A brewing storm is gathering momentum countrywide following a proposal voiced by union health minister anbumani ramadoss to make rural service mandatory for all medical students. the proposal will impose a year’s hardship posting in the under-provided outbacks of rural india. Dilip Thakore reports
A gale of hurricane proportions which could devastate the country’s already grossly inadequate and fragile healthcare system is gathering momentum within the country’s 262 medical colleges, offering study programmes in the dominant allopathic system of medicine, which churn out an estimated 31,000 qualified (MBBS) medical practitioners annually. (In contemporary India medical education is offered under four systems of health sciences — ayurveda, homeopathy, unani and allopathy — in 817 colleges across the country with an aggregate enrollment of 257,000 students. However this feature is focused upon issues relating to the country’s 262 medical colleges dispensing education in the mainstream allopathic system to 155,000 students).
The moving force behind the brewing storm is a proposal voiced by controversial Union health minister Anbumani Ramadoss to make a year’s rural service mandatory for all medical students. In effect this proposal, which is being promoted as a component of the National Rural Health Mission (NRHM 2005-12) launched by prime minister Dr. Manmohan Singh in April 2005, will not only lengthen the duration of the basic MBBS study programme (currently five and a half years) by a year, but would also require all medical students to experience a year’s hardship posting in the under-provided and under-serviced outbacks of rural India, prior to graduation.
The proposal aired by Dr. Ramadoss — a strong-willed minister used to getting his way in the 17-party Congress-led UPA (United Progressive Alliance) coalition government in New Delhi which recently completed three years in office — has dismayed the medical fraternity across the country. Ironically, the first banner of revolt against this proposal was raised in the minister’s home state of Tamil Nadu where students held coordinated protest demonstrations and called a one- day strike on September 5. Their continuous protests prompted Ramadoss to appoint a six-member committee chaired by Dr. R. Sambasiva Rao, additional director general of health services under the Union health ministry, to examine the ministerial suggestion. But the general perception within the students’ community is that the constitution of the Sambasiva Rao Committee is a mere stalling tactic, and that in any event Rao will toe the line drawn by the minister.
Therefore the agitation against the compulsory rural service proposal initiated by medical students in Tamil Nadu on September 5, has spread across the country with medical students staging demonstrations and marches in Uttar Pradesh, Bihar, Maharashtra, Andhra Pradesh and Karnataka, among other states of the country. On November 24, the fire of student opposition to this proposal swept across Delhi, when a thousand-strong posse of medical students from five Delhi-based medical colleges undertook a 5 km march across the national capital to express solidarity with protesting students in other parts of the country.
This confrontation between the country’s estimated 155,000 medical students’ fraternity and Ramadoss is rooted in the long-standing policy of heavy subsidisation of medical education in post-independence India. In pursuance of the socialist pretensions of the Congress party which has ruled at the Centre and in most states of the Indian Union for over 40 of the 60 years since independence, the promotion of private medical colleges has been strongly discouraged, although not entirely successfully. Currently the number of privately promoted medical colleges (147) outnumber Central and state promoted institutions of medical education (115). Nevertheless in keeping with the tenets of licence-permit-quota raj which almost destroyed Indian industry while enriching politicians and bureaucrats, the admission regulations and tuition fees chargeable by privately promoted medical (and engineering) colleges across the country are rigidly controlled by the Central and state governments, purportedly in the national interest.
Yet the actual ground reality has been that for the past six decades medical education, cornered mainly by pampered ruling elites and the middle class, has been given away almost free of charge in the 115 medical colleges promoted by the Central and state governments and is heavily subsidised in the 147 privately promoted institutions of medical education. Under a plethora of complex legislation made more complex by prolix judgements of the Supreme Court and the higher judiciary, even privately promoted medical colleges were compelled to surrender up to 85 percent of their seats to students divided into merit, partial-merit, scheduled castes, scheduled tribes and OBCs (other backward castes) — all of whom paid differentiated (below cost) tuition fees prescribed by state governments.
Institutional managements were left with a discretionary ‘management quota’ of 15 percent under which they could admit minimally qualified students of their choice. It’s hardly surprising that this officially condoned regime of cross-subsidisation prompted institutional promoters to levy heavy capitation/donation fees (repeatedly banned by the Supreme Court) upon students applying for admission under the management quota, and hundreds, if not thousands, of rackets connected with medical education bloomed.
