The Ukrainian Crisis has brought the problems of medical education in India to the fore. While the most urgent challenge has been to evacuate all the Indian students to bring them back safely and also to explore all the possibilities to rehabilitate them within the country. In a short to medium-term framework, India must aim at expanding its intake capacity in medical education by manifold but with due regard to quality as well as affordability. Here are the facts as well as the opinions and views of a cross-section of society for investigating the expansion in medical education.
The number of medical colleges has seen a rapid rise since Independence. In 1950-51, the country had only 28 medical colleges (27 Government & 1 Private), which by 1960-61 and 1970-71 rose to 60 (56 + 4) and 99 (89 + 10) respectively. By 1980-81 and 1990-91, the number of medical colleges had gone up to 110 (96+14) and 143 (102+41). At the beginning of this century, the number had risen to 176 (115+61). So far the number of government medical colleges, generally known for providing the best quality education at the most affordable cost, had been dominating medical education. Since then, things started changing in favour of the private sector, such that by 2010-11, the total number of medical colleges increased to 314 of which 180 were in the private sector whereas only 154 were in the government sector. Though the number of medical colleges has been increasing year on year, the bulk of the increase was in the private sector. As a result, by 2021-22, the total number of medical colleges had gone up to 595, of which as many as 293 have been in the private sector. Obviously, the share of government medical colleges in the country has come down from 96.43 percent in 1950-51 to 50.76 percent in 2021-22 (Table 1).
Category-wise intake capacity of the medical colleges could not be ascertained since 1950-51. The sporadic data as available from the National Medical Commission (NMC) indicates that the total annual intake capacity in medical education has gone up from 41,500 in 2010-11 to 88,370 in 2021-22, recording an increase of 112.9 percent. The share of government medical colleges in the annual intake has marginally increased from 45.2 percent in 2011-12 to 50.4 percent in 2021-22.
As the situation stands today, the country has 595 medical colleges comprising of 302 government, 218 private, 47 deemed universities, 3 central universities, 19 All India Institutes of Medical Sciences (AIIMS), and 2 Jawaharlal Nehru Institutes of Postgraduate Medical Education and Research (JIPMER). Taken as a whole, they admit 88,370 students to the MBBS programme each year. Of these, 44,555 intake is in the government sector while private medical colleges take 43,815 students.
Admissions to these seats are granted on the merit and cut-off of the UG-NEET examination, now conducted annually by the National Testing Agency (NTA). In 2021 as many as 15.44 Lakh students appeared in this qualifying examination. Critically, while 8.70 lakh students qualified the examination, only the top 88,370 could get admission in the government and private medical colleges in India, both. Importantly, over the years, the number of aspirants for medical education has been on the rise. The 2021 number, for example, was 12.97 percent higher than the number that had appeared in the UG-NEET in 2020. Cost, quality, affordability, and value-for-money being the major deciding factor, the top rankers in UG-NEET choose government medical college whereas the rest making a bit lower cutoff go to the private medical colleges, as per compulsion.
Additionally, about 10,000 students, mostly those who could not score enough to get a seat or just enough to get a seat in a private medical college, prefer to pursue their medical education abroad. Notably, a medical degree abroad in many cases may cost only a third of what it does in private medical colleges within the country. While we may not have specific data on the exact number of Indian students going abroad for medical education, the data on the number of students appearing in the Foreign Medical Graduates Examination (FMGE) clearly indicates that the number of students appearing in this screening test has been rising rather rapidly. While 12,116 students appeared in FMGE in 2015, the number has gone up to 35,774 in 2020. The number of destination countries too have been rising. As per National Board of Examinations (NBE) data, the number of countries to which Indian students go for medical education too has been increasing such that in 2018-19, foreign medical graduates from as many as 59 countries appeared in FMGE. Going by the number of students, the bulk of them are from 11 major destination countries, like China (7,795), Russian Federation (3,517), Ukraine (2,734), Kyrgyzstan (2,041), Nepal (1,622), Georgia (672), Philippines (638), Kazakhstan (535), Armenia (450), Bangladesh (426), and Tajikistan (276). The remaining 644 students had graduated from 48 countries.
