Should for-profit organisations be permitted to establish medical colleges?

A key recommendation on medical education by the government's planning body NITI Aayog is getting a lot of flak. In a recent report on overhauling medical education in India, the NITI Aayog had suggested that for-profit organisations be permitted to establish medical colleges. The reason for such a move, NITI Aayog members said, was to address the shortage of doctors in the country.

For now, only not-for-profit organisations such as trusts or other such organisations. The NITI Aayog report was sceptical about that fact that organisations running medical colleges are not driven by the profit motive. In fact, the report said they were “extracting profit” through “non-transparent and illegal means” and thus the restriction was counterproductive.

"Currently, the difference between a for-profit and a not-profit organisation running a medical college is thin," said Sujata Rao, former health secretary. "Medicine is already so commercialised. I am not at all in favour of privatisation of medical colleges. It would be disastrous in my opinion."

The new solution proposed of commercialising medical education is, however, fraught with danger. The NITI Aayog itself acknowledges the “unacceptably low standards” of private medical colleges especially in western and southern parts of India.

“If for-profit organisations are allowed to set up medical colleges, we are doomed,” said Dr GS Grewal, president of the Punjab Medical Council. And Grewal has good reason for this gloomy prophecy. Earlier this year, he exposed a racket running in Punjab's private medical colleges in which the management hired "ghost faculty", teachers who were on the rolls for just a couple of days to enable the colleges get their licences. These private colleges, although run by non-profit entities, were clearly flouting all rules laid down by the Medical Council of India to rake in profits. Grewal fears that these violations will only multiple with the entry of for-profit entities.

The Medical Council of India itself has been caught with its hands dirty in regulating medical education. In 2010, the then president Ketan Desai was arrested for allegedly accepting a bribe of Rs 2 crores to grant recognition to a medical college in Punjab.

New medical education regime

A Parliamentary Standing Committee said in a report released in March this year that the Medical Council of India had failed miserably and suggested radical changes to transform medical education in India. In May, the Supreme Court directed the government to consider and take appropriate action on the Parliamentary Committee recommendations and set up an oversight committee to oversee the functioning of the Medical Council of India. The NITI Aayog committee was set up soon after.

The report and the National Medical Commission Bill, 2016 seem to follow the path laid out by the Parliamentary Committee report in favour of replacing elected regulatory officials with government-appointed regulatory officials. The regulatory structure would comprise of a Medical Advisory Council with representation from all over India that will set the agenda for medical education.

The NITI Aayog also decided to devolve powers to four autonomous boards charged with undergraduate medical education, post-graduate medical education, medical assessment and rating, and registration and ethics.

Partial fee cap only

Another contentious suggestion by the NITI Aayog is that of a partial cap on medical college fees. The NITI Aayog says that regulating fees for all students in the private sector is not “enforceable” and is of the opinion that stringent regulation is “bound to encourage the continuation of the underground economy consisting of capitation fees and payments demanded on various pretexts throughout education”.

The planning body has recommended that a new National Medical Commission be empowered to fix norms for regulating fees for a proportion of seats not exceeding 40% of the total seats in private medical colleges and with medical education institutions given full freedom to decide fees for the rest of the student body.

“This will provide for cross-subsidisation from the rich to more meritorious but poor students or students from disadvantaged groups,” the report stated.

Grewal worries that this leaves too much unsaid on how the remaining 60%, who do not get merit seats, will pay.

“The policy document speaks nothing about controlling medical corruption," he said. "There is no criteria being fixed for seats in the private sector, nor have they spoken of affordability. There need to be guidelines for fixation of fees."

Ultimately, more expensive healthcare

In the 1980s, when the government allowed private medical colleges to be set up, there were many protests against it.

"I was a student then and with the Maharashtra Association of Resident Doctors," said Dr Arun Gadre, co-author of the book Dissenting Diagnosis, which is about the state of healthcare in the country. "We protested against this move then. Private medical colleges have been responsible for the corruption in medical education.”

Now allowing for-profit entities to run medical colleges will exacerbate problems in what will become a medical education market. "Would doctors who study from these colleges work in the rural or tribal areas?” asked Gadre.

Moreover, the NITI Aayog's suggestions could raise the cost of medical education, which in turn will increase the cost of healthcare.

“The point [of the exercise to rehaul medical education] was to bring down cost of education,"said Dr Avinash Supe, dean of KEM Hospital, who had deposed before the Parliamentary Committee. “A student who pays so much for his education will try to get his money back," he said. "These students are not going to treat our patients [the poor at public hospitals]. But if we bring down the cost of medical colleges, we will be imbibing a medical policy that will only benefit the country.”