Who will regulate the regulator?

Current medical educational scenario in India

Currently, India has 780 medical colleges with an annual intake of 118 190 MBBS students.¹ As per information provided by the Press Information Bureau, a Government of India organization, the doctor–patient ratio in India, in 2022, had already reached 1:834, including all physicians.² If one excludes the Ayush physicians and takes cognisance of Allopathic practitioners alone, the ratio is 1:1634.² Since many in India still prefer to seek the advice of Ayush physicians, the situation may not be overtly critical, seeing that the ratio is 1:834. However, it cannot be denied that we do need an increase in Allopathic medical seats to enable us to reach the WHO goal over the next decade or so, keeping in mind simultaneously the quality of education and the ‘outcomes’ of this education process.

The problem in India is not the availability of doctors but a maldistribution due to clustering of medical colleges in some states, with very few existing in others. The policy of rapid increase in seats without geographic reference depends on the principle of overflow, believing that if one creates more doctors, sheer overflow would result in redistribution to scarcely served areas for the sake of employability. This does not occur in practice since the vast majority of qualifying MBBS doctors prefer to pursue post-graduation, for which they would rather wait several years, than seek employment in distant areas that have scarce medical facilities.

There are two issues currently facing medical education. The first, as mentioned above, is clustering of medical colleges in a few states, and second, the majority of medical colleges are in the private sector rather than in the government sector. In view of massive investments required, private medical education is understandably far costlier than government medical education; the available seats are mostly taken by the rich and privileged, often with lower ranks in National Eligibility-cum-Entrance Test (NEET), compared to others who cannot afford private education. Consequently, after qualification, these physicians are unwilling to move to resource-scarce areas with the likelihood of less income in view of the large amounts of money they have already spent on medical education.

A hasty increase in medical colleges for political reasons often results in undesired side-effects. Recently, an article focused on this particular aspect. Siddharth Singh, in an article titled ‘Telangana’s medical college expansion: Built to heal, left to rot’, said, ‘From shuttered duty rooms and unsafe hostels to sprawling, unopened hospitals, Telangana’s bold push to set up a government medical college in every district has resulted in an overstretched, understaffed system. Students are left to teach themselves; doctors go unpaid and faculty shortage cripples learning,’ thus exposing a public healthcare vision mired in delays, neglect and a widening gap between promise and practice.³ This is what happens when the aim is rapid expansion without considering the adjunct requirements of quality medical education, like motivated teachers, infrastructure, clinical load, etc.

Government’s response to demand for medical education

The rapid increase in seats announced by the Government of India does not rest on the logic of felt needs. The Government argues that since the number of NEET applicants last year exceeded 22 lakhs (2.2 million) of whom over 12 lakhs (1.2 million) qualified and were eligible for medical seats,⁴ we need more seats in as short a time as possible to accommodate demand. Since the medical seats available were fewer than 1.2 lakhs (0.12 million), it was felt that there was a need to create an additional 75 000 seats on a war footing over the next 5 years.⁵ The argument that large numbers of NEET applicants necessitate a massive increase in seats is not logical. Increase in medical seats should be based on a detailed analysis of the adequacy of medical facilities across the country and the geographic misdistribution of healthcare personnel to man the healthcare services of the country adequately, rather than the number of students desirous of pursuing medicine as a career. Such an approach with engineering seats at the turn of the century resulted in large-scale unemployment of the outgoing engineering graduates. Increasing seats from 1.2 lakhs (0.12 million) to 2.0 lakhs (0.2 million) per year would still leave over 20 lakh (2 million) applicants disappointed, going by last year’s NEET application figures. Even if one considers only the pass rates in NEET, amounting over 12 lakhs (1.2 million) plus, over 10 lakhs (1 million) would not have been able to find a seat after qualification in NEET. It is neither possible nor desirable to provide a seat for every applicant.

Further, as per regulatory norms, new colleges can have a maximum of 150 seats per college, and the minimum number of teachers per college with this annual intake approximates 150. Hence, we need to add 500 medical colleges in the next 5 years to meet this target of 75 000 seats (or an annual increase of 100 medical colleges per year for the next 5 years). With huge shortages of teachers in existing medical colleges resulting in large-scale violation and manipulation of rules and other undesirable practices in the regulatory processes, as published recently,⁶ such a move would only compound the existing chaos. The same reference also published reports of massive violations of norms in accreditation processes.⁶ This, however, is beyond the scope of this article.

