Doctors sans state borders?

Admission Restricted: States are keen to reserve medical college seats for local students

Whether postgraduate (PG) medical education should be subject to state-specific domiciliary restrictions or be fully open to national-level competitive selection has become a question that is vigorously contested in the courts.

Five years after the National Entrance and Eligibility Test (NEET) commenced, several states have attempted to restrict selections in their territories to students who meet the requirement of local residency for a stipulated time period. The courts have generally been unsympathetic to this view.

Though there was a formula (initially agreed by all) to safeguard the interests of a state's own students, states like Maharashtra and Karnataka proposed a domicile criterion for PG medical education. The argument was that students from the state are more likely to go back to small towns and rural areas to serve, while students from other states prefer to go back to their home state. The proposals of both states were turned down by the Supreme Court. In contrast, the Madhya Pradesh High Court recently struck down admissions given to 84 students from outside that state although they had been admitted on the basis of their NEET scores.

In early April, the Supreme Court struck down Karnataka's notification that made it mandatory for those seeking admission to medical PG courses in the state to have had 10 years of education in the state. In February, the SC rejected a similar notification put out by Maharashtra. Despite the Supreme Court's unequivocal position on this matter, the Tamil Nadu government has said it would also make an attempt to secure more seats for local
students.

The purpose of NEET is to provide a standardised national examination for selection to PG courses. Within the NEET framework, each state has some leeway to provide seats to students from the state. But it cannot tilt the examination system to favour local students or reject students from other states who qualify for the open seats. However, there are anomalies that exist in the availability of medical colleges and PG seats across states. Further, even states which have a large number of medical colleges offering PG medical education plead that they need more local doctors to fill many vacancies in specialist positions in their health systems, especially in rural health facilities and district hospitals.

If local medical graduates take up the bulk of PG seats available in states that have the most number of medical colleges and seats available, those states that have few medical colleges will be greatly disadvantaged. These are also the states that have more challenged health systems and worse health indicators than the states with more medical colleges per unit of population. So, equity at the national level demands a better distribution of both basic and specialist doctors across the states as well as a better rural-urban ratio than presently available. Even states graduating many medical students from their undergraduate programmes have a legitimate aspiration to correct the rural-urban maldistribution.

How can we then reconcile these national needs and provincial priorities? First, we need to increase the number of postgraduate training facilities across the country, giving special attention to states where PG training medical colleges are sparse. While the establishment of new medical colleges will take time, district hospitals should be speedily upgraded to provide postgraduate training with affiliation to the National Board of Examinations, the closest medical college in the state or a regional AIIMS, if it exists in the state. Strengthening district hospitals is needed for improving health services to support the National Health Protection Scheme. It should also serve to fill the gaps in PG seats.

How do we ensure that the specialists produced are distributed well across the country? Leaving it to market forces will not work, as we have discovered. Making a few years of employment in state health services compulsory after completion of PG courses also will not serve to ensure equitable distribution of specialists across states. States with a high number of medical colleges will retain the specialists graduating from their colleges within their health services but those with few medical colleges will continue to suffer shortages.

To solve this problem, the central government should create an Indian Medical Service, with two tiers. It should recruit newly graduating specialists into a mandatory short service category of three years as well as create a permanent service category. The model of Railway Health Services could theoretically work well for the longer service as its doctors are well distributed across the country. However, the states will not accept such a centrally administered health service when delivery of health services is their responsibility. So, a service needs to be created which has an all-India character but with administrative control vested in individual states.

The short service component can be attached to Ayushman Bharat or the National Health Mission and funded by the Centre for well-distributed deployment across the country. After that mandatory period, the specialists can opt out to pursue careers outside government or opt for competitive recruitment into a permanent service modelled after all-India services like IAS and IPS which serve the whole country through state-affiliated cadres. State cadres can be created for the Indian Medical Service, too, on similar lines, with the consent and control of the states.

This requires reform that embodies the spirit of cooperative federalism and dispels the rancour of parochial claims that repeatedly contest NEET in courts. Ultimately, the health of the nation requires a health system configuration that serves all states well, with proper planning for the countrywide availability of qualified health professionals. NEET is the start, and not the end of that process.

(The writer is President of Public Health Foundation of India)