AILING EDUCATION: THE MEDICAL EDUCATION IN INDIA

Amar Jesani

310 Prabhu Darshan, 31 S. Sainik Nagar

Amboli, Andheri West, Mumbai 400058
Tel: (91)(22) 2677 0227. Email: jesani@vsnl.com

Recently, a new tehelka hogged the limelight in the Indian media. What was otherwise
widely known to many in the field evolved into a short-lived nationwide talk that
commercialisation of the Higher Education had created new conditions for the moneyed
people to enter professions like medicine and engineering. But the political and civil society
response to such revelation was not as dramatic the one seen in the anti-reservation agitation.
More so because while reservations for the lower castes united the entrenched castes and
higher classes under the flag of so-called merit, this was for them merely an issue of how the
business of education ought to be carried out within those who always had reservations due
to their higher economic positions. This vocal segment believed that issue here was only
about how such business should be carried out rather than problems of the business of
education as such and the issues of merit and quality, though mentioned, did not acquire the
high pitch of the anti-reservation. The neo-liberal economists also jumped into the debate
saying that it was primarily due to the problem of supply not matching the demand – let there
be as many medical colleges as moneyed and politically powerful people can establish, let
there be as many seats in those institutions that they can buy, and the corruption will
disappear because there won’t be extra demand to prompt people to pay the bribe. A deluge
of doctors will make health care accessible, the prices of health care would fall, and we will
reach the goal – “health for all”!!

Entrenched Vested Interests

In modern times the medical care has increasingly become dependent on doctors and
technologies. In popular image a health service is unthinkable without doctor and the
increasing number of the new sparkling hospitals, wonder drugs and state-of-the-art gadgets.
That is why in most of the countries today doctors occupy a strategic position in shaping the
nature of health system. In the era of corporatisation of health care in which the private
capital, particularly the finance capital and its private insurance companies are calling shots
in health care delivery system as well as in the technologies that go with it, this seemingly
traditional generalisation may sound hollow, but this appearance is due to the cooption and
cooperation of doctors with the new private players. Interestingly, if one reviews the history
of development of health service systems in the developed countries in last six decades, one
finds that the corporate capital in its quest for developing market-based for-profit health
system could easily co-opt the medical profession in countries like the US (and is in the
process of doing so in India). On the other hand, in other developed countries, particularly in
the UK and Canada, the universal access, not-for-profit health systems developed, at least in
their birth, in confrontation with the medical profession. In the UK the Beveridge report that
inaugurated the National Health Services that ensured universal access to all in the UK in the
post-World War II years had to contend with strong opposition from the organisations of
doctors. Barring a few small associations of doctors broadly aligned to the Labour Party or
having humanitarian views, the mainstream profession represented by the British Medical
Association did not whole-heartedly support the inauguration of universal access based
National Health Services. In a more dramatic way, in Canada in the 1960s, the attempt to
have universal access system was greeted by doctors with nation-wide strike actions. Indeed,
in both countries it was the boldness and far-sighted vision of now much-maligned political
class holding radical, liberal or humanitarian views that helped in overcoming the vested
interests of the medical profession aligned to the corporate profit. The point is, the doctors
comprise not only of a seemingly most important factor in patient care but they also comprise
of the most important social (and of course political and economic) stakeholders in any
health care service system. The private capital as well as the state has no alternative but to
contend with its social power for undertaking good or bad reforms in the health care services.

One important source of the power of medical profession is its monopoly over the occupation
of medical care. The beginning of the formal, legally sanctioned monopoly of this kind is
only 150 years old, though to many, it might appear, to have existed forever. The first law
that began the process of monopoly was passed only in 1857 in the UK that established
General Medical Council and made it mandatory to have a basic minimum formal
qualification for all doctors and their registration with the Council. Such law, the Medical
Council Act(s) is even less than 100 years old in India. Through this law, which is
implemented jointly by the elected representatives of the medical profession, the medical
bureaucrats and the members nominated by the government; the qualifications for entry into
medical profession, the content and quality of medical education and the ethical norms of
medical profession are controlled by the medical professionals in partnership with the
government representatives – the bureaucrats and nominees. Thus, the Medical Council laws
in India establish a relationship between the doctors and the society, whereby the doctors
acquire a monopoly of occupation of medical care in lieu of a commitment that they would
ensure that the quality and content of medical education would be of the highest standard
required, only those who qualify with such standards will be given entry into the profession
and above all, after they have entered, the profession will ensure that medical knowledge and
skills will be continuously updated and are used only for the care of the sick and not for
exploitation or that the medical skills will not be used for wrong purposes.

