Operation MBBS

The state of our medical education is such that experts say nothing short of a surgery would help. As wannabe and qualified doctors keep streaming out of the country despite an acute shortage, Praveen Donthi takes the pulse of the system.

On May 16, a 27-year-old named G. Murali was arrested in Tamil Nadu by a special investigation team from Delhi. The charge against him was of sending another person to write the Foreign Medical Graduate (FMG) exam in his place. Murali had completed a medical course in 2005 from Russia and needed to clear the FMG to start his practice here. He was not the only one charged: some 14 arrests have been made in the past few months. An investigating officer assures there would be more in the coming months.

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Last year was a watershed of sorts in India’s medical education. For the first time, the number of private medical colleges in the country overtook the number of government ones. When you consider that a seat in one of the private colleges could cost Rs 50 lakh to 60 lakh — comparable to Rs 850-8,000 charged at most of the government ones — you sense how difficult it is for a middle-class family to translate its dream of having ‘a doctor in the family’ into reality.

People have been looking out for ways to skirt this and other hurdles in the way of medical education. One of the most favoured ways is to study abroad, as Murali did. But then, on the way back, clearing the FMG and getting a licence to practise is easier than done. Ergo, those who do not want to take illicit routes, such as the one Murali tried, use their degrees abroad. And the shortage of some 6 lakh doctors in the country continues to stare us in the face.

Shortage breeds ignoble gains

Ironically, it’s this shortage itself that goes some way in making the ‘noble’ profession so lucrative. Consider this: there are only six doctors per 10,000 people in India at present. Of the 31,000-odd doctors passing out of the 270 medical colleges in India, many are not available for service here — either because they fail to clear the FMG, or because they search out greener pastures elsewhere.

The American Educational Commission for Foreign Medical Graduates says that Indian doctors, on an average, garner a quarter of all the 10,000-plus licences given out annually in the US. A few more are lost to other developed nations and a few others to administrative services (there were seven doctors among the IAS top 20 list this year).

In this vacuum is entering the private sector. Not only has the segment got 136 colleges (as against the government’s 134) across India, but they are also cornering the healthcare system. A recent Planning Commission report recognises the private sector as the main provider of ‘in-patient’ healthcare.

Forget private players; even foreign governments have sensed a sizeable business opportunity in this demand-supply mismatch. Countries such as Russia, Kazakhstan and Ukraine have been attracting Indian students for more than a decade now. Since 2004 China has emerged as a favourite. Now, it’s the turn of our poorer neighbour, Nepal. And the Philippines is close on its heels. According to the Medical Council of India (MCI), that conducts the FMG test and also issues eligibility certificates to those who want to go abroad, those going out of the country in 2006 and 2007 numbered around 5,100 and 7,000, respectively.

What’s up over there, doc?

Among those going out, there is a curious affinity according to region. If Russia is a favourite with Gujaratis, students from Andhra are queuing up for China, while Nepal is seemingly attracting students from all over India.

There are reasons for the newfound attraction for Nepal. At Rs 3 lakh to 28 lakh, the course fee is far cheaper than at the Indian private medical colleges. Also, the threshold for qualification is just 50 per cent (in the physics, chemistry and biology stream), as opposed to 70 per cent needed for most Chinese colleges.

Ajay Patel, who is in his fourth year at the Tver State Medical Academy, 150 km outside Moscow, says, “I had made up my mind in the 10th standard that I would study in Russia. I was paying a fee of Rs 75,000 in school; so the Rs 1.25-lakh course fee for MBBS was not all that much.” Why not try a private college in India? “They charge four or five times more than the Russian colleges,” replies the 23-year-old.

With countries such as Russia focused on making good from foreign students, some of the rules are being changed too. After all, some 900 students from India alone go over every year to get medical degrees from the country. Many colleges there have started teaching in English, separate from the local students. Patel says, “It’s been eight years since our college started teaching in English. Now even the faculty members have picked up the language quite well. We have an Indian mess and we celebrate all Indian festivals. In fact, there are 18 cricket teams in my college alone!” China, where there are an estimated 1,500 Indian medical students at present, has brought out a list of 30 colleges where foreign students (read Indians) would be taught in English. One plus for those crossing over to Nepal is that they don’t need a visa.

Those on the way back

What’s happening to those who are going abroad? What quality of education are they getting? Expectedly, the answer to either is not a straightforward yes or no. Education in Russia has gone through a turmoil since the disintegration of the USSR.

Sanjeev Kumar, vice-president of Saraswationline, a company that sends students abroad, says, “Even a tenth-pass student could get a medical certificate from there a decade or so earlier.” The quality of those coming back began to slide. An alarmed MCI stepped in and made it mandatory, since 2002, for all foreign medical graduates to clear the FMG exam, which is conducted by the National Board of Examinations twice a year.

According to S Roy Biswas, deputy director of NBE, only one in 10 students used to pass the exam each year. For a reason, Roy Biswas says, “Most of these foreign institutions pass the students, or their reputation will take a beating. They have to constantly attract students.” Last September, out of the 1,830 who appeared for the exam, only 193 cleared it.

But alarm bells went off earlier this year when the FMG pass percentage suddenly shot up. Out of the 1,851 students who took the exam this March, an unprecedented 1,087 passed it. A special investigative team of the Crime Branch started asking questions. Large-scale malpractices were unearthed. Murali was one of the students caught.

Surgery on the system

Can the situation at home be bettered? RK Srivastava, director-general of health services, says, “We are looking at relaxing the norms to set up medical colleges.” And private players are slowly assuming the major role in preparing our doctors.

There is a problem of distribution, too. Some 60 per cent of the colleges are currently in only in five states: Andhra Pradesh, Tamil Nadu, Karnataka, Kerala and Maharashtra. Delampady Narayana, health sector expert at the Centre for Development Studies, says, “The private colleges are coming up in the South mostly, where there are enough colleges already.”

A senior official at the health ministry throws up his hands at this uneven growth. “What can we do? Health is a state subject, and the other states have to take the lead,” he says.

There is the question of quality of education at these private colleges too. Narayana claims, “These private medical colleges are no different from those abroad. The exam is an eyewash.”

Srivastava says that among the solutions being “explored” are public-private partnerships, inter-country programmes, and intra-country programmes. Whichever the choice in the years to come, one thing is for sure: private education would be the way forward for our wannabe docs.