Remove caps on age, attempt for MBBS students: National Medical Commission

According to the Union health ministry data, there were 80,312 MBBS seats in India in 2020

Is a medical degree from abroad a win-win situation for the stakeholders and the nation? Should Indian middle-class and low-income families be stretching their resources for this? The National Medical Commission, the apex body that regulates medical education and medical professionals in the country, is trying to solve this challenge by recommending the removal of the age bar for entry to MBBS and lowering of fees for seats under government quota.

The NMC's recommendations have been sent to the Government of India after an extensive study by its experts. The Centre may soon come out with directives to this effect. A paper on the study has been published in the National Medical Journal (Medicine and Society).

Dr Aruna Vanikar, President Under Graduate Medical Education Board, along with three of her colleagues - Dr Vijayendra Kumar, Member (Full Time), Dr M Mintz, and Dr D Chakraborty, both Members (part time) - have worked together on the study, which has been published in the National Medical Journal (Medicine and Society) of the All India Institute of Medical Studies (AIIMS).

Dr Aruna Vanikar, President Under Graduate Medical Board, NMC

"We have recently published our findings in the National Medical Journal and have even made our submissions and recommendations to Union Ministry of Health, Government of India, who is in the process of finalising the same before making the same public," said Dr Aruna Vanikar, President Under Graduate Medical Board, NMC.

"We have also proposed that the minimum age criteria of 25 years for entering into MBBS entrance should be done away with. Instead, we have suggested that there should be no age limits for appearing for MBBS entrance and that anyone keen to do medicine should be able to do it at whatever age they are comfortable. For this, we have already increased the medicine seats in government-run medical colleges, across the country, so that parents from middle class and lower middle class would think twice before sending their children to go abroad for doing medical education and it is not the best solution. Also, the NMC has appointed a different committee to look into the revised fees for medical courses," explained Dr Aruna.

When asked if the recommendations would be implemented soon, Dr Aruna clarified, "It is a process, the Union Ministry of Health will put forward the proposal before the parliament and once the same get approved, the directives would come into force."

The doctor dream
"The Bachelor of Medicine and Bachelor of Surgery (MBBS) course is one of the most sought after by students of science streams in India and their parents. The main reason behind this choice appears to be the respect and, for some, monetary gains in the medical profession. Even if it appears that the profession is losing respect in society, medical professionals are still able to eke out a comfortable life so as to be counted among the elite. With rising inflation globally and locally, expenses incurred when healthcare and life-saving situations arise are huge.

About 51.9 per cent of MBBS seats in India belong to the government quota

The expense is ‘out of bounds' for most average and economically underprivileged families in India. The COVID-19 pandemic has exposed this daunting issue. Unfortunately, the Indian allopathic system has not fulfilled the need of equitable healthcare for its citizens. With such contrasting problems gnawing at society, children from average middle-income group families fail to realize their dream of becoming a ‘doctor'. For the privileged classes, there is often a need to have a successor to the family business of medicine/hospital," the report states.

Too many people, too few doctors
As per the data provided by the then Union Minister of State for Health, as of March 2019, there was 1 doctor for every 1,445 Indians for an estimated population of about 135 crore. This is lower than the prescribed norm of 1 doctor for 1,000 people by the WHO. The government said that besides these allopathy practitioners, there are 7.88 lakh Ayurveda, Unani and homoeopathy practitioners in the country. Assuming 80 per cent availability, it was estimated that around 6.3 lakh doctors practising these systems of medicine were available for service. Considered together with allopathic doctors, it gives a ratio of 1 doctor to 860 people. This exceeds the recommended WHO norms. Unfortunately, there is an inequitable distribution of qualified doctors in the country. The doctor-population ratios are widely different between states; Bihar and northeastern states such as Nagaland have very few doctors. Even when a state has a decent doctor-population ratio, the urban areas have much better ratios than the rural areas. According to the Rural Health Statistics of 2016, the number of doctors at primary health centres was 26,464 against sanctioned posts of 34,068. The shortfall at that time was 3,244.

The cost factor
As per the Ministry of Health and Family Welfare, the number of MBBS seats available in India in 2020 was 80,312. While three government medical colleges in the state of Punjab charge Rs 4.4 lakh as a full-course tuition fee, in some private medical colleges it is up to Rs 70 lakh. The NMC has been asked to design a new fee structure. The average annual per capita income of households is R44,901. This was revealed from the results of the Longitudinal Ageing Study in India (LASI) survey conducted in 2017-18. This accounts for about 39 per cent of the per capita income in the same year according to the National Account Statistics. This cross-sectional study was based on a relatively small sample (42,249 households), and its reference frame is confined to households that had at least one person aged 45 years or higher. Thus educating a child in the field of medicine is a challenge for a middle/low-income group family. Education in a private college in India is beyond the reach of these children with big dreams. For families looking for a successor to the family business of a hospital or running a medical education programme, economic constraints may not exist, the study revealed.