Inevitably, under the socialist dispensation, genuine philanthropists and education entrepreneurs who could have augmented capacity in medical education, were routinely denied licences and permissions to promote medical colleges even as the perennially cash-strapped Central and state governments failed to meet the bourgeoning demand. Nevertheless some of the more determined private sector entrepreneurs and philanthropists ran the licence-permit-quota raj gauntlet to establish high-quality and well-administered non-government institutions of medical education which number 147 countrywide currently. The humiliation, procrastination and discouragement that public-spirited medical education entrepreneurs suffered at the hands of politicians and bureaucrats arrogantly practising licence-permit-quota raj was graphically detailed by Selden Menafee, an American journalist who wrote The Pais of Manipal, an epic biography of the late T.M.A Pai (1898-1979) who laboured for over 20 years to promote the Kasturba Medical College in the small town of Manipal in Karnataka, which became the foundation block of the Manipal Education Group and Manipal University comprising 55 education institutions with an aggregate enrollment of 88,000 students.
Since then, notwithstanding the historic economic liberalisation and deregulation initiative of 1991, rigid government controls over medical education have begun to ease only recently following the Supreme Court’s historic judgements in the T.M.A Pai Foundation (2002) and P.A Inamdar (2005) cases, in which full benches of the apex court expanded the fundamental right conferred by Article 30(1) of the Constitution upon religious and linguistic minorities to “establish and administer educational institutions of their choice” to all citizens.
Interpreting the word “administer” broadly, the learned judges of the highest court have permitted privately promoted professional (medical, engin-eering, business management) colleges to prescribe their own admission procedures (subject to their being transparent and merit based) and levy “reasonable” tuition fees. Unfortunately waters of the clear stream of reason belatedly emanating from the Supreme Court on this issue have been somewhat muddied by a five-judge bench of the apex court in the Islamic Academy Case (2003), which has prompted state governments to establish admission and fees committees to supervise whether the admission procedures of private medical colleges are transparent and tuition fees levied reasonable.
| Health and medical services: How India compares | Health expenditure | ||||
| Pop. (million) | Public (% of GDP) | Private (% of GDP) | Physicians (per 100,000 people) | Children underweight (% under age 5) | |
| Japan | 129 | 6.4 | 1.5 | 214 | 6 |
| USA | 295 | 6.8 | 8.4 | 256 | 1 |
| UK | 60 | 6.9 | 1.1 | 230 | 0 |
| Germany | 83 | 8.7 | 2.4 | 337 | 0 |
| Rep. of Korea | 47 | 2.8 | 2.8 | 99 | 0 |
| Russia | 144 | 3.3 | 2.3 | 425 | 13 |
| Brazil | 184 | 3.4 | 4.2 | 115 | 11 |
| China | 1,308 | 2.0 | 3.6 | 106 | 14 |
| India | 1,087 | 1.2 | 3.6 | 60 | 49 |
| Nigeria | 129 | 1.3 | 3.7 | 26 | 29 |
| Bangladesh | 140 | 1.1 | 2.3 | 28 | 48 |
| Source: UNDP’s Human Development Report 2007-08 |
The outcome of this tenacious rearguard action of the country’s powerful educracy which seems determined to maintain its hold over professional education, is that the historic supply-side constraints of medical education persist, the judgements of the Supreme Court notwithstanding. Therefore medical students in government and private sector colleges as well have no option but to submit to the imperious order of the Union health minister — in a sound byte given to a television channel Ramadoss said the compulsory rural service proposal will be implemented regardless of the recommendations of the Sambasiva Rao Committee — which will extend the duration of their study programme by one year.
Moreover the medical students’ community is only too well aware that Ramadoss who has a free run of the Union health ministry, is given to having his way within the UPA coalition government. They can’t be unaware of how following a long-standing row with the student-friendly Dr. P. Venugopal, director of the country’s showpiece All India Institute of Medical Studies, Delhi, Ramadoss almost single-handedly piloted an amendment to the AIIMS Act, 1956 imposing a retirement age of 65 on the director of the institute through Parliament — blatantly ad hominemlegislation which fortunately, has been stayed by the Supreme Court.