The Government’s second response to the lack of adequate medical facilities around the country was to announce the opening of the Nation’s first ‘mixopathy’ or integrated combined Ayurveda and modern medicine degree in JIPMER, an institute of National Importance.⁷ This has been opposed uniformly across the country by both streams of medicine. It is true that evidence is being created to show that alternative systems of medicine have a role to play in modern medical care. There are areas where modern medicine finds itself limited and for which alternative medicine has an answer. There are also large numbers of the population who believe in alternative systems of medicine. However, the scientific basis of Ayurveda and modern medicine is totally different, and combining these two into a single stream over the same duration would result in physicians being undertrained in both systems, who would, therefore, not be able to provide quality care.

A better alternative for the Government would have been to provide access to alternative systems of medicine in all medical colleges so that patients who desire a particular stream of treatment would be able to do so, or one system may refer patients to the other system when they feel there is a role for the alternate system, rather than mix systems and create incompetent physicians. A similar effort to ‘mixopathy’, in the form of a condensed medical programme, was sought to be created around 2010–11 to create a new stream of medical graduates with a reduced course duration of 3–4 years called ‘Rural Physicians’. Difficulty in creating a proper curriculum, absence of information on whether such a move would prove popular amongst students as a career choice, and inability to decide on a future career progression for such graduates (whether and where they would fit into the postgraduate programmes) led to abandonment of the idea. This happened during the tenure of the erstwhile Governors of the Medical Council of India (MCI). The author was a member of the team entrusted with preparing a paper on this theme.

Regulatory response to the shortage of seats and the shortage of teachers

The regulator’s answer to the shortage of seats and teachers lies in the recent notifications from the NMC.

1. The Gazette notification released on July 2nd, 2025, acknowledged teacher shortage in medical colleges and, as a measure of relief, permitted the recruitment of basic scientists with non-medical qualifications to be recruited as teachers in five departments, to a maximum of 30% of the total number of teachers in that department.⁸ The departments were Anatomy, Physiology, Biochemistry, Microbiology and Pharmacology. This was a welcome move in view of the gross shortage of teachers in these departments owing to postgraduate seats remaining vacant for several years. This was a consequence of the reality that these subjects were not preferred career options for NEET-passed aspirants. Such a measure of allowing non-medical teachers had existed in the past but had subsequently been prohibited by the then regulator, the MCI. There was another clause in the past that required that these non-medical teachers would not progress to the posts of Heads of Departments, leading to dissatisfaction and a feeling of discrimination. It would be a welcome measure if that regulation were also withdrawn. It would go a long way to solve the problem of the shortage of teachers in the basic sciences and para-clinical subjects. Non-medical teachers are in their particular specialties by choice, and they are teachers by choice and have exhibited their commitment to excellence in teaching and training in the past. Medical teachers have often ended up in those subjects because they have not been able to find a placement in clinical disciplines and are sometimes ‘reluctant’ teachers.

2. A second, more contentious set of changes by the regulator was released in a press note by the NMC on July 5, 2025, namely, the modification of the teachers’ eligibility qualifications (TEQ) of the MCI to facilitate a rapid increase in the number of medical colleges without being affected by faculty shortages.⁹ This was reiterated in the revised TEQ by the NMC.¹⁰ The important recommendations were;

1. Non-teaching government hospitals with 220+ beds can be designated as teaching institutions.

2. Existing specialists with 10 years’ experience can be appointed as Associate Professors, and those with 2 years’ experience as Assistant Professors.

3. Senior consultants with three years of teaching experience in National Board of Examinations MS-recognized government medical institutions can be appointed as Professors.

4. Diploma holders working as Specialists or Medical Officers in the respective departments of a Government Medical Institution with or without an NBEMS programme can be appointed as Assistant Professor.

5. A cumulative period of up to five years served by a faculty member in the NMC or a university or state medical council, or medical education department, or medical research department shall be deemed as teaching experience.

6. Undergraduate (UG) and postgraduate (PG) courses can be started simultaneously in new medical colleges.

7. PG courses can be started if there are two faculty members in the department instead of three.

8. Bed requirements for starting PG programmes have been rationalised

9. The list of broad specialties qualifying to be feeder categories, for admission to a particular superspecialty, has been expanded so that no seat goes vacant.

10. Faculty with superspecialty degrees currently working in broad specialties can also be simultaneously designated as faculty in the super speciality departments.

11. Tutor / Demonstrator experience will count for eligibility for the post of Assistant Professor.

Many of these will have catastrophic consequences, not because they are a radical departure from the current norms, but because they have been made not with the intention of improving quality but merely to enable the start of new medical colleges on a war footing. Non-teaching experience is also counted as teaching experience. Faculty can simultaneously be shown in two departments to enable recruitment of postgraduates in both departments. This will affect and increase faculty shortage in both departments since the teachers will be there only part-time in each department. Diploma holders will now qualify to serve as teachers for degree programmes. Rapid inflow of ‘teachers of various ranks’ from the non-teaching cadre will drastically affect the promotional opportunities of those who have been teachers for long periods and are waiting for their promotion as per existing NMC norms.