Increasing Number of Doctors

In last two decades, the increase in number of medical colleges has been the highest ever
since independence. In fact, at the end of the first three and half decades after independence
we had only about 100 medical colleges, but in the two decades after that we established
additional over 100 colleges (we have now about 205 medical colleges) and also added
additional number of seats in most of the earlier established colleges. All in all, we have
more than doubled the production of doctors in last two decades. Interestingly, the issue of
producing too many doctors and investing heavily in medical colleges and their hospitals
instead of investing in the universal primary health programmes that could alleviate people’s
sufferings was hotly debated in the late 1970s and early 1980s. So much so that in the Sixth
Five Year Plan the government was forced to announce that as a policy it will not set up
more medical colleges. This promise has been violated both in the letter and spirit, and at the
same time a convenient way was found to circumvent the policy decision. That way was
encouraging establishment of the private medical colleges. A simple study of the date of
establishment of the private medical colleges in different states of India would show that in
the last two decades their growth was several times higher than ever in the first three and half
decades after the independence. The pliable Universities and Medical Councils were used by
the state and central governments to bend rules, fuel corruption and violate standards of
quality for accelerating the business of medical education. It is therefore not surprising that
many of those involved in establishing the money-spinning colleges are politicians working
in tandem with the leading lights of medical profession and the industry. Significantly, the
period of such take off of business of medical education and the violent agitations against the
reservations for lower castes in medical education coincide, and yet, the first highly visible
focus on this trade has come only in the year 2003. Indeed, the anti-reservation agitations had
little or nothing to do with the merit and quality, but everything to do with reproducing the
control and status of the entrenched castes and classes on the medical education and health
care services.

While the focus of publicly reported scandals is always on the allopathic or modern
medicine, it is often not recognised that doctors qualifying in non-allopathic medical sciences
are in higher number in the country. There are two more Medical Councils created under two
separate additional laws, viz. the Council for the Indian Systems of Medicine (ayurveda,
unani and siddha) and the Council for the Homeopathy. In these systems, there are 278
medical colleges, nearly one and half times more than those in the Modern System.
Interestingly, till early 1980s when the system was discouraging establishment of medical
colleges in the modern system of medicine, most of the private colleges – often with the
patronage of politicians and the state – were established in the non-allopathic systems. That
is one of the reasons why over 70% of the non-allopathic medical colleges were in the private
sector in the early 1980s and even now remain so. This extra-ordinary interest in establishing
non-modern systems medical colleges did not flow from any love for the Indian systems and
homeopathy. In fact, the government has shown great disregard to the non-modern system
and it spends only a tiny proportion of its budget for them. The lip service given to the non-
modern systems system has always been a political stunt, behind which the real idea was to
provide a back-door entry to all those who could not avail of admission in the modern system
colleges. While our medical councils for modern system are nearly defunct as far as
enforcing quality and ethics are concerned (they are more in news for wrong reasons than for
good work), the situations of medical councils for non-modern systems are worse, so much
so that many of them are run by the pliable government administrators and have not
conducted elections for years. This dis-functionality of the medical council provided good
route to those who entered medical profession by buying seats in non-modern systems
colleges to practice moderns system of medicine. But in the mid-1980s when the government
opened up the modern system for establishment of private medical colleges, such back-door
entry was supplemented by equally questionable front door entry for those who could buy
seats. Another reason, as stated earlier, for establishment of high number of private non-
modern system medical colleges till mid-1980s was that the government had no commitment
for investment in non-modern medical education, and so left that sector to the private players.
Interestingly, if one looks at the establishment dates of the non-modern private medical
colleges, one would find that over three fourth of them were established before nid-1980s,
thus showing that once modern system was opened up to private players, the capital
gravitated to more lucrative areas. The way things are now it is a matter of time – only few
years – when the number of medical graduates produced and the even number of doctors in
modern system will outstrip the total number of non-modern system doctors.

A point needs to be here made about the fun-fare with which the current ultra right-wing
government has been trumpeting its adherence to tradition and revivalism of the Indian
medicine. A visit to the websites run by the health ministry would show that best site is of its
department of Indian System of Medicine and Homeopathy (ISM&H), and it makes claims
about the increasing expenditure for the ISM&H and commitment of the government.
However, our observation on the development of medical education given above shows that
its is the modern system that is systematically promoted through the private sector
involvement, while the growth of the non-modern education is lagging far behind, so much
so that numerically, the modern sector is poised to take over in next few years. The issue is
not whether this is good or not, but that if that is what the government is doing, then there is
no justification for making claims to appease the constituency of the traditionalists.

Do we need more doctors?

