'With over 50 per cent of medical seats reserved for those who have the ability to pay a fee ranging from Rs 50 lakh to Rs 1.5 crore for a five-year MBBS course and quotas in accordance with affirmative policies in government colleges, the band of seats available for the not-so-rich and non-OBCs is very narrow.'
It came as a surprise to many Indians that there are over 18,000 students from India studying medicine in different cities of Ukraine, a fact that went largely unnoticed until Russia invaded Ukraine, making large numbers of Indian students stranded in a war zone.
While the central government is making every effort to bring the students back to India amidst Russian attacks, the question arises, why do so many Indian students go to study medicine in Ukraine?
"The fact that so many are going to such developing countries to study medicine is indicative of the failure of our policy," former health secretary K Sujatha Rao tells Syed Firdaus Ashraf/Rediff.com in the first part of an interview.
Have we failed as a country by not accommodating our students in medical courses, forcing them to go to countries like Ukraine to become doctors?
Basically, everyone would like to stay home and study in India. Meaning, that no one would really like to go to countries like Ukraine or China that have similar, or in some cases, may even have lower standards of education.
So the only reason they go is the cost factor -- it costs much lesser to become a doctor in Ukraine.
To answer your question, the fact that so many are going to such developing countries to study medicine is indicative of the failure of our policy.
In commercialising medical education, we have made it unaffordable for average middle class aspirants, perversely reserving it only for the rich and well-to-do.
With over 50 per cent of medical seats reserved for those who have the ability to pay a fee ranging from Rs 50 lakh to Rs 1.5 crore for a five-year MBBS course and quotas in accordance with affirmative policies in government colleges, the band of seats available for the not-so-rich and non-OBCs is very narrow.
I believe that those seeking medical education in Ukraine, China and Russia etc are from this narrow band.
Prime Minister Narendra Modi said last week that we must set up more medical colleges and asked the private sector to invest in the sector. Do you think this will help students in future?
It's nothing new. The private sector is investing to set up medical colleges since the 1990s.
What's new is that for the first time, a PM has directly invited the private sector to invest in medical education.
I am unable to guess the reason for this as it is the private investment in medical education that is the main cause for the growing frustration among students and their consequent migration to other countries.
Instead, it would have been appropriate if the PM had assured policy reform that would enable students to study in India.
And such a policy reform would need to be comprehensive -- increase public investment on one hand and ensure fair and affordable fees in private colleges on the other.
In fact, it is the current government that by law has allowed private colleges to charge as per market rates for the 50 per cent management quota (seats) and thereby further commercialised medical education.
So the PM's statement without promise of appropriate reforms is of no value for stemming student migration to other countries.
But doing that would also imply revamping medical education policy.
From which year did private medical colleges start picking up?
From the late 1990s and early 2000s. It is a post-liberalisation phenomenon.
The IMF (International Monetary Fund) loan had stringent conditions to reduce the fiscal deficit, that meant cutting down on government expenditures.
The health sector was badly affected in terms of budget, that were available only for maintaining our institutions and infectious disease control.
With the rising demand for doctors, market forces kicked in and private investors began finding medical education a lucrative investment proposition.
This was also the time when corporatisation of medical care took root with public policy providing incentives such as cheap land, custom duty exemptions etc.
There is nothing wrong in private medical colleges. CMC Vellore or Manipal are examples of excellent standards.
But with reckless and rampant privatisation with no adherence to maintaining standards, for every one good college there are today five medical colleges that should be shut down for providing substandard education and are just money-making machines for the investors.
In countries like the United States it works well, doesn't it?
In the US, there are few government hospitals or medical colleges -- the majority are private medical colleges.
But then the regulatory system is very strong, unlike in India where it is very weak.
But even the US is facing problems due to the high fees charged by the private medical colleges as it has resulted in high level of indebtedness among students.
So even after getting their medical degree, these students cannot go and work in the public health sector, rural areas or in some developing countries as they are tied down to look for jobs in private hospitals to pay back their loans.
The same situation is developing in India, a situation we cannot afford, given our socioeconomic conditions.
High medical fees means that a small cohort of the rich becoming doctors -- such persons either have their own nursing homes or go to the US/UK for further specialisation or Dubai and middle east or look for jobs in cities to maintain their standard of life.
Some who have taken loans or sold assets to become a doctor need to seek jobs in corporates hospitals, for earning money to repay loans.
So none from this lot would want to work in government, do public health or work in rural areas that do not have the same quality of life that cities offer.
Why is there such a huge difference in the fee structure between India and Ukraine for medical studies?
Two reasons. One is greed. Private medical colleges, say in states like Karnataka or Tamil Nadu, charge almost Rs 1 crore for a MBBS degree and almost double for the NRI quota students.
