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Should medical students protest compulsory rural service? 

A gale of hurricane proportions which could devastate the country’s already grossly inadequate and fragile healthcare system is gathering momentum within the country’s 262 medical colleges, offering study programmes in the dominant allopathic system of medicine, which churn out an estimated 31,000 qualified (MBBS) medical practitioners annually. (In contemporary India medical education is offered under four systems of health sciences — ayurveda, homeopathy, unani and allopathy — in 817 colleges across the country with an aggregate enrollment of 257,000 students. However this feature is focused upon issues relating to the country’s 262 medical colleges dispensing education in the mainstream allopathic system to 155,000 students).

The moving force behind the brewing storm is a proposal voiced by controversial Union health minister Anbumani Ramadoss to make a year’s rural service mandatory for all medical students. In effect this proposal, which is being promoted as a component of the National Rural Health Mission (NRHM 2005-12) launched by prime minister Dr. Manmohan Singh in April 2005, will not only lengthen the duration of the basic MBBS study programme (currently five and a half years) by a year, but would also require all medical students to experience a year’s hardship posting in the under-provided and under-serviced outbacks of rural India, prior to graduation.

The proposal aired by Dr. Ramadoss — a strong-willed minister used to getting his way in the 17-party Congress-led UPA (United Progressive Alliance) coalition government in New Delhi which recently completed three years in office — has dismayed the medical fraternity across the country. Ironically, the first banner of revolt against this proposal was raised in the minister’s home state of Tamil Nadu where students held coordinated protest demonstrations and called a one- day strike on September 5. Their continuous protests prompted Ramadoss to appoint a six-member committee chaired by Dr. R. Sambasiva Rao, additional director general of health services under the Union health ministry, to examine the ministerial suggestion. But the general perception within the students’ community is that the constitution of the Sambasiva Rao Committee is a mere stalling tactic, and that in any event Rao will toe the line drawn by the minister.

Therefore the agitation against the compulsory rural service proposal initiated by medical students in Tamil Nadu on September 5, has spread across the country with medical students staging demonstrations and marches in Uttar Pradesh, Bihar, Maharashtra, Andhra Pradesh and Karnataka, among other states of the country. On November 24, the fire of student opposition to this proposal swept across Delhi, when a thousand-strong posse of medical students from five Delhi-based medical colleges undertook a 5 km march across the national capital to express solidarity with protesting students in other parts of the country.

This confrontation between the country’s estimated 155,000 medical students’ fraternity and Ramadoss is rooted in the long-standing policy of heavy subsidisation of medical education in post-independence India. In pursuance of the socialist pretensions of the Congress party which has ruled at the Centre and in most states of the Indian Union for over 40 of the 60 years since independence, the promotion of private medical colleges has been strongly discouraged, although not entirely successfully. Currently the number of privately promoted medical colleges (147) outnumber Central and state promoted institutions of medical education (115). Nevertheless in keeping with the tenets of licence-permit-quota raj which almost destroyed Indian industry while enriching politicians and bureaucrats, the admission regulations and tuition fees chargeable by privately promoted medical (and engineering) colleges across the country are rigidly controlled by the Central and state governments, purportedly in the national interest.

Yet the actual ground reality has been that for the past six decades medical education, cornered mainly by pampered ruling elites and the middle class, has been given away almost free of charge in the 115 medical colleges promoted by the Central and state governments and is heavily subsidised in the 147 privately promoted institutions of medical education. Under a plethora of complex legislation made more complex by prolix judgements of the Supreme Court and the higher judiciary, even privately promoted medical colleges were compelled to surrender up to 85 percent of their seats to students divided into merit, partial-merit, scheduled castes, scheduled tribes and OBCs (other backward castes) — all of whom paid differentiated (below cost) tuition fees prescribed by state governments.

Institutional managements were left with a discretionary ‘management quota’ of 15 percent under which they could admit minimally qualified students of their choice. It’s hardly surprising that this officially condoned regime of cross-subsidisation prompted institutional promoters to levy heavy capitation/donation fees (repeatedly banned by the Supreme Court) upon students applying for admission under the management quota, and hundreds, if not thousands, of rackets connected with medical education bloomed.

