Seeking graduation in medical colleges outside India: Is it a ‘win–win’ or ‘lose–lose’ situation for the stakeholders and the nation?

Doctor–population ratio in India

As per the data provided by the then Union Minister of State for Health in the Rajya Sabha in March 2019, there is 1 doctor for every 1445 Indians for an estimated population of about 1.35 billion (135 crore).¹ This is lower than the prescribed norm of 1 doctor for 1000 people by the WHO. He also mentioned that besides these allopathy practitioners, there are 0.78 million (7.88 lakh) Ayurveda, Unani and Homeo-pathy practitioners in the country. Assuming 80% availability, it was estimated that around 0.63 million (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.^1–3 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. The Times of India of 2 September 2018 reported that Delhi, Karnataka, Kerala, Tamil Nadu, Punjab and Goa have more than 1 doctor for a population of 1000.² The ratio of doctors in Tamil Nadu is 4, in Delhi 3, in Punjab and in Goa 1.3 and in states of Karnataka and Kerala, the ratio is 1.5 doctors for every 1000 persons.² 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 3244 only.³

Current status of undergraduate medical education in India

As per the Minister of State in the Ministry of Health and Family Welfare, the number of MBBS seats available in India in 2020 was 80 312.⁴ While three government medical colleges in the state of Punjab charge ₹0.44 million (4.4 lakh) as full-course tuition fee for the MBBS course, in some private medical colleges it is up to ₹7 million (70 lakh).⁵ According to the Business Today, there is a huge disparity in fee structure for MBBS in various medical colleges ranging from ₹0.6 million (6 lakh) to ₹2.5 million (25 lakh).⁶ The NMC has been asked to design a new fee structure.

The average annual per capita income of households is ₹44 901. This was revealed from the results of the Longitudinal Ageing Study in India (LASI) survey conducted in 2017–18.^7,8 This accounts for about 39% 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.⁸ 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.

NEET scenario

The NEET is conducted by the National Testing Agency. This examination is mandatory for students seeking admission to medical colleges in India. As per the information available on their website, about 1.4 million (14 lakh) students appeared for the NEET examination in 2019 and 2020.⁹ Of these, 5.8% get admission to medical colleges (Table I). A number of MBBS seats were not taken up in 2021.¹⁰ One of the reasons is likely to be the high fees in these colleges.

What are the options for students aspiring to become doctors?

The above data establish that 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, 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 return to India.

Issues related to education in CIS and neighbouring countries

Medium of imparting education: Education in most 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 language other than English is 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 schools separate from their local peers. A majority of these students get no/miniscule clinical exposure, which is the mandatory foundation for becoming a good doctor.

Some of the temptations offered to the students and parents for seeking admission to colleges in these countries are:

1. Infrastructure: These countries project that they offer state-of-the-art facilities including resources for medical equipment and laboratories compared to the below standard ones in private colleges in India. This may not be true in many instances. In addition, infrastructure although important, may not be the most important point, for it is not the infrastructure alone but the student’s ability to assimilate knowledge, and the teaching material which in the present context is ‘patients’, who are the most crucial for learning how to deal with human ailments whether serious or otherwise.

2. Low cost of study and adequate period of training: It is estimated that average tuition fees in these countries range from ₹0.25 million (2.5 lakh) to ₹1.5 million (15 lakh) per year.^11–13 Apart from tuition fees, expenses for sustenance are also incurred. Thus, on average from ₹1.5 million (15 lakh) to ₹4 million (40 lakh) are spent for the student to become a medical graduate who spends about 3.5–6 years abroad.^7,11–13 Unfortunately, the course duration and contents of training offered by the best of centres in these countries vary from 4 to 6 years. The clinical exposure of these students is deficient when compared to the students studying in India. In the Covid-19 pandemic, these students were/are stranded and have no institution from where they can seek guidance or support. They are not allowed entry in the countries where they were studying in the pre-Covid era or there are many other issues including their safety in health matters. There are not many institutions in India which can accommodate them for a variety of reasons.

3. Personality development: Students graduating from outside India are believed to build up their personality due to their exposure to students from other parts of the world, learning foreign languages and exchange of knowledge and culture at the international level. Although this is partly true, what is the ultimate goal of these students? If they want to migrate outside India, this gateway is a golden opportunity for these students. However, if they wish to practise medicine in India, are they really benefiting from their foreign degree? Considerable introspection is required on the part of a family sending its child to these countries in search of greener pastures. If these children want to return to India to practise medicine, how many of these advantages count? Do any of the benefits mentioned really translate into a true benefit in the practice of medicine in India?