It’s a telling commentary on the low priority accorded to education by the UPA government that none of its ministers has ever granted an interview to EducationWorld, despite it being the sole education news and analysis publication countrywide. EW’s Delhi-based correspondent Autar Nehru made repeated calls to Ramadoss’ office to elicit a direct sound byte from the minister, alas, to no avail. Nevertheless Ramadoss’ rationale for issuing the compulsory rural service diktat is well known. Since medical education, especially in the country’s 115 government medical colleges is heavily subsidised, medical students should pay back at least a part of the subsidy by way of compulsory rural service, he says.
Ex facie Ramadoss’ argument is unexceptionable. As outlined above, over the past 60 years since the country became independent and misguidedly adopted the socialist model of development, government control over higher education and medical education in particular, has become so pervasive that the overwhelming majority of medical students pay diverse, below cost tuition fees instead of the actual cost of medical education assessed at Rs.4.15 lakh per year by the Medical Council of India. For instance students in government-run medical colleges in Tamil Nadu pay a mere Rs.4,000 per year as tuition for their medical education. On the other hand students in private medical colleges in the state pay Rs.3.3 lakh per annum for their MBBS education.
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India’s poor public healthcare record How has India fared in providing healthcare to its citizens in recent years? Useful insights can be obtained from an analysis of the recently released results of the third National Family Health Survey (2005-06). There is good news on the population front with a further slowing down in rates of population growth. India’s total fertility rate (TFR) is down to 2.7 — significantly lower than the TFR of least developed countries (5.0), Sub-Saharan Africa (5.5) and low human development countries (5.8). At the same time, however, there are some disturbing trends that can adversely affect India’s potential to cash in its demographic advantage. Improvements in healthcare for children have been agonisingly slow during the past seven years despite the hype surrounding economic growth. India’s infant mortality rate (IMR) is reported at 57 deaths per 1,000 live births — down from 68 in NFHS-2 (1998-99). But it’s still significantly higher than IMRs reported by China (26), Sri Lanka (12), Vietnam (17), Egypt (26), Indonesia (30) and even Bangladesh (56). Another area where progress and performance have been depressingly poor is child malnutrition which still remains among the highest in the world. According to NFHS-3, 43 percent of children under age three in India are malnourished (under-weight) — up from 40 percent in 1998-99. Again, 79 percent of children aged between six-59 months are anaemic — up from 74 percent in 1998-99. The factors behind the poor health of India’s children are not difficult to discern. First, there’s been very limited increase in the coverage and reach of health services for children. For instance, the proportion of fully immunised children between 12-23 months inched up from 42 percent in 1998-99 to 43.5 percent in 2005-06 — an increase of less than 2 percentage points over seven years. Similarly, three out of every five births still takes place at home, and the proportion of deliveries attended by trained birth attendants rose from 42 to 49 percent — a mere 7 percentage points over seven years. These numbers offer important lessons for government and public health officials. First, India cannot afford to become complacent about its healthcare record. NFHS-3 reveals that even so-called good health and high-income states cannot afford to become complacent about public health issues. Between 1998-99 and 2005-06, immunisation coverage slipped in ‘rich’ states like Punjab, Maharashtra and Gujarat; and also in ‘good health’ states like Tamil Nadu and Kerala. Secondly, the roots of health and fertility improvements extend beyond medical interventions. We need to understand the social, economic and behavioural determinants of health and fertility outcomes and acknowledge that modernisation and higher incomes are not sufficient to ensure good health outcomes. Despite progress, strong biases against the girl child endure in Indian society. Neither has there been any marked improvement in caring practices for new born children — especially when it comes to breast-feeding or the introduction of solids after six months — so vital for healthy child nutrition. Third, public expenditure and investment in public healthcare has to experience a quantum jump. In countries that report the highest life expectancy (80 years and above), public expenditure on health varies from 6.3-6.4 percent of GDP in Australia, Japan and Italy to 8 percent in Sweden and 8.8 percent in Iceland. In contrast, public expenditure in India aggregates barely 1-1.2 percent of GDP. Simultaneously the public-private spending mix on healthcare has to change dramatically. We need to reverse the current 25:75 public-private mix to 75:25, which is the norm in countries where health outcomes are positive. Finally, and perhaps most significantly, the Central and state governments — indeed society — need to evolve a consensus on the issue of providing universal, affordable and good quality healthcare to all. And all stops need to be pulled out to translate this consensus into a national priority. (Excerpted from an essay in EducationWorld (November 2007) by Dr. A.K. Shiva Kumar, consultant to Unicef and visiting professor at Harvard University) |
In neighbouring Karnataka under a concordat signed between the government and the state’s 45 private dental and medical colleges grouped under the Consortium of Medical and Engineering Colleges of Karnataka (COMED-K), 40 percent of the seats available annually in private medical colleges have to be allotted to Karnataka-domiciled merit students who top the state government’s annual CET (Common Entrance Test) at a tuition fee of a mere Rs.35,000 as against the annual fee of Rs.3.8 lakh payable by other students next in order of merit, and Rs.8.8 lakh plus per year payable by NRI or NRI-sponsored (a legal fig leaf) students.
