AILING EDUCATION: THE MEDICAL EDUCATION IN INDIA
Amar Jesani

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 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 as 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 by those who always had reservations due to their higher economic positions.

This vocal segment believed that the 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 anti-reservation. The neo-liberal economists also jumped into the debate saying that it was primarily due to the problem of supply not matching 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 medical care has increasingly become dependent on doctors and technologies. In the popular image, a health service is unthinkable without a doctor and the increasing number of 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 systems. In the era of corporatisation of health care in which the private capital, particularly the finance capital and its private insurance companies are calling the shots in the 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 a 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 the 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 a seemingly most important factor in patient care but they also comprise 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 power of the 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 in the West that began the process of monopoly was passed only in 1857 in the UK that established the General Medical Council and made it mandatory to have a basic minimum formal qualification for all doctors and their registration with the Council. Such a 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 the 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 the 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 the 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 additionally over 100 colleges (we have now about 205 medical colleges) and also added additional 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 letter and in 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 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 the 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 continue to remain so even now.

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 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 colleges affiliated to the modern system. While our medical councils for a modern system are nearly defunct as far as enforcing quality and ethics are concerned (they are more in the news for the 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 the medical profession by buying seats in non-modern systems colleges to practice the modern 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 the establishment of a high number of private non-modern system medical colleges till the 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 the mid-1980s, thus showing that once the 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 a 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 made here about the fanfare with which the current ultra right-wing government has been trumpeting its adherence to tradition and revivalism of Indian medicine. A visit to the websites run by the health ministry would show that the 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 the commitment of the government. However, our observation on the development of medical education given above shows that it is the modern system that is systematically promoted through the private sector involvement, while the growth of 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 this 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 the medical profession and the government. They dole out data showing that we have one doctor for over 2000 persons in the country 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 conducting a medical practice. With them, the ratio would be very close to the situation in developed countries.

Another extreme of the argument is that we already have too many doctors, but more importantly, these too many doctors serve an 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 a vested interest in mystifying the medical care, being 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 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 idea of how to take care of the first-contact primary health care needs of the people and have understanding and skills in referring those who need doctor's care to the Primary Health Centres of the government at the 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 even more 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 conduct their practice primarily in the underserved slum areas. So not counting them to win an argument and to believe a priori that the entire organisation of health care must be planned keeping only modern doctors in focus will be far from the ground reality. Therefore, in terms of sheer numbers, it is clear that we have nearly the 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 improves 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 provides a remedy that is not adequate for the needs and expectations of people.

It is also true that we do not only have a 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. Certain regions of the country also have a disproportionately higher concentration of doctors than others. But this correct diagnosis is not translated into the correct remedy, i.e. 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 a policy is fine for an interim period to meet the immediate needs, but not adequate in longer run. By bypassing the contentious issue, it only allows the current affair of doctors' or health system's irresponsibility in allowing the 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 is by establishing more services in the 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 a 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 the 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 themselves in areas where there are 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 already exist. 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. Through 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, protecting the environment and so on.

These policy instruments have not been found to be against the democratic ethos of our country, nor of the developed countries. Such measures would also have an 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 West 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 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: the contention of the pro-market neo-liberals that a greater supply of doctors will be desirable and will also bring down the 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 take a closer look at the nature of the market in general and the specific nature of the market in health care in particular. The usual argument is that when supply increases, the competition increases and that brings down the price. In health care, the opposite happens (and is happening), and that too 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 the 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 the patient ought to consume.

Even in the best of situations respecting a patient's autonomy, the patient is able to choose only from few options offered by the doctor and such choice 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. Further, the experience shows that greater 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 these not only keep the price high, but the over-concentration of doctors will 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 health care is provided through a 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 GDP 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, a severely restricted if not absent market at the point of delivery of health care and of course rationally planned distribution of health care resources. That is the reason why the entire UK has a fewer 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 and the 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 a lower cost of health care but very high cost fuelled by consumption of even things that one does not need. And consuming medical care when not required is emerging as one of the biggest health problems in all market based health care services in developed countries.

That is the reason why more medical colleges will not reduce demand for medical seats, for the unregulated market will keep absorbing an ever increasing number of doctors, who in turn will keep exploiting patients without a significant health outcome for the general population, and in the end, the whole system will 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 history. If not from history, then at least as a part of the globalisation import from the developed countries, we can glean those good policies of restructuring the health care in such a way that the market mechanism and the commercialisation is drastically cut down and health care is made universally accessible.

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