Inevitably, under the socialist dispensation, genuine philanthropists and education entrepreneurs who could have augmented capacity in medical education, were routinely denied licences and permissions to promote medical colleges even as the perennially cash-strapped Central and state governments failed to meet the bourgeoning demand. Nevertheless some of the more determined private sector entrepreneurs and philanthropists ran the licence-permit-quota raj gauntlet to establish high-quality and well-administered non-government institutions of medical education which number 147 countrywide currently. The humiliation, procrastination and discouragement that public-spirited medical education entrepreneurs suffered at the hands of politicians and bureaucrats arrogantly practising licence-permit-quota raj was graphically detailed by Selden Menafee, an American journalist who wrote The Pais of Manipal, an epic biography of the late T.M.A Pai (1898-1979) who laboured for over 20 years to promote the Kasturba Medical College in the small town of Manipal in Karnataka, which became the foundation block of the Manipal Education Group and Manipal University comprising 55 education institutions with an aggregate enrollment of 88,000 students.

Since then, notwithstanding the historic economic liberalisation and deregulation initiative of 1991, rigid government controls over medical education have begun to ease only recently following the Supreme Court’s historic judgements in the T.M.A Pai Foundation (2002) and P.A Inamdar (2005) cases, in which full benches of the apex court expanded the fundamental right conferred by Article 30(1) of the Constitution upon religious and linguistic minorities to "establish and administer educational institutions of their choice" to all citizens.

Interpreting the word "administer" broadly, the learned judges of the highest court have permitted privately promoted professional (medical, engin-eering, business management) colleges to prescribe their own admission procedures (subject to their being transparent and merit based) and levy "reasonable" tuition fees. Unfortunately waters of the clear stream of reason belatedly emanating from the Supreme Court on this issue have been somewhat muddied by a five-judge bench of the apex court in the Islamic Academy Case (2003), which has prompted state governments to establish admission and fees committees to supervise whether the admission procedures of private medical colleges are transparent and tuition fees levied reasonable.

Moreover the medical students’ community is only too well aware that Ramadoss who has a free run of the Union health ministry, is given to having his way within the UPA coalition government. They can’t be unaware of how following a long-standing row with the student-friendly Dr. P. Venugopal, director of the country’s showpiece All India Institute of Medical Studies, Delhi, Ramadoss almost single-handedly piloted an amendment to the AIIMS Act, 1956 imposing a retirement age of 65 on the director of the institute through Parliament — blatantly ad hominem legislation which fortunately, has been stayed by the Supreme Court.

It’s a telling commentary on the low priority accorded to education by the UPA government that none of its ministers has ever granted an interview to EducationWorld, despite it being the sole education news and analysis publication countrywide. EW’s Delhi-based correspondent Autar Nehru made repeated calls to Ramadoss’ office to elicit a direct sound byte from the minister, alas, to no avail. Nevertheless Ramadoss’ rationale for issuing the compulsory rural service diktat is well known. Since medical education, especially in the country’s 115 government medical colleges is heavily subsidised, medical students should pay back at least a part of the subsidy by way of compulsory rural service, he says.

Ex facie Ramadoss’ argument is unexceptionable. As outlined above, over the past 60 years since the country became independent and misguidedly adopted the socialist model of development, government control over higher education and medical education in particular, has become so pervasive that the overwhelming majority of medical students pay diverse, below cost tuition fees instead of the actual cost of medical education assessed at Rs.4.15 lakh per year by the Medical Council of India. For instance students in government-run medical colleges in Tamil Nadu pay a mere Rs.4,000 per year as tuition for their medical education. On the other hand students in private medical colleges in the state pay Rs.3.3 lakh per annum for their MBBS education.

Quite clearly students in government-owned medical colleges are heavily subsidised by the citizenry, and in private colleges government students are heavily cross-subsidised by other students presumed to be more affluent. Yet under the minister’s proposal, all students should equally be subjected to compulsory rural service.

