The rapid changes in lifestyle and increase in chronic diseases, an effective demand for healthcare services and technology combined with a deteriorating economy during the 1990s, forced governments to privatise medical education.
This policy has resulted in the phenomenal explosion of private colleges that increased from 41 in 1990 to 209 in 2014, accounting for an 8% growth per year compared to 3% in government colleges. Of this, two-thirds are in the five southern states and Maharashtra.
The private medical college model is based on a three-tier fee structure. For example, in Andhra Pradesh, half the students admitted under the government quota pay a nominal fee of Rs 50,000 per annum, those under the management quota (35% of seats) pay Rs 12.5 lakh, while the 15% seats earmarked for NRI’s pay six times of that. Added to this are the unofficial payments or capitation fee that ranges from Rs 50 lakh to 1.5 crore for MBBS course and Rs 2 to 3 crore for an MD seat under the management quota. In the country, the capitation fee market is an estimated Rs 20,000 crore per year.
The financial model then determines the admission policy. While the government quota students have to prove their merit either in their school examination or a common entrance test, the management quota students must have the ability to pay. There are, however, few exceptions such as the Christian Medical College, Vellore, who have their own criteria for admissions, but ones that are not determined on ability to pay. In other words, out of the 50,000 MBBS seats, 50% is filled on grounds of privilege entailing huge unintended consequences to the character of the health system that is increasingly becoming inequitable, commercial and of low quality.
Besides, for a meritorious middle-class aspirant, with over 35 admission tests, medical education is clearly an unaffordable proposition.
In addition to this crude commercialisation of the medical profession, there was one more concern that provoked the need to institute the National Eligibility-cum-Entrance Test (NEET), the rapid deterioration in the knowledge levels of students entering medical colleges. There is a variance between the competitive Central Board of Secondary Education (CBSE) standard and the Secondary School Certificate (SSC) standard followed in a dozen states. While the CBSE syllabus focuses on science and math, the SSC is more focused on liberal arts, besides being plagued with the non-availability of science, English and math teachers.
Added to this already distressing situation has been the emergence of a brand of populism that bases itself on chasing the lowest common denominator by reducing quality and standards, be it the training curricula for an Auxiliary Nurse Midwife, or diluting the SSC standards on grounds of equity, rather than fostering hard work and a spirit of excellence in every student without discrimination of caste or social status. The former is easy to do but the latter requires a sustained commitment to education, appropriate levels of public investment, institutional effort and good governance.
Thus, a state like Tamil Nadu, once the land of Ramanujam and innovation, is witnessing a rapid fall in number of students qualifying in national-level tests like the Civil Services Exams or the Joint Entrance Exams for IITs. States like Telangana and Andhra Pradesh have done better and have been more aspirational by harmonising their standards at a par with all-India boards like CBSE and Indian School Certificate Examination.
Rampant commercialisation and the large number of tests resulting in a denial of fair opportunity were thus the two major factors that compelled the Supreme Court to push the government to consider a common entrance test. Accordingly, the NEET was envisioned to lay down uniformity in minimum standards dictated by the demands of the profession, and reduce the discretionary power of the private managements to cherry-pick their students. The process aimed at ranking all students who have scored the minimum cut-off state-wise, community/caste-wise, urban-rich wise, states/college-wise were then enjoined to admit students from out of such a list, picking the best in the desired category.
Scuttling NEET
The private medical colleges had successfully scuttled the first attempt to introduce NEET in 2013. The second effort in 2016 was stayed by an ordinance exempting government colleges and students under government quota from NEET “for one year” issued by a nervous government unable to withstand the demand to postpone or scrap NEET – a demand that sought to be justified on the grounds of “time to prepare, in view of the variance in standards between SSC and CBSE.
It is known that such variance issues cannot be addressed within one year. What has given the game away is that those protesting the loudest were from the three states that have the highest number of private medical colleges–Tamil Nadu, Karnataka and Maharashtra. While the silence of the private sector has been deafening, it is to be seen whether the ordinance will give them the entry point to seek a similar relief on grounds of equal treatment.
The NEET has become a partisan issue. While for some, the postponement of the examination brought relief, to the majority of the meritorious and those willing to put in the additional hard work, it has once again meant continuance of the status quo and the country losing the historic opportunity to bring in the much desired reform.
What has emerged in all this is the question of what the public policy is seeking to convey. First, it signals the fact that the CBSE is indeed the required standard for pursuing the medical profession, but then also agrees to permit the lower standard (lowered competencies in biology and chemistry) students to continue seeking admission in medical colleges. Secondly, the power of the states (the political and medical complex nexus) and the media to “scuttle reform”, leaving little hope for the break that the profession badly needs. Thirdly, the lower priority to the needs of the sick getting the best to serve them. And finally, in not providing any incentive to the states to improve their educational standards.
In conclusion, it is argued that the importance of NEET needs to be assessed by answering two concerns. First, patient welfare and the principle of equity that makes it incumbent for merit and aptitude and not privilege to be the criteria for becoming a doctor. Second, given the toughness of medical science, whether we as a people are happy with doctors having minimum competencies in core subjects like chemistry and biology? As for the rights of the states, so long as doctors of one state have the right to treat patients of another, states have an obligation to fulfill the minimum criteria that is acceptable to all.
(The writer is former secretary, Ministry of Health, Government of India)