Medical teaching out of sorts

The Russian aggression in Ukraine has brought an unexpected focus on India’s medical education system. The images of Indian medical students stranded in various Ukrainian cities are disturbing. The students have found themselves caught in war zones and on the borders of neighbouring countries while fleeing conflict areas. The evacuation also brings back memories of Indian students stuck in Wuhan in China after the coronavirus pandemic broke out years ago. It is well known that a large number of Indian students head to foreign universities for medical education, but the sheer number of them in Ukraine has come as a surprise. This has necessitated the need for a thorough review of India’s medical education system.

It is meaningless to propose that the private sector can rid the health sector of all its ills, including the flight of students abroad. The government needs to step in.

Among the chief reasons being cited for Indian students opting to study medicine in foreign universities is the high fee structure in India, and also the lack of an adequate number of medical seats in Indian colleges. This is partly correct, but the problem is much deeper and closely connected with the state of the country’s health system. The only way to address the problem is to bring about structural changes in the health system, of which medical education is a sub-system. The first systemic survey of the health system, including medical education, was done by the Health Survey and Development Committee under the chairmanship of Sir Joseph Bhore in the 1940s. Many of the recommendations of the panel were implemented after Independence and new institutions were created to serve the health needs of people, and medical curricula were modified based on these needs. No such comprehensive and wide-ranging review of the health system was done after this exercise, though expert committees were formed to examine specific issues from time to time.

The link between the health needs of people and medical education got severed with the entry of the private sector in the 1980s, which was also the period when private corporate hospitals were permitted to operate. Till this point, private sector participation in health services and medical education was restricted to institutions run by charitable, religious and minority institutions. The policy decision to allow for-profit or corporate players led to mushrooming of private medical colleges as well as corporate hospitals. Medical education being a state subject, some states aggressively promoted private medical colleges. The regulator, Medical Council of India (MCI), which was supposed to be a self-regulatory body, helped private players. Surplus money from agriculture was diverted into medical — and engineering — education in some states, with many of the private colleges owned by political leaders or their cronies. The courts also ruled that privately run professional education institutions had a right to charge fees higher than government institutions. Anomalies like NRI and promoter’s quotas crept in. Medical seats began to be sold to the highest bidder.

The result of all this was the wild growth of medical colleges as a commercial business. In addition, the growth of private medical colleges was mostly in western and southern states, leading to a skewed distribution of medical colleges. Southern states have a greater share of government-run medical colleges as well. For dental education, the number of colleges being approved was so huge that many had no takers and dental graduates are being offered salaries lower than even drivers and plumbers. The overall quality of medical and dental education deteriorated. Many private medical colleges do not have qualified staff or attached teaching hospitals. On the other hand, the demand for medical and dental seats rose. Given the lure of high salaries in corporate hospitals or private practices in urban areas, parents of children who could not afford a seat in ‘capitation’ colleges started sending their students to teaching shops outside India.

The experience shows that private participation in medical education has failed. The shortage of qualified medical personnel in rural areas continues. The concentration of doctors in urban areas and cities is high. There is the clamour of certain specialities while expertise in others, like preventive medicine, public health and communicable diseases is slacking. The distribution and spread of medical colleges are tilted in favour of some states. Medical training is out of bounds for the poorer sections of society. Above all, the cost of health services in the private sector has skyrocketed. In such a scenario, it is meaningless to propose that the private sector can rid this sector of all its ills, including the flight of students to unlikely destinations like Ukraine.

Government agencies pushing for more privatisation only need to look at some of the solutions experts have proposed in the recent years. One such set of ideas came from the panel on Universal Health Care (UHC) a few years ago. It was suggested that the government should open medical colleges in underserved districts and attach them to the existing district hospitals. And in these colleges, preference should be given to students from rural areas. This way, new medical colleges can be opened in deserving regions and they can turn out doctors who would be willing to serve in rural areas as they would be drawn from the region. In addition, these doctors will be better equipped in their skills and clinical experience as they would get exposed to local health problems during their training. These could be snakebites, maternal child mortality, leprosy, water-borne diseases and so on. In addition, the training of doctors should not be addressed in isolation, but as part of overall health workforce planning. Several new ideas can be implemented based on needs in different regions and states. Such a strategy is critical if India is to achieve the goal of UHC as enshrined in the Sustainable Development Goals (SDG) agenda. The plight of young Indians caught in a war zone should serve as a wake-up call.