Medical PG seats being sold! The conundrum of privatized medical education.

Sir,

It was astounding to read the article in the daily ‘The Times of India’ dated August 19, 2011 on a medical postgraduate seat sold out for Rs. 1.7 crore1. Though it was not something new, keeping in mind the recent trend towards privatization of medical education in India. For a scholarly take on the phenomenon, I would make note of some historical turning points and discuss the implications arising thereof.

Firstly there has been a slow yet consistent change in the economic policies of India post 1990s marked by the shift of provision of social services from government sources to the non-government (for-profit and not for-profit) sector under the name of neo-liberal policies. This included the privatization of higher educational services (such as medical education). The logic being (presumably) low social returns on expenditure in higher education23 and preservation of limited resources for the more important task of financing primary and secondary education4. Moreover, the impetus to private medical education was to offset the short supply of medical professionals. To facilitate establishment of private medical colleges the government from time to time provided land to private players for free or at discounted rates5, relaxed norms for the requirement of minimal land area6 and exempted tax for importing high end medical equipment.

The second turning point was the Honourable Supreme Court's (SC) judgment on the TMA Pai Foundation & others vs. State of Karnataka case7 and other related judgments followed by ‘The Private Professional Educational Institutions (Regulation of Admission and Fixation of Fee) Bill, 2005’ allowing maximum autonomy to the private medical institutes with respect to admission procedure (including control over entrance tests)8, fee structure, and abolishing of State quotas9. It allowed up to 50 per cent seats to be reserved under the management category while only 15 per cent for general category to be filled on an all-India basis. The said bill's ambiguity over allowable profits (termed ‘reasonable surplus’), fair and transparent admission procedure under the ‘management category’ without any legal/administrative tool for the State to oversee, control and intervene had allowed scope for manipulation by private colleges10. In addition, sting operations by media group have unearthed the practice of capitation fees despite SC judgments illegalizing it11.

The third turning point was the revelations made by the arrest of President of Medical Council of India (MCI) Ketan Desai on charges of corruption. This also resulted in the dissolution of MCI in 2010. Though Desai was removed from the said position (on charges of misuse of office) earlier in 20011213, he regained his presidentship in 2009. In 2010, Desai and three others were caught red handed in a bribery case related to MCI recognition of a private medical college14. This need for (re-)recognition from the MCI in the face of many private medical colleges lacking the minimum standards has sown the seed for corruption. As many would agree, such practices have now been prevalent for a long time, thus to assume a single person to be at the root of the problem would be erroneous. In addition, such corruption is partly augmented by the involvement of certain politicians in the management of various medical colleges13.

The fourth turning point has been the amorphous and disjointed changes in the consciousness of the young Indian medical professionals on the issue of medical practice and medical specialization. In present times (super-) specialization in medical discipline is becoming an essential requirement in the opinion of young medical graduates. Partly this may be due to the trend in (bio-) medical sciences towards increased dependence on technology, and partly this is determined by the medical market (in the case of Indian graduates the private practice and corporate hospital arena, the migration to first world nations or the concentration of government provided advanced medical facilities in urban influential areas). The importance of research and teaching which is the essence of postgraduate medical training has entirely been usurped by the market of specialized clinical practice. At the same time private healthcare is ailing under the pressure of unhealthy competition resulting in irrational prescription practices and unwarranted diagnostics15 which may be socially wasteful and personally burdensome.

The establishment of private higher education in India was a commitment towards market economy and an outcome of the shortfall of public resources for funding. The expansion though, took place due to collusion between powerful politicians and the government apparatus in-charge of control of its standards. In the aftermath what can be seen is confusion not only in the ideological commitment of the Indian polity and in the regulatory understanding of Indian judiciary but also in the values of merit among the Indian middle class. The reformation of ad hoc body appointed by the Government in 2010 for overseeing MCI functions, instead of attempting to restore the democratic nature of MCI is evidence towards reluctance to correct the ailing system. Even a new bill, “Prohibition of Unfair Practices in Technical Educational Institutions, Medical Educational Institutions and Universities Bill, 2010”16 attends only to a minor aspect of this corruption at the exclusion of correcting other shortcomings of the system. The proposal of Common Entrance Test (CET) for all medical colleges (including admission to private colleges) throughout India at the graduate and postgraduate level17 is a welcome decision as it decreases hassles for students and is a positive step towards transparency in admissions, though it did not take place in 20111819. It is surprising not only because the committee that proposed the CET has been replaced, but also because they have been replaced by members who have wide ranging conflicts of interest pertaining to their present position20.

I would conclude with a few questions that can be of importance to rethink on the foregoing issues. Since education is thought to help transcend inequality, what implications do these developments have on the affirmative action group?21 What do meritorious students and the middle class make out of such changes? What effects do such practices have on the quality of medical education and medical graduates? Do economic policies in higher education as applied in the Indian context have to play a part in the pattern of corruption. Has the increased number of medical graduates contributed to the improved supply of doctors to the rural areas? Last but not the least, what is the social cost of high fee structure/capitation fee for medical education and medical practice, in general? The answers to these complex questions may help us chart a corrective course.