But the lower cost and ease of admission abroad entail enormous uncertainty, as on average only 16 percent of the foreign medical graduates are able to qualify for the mandatory FMGE to be able to practice in India. The pass percentage varies from country to country but it has never been higher than 25 percent during the past 7 years.
It appears that the number of students going abroad for medical education may rise exponentially once the Medical Commission of India (MCI) makes it mandatory for every medical graduate from India as well as abroad, to qualify for the National Exit Test (NExT). The NExT would take away a major advantage and reason for paying three times more for pursuing their medical degree from a private medical college in India, as it saves them from the hassle of qualifying FMGE screening. if everyone has to sit for the exit test, which will decide whether the students can practice in India or not, many may be tempted to get cheaper and, at times, better education abroad.
It is apparent that India stands to gain a lot by expanding its medical education and, thus, be able to not only overcome the shortage of medical professionals within the country but also take a lead role in providing medical professionals for the world as a whole. A simple market logic would suggest that enough capacity needs to be created to accommodate all the demand to mitigate the supply-demand mismatch. But this logic may not be acceptable for fear of dilution in the quality of medical education and training.
Mukul Gupta, an experienced educational administrator, a former director of Management Development Institute (MDI) and a data scientist, argues that all those who have merit and inclination for medical education need to be provided the opportunity to pursue their passion within the country. He estimates that out of 16 Lakh aspirants taking UG NEET, about 8 Lakh score 50th percentile or higher. This, according to him, reflects the genuine demand for medical education. The fact that only 12.5 percent of them get accommodated, a whopping 87.5 percent have no option but to look for opportunities abroad. Dejected and disappointed, most take a few more attempts and then give up their dream, he laments.
Alternatively, the manpower planning approach could be used to determine the demand and requirements of medical professionals and practitioners, and the capacity enhancement could be attempted accordingly. World Health Organization (WHO) recommends a minimum of one doctor per 1000 patients. India claims that it has already accomplished the norm, as the country has 13 lakh medical practitioners which amounts to one doctor per 834 patients. Experts, however, differ with the numbers and argue that the cited figures are based on the Indian Medical Registry, which contains the names of practitioners who are not necessarily active as the list is found to include even those who may have died, retired, emigrated, or stopped practicing. They feel that the real numbers may, in fact, not be remotely close and at best India would be having a maximum of 1 doctor for every 2000 patients.
Sanjay Mishra, a director at the Commonwealth of Learning points out to an article by Bhavin Jankharia in the Times of India which states that we do not even know how many doctors are presently practising in the country, what to speak of any reliable forecasting for the demand for doctors in the country. It further asserts that the situation is in fact much worse than anticipated and in a ten-year time framework, the country would be faced with serious shortages of medical practitioners. The policy planners in our country rarely work out detailed estimates of requirements of doctors, engineers, physicists, etc., and do perspective planning accordingly, laments Sudhir Raniwala, a former professor of Physics at the University of Rajasthan.
Total disregard for the quality and relevance in the expansion of general, professional, and technical higher education has been the biggest bane of our system so laments Vinod Kumar, another former professor of Physics at the same university. The proliferation of higher educational institutions and intake capacity has been a major pitfall of our higher education policy, he states further. India needs to expand its medical education to provide due opportunity to the young, meritorious, and talented students but must not prohibit people from going abroad for education feels Shamsu Zaman Ansari, a consultant in market prognosis and country manager in the middle-east.
Given the huge gap between the supply and demand for MBBS, the intake capacity needs to be doubled in the immediate terms with due regard to access and affordability, though it would not check emigration for medical education, instead would ease the admission situation says Aaeen Ahamad, a Delhi-based edupreneur. S.K. Singh, an academic administrator with long years of experience with the private and public higher education institutions and universities begs to differ and states that no amount of increase in the number of medical seats in the country would curb emigration of students as nearly 90 percent of those who go abroad are able to secure no more than 20 percent score in the UG NEET. The claim may be a bit of exaggeration as the factual data indicates that the 50th percentile student, the last eligible student who had qualified UG NEET 2021 and was, thus, eligible for admission abroad had scored 19.7 percent.