Two extreme schools of thoughts have conflicted and pulled the policy on the establishment
of medical colleges and production of doctors in last three decades. The first one is from the
establishments of medical profession and the government. They dole out data showing that
we have one doctor for over 2000 persons in the country and so we need to produce more
doctors if we want to reach health care to all. They argue that this ratio is a far cry from the
situation in developed countries where there is one doctor for 300 to 600 persons. Now, at
best, this argument is only a half-truth. It hides more than reveals, for it does not take into
consideration some 55% of all qualified and registered doctors who also legitimately practice
medicine but are from the non-modern systems. If all doctors are taken into consideration,
we have a healthy doctor population ratio of about 700. The fact is that in addition to the
legally qualified and registered doctors of all systems we have over half a million more
doctors who are legally non-qualified but are doing medical practice. With them, the ratio
would be very close to the situation obtaining in developed countries.

Another extreme of the arguments is that we already have too many doctors, but more
importantly, these too many doctors serve inadequate purpose, as they do not practice for the
people who actually need care, the poor and other lower strata as well as those who are in
remote areas. Besides, the doctors have vested interest in mystifying the medical care, be
only curative oriented and thus do not do almost anything for prevention and promotion of
health care. The predominant curative orientation thus thrives on the increasing number of
people falling sick due to lack of social orientation of medicine, and therefore they consume
most of the health resources without producing proportionate health benefits. Besides, the so-
called high quality of medical education makes them hospital and technology oriented, and
virtually unfit for doing practice in the under-served and underdeveloped areas of the
country. Therefore, this position argues that we do not need more doctors but we need village
health workers who would stay in villages, have some know-how to take care of the first-
contact primary health care needs of the people and have understanding and skill in referring
those who need doctor’s care to the Primary Health Centres of the government at right time.
In fact it was the voice of this section that pressurised the government to declare in the Sixth
Five Year Plan that it will not establish new medical colleges.

As we can see, the first argument is patently false. No health policy in this country can ignore
over a million non-modern system doctors cheerfully practicing, and more number of them
doing it in rural areas than the modern doctors. Besides, even in urban areas it would be very
clear even by cursory observation that they do their practice primarily in the underserved
slum areas. So not counting them to win an argument and to believe a priori that entire
organisation of health care must be planned keeping only modern doctors in focus will be far
from the ground reality. So in terms of sheer numbers, it is clear that we have nearly
adequate number of doctors and we should design our medical education to ensure that the
healthy doctor population ratio is maintained. The argument could at best be to impart extra
training to the non-modern systems of doctors (for that matter even to modern system doctors
as there is no organised mechanism in place for their continuing medical education) so that
the quality of care provided by them improve and more importantly, the irrational and
unscientific practice by them is reduced. The second argument here therefore is more valid
than the first one. However, the second argument while diagnosing the disease correctly,
gives a remedy that is not adequate for the needs and expectations of people.

It is also true that we do not only have nearly adequate number of doctors but also that these
doctors are mal-distributed. That is, a majority of doctors are located in urban areas while a
majority of people live in rural areas. Not only that certain regions of the country have
disproportionately higher concentration of doctors than others. But this correct diagnosis is
not translated into the correct remedy, that is, it is not translated into policy instruments that
could gradually affect the redistribution of doctors so that underserved areas and people
could have services available. Instead, the second argument only prescribes the bypassing of
doctors. Such policy is fine for an interim period to meet the immediate needs, but not
adequate in longer run. Besides, by bypassing the contentious issue, it only allows the current
affair of doctors’ or health system’s irresponsibility in allowing over-concentration of doctors
in some regions to go unchallenged and to continue. The data on doctors collected by the
Census show that in last four decades the proportion of doctors located in rural areas has
steadily declined, so there is no reversal of the trend in sight and the intervention of the
government is warranted.

The government could intervene to correct this anomaly in at least one of the two ways or
can use both ways. The first way is by establishing more services in public sector and thus
hiring more doctors to work in rural and remote areas. At present only about 10% of doctors
of all systems of medicine work in the public or government sector, the rest either pursue
their private practice or are employed by private institutions. With only such tiny proportion
of all doctors with it, the government health system cannot be expected to reach health care
to all. This would mean expanding government health system as was promised in the Bhore
Committee report (1946) at the eve of independence. The second way for correcting anomaly
is by the use of market and non-market regulations. These regulations could be through
incentives and/or disincentives. That is, by providing monetary or facility incentives to those
who want to locate in areas where there is less services, and the disincentives could be
through taxing and putting restriction – monetary and facility related – on those who choose
to locate where more services are already there. The disincentives could also include making
the process of registration of doctors sensitive to the doctor population ratio of the district
where the practice is intended to be located. By this the registration or license to practice
could be used to redistribute doctors. Indeed, such policy instruments are not so new in other
sectors, for instance the government has used them for redistributing industries, decongesting
localities, protect environment and so on. These policy instruments have not been found to be
against the democratic ethos of our country, as well as in the developed countries. Such
measures would also have effect on the commercialisation of medical education. This is
because many of those moneyed people interested in making quick bucks in big urban
centres would know that they would be required to serve interior and smaller areas, and thus
the attraction to milk the market rich areas would decrease. But those who are from the
underserved areas and want to locate their practice there only would get into the colleges.
The colleges will continue to get students and yet, the madness for medical education would
come down.