Quite clearly students in government-owned medical colleges are heavily subsidised by the citizenry, and in private colleges government students are heavily cross-subsidised by other students presumed to be more affluent. Yet under the minister’s proposal, all students should equally be subjected to compulsory rural service.
“We feel that while the proposal to make one year’s compulsory service in rural areas can justifiably be imposed on students admitted into government medical colleges whose education is heavily subsidised by the Central and state governments, it cannot be made applicable to students admitted into private medical colleges who are required to pay substantially higher fees to meet their operational and mainten-ance costs. This would be highly discriminatory,” says Dr. H.S. Ballal, pro-chancellor of Manipal University, which since its first constituent Kasturba Medical College was promoted in 1953, has acquired a global reputation for providing high quality medical education (annual fee for its four-and-a-half year MBBS programme: Rs.4.26 lakh).
The bewildering fees structures with which the Central and state governments have saddled institutions of medical education is compounded by the sin of neglect of the healthcare sector in general, and rural healthcare infrastructure in particular. Shockingly government (Centre plus states) expenditure on provision of healthcare services and infrastructure aggregates a mere 1.2 percent of GDP (Rs.45,000 crore) per year, a sharp contrast with the global average of 4 percent of GDP and the 6-7 percent of GDP spent on public health services in developed countries such as Sweden (8 percent), UK (6.9 percent) and China (2 percent, see table p.36)
Given this pathetic annual provision for public health services, it’s hardly surprising that instead of properly equipped hospitals and nursing homes, the overwhelming majority of the population in rural India has to make do with a mere 22,669 government primary health centres (PHCs), which are obliged to provide outpatient services to socio-economically disadvantaged villagers (over 300 million rural Indians subsist on less than $1 per day equivalent). Yet it’s an open secret that the government funded PHCs have been a colossal failure and that drugs and formulations provided to them for free distribution are routinely sold away to local traders and worse, they tend to be plagued by mass absenteeism of officials, paramedics and nurses, most of whom farm out their jobs and show up only to collect their paychecks.
According to Ravi Duggal, a healthcare researcher who studied India’s rural healthcare service a decade ago, the country’s PHCs equipped with an average of six beds — “one for every 30,000 population” — are grossly inadequate to service the rural population. “Doctors do run OPD (out patient departments) clinics at the PHCs but the supplies and services are so inadequate that the clientele is automatically restricted in numbers. Hence it is not surprising that the HSSO (health sample statistics organisation) in the 42nd Round Survey on health care utilisation, found that of all routine ailments treated in rural areas, only 5 percent were treated in PHCs. The remaining went either to city public hospitals and dispensaries (20 percent), or to private practitioners (59 percent) and private hospitals,” wrote Duggal in Health Action (vol 5, No.8 — 1992).
In the circumstances it’s hardly surprising that medical students believe that compulsory rural service as proposed by the Union health minister is a purposeless exercise. “It’s well-known that PHCs lack the physical infrastructure, and diagnostic equipment and facilities for practising medicine. If proper infrastructure is provided by government, most students would be willing to put in a year’s rural service as they would acquire valuable practical experience. Moreover in principle it’s unfair that rural citizens should be provided the services of under-qualified medical students being paid a mere stipend. Instead, if the government were to offer fully qualified doctors half-decent salaries and perquisites, many qualified medical practitioners would be ready, willing and able to serve in rural India,” says R. Vikram Vignesh, a final year student of the government-promoted Stanley Medical College, Chennai (annual tuition fee: Rs.4,000).
