Where demand exceeds supply
THE STRIKE by the medical students in Tamil Nadu focuses attention, once again, on the medical education system in the country, which still does not have a coherent policy on the subject. The blame for this rests on the successive Central Governments and the various State Governments, which lacked the political vision and will to create such a policy. In 1975, the Srivastava Committee in its comprehensive recommendation for medical and health education observed: "The fact is that there is no structure to bring about the needed changes..." (Health for All: An alternative strategy; Indian Council of Social Sciences Research 1981, Pg. 169). Further it observed: "It is therefore of the utmost importance that a suitable structure or an organisational framework should first be established which is charged with the task of implementing the needed reforms and of initiating and nursing the change process. We are thus convinced of the need for the establishment of an UGC-type body for medical education and reaffirm the recommendation made on the subject by the Education Commission (1964-66). In the absence of some such machinery with the authority and resources to implement the desirable reforms, we are afraid that the quality and relevance of medical education may continue to remain as a no man's land between the Centre and the States...".
The important arguments put forth by proponents of private medical colleges are: (i)There is a need for more doctors, especially in rural areas, and (ii) there is a demand for medical education, the State has no resources to meet the demand, and hence private colleges are desirable. These two arguments are closely linked. In 1981, the study group set up jointly by the Indian Council for Social Science Research (ICSSR) and the Indian Council for Medical Research (ICMR), published its findings in Health for All: An Alternative Strategy. With regard to medical education it stated, inter alia: "It is obvious that we are going in for an over-production of doctors.... this will be a colossal waste of human resources apart from a serious threat to the health of the people." The report also suggested two immediate steps: a)There should be no new medical college and no increase in the intake of existing medical colleges. b)There is no need at all to set up new and additional institutions to train additional doctors through short-term courses. When the report was published in 1981, there were about 2,20,000 allopathic doctors and another 6,00,000 registered and unregistered medical practitioners. About one-third of the allopathic doctors were in the public sector and the rest in private practice. There were 106 medical colleges with an annual output of more than 11,000 doctors. In 2002, according to the Ministry of Health and Family Welfare annual report 2001-2002, there are 187 medical colleges with an output of 19,000 students.
The Ministry notes that in the Sixth and Seventh Five Year Plan periods, the Central Government policy was to discourage opening of new medical colleges. The policy was reviewed in 1991 and on August 27, 1992, the President promulgated an Ordinance to amend the Indian Medical Council Act (1956). This ordinance was converted into an Act of Parliament in 1993. The main provision of the Act dispenses with the need to seek prior permission of the Central Government to establish an institution imparting education in medical sciences, increasing the intake of students, or introducing a new or higher course of study. Thus, within two years (1991-1993), the Central Government, without any public debate in civil society and against the recommendations of its own expert committee, passed an Act of Parliament regarding medical education.
The reasons given for the Act are revealing. The Ministry of Health and Family Welfare website states, ".... it was recognised that a large number of posts of doctors were lying vacant in many places, especially rural areas and there was tremendous pressure for gaining admission into medical colleges." This is specious reasoning indeed, especially when several reports commissioned by the Government itself point out that two-thirds of doctors are in private practice and increasing the number of doctors would not solve the problem of shortage in rural areas. To quote the ICSSR - ICMR report: "The medical education system and the health care delivery system have each gone their separate ways. There is little congruence between the role of the physicians and the needs of society, little equilibrium between medical education and health care". Thus, it is obvious that the decision to permit more medical colleges, especially in the private sector, has nothing to do with the needs of society. It is merely fulfilling the demand of an affluent pressure group. The World Bank, had also warned of an oversupply of doctors in countries such as India. It also pointed out several other ills of doctor oversupply. A high number of specialists tend to increase the frequency of unnecessary and often risky procedures. This pushes up health care costs and reduces quality of care. A classic U.S. study showed that a 10 per cent increase in surgeons would bring about a three to four per cent increase in surgical operations the phenomenon of "supplier induced demand". Therefore, it is clear that the students are absolutely correct that there is no need for any more colleges in Tamil Nadu (or elsewhere), as far as the needs of society are concerned. In a truly democratic polity, such important policies would be widely debated in civil society. The argument that many meritorious students cannot get admission is also fallacious. In any course like medicine, where demand exceeds supply there has to be a cut-off point. If it is 90 per cent those getting 89 per cent will feel aggrieved, if it is 85 per cent those getting 84 per cent will feel aggrieved. This is a fact that we have to live with. It cannot be solved, because the solution (increasing the number of seats) is against the good of the society. All that has to be ensured in the interests of justice is that the mode of selection is fair and transparent.
The contention of the Government that it cannot prevent the establishment of new colleges is not based on fact. The Supreme Court, in the TMA Pai Foundation case, while agreeing that any one had the right to open a college also stated that this right was subject to reasonable restrictions. Moreover, it is always open to the State Government to enact a new law to regulate medical education and seek Presidential assent. It is an open secret that all private medical colleges collect capitation fees, and the amount runs into crores. No action has ever been taken against this practice . Every time a public-minded citizen points this out, he/she is asked to give proof. What then are our investigating agencies for? This is a serious allegation and should invite investigation.
The argument that neighbouring States permit such colleges is strange indeed. An unhealthy practice in a neighbouring State should not be imitated. The State Government must pressurise the Central Government to enact an Act of Parliament that regulates medical education throughout the country. Finally, it is sad that the students had to resort to a strike, because, the poor patients bear the brunt. But in a situation where other methods fail, a strike may appear to be the only option left.
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