by Prabhjot Singh*
One major fall out of the Russian invasion of Ukraine has been a wakeup call for planners and health educators over inadequacies of our medical education system. Still far short of achieving the world standard of providing a doctor for every 1000 people, corporate houses or private companies continue to shy away from accepting the medical education challenge to pull the country out of a grave crisis of acute shortage of trained doctors, nurses and paramedics.
Leave aside Karnataka, Maharashtra and Telangana, where politicians-turned-entrepreneurs are calling shots in providing medical education at exorbitant rates – almost 5-6 times that of government medical colleges – other states and union territories lag far behind.
In India, the gap between the MBBS seats available and aspirants is huge. Indian students going abroad for MBBS degrees are in fact helping the nation in bridging this gap at their own cost, security and well-being. The Ukraine crisis has added to their woes as they have to leave their medical schools in a distress without knowing whether they would ever be able to return.
India is not alone in grappling with a humanitarian crisis in trying to bring back its students from Ukraine. Several developing nations, including those from Africa, are equally affected. Nearly a quarter of the 76,000 foreign students who were in Ukraine before the Russians invasion were from countries like Nigeria, Morocco and Egypt, a BBC report said.
This is the result of a tradition that was set during the Soviet era when there was an effort by the government to attract students from newly independent African countries with an eye on long-term geopolitical interests. Over time, Ukraine has emerged as a gateway to Europe and European jobs for foreign students, both African and Indian. Ukrainian degrees are widely recognised in Europe for the quality of those who have acquired the stamp.
They have tailor made their courses by providing foreign students not only with their food and some faculty members speaking their language but also made their degrees affordable with a reasonable fee structure. An MBBS degree in any of these countries will cost anything between Rs 25 lakh and Rs 35 lakh while the same degree in a private medical college in India will be more than a crore of rupees touching in some 1.25 crore mark.
In China, some medical colleges have on their faculty experienced doctors of Indian origin working in the US. It is why China is one of the most popular destinations for Indian medical students. And the cost of medical education is competitive with other European or Asian countries.
If you know German and get admission in a German medical school, your education is totally free.
Recently, when the Ministry of Education came out with statistics, it revealed that for a total of 84,649 MBBS seats, as many as 16,14,777 candidates took the NEET (UG) examination, a mandatory entrance test for medical colleges, both government and private, in 2021. Almost 90 per cent of the candidates, 8,70,074 in all, cleared it. Because of limited number of seats available, only a little less than 10 per cent get into medical colleges in the country. Here the limited number of seats leave only one option available to these aspiring doctors. Most of them, especially those who can afford it, look outwards.
UK-based Kulwant Dhaliwal, who has been spearheading “Roko Cancer ” campaign in the South Asian continent in general and Punjab in particular, came out with some startling figures. Quoting Government of India officials, he says that nearly 1.20 lakh Indians are studying medicine abroad. Of these, nearly 23,000 are in China, 18,000 in Ukraine, 16,500 in Russia, 15,000 in Philippines, 10,000 in Kyrgyzstan,7500 in Georgia, 5200 in Bangladesh, 5200 in Kazakhstan, 4000 in Poland and 3000 in Armenia. He did not mention Nepal and other countries where again a sizable number of Indian students are doing MBBS.
The limited number of seats makes it difficult for all the qualified students to get degrees in medicine. Of the 562 medical colleges in the country, 286 are government and the rest private. While education in government colleges is comparatively subsidised, the fee of the MBBS course in private colleges varies. In Punjab, private medical education is fairly regulated by the state government, but the same cannot be said of many other states. Even this regulated fee is exorbitant for an average middle class family. It works out higher than the total fees charged for the full MBBS course in most of the Asian or European countries.
There is a huge difference in the fee structure for students admitted under NEET, government quota, management quota or NRIs quota. In September 2021, the Punjab government finally notified the fee structure for different categories of medical students in the State medical colleges, both government and private. The Punjab Government has fixed the tuition fee for first year in government colleges at Rs1,58,000, which would be subsequently increased by 10 percent every year for five years. So before a student completes his MBBS in the stipulated period, he or she ends up paying Rs 10 lakh. This excludes all supporting expenses, including hostel, food and at times even buying material for practicals. Many government medical colleges force their students to share the cost of laboratory materials. This cost comes to another three to five lakhs.
Elsewhere in India, tuition fee for students admitted under NEET UG programme is between Rs 67,000 and Rs 1.6 lakh per annum. For government sponsored seats it is between 3 lakh and 4 lakh per annum while under NRI quota it is between US $ 1.10 lakh to US $ 1.5 lakh for the full course.