4. Better return on investment (ROI): The advocates of foreign medical graduates (FMG) state that education in these countries provides a better ROI to the families since the education is cheaper and the FMG starts practising as a doctor in India or abroad and relieves the financial burden on the family. They also argue that these FMGs fulfil the need of doctors in India. However, the truth needs to be obtained by a systematic and thorough study.

Recognition of FMGs by erstwhile Medical Council of India (MCI) and NMC and outcome of Foreign Medical Graduate Examination (FMGE) results

Another major challenge these students face is if and when they return to India. It is mandatory for these students to clear the screening test called FMGE if they want to be registered to practise medicine in India. The FMGE is a licentiate examination conducted by the National Board of Examinations (NBE) in India. It was established as one of the mandatory requirements for Indian citizens who obtained a medical degree from a college outside India to practise medicine in India.¹⁴ The screening test was introduced in 2002 as a qualifying examination for Indian students obtaining their medical degrees from CIS countries, China and Nepal.¹⁴ In addition, the medical school from where training was obtained, was required to have been listed in the WHO International Directory of Medical Schools (the World Directory of Medical Schools). The legality of the test was challenged in Indian courts and was subsequently upheld by the Supreme Court of India in 2009.^14,15 The country-wise performance of Indian students in the FMGE is available on the website of NBE (Table II). Unfortunately, the results display that the number of successful candidates has been below 20%.¹⁶ From 2015 to 2018, out of 38 150 students, 7226 (18.9%) passed these examinations (Table II).¹⁶ What has happened to the remaining students is not known.

Considering all the aspects mentioned above, starting from cost of education, availability of infrastructure, personality development, and abysmally low rate of passing FMGE so as to practise medicine or pursue postgraduate medical education, a flight to CIS countries, Nepal, China or Bangladesh, does not seem to provide a better ROI.

Is it a ‘win–win’ or ‘lose–lose’ situation?

It requires research by academia, government policy-makers and introspection by the stakeholders, that when an abysmal <20% of FMGs returning from CIS countries/neighbouring countries qualify to practise medicine in India, what is happening to the other 80% of students who ‘graduated in medicine’ from these countries? Certainly, all or even the majority are unlikely to be pursuing postgraduation in foreign countries.

What is the way out?

The efflux of students to CIS 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.

Implementation of the National Exit Test (NEXT)

As per the NMC Act 2019,¹⁷ the NMC is likely to introduce a robust NEXT examination soon. The salient features of this test will be: a uniform final MBBS exit examination called NEXT step 1 for all students across the country as well as for students graduating from outside India who wish to practise medicine in India. The NEXT step 1 is mooted to be a multiple-choice theory examination in which all the students will appear simultaneously. Indian students who pass in theory will appear for a university practical examination, and if declared successful, these students will start their clinical clerkship/internship in the colleges from where they graduated. Foreign students who are successful in the NEXT step 1 examination will have to take up internship in designated hospitals/institutions. After being declared successful in internship, which will be certified by the mentors, all candidates will appear for the NEXT step 2 examination. These will be based upon the practical knowledge gained during internship. The examinations will be conducted at the state health university levels or centres of excellence or standard medical education centres where previous facilities do not exist. The timelines and details for these examinations will be publicised widely. Successful candidates will then be enrolled in the state/ national medical register. Each doctor will have his/her unique identity. This examination system will usher in high quality and transparency in the system.

Thus, FMGs, after being certified as medical practitioners in the countries where they pursued their medical graduation, will have to spend additional 15–18 months to be qualified as registered medical practitioners in India. Reviewing the poor performance of many of these graduates in FMGE over the years, the chance of dramatic improvement in the passing score with the introduction of NEXT is miniscule. The question whether they can practise as registered medical doctors in India will always be haunting these students and their families. The additional mental and economic stress incurred by them and their families is only likely to increase.

Certain tough steps need to be taken to save the health and future of the nation. These include capping of fees in all colleges/institutions with the support of Central and state governments, institutions, philanthropists and stakeholders, so as to make medical graduation more humane and worthy to be pursued. India needs high-quality doctors committed to the profession and not ‘substandard doctors’ to deliver basic services to patients.

To conclude, aspirants for medical graduation and their families should weigh the pros and cons before taking up admission in medical colleges in CIS or neighbouring countries. In addition, to curb the exodus of aspirants of medical education outside India, concerted efforts by the UGMEB– NMC and the health system at various government levels are needed to rejuvenate the health of medical education in India.