|MEDICINE AND SOCIETY
|Year : 2022 | Volume
| Issue : 3 | Page : 280-285
Increase in the number of MBBS seats through the scheme of one medical college per district: The debate on quality versus quantity and opportunity to strengthen family physician system In India
Independent Researcher & National President, Academy of Family Physicians of India, Ghaziabad, Uttar Pradesh, India
|Date of Submission||27-Nov-2022|
|Date of Decision||06-Dec-2022|
|Date of Acceptance||09-Dec-2022|
|Date of Web Publication||28-Dec-2022|
Dr. Raman Kumar
Academy of Family Physicians of India, 049, Crema Tower, Mahagun Mascot, Crossing Republik Ghaziabad - 201 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
India currently hosts the largest medical education system in the world with 650 medical colleges and 98613 MBBS (undergraduate) training seats. The reasons for Indian Medical Graduate's international migration and internal distribution within India have been multifactorial. There are push factors (with India) as well as pull factors (international host countries). Almost the same reasons are implied to the distribution and availability of the medical workforce geographically within India. To address the regional disparities in medical education and the availability of human resources in health, the policy of establishing one medical college in each district in India was initiated. Impressive progress has been achieved so far. However, the policymakers must look at it critically to be able to steer this project towards meeting the public health objectives of the country in the coming century. The discussion must include arguments on the type of doctor India needs. Indian can no longer afford the policy of having many cardiologists as compared to miniscule number of trained family physicians. All specialist system is being perused at the cost of a generalist health system. This paper critically looks at the district medical college scheme and exponential growth in the number of medical seats in India. Statistical success alone cannot address the public health needs and medical care of the Indian population. The creation of the National Medical Commission (NMC) has eased the criteria for recognition of new medical colleges; however, several limitations of the Medical Council of India are being carried forward within the functioning of NMC. Unless, there is a focus on creating employment and retaining medical graduates within the health system, it is worthless producing millions of them.
Keywords: Competency-based medical education, district medical college, Indian medical graduate, NEET PG, next
|How to cite this article:|
Kumar R. Increase in the number of MBBS seats through the scheme of one medical college per district: The debate on quality versus quantity and opportunity to strengthen family physician system In India. J Med Evid 2022;3:280-5
|How to cite this URL:|
Kumar R. Increase in the number of MBBS seats through the scheme of one medical college per district: The debate on quality versus quantity and opportunity to strengthen family physician system In India. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:280-5. Available from: http://www.journaljme.org/text.asp?2022/3/3/280/365856
| Background – India, the Largest Medical Education System in the World|| |
India will soon become the most populous country of the world. Providing health-care facilities to such population with high levels of morbidity at low cost is a challenging task for any government. Being one of the most populous countries and densely populated habitats on the earth, human resources in health have always been scarce. However, in terms of numbers, India has always been a leader in medical education system and currently hosts the largest medical education system in the world with 650 medical colleges and 98613 MBBS (undergraduate) training seats. Many more are yet to come since the impact of starting a medical college in each district of India is yet to come. Comparing globally India's average annual output of graduates per medical college is much less as compared to 149 in Western Europe, 220 in Eastern Europe and 930 in China. In addition, medical colleges are unevenly distributed among different states, regions and urban and rural areas; and present wide disparities in the quality of education. The shortfall of human resources in health has resulted in skewing the distribution of health workers such that vulnerable populations in rural, tribal and hilly areas continue to be extremely underserved. To address the regional disparities in medical education and the availability of human resources in health, the policy of establishing one medical college in each district in India was initiated. Impressive progress has been achieved so far. However, the policymakers must look at it critically to be able to steer this project towards meeting the public health objectives of the country in the coming century. The discussion must include arguments on the type of doctor India needs. India can no longer afford the policy of having many cardiologists as compared to a miniscule number of trained family physicians. All specialist systems are being pursued at the cost of a generalist health system. This paper critically looks at the district medical college scheme and exponential growth in the number of medical seats in India. Statistical success alone cannot address the public health needs and medical care of the Indian population. The creation of the NMC has eased the criteria for recognition of new medical colleges; however, several limitations of the Medical Council of India (MCI) are being carried forward within the functioning of NMC. Unless, there is a focus on creating employment and retaining medical graduates within the health system, it is worthless producing millions of them. Existing fallacies within the medical education system pose a serious risk to the policy aspirations of the 'one medical college at each district scheme'.