This line of argument is supported by Dr. Atul Sonker, recently appointed assistant professor in the department of transfusion medicine in Lucknow’s Sanjay Gandhi Postgraduate Institute of Medical Sciences after 14 years of study and internship. “By making rural service mandatory for students, government will prolong medical studies and put off many aspiring medicos from entering this profession. It’s bad policy to force medical students into rural PHCs, which are ill-equipped to utilise their services or improve their education. On the contrary it will de-motivate thousands of youth from studying to become doctors who are urgently needed by the country. A better option would be to attract qualified medical practitioners into rural areas by paying full salaries to government doctors and providing them other incentives,” says Sonker.
A more pernicious fallout of the compulsory rural service scheme for medical students which it is feared is a fait accompli — regardless of the recommendations of the pliant Sambasiva Rao Committee — is that it has adversely affected the morale of the volatile medical students’ community which believes it has been singled out for discriminatory treatment.
According to Dr. Anil Sharma, a spokesperson for the Resident Doctors Association of AIIMS, Delhi, the fine print of Ramadoss’ compulsory rural service proposal is that medical graduates serve for one year, postgrads for two years and super specialty graduates for three years. “If this proposal is enacted into law as seems likely, for a super specialty graduate the entire study period will aggregate 17 years! This at a time when the medical profession is losing its lustre. The argument that medical education is subsidised and therefore students need to pay back the cost of their tuition to society is also flawed. Engineering education in the IITs is also heavily subsidised, but there is no demand that IIT graduates must serve in rural areas,” argues Sharma.
Provision of rural infrastructure which would make compulsory service meaningful and questions of equity between engineering and medical students apart, a more fundamental objection to the compulsory rural service proposal centres around the issue of whether medical students are sufficiently equipped to serve any useful purpose in the rural outbacks of the country. “One of the curious anomalies of medical education in India is that postgraduate qualifications are the prerequisite of faculty appoint-ments. As a result raw undergraduate students taught by specialists rather than general physicians, are ill-equipped to serve as medical practitioners of first contact in rural India. Changes in the medical education curriculum are required, prior to enacting the law mandating compulsory rural service for students. Moreover there is the question of students paying differential fees for medical education which has to be sorted out as well. Quite clearly a lot of groundwork needs to be done before transforming this proposal into law,” opines Dr. S. Kumar, the knowledgeable principal of Bangalore’s showpiece private sector M.S. Ramaiah Medical College which has 850 undergraduate and 250 postgrad students on its muster rolls.
Against this complex backdrop — the outcome of ill-conceived over-subsidisation of medical education for the past half century — the hasty populist diktat of Union health minister Ramadoss mandating a year’s compulsory rural service for the country’s 155,000 medical students is misconceived. As suggested by Dr. Kumar, considerable groundwork and reconciliation of the contradictions which characterise medical education in contemporary India, is a precondition of righting the historical wrong of continuously depriving rural citizens of healthcare services. Among the issues which require debate and attention of education experts are: replacement of indiscriminate subsidies in medical education with long-term loans and a targeted subsidies regime; restructuring of syllabuses and curriculums to enable medical graduates to cope with prevalent rural conditions; finding ways and means to improve the country’s 22,669 dilapidated primary health centres and devising incentives to attract voluntary service in the rural hinterlands.