The previous system ensured that UG programmes are started first and PG programmes only after completion of the first batch of undergraduates have completed the programme. This process ensured adequate infrastructure facilities, sufficient equipment and laboratory facilities, adequate staff, experienced teachers and adequate clinical load, all these measures being a mandate for good postgraduate training, before commencement of postgraduate programmes. The current clause completely negates this benefit by simultaneously offering UG and PG programmes. Also, even with the simultaneous start of UG and PG programmes, it takes 3 years to complete the PG programme and a further period of teaching experience before qualifying as teachers. Hence, there is no advantage in starting simultaneous UG and PG programmes to enable the adequacy of teachers. All in all, a recipe for disaster, with no benefit visualized, no analysis or consultations and no reflection on how these measures would affect the ‘competency-based education’ of the NMC to produce an Indian Medical Graduate (IMG) with 7 attributes and over 40 sub-competencies.

Already, the competency-based programme for MBBS in India has reached its capacity limits with very large admission numbers, amounting to 250 per year in many colleges, which makes small-group teaching, a mandated norm for CBE, nearly impossible in most colleges. This, when compounded with the massive shortage of teachers along with the gross shortage of clinical material in view of the healthcare costs in private institutions, has seriously affected teaching in medical colleges. There has been an increasing shift to simulation-based education and standardized patients already, due to patient shortage greatly compromising the quality of the outgoing graduate. A massive, large-scale increase in seats within a short span of 5 years and the usage of non-teachers as teachers will add to the current inadequacy of training, leading to irreparable damage to the quality of medical graduates in India.

A possible better and smoother path toward the goals

There is a famous poem by Ralph Waldo Emerson which goes as follows:

‘Do not go where the path may lead, go instead where there is no path and leave a trail’. There may be better alternative paths, other than the one obvious and proposed to be implemented now, which ultimately lead to the same goals with better results. By going down this path, one would have left a trail behind for others to follow.

It is accepted that there is a need for an increase in medical seats, since we are not close to the WHO goal (if one excludes Ayush physicians). However, to not compromise quality, further increase in modern medicine doctors can be planned systematically on a country-wide basis, starting new medical colleges in areas where there are few colleges first, so that the workforce is uniformly distributed across the country. The greatest problem in healthcare in India is not the total number of doctors but the skewed distribution, resulting in medical colleges being clustered in 4–5 states.

A better path, therefore, is to plan expansion phase-wise over the next 10 years to reach the target of 2.0 lakh (0.2 million) medical seats. There are 759 district hospitals in India, all of them with adequate beds, and more than adequate clinical load, and a large number of specialists.¹⁰ Since these districts are spread all over the country, priority can be given to converting these district hospitals phase-wise into medical colleges, giving first preference to those districts that are less well served. The target would be to complete the conversion over the next ten years. Since these hospitals are already busy with sufficient clinical load, all that is required is to equip them with other instruments required by regulators and simulation facilities to prepare the students for clinical encounters, in addition to building college facilities. The advantage of this approach would be:

1. It will be less expensive since the government would have to spend only on creating college facilities and extra equipment as required for teaching prescribed by the regulator.

2. Since it is a 10-year process, the expense would be spread out and not be a budgetary constraint.

3. It would be a salutary process since those areas that are ill-served would get first preference.

4. No medical college should be allowed to admit more than 100 students annually. It is well known that the quality of education depends on annual intake, the student/teacher ratio, the clinical facilities and the motivation of both students and teachers. Seven hundred and fifty new colleges with an annual intake of 100 students would enable us to reach the figure of 75 000 planned by the government to reach the target of 2 lakh medical admissions per year.

5. 230-bed hospitals, as proposed in the regulatory Gazette, would be totally inadequate for training 100 students in CBME.

6. Since the increase is focused on government institutions with already existing hospitals, the cost of education per student will not be astronomical, since medical education will be less expensive, and more deserving students from the underprivileged classes would secure admission.

7. Simultaneously, the government should focus on a major increase in Allied Healthcare personnel, like Physician Assistants and Physician Associates and similar cadres to increase the workforce spread to remote areas. They will be able to provide basic services at the doorsteps and advise transfer to the nearest medical college when required. District-wise distribution of medical colleges would ensure that no tertiary centre is far from the deserving sick public.

8. The move to recruit pre-clinical teachers possessing non-medical qualifications should continue.

I am reminded of a famous quote by Lao Tzu, ‘If you do not change direction, you may end up where you are heading’, which in this case is disaster. The proposed changes are likely to impact medical education in the country deeply. It is time for deep reflection, discussion and change of direction to reach the desirable goal.