"We feel that while the proposal to make one year’s compulsory service in rural areas can justifiably be imposed on students admitted into government medical colleges whose education is heavily subsidised by the Central and state governments, it cannot be made applicable to students admitted into private medical colleges who are required to pay substantially higher fees to meet their operational and mainten-ance costs. This would be highly discriminatory," says Dr. H.S. Ballal, pro-chancellor of Manipal University, which since its first constituent Kasturba Medical College was promoted in 1953, has acquired a global reputation for providing high quality medical education (annual fee for its four-and-a-half year MBBS programme: Rs.4.26 lakh).

The bewildering fees structures with which the Central and state governments have saddled institutions of medical education is compounded by the sin of neglect of the healthcare sector in general, and rural healthcare infrastructure in particular. Shockingly government (Centre plus states) expenditure on provision of healthcare services and infrastructure aggregates a mere 1.2 percent of GDP (Rs.45,000 crore) per year, a sharp contrast with the global average of 4 percent of GDP and the 6-7 percent of GDP spent on public health services in developed countries such as Sweden (8 percent), UK (6.9 percent) and China (2 percent, see table p.36)

Given this pathetic annual provision for public health services, it’s hardly surprising that instead of properly equipped hospitals and nursing homes, the overwhelming majority of the population in rural India has to make do with a mere 22,669 government primary health centres (PHCs), which are obliged to provide outpatient services to socio-economically disadvantaged villagers (over 300 million rural Indians subsist on less than $1 per day equivalent). Yet it’s an open secret that the government funded PHCs have been a colossal failure and that drugs and formulations provided to them for free distribution are routinely sold away to local traders and worse, they tend to be plagued by mass absenteeism of officials, paramedics and nurses, most of whom farm out their jobs and show up only to collect their paychecks.

According to Ravi Duggal, a healthcare researcher who studied India’s rural healthcare service a decade ago, the country’s PHCs equipped with an average of six beds — "one for every 30,000 population" — are grossly inadequate to service the rural population. "Doctors do run OPD (out patient departments) clinics at the PHCs but the supplies and services are so inadequate that the clientele is automatically restricted in numbers. Hence it is not surprising that the HSSO (health sample statistics organisation) in the 42nd Round Survey on health care utilisation, found that of all routine ailments treated in rural areas, only 5 percent were treated in PHCs. The remaining went either to city public hospitals and dispensaries (20 percent), or to private practitioners (59 percent) and private hospitals," wrote Duggal in Health Action (vol 5, No.8 — 1992).

In the circumstances it’s hardly surprising that medical students believe that compulsory rural service as proposed by the Union health minister is a purposeless exercise. "It’s well-known that PHCs lack the physical infrastructure, and diagnostic equipment and facilities for practising medicine. If proper infrastructure is provided by government, most students would be willing to put in a year’s rural service as they would acquire valuable practical experience. Moreover in principle it’s unfair that rural citizens should be provided the services of under-qualified medical students being paid a mere stipend. Instead, if the government were to offer fully qualified doctors half-decent salaries and perquisites, many qualified medical practitioners would be ready, willing and able to serve in rural India," says R. Vikram Vignesh, a final year student of the government-promoted Stanley Medical College, Chennai (annual tuition fee: Rs.4,000).

This line of argument is supported by Dr. Atul Sonker, recently appointed assistant professor in the department of transfusion medicine in Lucknow’s Sanjay Gandhi Postgraduate Institute of Medical Sciences after 14 years of study and internship. "By making rural service mandatory for students, government will prolong medical studies and put off many aspiring medicos from entering this profession. It’s bad policy to force medical students into rural PHCs, which are ill-equipped to utilise their services or improve their education. On the contrary it will de-motivate thousands of youth from studying to become doctors who are urgently needed by the country. A better option would be to attract qualified medical practitioners into rural areas by paying full salaries to government doctors and providing them other incentives," says Sonker.