| District Medical College Scheme: Expansion of Medical Education System in India: 2014–2022|| |
To address the equitable distribution of human resources in health, the policy of establishing one medical college in each district in India was initiated. The objectives of this scheme were (a) increase seats at the undergraduate level in the government sector, (b) bridge the gap in the number of seats available in the government and private sectors to ensure the availability of more MBBS seats for students who cannot afford expensive medical education in the private sector, (c) mitigate the shortage of doctors by increasing the number of undergraduate seats in the country for equitable health-care access across the states, (d) Utilise the existing infrastructure of district hospitals for increasing undergraduate seats in a cost-effective manner by attaching new medical colleges with existing district/referral hospitals, (e) meet the healthcare needs of the growing population and ensure that doctors are available at primary health centres, community health centres and district level health-care institutions to ensure service guarantee under national health policies and (f) expansion of medical education system preferably in underserved areas.
According to a report of the Ministry of Health and Family Welfare titled 'Governance Reforms in Medical Education (2014-2022)', since 2014, India has witnessed an increase of 67% in the establishment of medical colleges along with around 96% increase in the number of government medical colleges and 42% increase in the private sector. This has resulted in an 87% increase in the UG (MBBS) medical seats, and the postgraduate medical seats have also increased by 105% since 2014. This is an impressive achievement over a period of decades. [Figure 1]a, [Figure 1]b and [Figure 2] represent the geographical representation of the existing medical colleges and the new medical colleges across India.
|Figure 1: Existing colleges vs new medical colleges (Source - Reform, Perform, Transform Governance Reforms in Medical Education 2014-2022, MOHFW, Government of India) |
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|Figure 2: Number of medical colleges per district Reform, (Perform, Transform Governance Reforms in Medical Education 2014-2022, MOHFW, Government of India) |
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| Training Doctors for the World – Push and Pull Factors for Doctor Retirement|| |
The Indian medical education system traditionally has supplied a medical workforce not only to India but also to the world. Apart from India, the United States, the United Kingdom and middle eastern countries have benefited from physicians trained and educated in India. The medical graduates of India have proven their capacities and competency worldwide much before their IT (Information Technology) counterparts took over the world during the recent decades – the top executives (the CEOs) and the business leaders of major IT companies are of Indian origin. Currently, over 10% of all physicians in the United States are of Indian origin and over 20,000 doctors from India are currently practicing in the National Health Service in the United Kingdom. The reasons for international migration and internal distribution within India have been multifactorial. There are push factors (with India) as well as pull factors (international host countries). Almost the same reasons are implied to the distribution and availability of the medical workforce geographically within India.
| District Medical Colleges: Employment, Remuneration and Retainership|| |
District medical colleges and policy to expand the geographical spread of the medical education system to the areas of need is a commendable initiative. However, it must be taken note that India has already achieved a 1:834 ratio of doctor population ratio and matched many OECD nation statistics if the number of AYUSH doctors is combined with allopathic doctors. Even within the coming few the desirable MBBS to population ratio is likely to be achieved. However, the addressal to the pressing needs of the population is expected to remain unsatisfactory.
