Making medical education a public good

With the doctor-population ratio at 1:1,500 in India, there is a dire need of doctors.

When thought leaders like Gurcharan Das and leading newspapers root for commercialising medical education, one has to sit up and take note. It is necessary to get engaged in the debate as health affects all — rich, poor, old and young.

The justification for commercialising medical education is that it will incentivise investors to set up medical colleges, increase the supply of doctors, induce competition and reduce the cost of tuition fees and services. Understanding the downside impact of such a policy, as unfolding in the U.S., can be illustrative.

The U.S. crisis

In a hard-hitting article, “How the Financing of Colleges May Lead to Disaster!” Rana Foroohar explains how in the U.S., the logic of “markets know best” resulted in the entry of banks, hedge funds, private equity, venture capital, for establishing colleges. Loan markets thrive by making student annuities “produce a fat and stable return in the form of tuition fees”. Post 2002, student debt has climbed to $1.2 trillion with 44 per cent of loan defaults among the “working-class students who either couldn’t afford to graduate or, once they did, found their degrees were largely useless in the marketplace”.

Clearly, quality has been a casualty. In 2009, a review showed that in the 30 leading for-profit universities, “17 percent of their budget was spent on instruction and 42 percent on marketing… and paying out existing investors.” As a critic put it, “Quality education and higher earnings are two masters. You can’t serve both.”

Free markets also widen inequality. While for-profit institutions chase the full-fee-paying students for the 30 per cent profit margins, the not-for-profit institutions also feel compelled to increase fees when public funding is reduced or withdrawn. Access, particularly for families with stagnant incomes and reduced capacity to repay loans, then becomes an issue. These factors are reportedly compelling the U.S. to revert to the pre-neo-liberal era of the 1960s of making higher education a public good.

Flawed logic in India

The NITI Aayog recommendations for reforming medical education need to be viewed in this backdrop. The three-point recommendation — allowing private investors to establish medical colleges untrammelled by regulations, freedom to levy fees for 60 per cent of the students to recoup their money, and making the exit examination the marker for quality and for crowding out substandard institutions — is expected to trigger healthy competition, reduce prices and assure quality.

Many have critiqued the policy response to the deep crisis as inadequate and with potential to worsen the situation.

Increased supply not guaranteed

India has 422 medical colleges with 58,000 annual admissions. With the doctor-population ratio at 1:1,500, there is a dire need of doctors. Non-availability of teachers has constrained further expansion, explaining why over half the colleges churn out poor quality doctors. Since teachers cannot be manufactured overnight, a comprehensive policy framework consisting of a package of innovative approaches such as use of technology, faculty training in pedagogical skills, permitting foreign faculty to teach and so on is required to optimise churning out of doctors appropriate to our needs from existing colleges besides establishing new ones.

Inequities in availability

The crisis in the health sector is not only about the gross number of doctors but their geographical spread and quality that privatising education or asking foreign universities to set up shop in India cannot address. It is pertinent to ask which investor is willing to set up colleges in Bundelkhand or Raipur and why doctors from the surplus States of Tamil Nadu or Karnataka do not go to work in Bastar or Adilabad where there is a desperate need for them. Language, culture, payment systems, social conditions and so on are barriers to such free movement of doctors. Such issues again need comprehensive responses as these areas with few doctors account for three-quarters of the maternal, infant mortality and morbidity due to infectious diseases.

Multiple fee structures

As seen, Tamil Nadu private colleges enhanced their fees in response to imposing restrictions on admission policies. Besides, due to the lack of transparency in fee fixations, the government will end up paying more than necessary for the 40 per cent government quota seats. For after all the fee structures levied for the government quota, full-paying domestic and NRI students will need to have parity for equitable treatment. Besides, high fees do not necessarily guarantee quality. For example, undivided Andhra Pradesh spent over Rs.6,000 crore per annum towards fee reimbursements to private engineering colleges even while the industry found less than a fifth of the graduates employable!

Increased supply, reduced prices

Economics drives behaviour. Over half to three-quarters of the students will want to pursue specialisation, go abroad, work in tertiary hospitals or city hospitals, or set up private practice. Barely 15,000 doctors may be available to work in rural areas, in the public sector or in public health and primary care as family physicians. Reversing this trend will require drastic changes in curriculum carrying downstream implications for career paths and may not have many students interested. Redressing this will require government intervention making public heath and primary care financially remunerative. In other words, the demand-supply equations in imperfect markets like health do not get smoothened by open door policies.

Quality a concern

Making a one-day exit examination the marker for quality is simplifying a skill-based profession like medical care. Quality is also about attitudes towards patient care, knowledge, values and competencies that are imparted by good teachers in classrooms and by bedside training. When profits become the focus, investing in such processes becomes secondary.

Impact on health

Medical education is an important determinant in the unit cost of services. Doctors account for a third of the price. This in part explains the substantial price differentials between public and private hospitals. So when public policy encourages high cost of production of doctors only to save on initial investment in setting up colleges, it pays for it in the costly services it procures. It’s a zero-sum game with the government losing much more, both in terms of public finance and welfare.

Public health and primary care in India is in doldrums, as evidenced by the rise in infectious disease like dengue or chikungunya and drug-resistant HIV/AIDS and tuberculosis. Containing the spread of infectious diseases and arresting the expensive-to-treat non-communicable diseases through high-quality primary care will require public investment in creating doctors who are trained and skilled appropriate to the country’s disease burden.

The free market ideologues need to reflect and study the crisis in the U.S. that such policies have had on higher education in general and the health sector in particular. It is necessary to question why Scandinavian, most European and several developing countries like Thailand provide free medical education and highly subsidised loans, cap the amount of fees and so on. If they are woolly headed socialists, so be it, as these countries have certainly demonstrated better social and economic standards of living than the U.S., a country we so desperately seek to emulate.

India has a large cohort of youth who need education to produce wealth and cannot afford to mortgage their lives in seeking it. Pragmatism and national interest must determine public policy.

Sujatha Rao is former Secretary, Union Ministry of Health & Family Welfare.