Interestingly, most of such policy measures would inevitably increase the health care
expenditure by the government. Indeed this is so in the capitalist developed countries, which
have for last half a century taken measures to ensure that their people have universal or near
universal access to doctors and health services. In the Western Europe and Canada, the
government pays over 75% of total health care expenditure in order to make universal access
to health care possible. Even in the market-based health care services of the US, the
government pays 45% of the health care expenditure and yet one third of its people do not
have full access to health care. In India, the government accounts for only 15% of the health
care expenditure, and this is absolutely inadequate for any effort in making health care
universally accessible. The votaries of the globalisation need to emulate good things from the
Western world and not only something that reinforces their elitism.

Market and medical practice:

Before we close our arguments, one essential point needs to be discussed, that is the
contention of the pro-market neo-liberals that more supply of doctors would be desirable and
would also bring down cost of medical education and make health care accessible. They are
so enamoured by the magic of the market that they refuse to pause and have a closer look at
the nature of market in general and the specific nature of market in health care in particular.
The usual argument is that when supply increases, the competition increases and that bring
down the price. In health care the opposite happens (and is happening), and that also with
devastating consequences for those who use it. It is assumed that with more supply, the
consumer chooses the cheapest and the best option. But in health care, the consumer hardly
knows what is appropriate for him or her to consume for the kind of problem he or she is
suffering from. At the most, the consumer would choose a provider after scrutinising
reputation of the available doctors in a locality, but is hardly in a good position to decide
what this chosen one would prescribe or do to the body. Thus, the doctor often chooses, on
behalf of the patient, what patient ought to consume. Even in the best of situation respecting
patient’s autonomy, the patient is able to choose only from few options offered by the doctor
and such choosing is far from the competitive price choice for consumption. As a
consequence, the doctors also double as sales person on behalf of the commodities to be sold,
and the more he or she sells, the higher is the profit. As a consequence, the experience show
that more availability of service does not mean lower price and better quality, but on the
contrary, it means over-investigation, over-medication and over-use of surgeries and
instruments. All of them not only keep the price high, the over-concentration of doctors
would also necessarily bring in new technologies faster and thus continuously push the prices
at higher level.

This is the chief reason why in those developed countries where the health care is provided
through market mechanism, the cost of health care is the highest. If one compares the health
care expenditure by the developed countries of the Western Europe and Canada where the
market in health care is seriously restricted with the private market-based health system of
the US, one finds that the former countries spend 9% or less of their GDPs on health and
provide universal access to all their citizens while the latter spends more than 14% of its
GDP on health and yet one third of its population has less than adequate coverage of health
care services. This explains that it was not for some abstract ideological reasons that the
countries of Europe and Canada opted for a system that is based on national planning,
severely restricted if not absence of market at the point of delivery of health care and of
course rationally planned distribution of health care resources. That is the reason why entire
UK has less number of CT-Scan and MRI machines than the number operating in the city of
Mumbai. In the former they ensure that all who need the use of those diagnostic machines
have access to them, while in the latter few get them even when they don’t need it but a
majority who actually need them do not get them because they have no money to buy. The
reason why so many who do not need so many diagnostic tests, so many medicines, so many
surgeries etc. and are yet subjected to them, is that, those decisions are taken by doctors or
with the advice of doctors. So the market saturation in health care often does not lead to
bankruptcies of doctors, but exploitation of patients, not less cost of health care but very high
cost fuelled by consumption of even things that one does not need. And consuming medical
care when one does not need is emerging as one of the biggest health problem in all market
based health care services in developed countries.

That is the reason why more medical college will not reduce demand for medical seats, for
the unregulated market will keep absorbing ever increasing number of doctors, who in turn
will keep exploiting without significant health outcome for general population, and in the
end, the whole system would not yield the expected benefit of reaching health care to all.

The tehelka on private medical colleges shown by the media all over the country is a part, or
a symptom of this vicious circle of medical care in market place. Even if the corruption
component of it is taken care of, the problem will persist unless we learn from the history, if
not from history, then at least as a part of globalisation import from the developed countries
those good policies of restructuring the health care in such a way that market mechanism, the
commercialisation, is drastically cut down and health care is made universally accessible.