Equally important is recruitment and retainership. The job markets for Indian medical graduates are paradoxically saturated and shrinking both internationally and domestically. Contrary to the extensive discourse on the deficiency of doctors in India, there are no campus interviews and selection for employment for any level of the medical course at any discipline at any medical college in India. There is no actual demand for medical doctors in the employment market. The average salary/income of a fresh graduate or postgraduate medical doctor is quite low as compared to other professionals in a similar industry. There is paradoxical over-saturation in most of the medical hubs and larger cities of India. At state levels, most of the medical officer-level employment has been converted into contractual jobs without any social security and no sustainable income. At private medical institutions, the situation is no different. The focus of the discussion is on producing medical graduates and addressing the doctor-population ratio; however, there is no plan on employment and retaining them for communities with pressing public health needs. There should be more focus on creating/sanctioning more employment and retaining them in the area of need. Does each of the districts in India have the capacity to employ a 100 MBBS doctors within the health system annually?
| Number and Types of Doctors India Needs|| |
The establishment of the NMC replacing the erstwhile MCI is a major regulatory framework change paving for liberating accreditation criteria towards the rapid opening of the new medical colleges. However, a few of the key concerns regarding the functioning of medical education have not been addressed yet. The medical experts are required in the primary care, secondary care and tertiary care domains. In any health system, primary care providers (family physicians) are available in maximum number, forming the base of the pyramidal structure and sub-specialities (super specialists) are required fewer in number representing the apex of the pyramid.
It is important to note that in the recently announced (2019) and highly publicised new MBBS curriculum the word 'family medicine' has not been even mentioned in the voluminous document. In past, many specialist colleagues presiding the MCI opined on record that there is no demand for family medicine/family physicians in the public and private sectors. As a matter of fact, the experts of the MCI continuously blocked 'Family Medicine' through misusing the various regulations of the MCI Act. There was a monopoly of specialist faculty over the medical education system in favour of their own specialist vocations. Over a period of several decades, MBBS qualification has evolved into a semi-specialist course and remains incomplete without specialist PG (MD/MS) training. There is no visible change yet to the apathy of disfranchising the family physicians from the formal medical education system. This is reflected by the following: (a) no independent and mandatory department of family medicine, (b) MBBS curriculum does not even mention the word, (c) family physicians are not eligible to become faculty, (d) family practice clinics are barred from becoming training locations, (e) no representation of family physicians in curriculum committee and (f) and no representation to family physicians in the governance of MCI.
As per the provision of the NMC Act 2019 under section 24 (1) ©, the Under-Graduate Medical Education Board is mandated to develop a competency-based dynamic curriculum for addressing the needs of primary health services, community medicine and family medicine to ensure healthcare in such areas. Similarly, under 'section 25 (1) (j)' the Post Graduate Medical Education Board is mandated to promote and facilitate postgraduate courses in family medicine.
| The Role of the MBBS Licensed Graduate Indian Health System? Does the National Medical Commission Continue to be a Specialist and Hospitalist Monopoly?|| |
The MBBS Competency-Based Medical Education (CBME) curriculum is conducted by exclusive specialist faculty at tertiary care hospitals experienced through a fragmented disciplinary and service approach. Earlier, there was great reluctance by MCI to introduce the family physician concept for MBBS doctors. This continues to be so with the NMC. Family medicine, the discipline to train family physicians, has not been introduced at MBBS nor is there any mandatory department to teach whole-person care. This is different from the person-centred approach and early exposure to family practice and primary care in countries such as the United States and the United Kingdom (KPMG Report 2022).
The NMC is governed by hospitalists and specialist doctors. Practicing family physicians do not have any representation at the apex regulator (NMC). The autonomous board of undergraduate medical education (for MBBS) is also governed by super specialists and specialist doctors. Now, the 92nd parliamentary standing committee on health and family welfare report also noted that the medical education system is designed in a way that the concept of family physicians has been ignored. The committee recommended that the government of India in coordination with state governments should establish robust programs in family medicine and facilitate the introduction of family medicine discipline in all medical colleges. This will not only minimise the need for frequent referrals to specialists and decrease the load on tertiary care, but also provide continuous healthcare for individuals and families.
