The shortage of medical staff in the public health sector has been one of the impediments in India’s Covid-19 containment strategy. Insufficient health workforce, among other issues, has been a long-standing problem, particularly in government health facilities that remain overburdened and understaffed.

A part of the reason why India is short of doctors is that medical education is expensive and those who have the means to acquire it either prefer to work in private health facilities in the country or migrate overseas, said experts, citing how the increasing fees in government medical colleges in the country are keeping the poor but deserving students out while creating health-services inequality between urban and rural areas.

We report from Punjab, which has increased the Bachelor of Medicine and Bachelor of Surgery course fee in its state-run medical colleges by 78% – from Rs 4.4 lakh previously to Rs 7.81 lakh – for the 2019-20 session.

Punjab’s fee structure is among the highest in the country, an IndiaSpend analysis of data from the Medical Council of India’s website shows.

Expensive government colleges

On May 27, Punjab raised the fee for MBBS course in the state-run medical colleges by 78%, from Rs 4.4 lakh previously to Rs 7.81 lakh for the next academic session.

The revised fee for the four-and-a-half years course will be split thus – Rs 1.5 lakh the first year, Rs 1.65 lakh the second year, 1.80 lakh the third and 1.95 lakh the fourth year, and Rs 91,000 for the final six months.

For context, Punjab’s per capita income currently stands at Rs 1.67 lakh per annum, data from the state government’s Economic and Statistical Organisation show.

In private medical colleges, the fee for the 50% government quota – seats controlled by the state government for ‘domicile candidates’ (state residents) – was hiked from Rs 13.4 lakh to Rs 18.55 lakh (38% increase).

For the management quota – seats which college authorities have the liberty to fill at their level based on candidates’ National Eligibility-cum-Entrance Test rankings – the course fee is now Rs 47.7 lakh instead of Rs 40.3 lakh earlier (18% hike).

This excludes students’ average monthly expenditure of Rs 10,000-Rs 12,000 on accommodation, books, food, etc.

Punjab has seen a 479% fee hike in state medical colleges in the past decade. In 2010, the MBBS fee in government medical colleges was increased from Rs 68,000 to Rs 1.35 lakh, a figure that was raised to Rs 4.4 lakh in 2015.

Calling the latest fee hike reasonable, in an official statement on June 4, medical education and research minister Om Parkash Soni said that the hike under the Shiromani Akali Dal and Bharatiya Janata Party alliance government was even higher – 98% in 2010 and 225% in 2015.

While the political blame game continues, only three government medical colleges in Uttarakhand and two in Tamil Nadu have a higher annual fee – Rs 4 lakh to Rs 4.26 lakh, and Rs 3.85 lakh to Rs 4 lakh, respectively, an IndiaSpend analysis of fee structure for the 2019-20 academic year shows.

While IndiaSpend could not trace any government-commissioned report on the socio-economic condition of students who enter medical colleges in Punjab every year, a 2008 research project – by Jaswinder Singh Brar, Ranjit Singh Ghuman and Sukhwinder Singh – of Punjabi University, Patiala, showed that just 4.27% of the total students who entered medical courses that year were from a rural background, even though 62.5% of the state’s population lives in rural areas.

There is no further study to back whether the number has gone up or down, but the overall situation continues to be unfavourable for rural students, said Brar, professor of economics at Punjabi University, Patiala.

Another 2006 research project by the university noted that when institutions hiked fees, they accelerated the ‘exclusion process’ of students from the marginalised sections of society from acquiring higher education, even those who were talented and hardworking.

The findings of the study remain relevant, said Ghuman, the principal coordinator of the study and now professor of economics at the Centre for Research in Rural and Industrial Development, Chandigarh. With fees rising over the years, the gap between the haves and have-nots has widened. “We conducted one more study for the Association of Universities, New Delhi in 2007 on ‘unit cost of higher education in Punjab’, which revealed that only 10% to 15% of Punjab households could then afford the fee of an MBBS course. The situation has deteriorated since then.”

A presentation made by the Punjab chapter of Indian Medical Association’s medical students’ network on the latest fee hike – to register their dissent – showed that in 2019, of the 4,560 aspirants who applied to participate in the Punjab state medical admissions process – termed “counselling” – 30% were from the “lower-middle-class income bracket”.

Source: Notifications from the Department of Medical Education & Research, Government of Punjab: March 2014, July 2015, May 2020.
Source: Medical Council of India, Medical Council Committee. Note: Number of colleges and seats as of March 31, 2020. Figures for fee are the highest annual fee in each state for the 2019-20 academic year. Figure for Punjab is the fee for the first year under the revised structure

Government versus private colleges

The exclusion of poor but deserving students from medical education began in the 1990s when the state, instead of expanding government-sponsored education, moved towards privatisation of medical education by allowing private colleges and deemed universities to come up, said Pyare Lal Garg, public health activist and former registrar of Baba Farid University of Health Sciences, Faridkot.

Government Medical College, Amritsar – North India’s oldest medical college – was established as a medical school in Lahore in 1864, and relocated to Amritsar in 1920.

After Independence, another GMC was set up in Patiala in 1953, followed by the Guru Gobind Singh Medical College and Hospital, Faridkot, in 1973.

Thereafter, the state did not build any medical college for over four decades until three years ago, when Chief Minister Amarinder Singh announced the establishment of the Dr B R Ambedkar State Institute of Medical Science, SAS Nagar.

