Anand Krishnan writes: The efforts to scale up, which are most welcome, must be re-envisaged to focus on quality and societal needs along with commercial viability.
India’s medical education system has attracted a lot of adverse attention due to the crisis in Ukraine and the resultant need for evacuating medical students, delay in post-graduate counselling because of reservation-related litigation and Tamil Nadu legislating to opt out of NEET. I take a look at what ails the system based on my close encounters with it, as a member of the faculty at a medical college and as a father whose daughters went through this process in the last decade.
There is a serious demand-supply mismatch as well as inadequate seats in terms of population norms. In private colleges, these seats are priced between Rs 15-30 lakh per year (not including hostel expenses and study material). This is way more than what most Indians can afford. It is difficult to comment on quality as nobody measures it. However, from personal experience, I can say that it is highly variable and poor in most medical colleges, irrespective of the private-public divide.
The MBBS degree continues to be an attractive option. However, unlike in the past, a substantial section of the middle class no longer feels that this is a good return of investment. Students opting for a medical career, with some exceptions, are of two types: Those who see this as a path to social and economic mobility. The second category is that of children of doctors, especially in the private sector, whose parents want them to continue their legacy. The first group is highly price-sensitive while the second is not.
The government’s initiative to open new medical colleges has run into a serious faculty crunch. Except at the lowest level, where new entrants come, all that the new colleges have done is poach faculty from a current medical college. Academic quality continues to be a serious concern. The Medical Council of India (MCI) did try to address many of the earlier loopholes of ghost faculty and corruption. It introduced the requirement of publications for promotions to improve the academic rigour of faculty. But this has resulted in the mushrooming of journals of dubious quality. The point is that the faculty and medical colleges will learn to game the system. Faculty salaries in many state government-run and private colleges are low and private practice is common. This ruins the academic atmosphere.
Another distinct feature of the medical education system in India is its complete disregard for students’ welfare. Only the top 0.25 per cent of the applicants get a seat in a decent government medical college. In times of scarcity, social justice takes a backseat. Most parents simply lack the wherewithal to weigh the pros and cons of individual medical colleges. The counselling process is very complicated to negotiate, even for a person like me. After my experience of reporting to a college at 9 am and leaving at 5 am the next day with scarcely any arrangement or hospitality in peak summer, I vowed not to send my daughter to an institution that has scant respect for its future students and their parents. The system is designed for non-resident and other wealthy Indians to capture the seats left unfilled due to their high prices. This is engineered by using a percentile system for defining eligibility — and not per cent — so that students with money and low scores can get through.
What do you do if you and your family have invested money and emotion in making you a doctor and you do not get enough marks to qualify for a government medical college? Many such students used to settle for a Bachelor in Dental Surgery degree. This led to a mushrooming of dental colleges of dubious quality and India produced far more dental surgeons than were in demand. Subsequently, several of these colleges shut down. The only option then is to do MBBS in a country that one can afford.
A situation of high demand coupled with a student-unfriendly system is designed for the entry of middlemen. As soon as you register with a coaching agency or the NEET results are out, you are bombarded with offers from agencies ensuring seats in Nepal, Mauritius, Ukraine, Russia, China and so on. Parents are lured into spending their hard-earned savings by middlemen who paint a rosy picture of the scenario in these countries. Even after this, these students often fail to clear the foreign medical graduate examination — this has a pass rate of 15 per cent. Caught between parental pressure and an unfriendly system, the students have nowhere to go.
We cannot discount the impact of the corporatisation of the health sector and the increasing need for specialisation in medical education. If the health sector is treated like a service industry with a profit motive, medical education provides human resources — like business managers. Universal need and information asymmetry are among the many reasons often cited to make the case for the exclusion of market forces in health services and medical education. The increasing need for specialisation, with students having to prove their worth at every level or pay through their noses, is becoming a scourge for the new entrants to the system. This explains the decline in attraction for the MBBS among a section of students.
So, what needs to be done? There are many who propose a rapid scale-up of seats by converting district hospitals into medical colleges using a private-public partnership model. The NITI Aayog seems to be moving in this direction. This is a dangerous idea without the government putting in place two things — a functional regulatory framework, and a good public-private model that serves the needs of the private sector as well as the country. We have so far failed miserably in both, largely due to the political-private sector nexus. Recent efforts by the National Medical Council (NMC) to regulate college fees are being resisted by medical colleges. The government should seriously consider subsidising medical education, even in the private sector, or look at alternative ways of financing medical education for disadvantaged students. Quality assessments of medical colleges should be regularly conducted, and reports should be available in the public domain. The NMC is proposing a common exit exam for all medical undergraduates as a quality control measure. This is loaded against students. I hope that the current scaling up efforts, which are most welcome, are re-envisaged to focus on quality and societal needs along with commercial viability.