The situation has not changed even with the enactment of the NMC. Despite the appeal from all quarters of professionals and the public, the NMC has refused to include Family Medicine (the discipline of generalised physicians) in the MBBS course and decided not expose the MBBS students to the generalist career pathway and vocation. It appears that there is an intent to drive the MBBS herd through mandatory postgraduate specialist programs. MBBS has become a 'mini specialist course' with no future without postgraduate training. There is a need to emphasise that the overall objective of an MBBS practice license is to prepare family physicians; however, at present, the family medicine discipline is excluded from the MBBS training.
The visible trajectory of promotion of ALL specialist health system: Equal number of MBBS and PG Seats and pan India expansion of super specialist culture and cost of care - At the cost of promoting family physicians for the society there is a visible push to promote specialist training for all medical graduates (MBBS) in India. Every health system needs an equal number of specialists and generalists. However, in India, the mandatory career pathway is arranged in the form of career progression from basic (MBBS), to specialist (MD/MS) and further moving towards super specialists (DM/MCh) qualifications. In many ways, the Indian health system is a hyper-privatised market-driven health system with little provision for gatekeeping, cost audit and value of community-based generalised medical care. The terminology of 'super specialist and super-specialist care' is used bluntly by the regulators and policymakers as a norm and as a political mandate. However, such terminologies are not used anywhere in the world except for India. Medical college hospitals are the apex tertiary care health-care institutions catering to a fraction of actual morbidity prevalent within the community. Many sparsely populated communities located in hilly, tribal, remote, islands and rural areas might not be suitable for the conventional tertiary care teaching hospital. Of the 750 patients who experience any illness during a given period, only one person requires admission to a tertiary care teaching hospitals. The medical college teaching hospitals are bound to expand the tertiary care services and the culture of super specialisation at the cost of generalist healthcare services. By converting each district hospital into a medical college, the general hospitals would be undervalued and vanished giving space to high-cost intervention-focused super specialist care.
| NEET PG/NEXT Coaching App: Is the Coaching Industry for Entrance Examinations Growing Bigger than the Medical Education System? Can Competency-Based Medical Education Save Grace?|| |
Due to underdeveloped vocational opportunities in diverse areas of human domains (e.g. sports/music/arts) medicine and engineering have remained the preferred early career pathways for most school students in India. This brings in a high level of competition for available opportunities. Special coaching classes are required to qualify through the National Level Entrance Examinations-NEET. Instead of developing the scholastic abilities of students, the entrance examinations have pushed them to acquire tricks of mastering multiple choice questions. For those who make it to MBBS, the ordeal is not over yet. The CBME curriculum was introduced with much fanfare in 2019. However, MBBS students compulsorily must go through the postgraduate entrance examination (NEET PG). Despite the increased number of postgraduate training positions, due to the hierarchy and financial proposition of different disciplines and specialties, the current trend among medical students is to start preparing early for the PG entrance examination and most students join coaching apps. Now that the NEET PG is being changed to NEXT (licensing examination cum postgraduate entrance test) the pressure on MBBS students is going to intensify. CBME automatically becomes dysfunctional and redundant in the situation of a policy articulation to offer every MBBS doctor a postgraduate seat (MD/MS). However, matching MBBS seats with PG seats is not going to solve the problem of the students as well as the Indian health-care delivery system. There are speciality-wise career choices and financial incentives for each discipline. This speciality-seeking tread can be verified from the website of any private medical college and comparing fees for different disciplines offered. Specialties such as radiodiagnosis and other clinical branches command maximum fee and respect while it is inverse for so-called non-clinical disciplines such as physiology as it is considered nonclinical.