The NEET scenario
NEET, conducted by the National Testing Agency, is a mandatory entrance examination for students seeking admission to medical colleges in India. As per the information available on their website, about 14 lakh students appeared for the NEET examination in 2019 and 2020. And a mere 5.8 per cent cleared and got admission to medical colleges. A number of MBBS seats were not taken up in 2021, one of the reasons is likely to be the high fees. As per the study, the students securing admission to MBBS courses in India are highly meritorious compared to their peers. The students who are keen to pursue medical education have some options, that is, either to take up admission in some other branch of biological sciences and attempt the NEET again, or take up alternative healthcare education such as Ayurveda, or go abroad to CIS countries like the Philippines, Bangladesh, Nepal or China. The CIS countries include Ukraine, Russia, Armenia, Azerbaijan, Kazakhstan, Kyrgyzstan, Uzbekistan, Turkmenistan, Tajikistan and Georgia. The last choice of going abroad is often out of desperation and with a hope of getting qualified as an MBBS and then returning to India, the study reveals.

Uncertain future
The future of Indian students who return as ‘foreign medical graduates' (FMG) after training in certain countries is often uncertain. "We analysed the current status of medical education in India, the Commonwealth of Independent States (CIS) and some neighbouring countries. Of approximately 1.4 million (14 lakh) students taking the National Eligibility cum Entrance Test (NEET), about 5.8 per cent get admission in medical colleges. There are about 554 medical colleges in India with 82,550 MBBS seats, 51.9 per cent seats belong to the government quota. Parents who send their children to a foreign country to do medicine spend R1.5 million (15 lakh) to R4 million (40 lakh) against an estimated annual income of R1.2 million (12 lakh) and the child spends 4-6 years in a foreign country. Of 38,150 FMGs who took the examinations conducted by the National Board of Examinations from 2015 to 2018, 18.9 per cent passed the FMG examination mandatory for registration to practise medicine in India," says the study.

"The National Medical Commission is trying to solve this issue by removing the age bar for entry to MBBS and recommending lowering of fees for MBBS in government quota. Seeking graduation in medical colleges outside India may not be advisable for those from the middle/ low-income group of India," said Dr Aruna.

Another issue, according to Dr Aruna is that, "Education in most foreign countries is conducted in the local language, which is different from the languages spoken in India. Even if a student is extremely good at picking up languages, learning medical terminology in a foreign language other than English is itself an uphill task for an Indian student, and understanding the patient's history and symptoms narrated in their local language and interpret them for assimilation of the problem concerned and tackle the same, is itself an exercise that may not turn out to be cost-effective in terms of energy, mental stamina and finances spent to obtain a medical graduation degree in these countries. If the language of communication is English, these students are taught in separate schools than their local peers. A majority of these students get no/miniscule clinical exposure, which is the mandatory foundation for becoming a good doctor."

What is the way out?
The efflux of students to CIS (Commonwealth of Independent State) countries, China, Nepal or Bangladesh is leading to exorbitant spending by the student's family with questionable monetary/material benefits to them, apart from the unnecessary drain of foreign currency of the nation to these countries. The experience of the past few decades and the changing scenario in India, this efflux can be reversed to an influx of students to India. Considering the drain on families that are sending their children to CIS nations to study medicines, the study suggests ways to turn the situation on its head.

Suggestions by NMC include:

(i) to build a robust system to improve upon the quality of medical education imparted across the nation; (ii) to try to minimize the gap between the level of education imparted in different institutions; and (iii) some other possible measures discussed below. The UGMEB-NMC is planning to address these issues. It is also planning to remove the upper age bar for aspirants seeking admission to medical graduate courses. Thus, students can try to make as many attempts as they desire, if they are keen to pursue medical graduation. This option can be taken by aspirants instead of going to these countries, explained Dr Aruna.

Table 1- Highlights of the National Eligibility cum Entrance Test (NEET)

Table 2 -
Country-wise performance of Indian students in the Foreign Medical Graduate Examination (FMGE) during 2015-18

Source- National Medical Journal

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