On the other hand, the fee for the first year of a private college under government quota is Rs3,68,000,and that of the management quota is Rs9,45,000. By the end of the fifth year in a private college, a student would have paid nearly Rs15 lakh under government quota and nearly Rs50 lakh under the management quota. The fee for the NRI quota is $110,000. These are fee structures that do not include board and lodging and the laboratory costs that unfortunately students are forced to bear.
Those going abroad for medical degrees also take a big risk as their degrees do not have instant recognition back home. They are put in a 10-year-window in which they are required to meet all the mandatory requirements before they get a licence to practice in the country. Despite this, they continue to do so, indicating the desperation in individual families where the offspring wishes to secure a medical degree, but an affordable seat is just not available in India.
The desperation to get an affordable foreign medical education is apparent from the fact that leaving aside the top three countries and Kyrgyzstan whose degree holders appear for the qualifying Indian test, Nepal accounted for 7.6 per cent and Bangladesh 2 per cent in 2018-19. The question that Kulwant Dhaliwal has raised is very pertinent. India is more prosperous and a growing economic power. He says what the Government of India needs to ask itself is what Nepal and Bangladesh got that it has not.
Indian medical students seeking degrees abroad mostly wish to return to India after graduation and have to take the foreign medical graduate examination. The numbers taking this test have gone up by more than three times since 2014-15. As against this, over the same period, the number of medical colleges has gone up by only 1.5 times and the number of seats by 1.6 times.
For medical students with foreign degrees, the National Medical Commission’s (NMC) has set up some regulations/ These Foreign Medicine Graduates (FMGs) regulations were promulgated in 2021, prohibiting transfer from a foreign university to an Indian university in the middle of an MBBS programme. The reason given was that the entrance guidelines and selection criteria differ.
The FMG regulations provide a 10-year window for students to obtain their degrees, complete their internships (one year in Ukraine and India respectively) and apply for Foreign Medicine Graduates Examination to receive their licenses. Since an MBBS degree in Ukraine takes an average of six years to complete and taking into consideration the additional two years required for internships, it therefore leaves the candidates with only two years to apply for their license in the 10-year window.
Given the current crisis, there is no way of knowing when these students will return to Ukraine to finish their studies. Thus the 10-year window may pose a big challenge for them, as they may not be able to apply for a license to practice medicine in India if they do not complete the formalities within that time frame. With the situation between Russia and Ukraine showing no signs to abate, India may have to take a decision to safeguard interest of these displaced students.
During 2021-22, only a quarter of the students who appeared for this test (it is held twice a year), cleared it, thus acquiring the right to practice in India. This success rate, low as it is, has itself gone up over the years. Those who eventually do not clear the test despite reappearing stand to lose the investment made in a foreign degree.
The numbers taking this test have gone up by more than three times since 2014-15. As against this, over the same period, the number of medical colleges has gone up by only 1.5 times and the number of seats by 1.6 times.
India is not alone in having to grapple with a humanitarian crisis in trying to bring back its students from Ukraine. Several African countries are equally affected. Nearly a quarter of the 76,000 foreign students who were in Ukraine when the Russians struck were from countries like Nigeria, Morocco and Egypt, a BBC report said.
This is the result of a tradition that was set during the Soviet era when there was an effort by the government to attract students from newly independent African countries with an eye on long-term geopolitical interests. Over time, Ukraine has emerged as a gateway to Europe and European jobs for foreign students, both African and Indian. Ukrainian degrees are widely recognised in Europe for the quality of those who have acquired the stamp.
One reason why there are fewer private medical seats than engineering is that private deliverers have kept away from medical education which has to be imparted over a longer duration. This means simultaneously there will be more batches going through the course and thus there is a need for more infrastructure. An MBBS course, including internship, needs 5.5 years to deliver whereas a bachelor’s course in management takes three. It is perhaps the longest than any other professional degree course, including engineering or finance.
Thus private investment in medical education is best done by those entities which can live with a longer gestation period and that typically comes with a degree of commitment to the idea.
The other side of the reality is that it is impossible for a middle-class family to afford private medical education and seats in government medical colleges are few and therefore open only to the most meritorious. The promoters of private medical colleges, like engineering colleges, are often without any earlier exposure to education and of variable integrity who will extract as much from the market as they can.
* Prabhjot Singh is a veteran journalist with over three decades of experience covering a wide spectrum of subjects and stories. He has covered Punjab and Sikh affairs for more than three decades besides covering seven Olympics and several major sporting events and hosting TV shows. For more in-depth analysis please visit probingeye.com or follow him on Twitter.com/probingeye