The second is our regulatory framework that is highly prescriptive and restrictive.
The model is designed for high upfront investment such as the need to own a 300-bed hospital.
This is followed by the minimum size of land, rooms, and infrastructure etc that require a lot of capital.
Though some relaxations and accommodation have been made, yet, we need far more radical reforms to make medical education affordable.
(NOTE: In April 2019, a NITI Aayog report found out that out of 89 new medical colleges that were approved in 2011-2018, 39 failed to clear inspection by the Medical Council of India. In most cases, the functioning of the hospital was found to be deficient.
According to MCI rules, a medical college with 100 seats needs to have a functional teaching hospital with at least 300 beds, with 60% occupancy at the time of submission of application to the MCI. Read here (external link).)
Approximately, what is the fees an MBBS student pays at a private college in India?
It is anywhere between Rs 50 lakh and Rs 1 crore, depending on the state.
While West Bengal and Bihar are the cheapest, Karnataka and Gujarat the costliest.
Reputation of the college also matters. If it is not so well reputed, charges may be less than Rs 10 lakh per year. But colleges in Karnataka charge almost Rs 20 lakh per year and nearly double for NRIs.
But then one needs to compare it with government colleges -- while AIIMS-like institutions charge ridiculously low fees, in the states, government colleges charge about Rs 1 lakh or so per year.
The Supreme Court of India did try to bring in some moderation in fee structures by asking states to constitute fee fixing committees.
Barring Telangana and Andhra Pradesh, where such committees have been able to moderate the fees, no other state seems to have implemented the Supreme Court guidance.
However, the recent Act of the government, allowing private medical colleges to charge market rates for the 50 per cent seats falling under management quota, will make it difficult for the government to intervene in capping fees or regulating them without appropriate legislative amendment to the Act.
This is likely to take a long time as most medical colleges are 'owned' by politicians and their proxies.
And if the government seeks to intervene without amendment to the laws, it will result in litigation.
So the government has needlessly got itself into a bind. As a result of the National Medical Commission Act of 2019, fees have gone up further.
When Ukraine colleges can give a medical degree for Rs 25 lakh to Indian students, that too for a six-year course, why can't Indian private medical colleges do the same?
I have already explained why. Unlike, say in Japan, in India the majority of investment in medical education comes from investors who have nothing to do with medical education or the health sector.
Their only concern is profits and dividends. So, once you look at medical education as a business proposition then fees will be charged with the intention of making profits, not necessarily to create good doctors.
And sadly, our public policy is encouraging and incentivising such considerations and thought processes instead of the other way round.
This is so different from China or Ukraine or even capitalist countries like Norway and the United Kingdom where medical education is part of the university system where higher education is affordable and made accessible to all.
In Norway, medical education is not only free, but students are given scholarships to incentivise them to study.
We need to remember that medical education is tough and becoming a doctor is no cakewalk. It is an arduous task and requires long hours of study and motivation.
What is the patient to doctor population ratio in India?
It all varies from state to state. In a state like Bihar, you have one doctor for 20,000 people and in a state like Karnataka you will have one doctor for 900 against the national standard of one doctor for 1,535 patients.
With so many students going to study MBBS abroad, do you feel this ratio will improve in future?
No, it is not easy for these MBBS students who study abroad to become doctors in India.
These students have to clear the National Medical Council exams and only then can they become doctors in India.
And many of them fail too, because MBBS studies in some of those countries are not of good standard.
Some of these colleges abroad are not recognised by the National Medical Council too.
Those who pass can practise and some of them who fail don't practise and get the degree only for social status.
Are teaching standards for MBBS courses so bad in those countries?
I don't know how bad or on par are the courses in medical colleges of Ukraine or other countries. I know that in several colleges in China, Indian doctors go to teach, partly for the lack of faculty and language barriers.
We have a policy of reciprocity in giving recognition to such courses.
The US does not recognise our degrees for example, so we too do not recognise theirs.
Medical profession, the world over, in that sense operates like a closed club to keep their monopoly status.
If they keep it open then anyone from any country can come and set up shop and compete, impacting their earnings.
Besides reciprocity, there is a process for recognising foreign degrees.
The MCI -- now the NMC -- examines the curriculum, course content, practical training the faculty, infrastructure etc and if found appropriate, accords recognition.
Besides, students who study abroad, upon return have to take an examination for getting their licence to practise.
I remember that a majority of the students used to fail and they would then resort to bringing political pressure.
It is really a complex issue, highly nuanced and layered, necessitating a far more sophisticated policy making than just pretending that markets can sort out the issues. They don't.
Not in the health sector and that reality is one that our policy makers have to and must recognise.