| An Education Industry Awarding Qualifications and License to Practice Medicine|| |
The business model of many private medical colleges is dependent on the fee charged from the students and trainees. With few exceptions, the income generated from the medical service rendered is only a fraction of the fee charged from the students. There are dummy patients and ghost faculty to meet the accreditation criteria of running a medical college. Services of such tertiary care hospitals are nonsignificant to the community. Service delivery is a secondary process to the MBBS-producing assembly line. The entire process is focused on maintaining the legally accredited structure of the medical college. Such institutions maintain profitability through high fees collected from students and awarding them licensed professional qualifications on the assembly line. India is perhaps the only country where the resident physicians pay a disproportionate proportion of family wealth to get the opportunity to work as postgraduate residents as a journey towards achieving clinical speciality practice license. In most countries, they are paid as graduate doctors as per work hours as residents for taking care of the workload.
| Representation of Eligible District School Students (10 + 2) at the District Medical Colleges|| |
Districts vary according to their developmental indices in India. There are developed districts and there are aspirations districts where the level of development is inadequate. One of the focuses of the district medical college scheme has been to prioritise the aspirational districts to ensure the availability of advanced medical facilities and training human resources. However, the MBBS student recruitment/entrance criteria in India did not consider the developmental status of the student's district. It is not uncommon to observe that most seats are occupied by students of the best school in a state mostly located within capital cities of the states and around the other developed districts. Students of a few schools do exceptionally well at entrance examinations. Further, the coaching institutions for entrance examinations are located mostly in the state capitals. At all India level, the same pattern is observed. There is an over-representation of few districts and schools whereas there are several districts that are markedly underrepresented in higher educational institutions, more so in the field of medicine. If recruited from outside the district and state through an open entrance examination, students are likely to return to their native place after completion of their course. Research has shown that students from rural backgrounds and underserved areas are inclined to serve back within their own regions. If the present entrance criteria are applied at district medical colleges the concerned district will continue to be deprived of precious human resources despite having a medical college. Therefore, it should be considered to reserve at least 50% of the MBBS seats for eligible local school students. Otherwise, there will be a continued accumulation of numbers and improved ratio but little impact on the desired health status of the districts.
| Cost of the Universal Health Coverage: Public Private Partnership Medical Education and Tertiary Care Service Delivery Based on Public–Private Partnership Model|| |
The Government of India had announced the establishment of medical colleges in every district through the public–private partnership (PPP) model in the Union Budget 2020. Simultaneously, NITI Aayog had approached the state government with the proposal of the PPP of medical colleges, in early 2020. Industry bodies have recommended policy-level interventions and reforms aimed at increasing the overall ease of setting up and operationalising medical colleges by the private sector to bridge the persistent gap in the demand and supply of doctors in the country. Under such circumstances, the district medical colleges are more likely to be evolved as PPP medical colleges delivering tertiary care services on the PPP model. At the outset, such expenses might be covered under Ayushman Bharat Yojana (the universal health-care funding) with limited gatekeeping and regulation of services. Such a model would be financially not sustainable on a long-term basis. It may not be necessary to apply the same tertiary care teaching hospital philosophy as is implemented at the district medical colleges; instead, the services can be focused on general care and integrated with community health services. The Ayushman Bharat Card only covers hospitalisations and does not cover the services of physicians based in community and delivering primary care services. The success of any universal health coverage (financial tool) is directly dependent on the effective gatekeeping of tertiary care (expensive) services and not on building referral pathways for the expensive tertiary care system.
| Conclusion|| |
The scheme of one medical college in each district is an excellent project given the fact that the geographical coverage of medical colleges across India is improving and there are now more medical colleges in the government sector. However, the policymakers must look at it critically to be able to steer this project toward meeting the public health objectives of the country. It is not just about quality vs. quantity, the entire medical education system of India needs to be aligned with the objective of covering the entire population achieving – affordability, accessibility and availability in healthcare. The tertiary care development must be balanced with equal push for family physicians/family medicine. The ongoing inherent fallacies of the Indian education system and the Indian medical education system should also be addressed. Numerical and statistical improvement of doctor–patient ratio is unlikely to impact the overall health status of the population unless the right type of doctors is produced and they also are employed and retained within the health system.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2]