For the past three years, Delhi-based Ashish Kumar has been trying to crack the National Eligibility and Entrance Test (NEET) for an entry into the Bachelor of Medicine and a Bachelor of Surgery (MBBS) course at a good medical college in India. While he has been clearing the test, his marks have dangled between 400 and 450 out of the grand total of 720. His low marks always meant that he could not qualify for any government medical college. While he could have easily gotten admission in a private college, he did not have the means to afford its exorbitant fee, unlike many others who could, even with lower ranks. Kumar is now considering countries that offer medical education at a cheaper rate as pursuing the course in India seems unviable.
Like Kumar, thousands of students scour for universities abroad for their undergraduate medical courses while not many from other countries consider India as their destination for medical studies. This can be attributed to the cost of education, accessibility and also the vague and opaque regulatory process for medical colleges.
NEET And Tardy
In India, admission to the undergraduate medical courses, including MBBS, in all medical institutions goes forward only after the student has cleared the contentious NEET conducted by the National Testing Agency. In 2021, out of 16 lakh students who took the test, about 8 lakh cleared it. Generally, candidates who score 600 and above can eye government colleges and the ones below that, between 450 and 600—the ones just like Kumar—are left to the mercy of private colleges.
Here is the plot hole: India does not have enough seats in government colleges to accommodate all the students who clear the test. In 2021, for instance, the available seats could take in only 10 per cent of the successful candidates. Over the past few years, the number of medical seats in colleges has increased from 60,000 to 80,000 with the government setting a target of 1,00,000 seats before the academic session of 2022-23 commences. Of the current number of seats, around 42,000 are in government colleges and the rest are in private colleges.
It is clear that the increase in seats is not commensurate with the increasing demand as more students are clearing NEET every year. The next impediment in students’ medical journey—exorbitant fee in private colleges—has also remained largely unaddressed by the government. While the government colleges offer subsidised undergraduate medical education at around Rs 5 lakh for MBBS, the lowest fee for the complete course in any private college is over Rs 70 lakh.
On September 25, 2020, the Medical Council of India (MCI), India’s former apex regulator for medical education, was replaced by the National Medical Commission (NMC) under the National Medical Commission (NMC) Act, 2019 which replaced the Indian Medical Council Act, 1956.
Under the new act, guidelines were to be framed by the NMC to fix the fee of 50 per cent seats in all private medical colleges in accordance with that of government colleges. Following this, the NMC recently issued a circular asking India’s private medical colleges to charge a fee equivalent to that of government colleges on 50 per cent of their seats. While the circular is being seen as a step in the right direction, its implementation seems to be plagued with problems, making it seemingly unfeasible.
“If we admit 50 per cent of students on the fee charged in the government college, then we will have to charge Rs 5 lakh instead of Rs 75 lakh from those students. Who will compensate for the loss?” asks a private medical college owner. “If the government asks us to recover it from the remaining 50 per cent seats, those seats will cost close to Rs 1.5 crore and medical education will become more unaffordable,” he adds, explaining his conundrum.
A Costly Affair
Private medical colleges owners in India believe that every aspect of medical education in India is overregulated with unnecessary essential requirements related to land, number of faculty members, nurses and administrative staff. The requirements, which incur a huge cost in opening and running a medical college, haven’t been touched by the new act.
However, it has relaxed certain other aspects. For instance, to get recognition under the previous law, a new medical college had to undergo an inspection every year for five years. In the process, many used to fail in terms of compliance and lose permission to admit fresh batches for that academic year. Many colleges were also shut down due to an allegedly discriminatory approach by the erstwhile MCI over a small percentage of deficiency in faculty, the status of admitted patients and infrastructure, claim some colleges.
The new law has discarded that provision and colleges will now be inspected only twice—once at the time of its opening and once five years later—to see if they have complied with the norms related to faculty, administrative staff and infrastructure. However, many colleges have alleged that NMC is violating the legal provision and carrying on annual inspections as used to happen earlier.
It was only in 2020 that the 20-acre campus rule, set by the MCI, was eased by the NMC and the land clause was done away with. However, as the infrastructural requirements to open a medical college remain the same, colleges say that removing the land clause hasn't brought any relief. For instance, as per the previous as well as the new norm, it is mandatory for a recognised medical college to have a 650-bed fully functional hospital.
To assess the costs involved, let us take a look at what it takes to establish a 150-seat medical college. As per government norms, in the first year, a batch of 150 students must have a 300-bed hospital with faculty, nurses, emergency services, an out patient department with a footfall of 1,000 patients every day, among other things. By the time the college admits its fifth batch, the hospital would have to upgrade to at least 650 beds, of which 75 per cent will have to be occupied at all times, with added infrastructure and manpower. Besides the hospital staff, it would need 212 faculty members to teach 600 —first to fourth year—students.
“In the first two years, students only study anatomy, physiology, biochemistry, pathology, pharmacology, forensics and community medicine. These are pre- and para-clinical subjects for which students do not need any hospital setting,” explains an official at a private medical college in Haryana.