A more pernicious fallout of the compulsory rural service scheme for medical students which it is feared is a fait accompli — regardless of the recommendations of the pliant Sambasiva Rao Committee — is that it has adversely affected the morale of the volatile medical students’ community which believes it has been singled out for discriminatory treatment.

According to Dr. Anil Sharma, a spokesperson for the Resident Doctors Association of AIIMS, Delhi, the fine print of Ramadoss’ compulsory rural service proposal is that medical graduates serve for one year, postgrads for two years and super specialty graduates for three years. "If this proposal is enacted into law as seems likely, for a super specialty graduate the entire study period will aggregate 17 years! This at a time when the medical profession is losing its lustre. The argument that medical education is subsidised and therefore students need to pay back the cost of their tuition to society is also flawed. Engineering education in the IITs is also heavily subsidised, but there is no demand that IIT graduates must serve in rural areas," argues Sharma.

Provision of rural infrastructure which would make compulsory service meaningful and questions of equity between engineering and medical students apart, a more fundamental objection to the compulsory rural service proposal centres around the issue of whether medical students are sufficiently equipped to serve any useful purpose in the rural outbacks of the country. "One of the curious anomalies of medical education in India is that postgraduate qualifications are the prerequisite of faculty appoint-ments. As a result raw undergraduate students taught by specialists rather than general physicians, are ill-equipped to serve as medical practitioners of first contact in rural India. Changes in the medical education curriculum are required, prior to enacting the law mandating compulsory rural service for students. Moreover there is the question of students paying differential fees for medical education which has to be sorted out as well. Quite clearly a lot of groundwork needs to be done before transforming this proposal into law," opines Dr. S. Kumar, the knowledgeable principal of Bangalore’s showpiece private sector M.S. Ramaiah Medical College which has 850 undergraduate and 250 postgrad students on its muster rolls.

Against this complex backdrop — the outcome of ill-conceived over-subsidisation of medical education for the past half century — the hasty populist diktat of Union health minister Ramadoss mandating a year’s compulsory rural service for the country’s 155,000 medical students is misconceived. As suggested by Dr. Kumar, considerable groundwork and reconciliation of the contradictions which characterise medical education in contemporary India, is a precondition of righting the historical wrong of continuously depriving rural citizens of healthcare services. Among the issues which require debate and attention of education experts are: replacement of indiscriminate subsidies in medical education with long-term loans and a targeted subsidies regime; restructuring of syllabuses and curriculums to enable medical graduates to cope with prevalent rural conditions; finding ways and means to improve the country’s 22,669 dilapidated primary health centres and devising incentives to attract voluntary service in the rural hinterlands.

Prof. Seetharamu suggests that a much better option would be to change the mindset of medical students through "socialisation of the medical education curriculum". "Currently ‘community medicine’ is a subject which is cursorily taught to medical students in their early years. This subject, which could sensitise them to the miserable health conditions in rural India and infuse a spirit of voluntary service within them, needs to be given much greater importance. But meanwhile, imposition of quick-fix solutions is likely to prove disastrous," he says.

There is considerable wisdom in this warning which the health ministry and the UPA government at the Centre would do well to heed. According to reports emerging from Yojana Bhavan Delhi, headquarters of the Planning Commission, the strong-willed Dr. Ramadoss has persuaded the commission to almost triple annual public expenditure on health services from the current Rs.45,000 crore per year to Rs.136,000 crore during the Eleventh Plan period (2007-12). Hopefully these higher allocations will be prudently spent to improve the prevailing pathetic conditions of the country’s PHCs, to attract idealistic medical practitioners to serve in them. Simultaneously the Union government’s languishing PURA (provision of urban facilities in rural areas) programme needs to be revived to integrate the rural outbacks of village India with the fast-track economy of resurgent India.

The current countrywide turmoil in medical education will have served a useful purpose if it focuses national attention on the deplorable neglect of healthcare infrastructure in rural India. It’s an issue which needs immediate remedial attention.

With Autar Nehru (Delhi); Vidya Pandit (Lucknow); Vidya Sundaresan (Mumbai) & Hemalatha Raghupathi (Chennai)