Manpreet Arora, a faculty at the Central University of Himachal Pradesh (CUHP) feels that the expansion should be based on some objective criteria and sustainability in mind. The expansion strategy should, rather than being aimed at stopping Indian students from going abroad, be geared towards adding adequate capacity to enable the desirous but deserving students to get medical education at an affordable cost. Even if the additional intake may not lead to better employability of the medical graduates, it may trigger medical entrepreneurship, she asserts.
Expansion with a focus on excellence is what Tayyab Shaikh, a human resource professional with long years of experience in the aviation sector emphasizes. Sunil Umarao, a social media enthusiast, however, feels that while creating additional capacity in medical education may not be a problem, maintaining standards and promoting excellence would be a huge challenge and that the mushroom growth in Engineering and Management education in the country is a glaring testimony to that. So is the view of Anand Mohan Agrawal, the Pro-Vice-Chancellor of a private university. It is not just the capacity constraint but a wide variety of factors that play their role in limited access to medical education leading to some travelling abroad for the same, says Salahuddin Ayyub, a deputy director at the Services Export Promotion Council (SEPC).
Quality and affordability in medical education are more critical than mere capacity enhancement says Nafis Ahmad, a Professor in the dental college of Jamia Millia Islamia. Private medical colleges are exorbitantly expensive and serve only the rich rather than the most meritorious, who find it impossible to study in those colleges and have no option but to look overseas, he further adds. Mukesh Gupta, a wellness counselor, and the Chief Coordinator at the Rehabilitation Council suggests simplifying the rules and regulations for admission and also encouraging innovation and research in medical education.
Though the availability of talent in the country, as pointed out by Mukul Gupta, suggests a 7-8 fold increase in the number of medical seats at the undergraduate level, even doubling the intake would be a challenge, due to the limited availability of qualified faculty, trained manpower and human resources needed for the medical education. The road to capacity enhancement in medical education needs to be treaded with caution and with due regard to the maintenance of standards and quality. All the more critical is the affordability, without which a good number of meritorious students may not be able to take admission. India could, in fact, create enough capacity to not only serve the meritorious and deserving Indians but should also become a lucrative destination for quality medical education for international students.
While no one could argue for diluting the standards in medical education to produce more doctors, we may have to address the issue of enhancing the intake capacity within the country on priority. Additionally, the country presently has a sizeable number of people with an MBBS qualification from foreign countries who have not been able to clear the Foreign Medical Graduate Examination. We may think of enabling such graduates in qualifying FMGE through foundational and preparatory courses to help them overcome deficiencies in their education and training as well as knowledge gaps due to curricular incompatibility abroad. It has been often mentioned that the foreign medical graduates suffer on account of exposure and training in the limited number of disease spectrum and are often ill-equipped to deal with many diseases that are rampant in India, like Tuberculosis, Malaria, congenital disorders, and prenatal complications, and subjects that are exclusive to the Indian medical education system, such as forensic medicine.
In the medium-term framework, the country has no option but to keep pace with the ever-increasing demand for medical education. The major stumbling block in this regard appears to be the dire shortages of faculty and trained human resources. It has been suggested by some that permitting non-medical teachers with M.Sc. and Ph.D. qualifications in allied and cognate disciplines like Anatomy, Physiology, Pharmacology, Biology, Bio-Chemistry, Bio-Technology, Bio-Engineering, etc. to teach in medical college may help a great deal. In any case, this is a chicken and egg kind of story. We can’t expand due to a shortage of faculty but the only way of addressing the issue of faculty shortage is by expanding the medical education at the undergraduate, postgraduate, and super-speciality levels.
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