India’s medical education system has attracted a lot of negative attention due to the crisis in Ukraine and the resulting need to evacuate medical students, backlog in post-graduate counseling due to disputes over reservations and Tamil Nadu legislation to opt out of NEETs. I examine the ills of the system based on my close contact with it, as a medical school faculty member and as a father whose daughters have gone through this process over the past decade.
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There is a serious mismatch between supply and demand as well as inadequate seats in terms of population standards. In private colleges, these places cost between Rs 15 and 30 lakh per year (not including accommodation fees and study materials). This is more than most Indians can afford. It is difficult to comment on the quality because no one measures it. However, from personal experience, I can say that it is highly variable and poor in most medical schools, regardless of the private-public divide.
The MBBS degree continues to be an attractive option. However, unlike in the past, a significant portion of the middle class no longer considers this to be a good return on investment. Students who opt for a medical career, with few exceptions, are of two types: Those who see it as a path to social and economic mobility. The second category is that of the children of doctors, especially in the private sector, whose parents want them to carry on their legacy. The first group is very price sensitive while the second is not.
The government’s initiative to open new faculties of medicine has come up against a serious shortage of professors. Except at the lowest level, where new entrants arrive, all the new colleges have done is poach faculty from an existing medical school. Academic quality continues to be a major concern. The Medical Council of India (MCI) has attempted to address many of the previous shortcomings of phantom faculty and corruption. It introduced the publication requirement for promotions to improve the academic rigor of faculty. But this has resulted in the proliferation of journals of dubious quality. The point is that medical school and faculties will learn to outsmart the system. Faculty salaries at many public and private colleges are low, and private practice is common. It ruins the academic atmosphere.
Another distinct feature of the medical education system in India is its complete disregard for the welfare of the students. Only the top 0.25% of applicants get a place in a decent government medical school. In times of scarcity, social justice takes a back seat. Most parents simply cannot afford to weigh the pros and cons of each medical school. The consultation process is very complicated to negotiate, even for someone like me. After my experience of showing up to college at 9 a.m. and leaving at 5 a.m. the next day with virtually no accommodation or hospitality in the height of summer, I vowed not to send my daughter to an institution that has little of respect for his future students and their parents. The system is designed for non-residents and other wealthy Indians to capture seats left vacant due to their high prices. This is designed using a percentile system to define eligibility – not percentage – so students with money and low scores can pass.
What do you do if you and your family have invested money and emotion into making you a doctor and you are not getting enough grades to qualify for government medical school? Many of these students used to settle for a bachelor’s degree in dental surgery. This led to a proliferation of dental schools of dubious quality and India produced far more dental surgeons than the demand. Subsequently, several of these colleges closed. The only option then is to do MBBS in a country that one can afford.
A situation of high demand combined with a system hostile to students is designed for the entry of intermediaries. As soon as you register with a coaching agency or the NEET results are known, you are bombarded with offers from agencies securing places in Nepal, Mauritius, Ukraine, Russia, China, etc. Parents are encouraged to spend their hard-earned savings through intermediaries who paint a rosy picture of the situation in these countries. Even after that, these students often fail the overseas medical graduate exam – this one has a 15% pass rate. Caught between parental pressure and a hostile system, students have nowhere to go.
We cannot ignore the impact of the corporatization of the health sector and the growing need for specialization in medical education. While the health sector is treated as a for-profit service industry, medical education provides human resources, such as business leaders. The universal need and asymmetry of information are among the many reasons often cited to justify the exclusion of market forces in health services and medical education. The growing need for specialization, with students having to prove themselves at all levels or pay the nose, is becoming a scourge for new entrants to the system. This explains the decline in attractiveness for the MBBS among some students.
So what should be done? Many are proposing a rapid increase in the number of places by converting district hospitals into medical schools using a public-private partnership model. The NITI Aayog seems to go in this direction. It is a dangerous idea without the government putting two things in place – a working regulatory framework and a good public-private model that meets the needs of the private sector as well as the country. So far, we have failed miserably on both counts, largely because of the link between the political sector and the private sector. Recent efforts by the National Medical Council (NMC) to regulate tuition fees have been met with resistance from medical schools. The government should seriously consider subsidizing medical education, even in the private sector, or consider other ways to fund medical education for disadvantaged students. Quality assessments of medical schools should be conducted regularly and the reports should be available in the public domain. The NMC offers a common exit exam for all medical students as a quality control measure. This is charged against the students. I hope current scaling efforts, which are welcome, will be revisited to focus on quality and societal needs as well as commercial viability.
This column first appeared in the print edition of March 10, 2022 under the title “After the evacuation”. The author is a professor at the Center for Community Medicine, Indian Institute of Medical Sciences, New Delhi. Views are personal