Reforms crucial to set right India's skewed medical education model
Seethalakshmi S
76,000 doctors graduate every year in a country with a population of 130 crore. The corrupt regulatory authorities for medical education in India have reduced the healthcare system in rural areas to a point where the poor walk for kilometres on end to find a doctor. The Covid-19 pandemic has exposed the wide gaps in our healthcare system and the lopsided rural health service policies of the successive governments. Systemic reforms are the need of the hour and it’s time we must loosen up our resolve that quantity will dilute quality specially in healthcare.
When a group of medical students told the Karnataka High court that they cannot comply with the compulsory rule for every medical student to do government service, it was not their defiance that was shocking but the reasons for it - we pay Rs 75 lakh for a medical seat and cannot work for pittance!
Though the young doctors made it clear that they will come to the aid of the government and assist in Covid-19 duty by serving in government institutions, they were also clear about not making it as their career.
Historically, medical education policies across India have been piecemeal legislations. Lopsided medical education policies to address doctor shortage in government service have resulted in states floundering during the pandemic. States which decided to get young doctors into the government service framed policies that allowed them to openly flout it. For instance, a clause in Karnataka’s Compulsory Rural Service Rules allows students to pay a penalty and skip the compulsory rule. This made a mockery of the government's own rule.
The Medical Council of India thought a first world regulatory structure will work for a country with third world infrastructure. Young students whose parents pledged their life time savings and properties to get that coveted medical degree obviously wanted a return on investment, which a government hospital cannot afford. Added to this are poor salaries and horrible working conditions. If doctors in Europe and the US work 48 hours a week, they work for close to 60 to 70 hours a week in India, sometimes stretching up to 85 hours. And, what do they get at the end of the day – neither reward nor recognition.
But at the core of this lies the severe shortage of medical seats. The argument ‘quantity-dilutes-quality’ is misplaced, leaving too few seats for too many students. In 2019, 15 lakh students appeared for the National Eligibility Entrance Test (NEET) of which 7 lakh cleared. And for the first time in its 64 year history, the MCI added a paltry 14,863 seats. Even after this there were just 80,312 seats. The number of medical seats rose from 54,348 in 2014 to 80,312 in 2020.
Predictably it’s a scramble when 7 lakh students are fighting for 80,312 seats in 541 medical colleges (280 government and 261 private colleges) across India.
A World Bank study revealed that a small country like Cuba produces the largest number of doctors per capita in the world
(6.7 per 1000 as against 2.5 per 1000 in US and 0.7 per 1000 in India). Our shortage of doctors and nurses stood at three and six million respectively.
Quite naturally, it has a cascading effect. With so less number of doctors graduating, our hospitals are perpetually understaffed. There again it is the battle between where the young graduates will join - with private hospitals being the first choice and naturally so. The preparations for a child to become a doctor in India begins as early at 14 years of age. The exorbitant coaching fees, then the capitation fee (if you do not get a government college seat) and then the expenses for the next six years. The investment into medical education runs to crores for a large number of students simply because the number of seats are so few.
The Covid-19 pandemic has exposed years of medical education mismanagement in India. The shortage of doctors is staring at us like never before. There are barely 2000 cardiac surgeons, 50,000 gynaecologists (as against 2 lakh requirement), 50,000 paediatricians (as against 2 lakh requirement), 10,000 radiologists (as against the requirement of 1.5 lakh) and 1400 neurosurgeons for a population of 1.3 billion people. There were just 4500 specialists who can work in Intensive Care Units (ICUs) forcing even the private hospitals to sit back and pray that patients do not get into the ICU stage when the number of Covid-19 cases soared.
And experts say it is a combination of factors that has led to this sad state of affairs. The entire premise itself is wrong. Anyone desirous to start a medical college needs to be ready with Rs 400 to 500 crore to build the college infrastructure. And then the investor starts looking for returns by pricing each medical seat at Rs 40 to 50 lakh, which in turn results in the students too expecting a return on their investments and refusing government service. It’s like a whirlpool.
The Recovery Pill
1. The first step is to equalize undergraduate and postgraduate seats in India so that the number of specialists go up proportionately.
2. Seats for specialisations like neurosciences must go up, significantly at a time when more people are facing mental health issues.
3. Drop clauses that mandate huge investments to the tune of several hundred crores to start a medical college. You do not need a Rs 500 crore investment to teach 250 students (150-200 UG and 100 PG/fellowships). We can learn from the Caribbean Islands where 35 odd medical colleges are training fantastic doctors for the United States and other countries from a rented 50,000 sq ft space.
4. Make paramedical training compulsory and robust to address doctor shortage especially in rural areas.
The essence of medical education must come to the aid of the healthcare sector, and for that radical reforms are the need of the hour.
Seethalakshmi S is Director (Policy & Strategy) at The Institute for Policy Research - A Centre for Multidisciplinary Studies, Bengaluru
Reach out to the author at: seethalakshmi@theipr.org