Make medical education affordable, accessible

Senior Economic Analyst

The plight of the Indian students, mostly medical, in Ukraine has highlighted several anomalies. India takes pride in the medical tourism dollars that it earns by way of offering treatment, but there is a critical shortage of doctors. Simultaneously, there is a shortage of medical education seats. Last year, a massive 1.6 million appeared in tests for admission to only 90,000 seats in all government and private medical colleges.

The other side of the reality is that it is impossible for a middle-class family to afford private medical education and seats in government medical college are few and therefore open only to the most meritorious. The promoters of private medical colleges, like engineering colleges, are often without any earlier exposure to education and of variable integrity who will extract as much from the market as they can.

Fees for a degree in a private medical colleges can go up to Rs 1 crore when a government college charges between Rs 67,000 and Rs 3 lakh. No wonder, parents often find a medical degree in countries like Russia, China and the Ukraine cheaper than a privately acquired one in India.

The prime minister has invited the private sector to take up a bigger role in delivering medical education. Anand Mahindra, head of the eponymous automobile group, has asked his educational complex in Hyderabad which delivers engineering, management and legal education to look into medical education also.

One reason why there are fewer private medical seats than engineering is that private deliverers have kept away from medical education which has to be imparted over a longer duration. This means simultaneously there will be more batches going through the course and thus there is a need for more infrastructure. An MBBS course, including internship, needs 5.5 years to deliver whereas a bachelor’s course in management takes three.

Thus private investment in medical education is best done by those entities which can live with a longer gestation period and that typically comes with a degree of commitment to the idea. Hence, the prime minister’s plea is best responded to by the corporate sector which has a longer perspective than other businesses.

A fundamental question remains. How have Russia, China and Ukraine come to acquire a degree of capability in delivering medical education which India has not been able to? The answer is that they are all more developed countries with a higher per capita GDP and a longer experience in the development process than India.

What is equally important is that they all have a socialist background and consider it natural that the state should fund development of the educational infrastructure. Thus today, these countries have a ready educational infrastructure with the necessary development costs already sunk. This also explains why they have the capacity to spare to offer education as a service — get into this service export so to speak.

As the scope for immediate corporate investment in medical education is limited, for even upper middle-class parents to be able to find Indian medical education affordable, the government has to sharply hike its investment in medical education. This is also for the cardinal reason that there are too few doctors in India and the country needs to sharply and quickly hike its output of trained doctors. Without this, healthcare delivery cannot reach the desired levels.

There needs to be Centre-state cooperation with the state governments bearing a part of the load. For example, the states can be asked to provide land free for the medical colleges that can come up with Central funding. As for the Centre, it needs to formulate rules which are both geared to ensure quality without being unnecessarily bureaucratic and cumbersome.

Just as governments need to improve the ease of doing business, they need to do the same to improve the ease of delivering private medical education. Currently, the most daunting requirement a private medical education provider has to face is the necessity to also simultaneously run a hospital with four times the number of seats. This is so that interns can have a place to work.

However, thinking is progressing along the right lines with the Union Budget containing a proposal to attach medical colleges to district hospitals. Plus states that offer land at concessional rates to set up medical colleges will get viability gap funding from the Centre.

India is not alone in having to grapple with a humanitarian crisis in trying to bring back its students from Ukraine. Several African countries are equally affected. Nearly a quarter of the 76,000 foreign students who were in Ukraine when the Russians struck were from countries like Nigeria, Morocco and Egypt, according to a BBC report.

This is the result of a tradition that was set during the Soviet era when there was an effort by the government to attract students from newly independent African countries with an eye on long-term geopolitical interests. Over time, Ukraine has emerged as a gateway to Europe and European jobs for foreign students, both African and Indian. Ukrainian degrees are widely recognised in Europe for the quality of those who have acquired the stamp.

Indian medical students seeking degrees abroad mostly wish to return to India afters graduation and have to take the foreign medical graduation examination. The numbers taking this test have gone up by more than three times since 2014-15. As against this, over the same period, the number of medical colleges has gone up by only 1.5 times and the number of seats by 1.6 times.

During 2021-22, only a quarter of the students who appeared for this test (it is held twice a year), cleared it, thus acquiring the right to practice in India. This success rate, low as it is, has itself gone up over the years. Those who eventually do not clear the test despite reappearing stand to lose the investment made in a foreign degree.

Thus students going abroad for medical degrees take a risk. Despite this, they continue to do so, indicating the desperation in individual families where the offspring wishes to secure a medical degree, but an affordable seat is just not available in India.

The desperation to get an affordable foreign medical education is apparent from the fact that leaving aside the top three countries and Kirgizstan whose degree holders appear for the qualifying Indian test, Nepal accounted for 7.6 per cent and Bangladesh 2 per cent in 2018-19 (the latest figures available). The question that India needs to ask is what have Nepal and Bangladesh got that India has not.