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Case for emigration tax Half a century of heavy subsidisation of medical education — cornered by post-independence India’s aggressive me-first ruling elites and middle classes — by some of the poorest taxpayers in the world is somewhat belatedly eliciting demands for payback. Public opinion is growing in favour of compulsory rural service for students and/or graduate medical practitioners, or for cash payback of the cost of subsidised medical education. Although there is a tacit conspiracy of silence within the middle-class controlled media on the subject, the plain truth is that (allopathic) medical education, particularly education dispensed by the country’s 115 government medical colleges, promoted at considerable public expense, is massively subsidised. Against the Medical Council of India’s officially endorsed calculation that the actual cost of provision of medical education is Rs.4.15 lakh per student per year, annual tuition fees prescribed by some state governments are as low as Rs.4,000 in Tamil Nadu, Rs.15,000 in Karnataka, and Rs.24,000 in Maharashtra. Even in the country’s 147 private medical colleges the tuition fees payable by the great majority of students are fixed below cost by state government committees which prescribe and administer a complex regime of cross-subsidies, notwithstanding two landmark judgements of the Supreme Court in the T.M.A Pai Foundation (2002) and P.A. Inamdar (2005) cases expanding the fundamental right conferred by Article 30(1) of the Constitution on all linguistic and religious minorities to “establish and administer educational institutions of their choice”, to all citizens. The Central government which has established a handful of capital-intensive medical colleges modeled on the lines of New Delhi’s showpiece All India Institute of Medical Sciences also provides highly subsidised education to students who pass its stiff entrance examinations. For instance AIIMS provides undergraduate education at a mere Rs.250 per annum and postgrad education at throwaway prices. Nor is it a secret that almost half the alumni of AIIMS who receive the benefit of way-below-cost education take wing at the earliest opportunity to carve out lucrative careers abroad, particularly in Britain and the US. At the 35th convocation ceremony of AIIMS held on October 23, Union health minister Anbumani Ramadoss made a pathetic plea to the graduating medical practitioners and nurses to remain in India to serve the public which had subsidised their expensive education. “Don’t go outside India. Serve the nation, as the people need your services the most,” he implored the 749 doctors and nurses who graduated from the institute on the day. The minister’s belated anguish about the huge loss suffered annually by the economy and the public which subidises the education of the estimated 2.56 lakh medical students (all systems — ayurveda, homeopathy, unaniand allopathy), is overdue. According to a study conducted in 2006 by the Delhi-based Media Studies Group in association with the Centre for Developing Societies, over 52 percent of 42 batches of AIIMS alumni have migrated to foreign, mainly western, countries with 87 percent living and working in the US. In 1968 a massive 87 percent of AIIMS graduates migrated to foreign countries where they have accumulated vast fortunes. Little wonder that a United Nations study on the brain drain phenomenon conducted in the mid-eighties indicated that the benefit already accrued to Western countries from the continuous inflow of skilled professionals, by far outweighs the aggregate foreign aid dispensed by them to third world countries during the past half century. |
“It’s important for Dr. Ramadoss and the Sambasiva Rao Committee which is examining the issue, to understand that improved rural infrastructure and living conditions are prerequisites of introducing compulsory rural service for medical students or graduates. Almost 35 percent of medical students are women who will experience extreme hardship and danger if they are forcibly posted to remote rural areas which tend to be women unfriendly. In effect this proposal could well dissuade large numbers of young people from entering the medical profession which would reduce the supply of medical practitioners into Indian society,” warns Dr. A.S. Seetharamu hitherto professor of education at the Institute for Social and Economic Change (estb.1972) and currently education advisor to the Karnataka state government.
Prof. Seetharamu suggests that a much better option would be to change the mindset of medical students through “socialisation of the medical education curriculum”. “Currently ‘community medicine’ is a subject which is cursorily taught to medical students in their early years. This subject, which could sensitise them to the miserable health conditions in rural India and infuse a spirit of voluntary service within them, needs to be given much greater importance. But meanwhile, imposition of quick-fix solutions is likely to prove disastrous,” he says.
There is considerable wisdom in this warning which the health ministry and the UPA government at the Centre would do well to heed. According to reports emerging from Yojana Bhavan Delhi, headquarters of the Planning Commission, the strong-willed Dr. Ramadoss has persuaded the commission to almost triple annual public expenditure on health services from the current Rs.45,000 crore per year to Rs.136,000 crore during the Eleventh Plan period (2007-12). Hopefully these higher allocations will be prudently spent to improve the prevailing pathetic conditions of the country’s PHCs, to attract idealistic medical practitioners to serve in them. Simultaneously the Union government’s languishing PURA (provision of urban facilities in rural areas) programme needs to be revived to integrate the rural outbacks of village India with the fast-track economy of resurgent India.
The current countrywide turmoil in medical education will have served a useful purpose if it focuses national attention on the deplorable neglect of healthcare infrastructure in rural India. It’s an issue which needs immediate remedial attention.
With Autar Nehru (Delhi); Vidya Pandit (Lucknow); Vidya Sundaresan (Mumbai) & Hemalatha Raghupathi (Chennai)
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