion potential patients, the challenges are daunting.

In November I had the pleasure of being a guest of the Society for Emergency Medicine India (SEMI) at their annual meeting, EMCON. The event gave me the opportunity to observe emergency medicine in India, and make a few observations as an outsider.

The conference has grown in the number of attendees, as well as topics and workshops, over its 16 years of existence. It’s been great to witness Indian emergency medicine take off, and to celebrate Indian emergency medicine’s accomplishments in Mumbai. The conference attracted approximately 1,200 delegates from all over India as well as from many neighboring states where emergency medicine (EM) is also just starting to be discussed as a possible way to improve the delivery of healthcare services. There was also a large contingent of foreign faculty and guests from the U.S., U.K., Australia, Singapore and other places where EM is better developed and integrated into essential health services. While the excitement for EM is palpable, much needs to be done to support its growth and firm foundation in the Indian healthcare system.

In addition to the meeting, there was a lot of discussion about the future of Indian EM. The health system in India is multi-layered and has various sources of funding and training models for providers, often with little agreement on common standards/competencies and accreditation criteria. In 2013 the creation of the Diploma of the National Board (DNB) program for EM was sanctioned by the National Board of Examinations (NBE), one of the two agencies created by the Indian parliament to devise and regulate Indian medical residencies. Dr. Bipin Batra, CEO and Executive Director of the NBE, was one of the honorary guests at EMCON, and he has been the key person responsible for helping develop the DNB in EM, which previously had many false starts in India. While some of the details of the DNB training program are still being worked out, the basic premise is it’s a three year residency training program and qualified applicants must possess a MBBS and clear a common entrance and exit exam to qualify as a DNB. Approximately 20 hospitals throughout India have received a number of DNB EM residents, and typically the NBE allots anywhere from two to four residents to each Indian emergency department. A strategic MOU was signed between Boston University in the U.S. and SEMI to work jointly with the NBE to develop faculty training programming for Indian EM physicians who will now be responsible for teaching the new generation of Indian DNB residents. Most faculty have migrated to the emergency department from another specialty (“grandfathered”) and require some faculty development, to ensure well-rounded competencies in EM, as well as assessment and curriculum development skills.

In response to the popularity of EM, it is expected that there will be a growth of 250 new EM residency positions created very shortly in India, not all of them officially sanctioned by the DNB or another government-sanctioned accrediting agency. The idea of starting this number of new residencies and educating the proposed army of EM doctors is mind-boggling! However, with 1.2 billion people in India, many without basic emergency services, there is an urgency to accelerate EM training. The scale of this initiative raises many questions. How do you attract high quality teachers? How do you individually mentor so many trainees? Will the course standards be the same across all the programs? Will graduates obtain jobs and be attractive to employers after they finish their training? Is the health system ready for such a large influx of specialty trained doctors in such a short time frame? Will there be a common exam? So many questions that must be answered . . . all the while working to raise standards. While there is already strong collaborations between several private institutions and their American training partners including Upstate Medical Center, George Washington University and others to host and provide teaching for Master of Emergency Medicine programs, the current foreign collaborations will not support 250+ new doctors. The U.K. College of Emergency Medicine provides the MCEM exam as an entrance examination and Australia has just entered into a partnership with the Indian government to help with the development of trauma systems.

Most of the Indian population, however, receives healthcare services from the government, which has under-spent and misspent on services that are not well matched to the needs of most of the population. While the Indian government typically does a good job with delivering vaccines and some preventative services, the general healthcare infrastructure is weak and unresponsive to the needs of most Indians, and that includes emergency care services.

While the creation of the DNB in EM was a significant milestone in the development of EM, much needs to be done to further support its growth and to strengthen the entire Indian national health system. The WHO recommends that each country spend between eight to 12 percent of its GDP on healthcare, but India has spent a little less than four percent on healthcare as per the latest figures from the WHO published in 2012. Within that four percent, approximately three percent is spent at private healthcare providers that cater to a middle and upper class elite who are typically urban and have access to some of the latest and most developed therapies available anywhere in the world. Most of the Indian population, however, receives healthcare services from the government, which has under-spent and misspent on services that are not well matched to the needs of most of the population. While the Indian government typically does a good job with delivering vaccines and some preventative services, the general healthcare infrastructure is weak and unresponsive to the needs of most Indians, and that includes emergency care services. EM can play a significant role in improving the Indian health system responsiveness and provide services that most Indians will need for themselves or their families at some point in their lives. The Indian government should consider developing EM as a national priority and use it as a central plank to improve health system responsiveness and inclusiveness.

There has been tremendous attention on the development of physician training for EM, but anyone who works on the clinical side knows and understands that good emergency care requires a full team of skilled professionals including nurses, pre-hospital care specialists and allied health. While there has been some thought about this at an institutional level, there will need to be an equally large, national response to develop skills if EM is to be able to provide system-wide services.

As I relaxed in the faculty lounge in the luxury conference hotel with some of my Indian colleagues and friends in Mumbai and contemplated the opportunities and risks of developing EM in India I thought to myself: Wow! Only in India!

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

This article originally appeared in Issue 15 of Emergency Physicians International.

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