“It is only the third year onward that they need to learn clinical subjects such as surgery, paediatrics, gynaecology, etc. So, for 450 students, we have to create a huge set-up in a 650-bed hospital with 212 faculty, 370 nurses, over 100 technicians and several other facilities,” he adds.
All in all, the cost of opening a medical college can range anywhere between Rs 700 crore and Rs 1,000 crore, depending on the city and the area.
“Who will spend Rs 1,000 crore? Only big businessmen and politicians. If they are investing so much money, they would hope for high returns as well,” says an official of a private college in Uttar Pradesh, adding that the cost to cover the essential requirements to open a medical college in India is so huge, and irrelevant, that the cost of education is bound to go up manifold. The colleges have to cut corners, resort to unfair means and manipulate norms to fulfill it, he says.
If a college does not comply with the norms, it loses its recognition status and is barred from admitting a fresh batch of students. “This whole process causes corruption to breed and quality to be compromised with,” says the owner of a Haryana-based private college.
Foreign Grounds, Familiar Challenges
The dejected students, who miss the government college bus and cannot afford to pay the high fees of private colleges, find themselves in a tough spot. While some give up on their doctor dreams and drop out, the others flock to countries that offer cheaper medical education at a cheaper cost.
Countries like Ukraine, Uzbekistan, Kazakhstan, China, Russia and the Philippines, which see an influx of Indian medical students, have colleges with a minimum fee for a course—MBBS, for instance (4.5-year course plus 1-year internship)—that is two to four times lower than what it costs in India.
Studying abroad, in itself, is not bereft of challenges. Once these students finish their course there, a screening test—the Foreign Medical Graduate Examination—awaits them back home. Only the ones who clear this test get registered as doctors in India. Further, the NMC has enacted new regulations for foreign medical graduates on November 18, 2021, which have imposed strict conditions on students going abroad making it more difficult for them to fulfil their dream.
Experts say that only 20-30 per cent of all the students who take the test clear it and become doctors in India and the rest look for alternate career options. They attribute it to the poor quality of education these students get in some of the countries abroad which justifies its cheap value.
“The passing percentage in the screening test is less than 30. This is because countries like China and Russia offer differential medical education systems in which they follow strict regulatory norms for their own students but compromise with training and facilities for international students, including Indians,” says Dr R.K. Srivastava, former chairman of board of Governors of the dissolved MCI. He says that medical colleges in these countries calculate the return of investment by compromising with the standards of establishing a medical institution, faculty and skill training as they know that these doctors (foreign students) have to go back to their own country to work.
“In the USA, the cost of medical education is three times more than that in India because they follow a more robust, long-duration and high-quality education system,” he adds.
Some education counsellors and owners of private medical colleges in India, however, disagree with Dr Srivastava’s view. They feel that the low passing percentage cannot solely be an indicator of teaching quality and skill training.
Anuj Goyal, an education counsellor who runs a firm called Get My University, says that Indian students who go to countries like Bangladesh and the Philippines perform better in screening tests as compared to those who go to low-density countries like Russia.
He explains why: “Students going to high-density countries like Bangladesh or the Philippines find a similar training environment as in India. The student-patient ratio, population density, climatic condition, teaching language, among others, are multiple factors that influence the passing percentage.”
Delhi-based counsellor Ravi Kaul suggests that the passing marks for NEET should be raised above 300 from the current 138 for the general category and 108 for SC/ST candidates so that students with poor marks do not have to look for options abroad.
“Today, if you have 108 out of 720, admission is out of the question in India. So, students choose an inferior college abroad. Such students bring down the passing percentage of screening tests,” says Kaul.
Meanwhile, the new act has made provisions for an exit exam—the National Exit Test— for both Indian and foreign students after completing their medical courses from 2024 onward. Education counsellors say that quality comparison will become more meaningful after that.
The Way Forward
Some experts suggest that the intake capacity of each college should be increased by two to three times to accommodate and train more students using the same infrastructure. Then there are others who believe that increasing the number of seats will bring down the quality.
“In medical education, the more you get to see the patients, the better you become as a doctor. The increase in seats will impact the patient-doctor ratio,” says an MD student from AIIMS.
One section of experts feels that the government should not just give permission to open medical colleges but also affiliate them with stand-alone hospitals so that students can get their training in these hospitals. However, some medical experts are skeptical about this model being successful as both teaching and hospital businesses have their own interests and targets.
“This can only be successful when the ownership of the college and the hospital remains in the same hand. The government should encourage big hospital groups, especially Max, Fortis, Apollo, etc., to enter medical education as well,” says Dr Gulshan Garg who runs an NGO called Sankalp. “If the regulatory framework needs to be tweaked to make these big hospital chains enter medical education, it should be done,” he adds.
Dr Srivastava, on the other hand, suggests a minimum viable product model for colleges to make affordable medical education a reality. He feels that the cost will come down considerably if medical colleges spend on basic necessities instead of expensive buildings and luxurious infrastructure.
“Instead of low-volume and high-cost investment, which is happening at present, it should rather be high-volume and low-cost. The government, the regulator and medical colleges should think about it,” he says.