Medical education: public funding, role key

The Union cabinet recently cleared the National Medical Commission (NMC) Bill 2019. One of its salient features is the clause to regulate fee and other charges for 50% of seats in private medical colleges and deemed universities. By this, it seems to contradict the spirit of the draft National Education Policy (NEP), which seeks to accord autonomy to medical colleges on deciding fees.

In light of the numerous egregious cases of corruption in medical education and a widespread demand to regulate fees in private colleges on the one hand, and the drive to achieve excellence and equity on the other, it is important to ascertain the correct recipe of regulating and paying for medical education.

The government already regulates fees for up to 85% of seats in most private medical colleges. Bringing deemed universities into the fold, which are hardly a tenth of the total number of medical colleges in the country, will make little difference, especially if the ceiling is concurrently brought down to 50% of seats. So, in effect, the NMC Bill actually allows greater latitude to private colleges in fee-setting, as espoused by the NEP.

Stringent fee control can be counterproductive. Medical education is a costly endeavour and expecting any public or private medical college to deliver quality education and research without sufficient financial backing and administrative latitude is fruitless. This is consistent with international experience. In India, over-bureaucratisation, underfunding and lack of autonomy in government colleges has stifled the environment for research and excellence in teaching.

Tight fee control over a large share of seats in private colleges partly fuelled the practice of collecting huge sums illegally. A reasonable degree of autonomy to colleges, along with effective provisions to deter commercialisation, is needed, and the NEP gets it right on this.

Private colleges could be cash-strapped when it comes to investing in quality education and research, but this never acted as a deterrent to a rapid growth in their number, due to an ecosystem that has allowed profiteering interests to topple philanthropic interests in medical education since the 1980s.

The decade 2001-2010 witnessed a peak in the growth of private medical colleges, and a plunge in their educational standards. The ‘light but tight’ regulatory framework outlined in NEP, which aims to cultivate public spiritedness and discourage commercialisation of education, can reverse the trend.

While principles like academic autonomy (freedom to set own curriculum) for medical colleges and public disclosure of information to uphold the ‘court of public opinion’ are highly commendable, one wonders about the feasibility and potential efficacy, given our current context where medical colleges are highly deficient in skilled manpower and technical capability, and public opinion is rather disinterested. Thus, as forward-
looking as the NEP is, it appears in certain respects to be punching much above its weight.

But with greater autonomy and lifting of fee controls at both public and private colleges, the question of affordability of medical education becomes critical. The NEP mandates 25-100% fee waivers for 50% students, with 20% students receiving full fee waiver. This will clearly be insufficient to take care of the large majority of students, who would then be worse off than in the present system — not counting the upward push on fees that the fee-waived seats will exert. This would belie the stated aim of the NEP of increasing access to healthcare education and lowering the cost of education.

A possible solution could be to develop student-friendly loan programmes, but this again could be fraught with adverse implications. Costly medical education and student indebtedness after medical school are known to change the trajectory of healthcare services for the worse — by diverting emphasis away from community and primary healthcare into more specialised and costly forms of care, reinforcing the elitist skew in medical education and making some medical specialties unduly more attractive to students than others. These are problems we are already struggling with. Large-scale implementation of such a loans-based solution would be contextually inappropriate for the Indian setting.

The solution lies in the traditional prescription of increasing public funding and role in medical education, while not turning away from the progressive regulatory framework suggested by the NEP. In this respect, the Flexner report on medical education in the US, a landmark document that has influenced medical education across the globe in the last century, can provide valuable insights – especially considering that multiple aspects of Indian healthcare are being subtly envisaged (often mindlessly so) to be modelled after that in America.

Flexner demonstrated that fees from students can fund only about a third to half of medical school expenditures, and that medical education must continue to be mainly a social function, lest commercialisation should invariably degrade educational standards. Many private medical colleges in India have been little different in spirit from the ‘proprietary’ medical schools that Flexner denounced in his report. While greater autonomy to medical colleges and ‘light but tight’ regulation are crucial, the same must not undermine public role in medical education.

(The writer is Editor, The Indian Practitioner, and a medical doctor based in Mumbai)