Medical Education Policy has Many Inadequacies

The draft of National Education Policy 2019 is in public domain. This means people across the country can give their inputs on this draft before it is discussed in the standing committee followed by debate in the parliament for formal adoption. The document dwells on various aspects and different sectors of the education. Medical education is generally debated along with the national health policy document where general guidelines about the approach are presented. But the present National Education Policy document too has given space to it as 'Healthcare Education' in the Clause number 16.8.

The initial part of the document recognizes "that Healthcare Education must ensure that skilled doctors, nurses, and paramedics are trained in a scheme that appreciates pluralistic health education perspectives alongside specific disciplinary foci. Reforms in medical education must necessarily have a profound impact on the quality of healthcare delivery. The goals and standards for medical education must be derived from the vision of 'state of the art, quality, and affordable healthcare for all'. Reforms in healthcare education must aim to improve the quality of infrastructure for primary and secondary healthcare, particularly in rural areas. Improving access to healthcare education for rural students, and lowering the cost of education is key to achieving this goal".

The sub clause 16.8.1 deals with the basics of MBBS training and lays stress on regular assessment of the students. This is important step. It stresses on introducing rotatory internship. The rotatory internship already exists; without a certificate of having done this one does not get the degree. It is another matter that because of pressure of entrance into post graduate courses, the students do not spend much time in it. However for training a basic MBBS doctor for general practice it is important that the young doctors spend stipulated time in the hospital during the internship seriously.

Next clause suggests introducing the basic course for first 1-2 years. After this they will be free to join MBBS, BDS or Nursing etc. It is not clear in this how this will be done. The document leaves the issue to be discussed with the National Medical Commission (NMC). Bridging of courses, that is lateral entry of students from nursing and other disciplines to join is another point taken up in this clause. How this will be integrated is again not clear in the draft.
The clause 16.8.3 deals with the exit examination for the MBBS graduates. The document has outlined that the students will appear in the examination after 4thyear. Selection to the post graduate courses will also be made on the basis of this exit examination so that the students do not have to appear in the examination for PG courses again. But what is not clear is the status of the students who are not able to get minimum qualifying marks. These students have already appeared in the final year examination in different subjects. Those who have passed in the regular exam will not get the degree until they get minimum qualifying marks in the exit exam.

The students from medical colleges which are better equipped are likely to clear the exit exam. But since the exit exams are in the MCQ format, the result may not be as expected. This is an extra stress on the students. In fact the logic behind it is to discourage the students from getting admission to the substandard colleges. This amounts to in fact running away by the government from the responsibility to ensure quality education in all the colleges. The NEET exam is already under lot of debate. Some states like Tamil Nadu are opposed to it and they lay stress on rules for the medical education to be state specific also. There are also issues of language in the examination.

The WHO recommends one doctor per one thousand of population. Replying to a question, the Minister of State for Health, Smt. Krishna Patel had told in the Lok Sabha that on 31st March 2018 that 1022859 doctors of modern medicine are registered with various state medical councils. She further said that around 8 lakh doctors are actively available at one time. This means that the doctor population ratio in India is 0.62 doctors per one thousand populations. While nearly 70 per cent of India's population lives in rural areas, the rural India has 1/4th the doctors as compared to urban areas. This is a huge gap to be fulfilled. Thus we need more doctors for our population. For this the government plans to open more colleges. To fulfill the health requirements of our people we have to have medical colleges which impart relevant training to the students and orient them to the needs of our society and encourage them to work in areas so far neglected.

A review of the medical education scenario shows that admission to the medical colleges has been a contentious issue for quite some time. Initially most of the medical colleges were in state sector. Going by the information from the website of Medical Council of India, at the time of independence, there were 20 colleges out which only one was in private sector. Most of new additions were in the state sector till late eighties. But after the shift in economic policies and neo liberal model of development the whole scenario changed. Between the periods 1990 to 2017 number of colleges opened in private sector was 238 while only 115 were opened in state sector. Many of these were made as deemed universities which could have their own examinations, admission system and fee structure.

Many of these were charging under hand money as capitation fee. Merit was completely ignored and money became supreme. Seats are reserved under the management quota where they can charge at their will. For example in the state of Punjab the tuition fee in the government colleges is Rs.13.4 lakh for the full course of MBBS for 4.5 years. In the private colleges in the seats under the management and the NRI quota it varies from Rs. 35 lakh for the full course to Rs.63.9 lakhs. Astonishingly telephonic enquiry from the Era's Medical College Lucknow revealed the tuition to be 17 lakh per annum which with 10 per cent increase every year comes out to be nearly Rs. 91.34 Lakh for MBBS course. The PG seats tuition fee in this college is up to Rs. 49 lakhs per year. That means for MBBS and MS/MD both from this college, one will have to pay nearly 2.5 crore rupees and an additional charges for books, travel etc. This means the student has to spend nearly 3 lakh rupees per month or Rs. 10000/- per day.

This is a cruel joke. In our country where vast majority of population is devoid of even basic needs, it is literally impossible for them to imagine to send their wards to the medical college even when they are on merit. There was hope that after introduction of NEET, capitation fee will end. But what has happened is to the contrary. The private colleges increased their tuition fee and are now earning legally in white money. This will simply undermine the quality of medical education and not fulfill the needs of society we are striving to achieve. Going by the track record it appears that the advice to the MCI to regulate the fee structure can turn out to be an eye wash.

The proposal to upgrade 600 district hospitals to teaching ones sounds good. This again would require lot of funds. Similar is the case of post graduate courses in which seats are proposed to be increased. The national medical commission in its outlines has said that the private players will be allowed to open medical colleges where only up to 40 per cent seats fee will be governed while the rest will be free for the institutions to charge the tuition fee.

The situation of the allied branches and paramedical branches is worse. Most of such colleges in private sector that are imparting nursing training, laboratory training and other courses do not fulfill the requirements. Many of these do not have any hospital attachment. The proposals in this document that these training programmes will be hospital-based, at those hospitals that have adequate facilities, including state-of-the-art simulation facilities, and adequate student-patient ratio and that these courses will be made accessible and affordable to students from rural backgrounds. Focus will also be given to priority areas like physiotherapy, hospital management, medical engineering and technology etc. All this has to be watched. For this we need to increase funds in the public sector.
The proposal to upgrade Ayush is welcome. There is need to make them evidence based and more scientific. State must recognize its responsibility to health and education if it really wants to serve the people. Health and medical education cannot be left to market economy mechanism, they should be taken as social responsibility. The governing bodies for the purpose need to be democratic. The structure of NMC has 25 members, all of whom will be nominated by the central or the state government/UT. This makes the regulatory body totally undemocratic with only bureaucratic control and no involvement of various stake holders.