On the other hand, five private medical colleges came up in the state over two and a half decades, one of which, Chintpurni Medical College in Pathankot, was closed down in November 2017 due to quality issues.

Another private college, Gian Sagar Medical College and Hospital in Patiala, was on the brink of closure in May 2017 when the state government withdrew its ‘essentiality certificate’, a mandatory requirement for the establishment of a medical college.

The college’s MBBS students were shifted to government medical colleges in Amritsar, Patiala and Faridkot. Once the college improved its infrastructure, a Medical Council of India team inspected its facilities in January before allowing it to admit 150 students for the 2020-21 session, and the state restored its essentiality certificate.

In Punjab, 1,425 MBBS seats are available for the next academic session, of which 650 are in government colleges and 775 in private colleges, according to Medical Council of India data.

Infrastructural issues remain

The Punjab chief minister’s office tweeted that the cabinet increased the fee to ensure better medical education and infrastructure facilities for students.

However, the health infrastructure and quality of medical education have not improved in conjunction with the fee hikes, as alumni and faculty pointed out.

Since 2015, the fees for Doctor of Medicine and Master of Surgery courses have increased thrice, said Gagandeep Singh, general secretary of the resident doctors’ association of GMC Patiala, but “we have had the same shabby hostel conditions and poor treatment facilities”.

The Medical Council of India’s new curriculum requires ultra-modern lecture theatres, updated libraries and laboratories, which requires investment worth crores, said a former president of Punjab state medical and dental teachers’ association, who did not want to be named. But such investment has not been made despite fee hikes, the doctor said.

Higher fees, fewer doctors

High fees not only keep the poor students out of the field of medicine, thereby exacerbating socio-economic inequality, but also deter doctors who graduate after paying enormous fees from joining relatively low-paying government jobs, said Ghuman of Centre for Research in Rural and Industrial Development.

People are unwilling to join government medical institutions because of the high costs of medical education, lower government salaries, irregular payments in government hospitals and the lack of opportunity for growth in government medical jobs, Arun Kumar Tiwari of the Asian Development Research Institute, a New Delhi-based research organisation, had told IndiaSpend in this July report.

“Since long, government investment in medical education and the health sector has either been stagnant or gone down considerably,” said Gagandeep Singh, president of Punjab Civil Medical Service association, a union of government doctors in Punjab. “On the contrary, private medical education, despite serious quality issues, has been promoted and allowed to flourish, knowing well that it will serve only the elite.”

This is pushing medical education out of many students’ reach besides burdening common people with expensive healthcare, he said. “The disparity is already visible – all major and quality health services are concentrated in big cities while dispensaries and primary healthcare centres at the village and town level have poor infrastructure and shortage of staff.”

Punjab Medical Council, the official body that registers all medical practitioners in the state, has registered 55,000 doctors in Punjab since 1947. However, the current registration is not more than 15,000, said Akash Deep Aggarwal, registrar at the council.

“But the actual [active] strength of doctors may vary between 20,000 and 25,000 because many don’t renew their mandatory registration every five years [some also leave the state or the country without informing the council].”

Even if a conflated figure of 25,000 active doctors in the state is assumed, it makes for 8.3 doctors per 10,000 people in Punjab – which has an estimated population of 3.05 crore – against the World Health Organization’s recommendation of 10 doctors per 10,000. This is lower than India’s average of 8.57 doctors per 10,000, as IndiaSpend reported in March 2020.

Although India’s availability of doctors has doubled from 5,55,600 in 2000 to 11.6 lakh in 2018, the country is still among the 40% of WHO member-states not fulfilling the mandatory doctor-to-population ratio, as per the WHO’s 2020 statistics.

India has a shortage of an estimated 6,00,000 doctors and 20 lakh nurses, according to a study by the US-based health research organisation, the Centre for Disease Dynamics, Economics & Policy.

One in 10 registered allopathy doctors in India joins government hospitals, as per this report based on data from the Central Bureau of Health Intelligence.

The trend in Punjab is no different. In the three government medical colleges in the state – GMC Amritsar, GMC Patiala and GGSMCH Faridkot – 33% posts of doctors are vacant, as revealed by the state’s medical education and research minister Soni in response to a question by an opposition MLA during the March 2020 budget session.

Public health and government hospitals are a state subject and the responsibility to ensure the availability of doctors in public health facilities lies with state/Union Territory governments.

In the health department, too, 863 posts of doctors are vacant in the district and-tehsil-level hospitals, including 500 medical officers (general), 328 medical officers (specialist), 35 medical officers (dental), showed a media release issued on June 30 by the state government. This amounts to approximately 20% vacancies, said Arvinder Gill, deputy director, Punjab health department.

In the wake of the Covid-19 health crisis, the state government gave the approval to fill the vacant posts in the health department and medical colleges by September.

The fee hike, however, will have a reverse effect; doctors produced by the state will never come back to serve it, said Indervir Singh Gill, organising secretary, Punjab Civil Medical Service association, “The hike will ultimately deteriorate the state’s rural health services and widen the gap between rural and urban healthcare systems.”

Where do doctors go?

Most newly graduated doctors from medical colleges either go abroad or find jobs in the private sector because the pay scale in the government sector is lower and the working conditions are less comfortable, said Amarbir Singh Bhoparai, general secretary of the teachers’ association at GGSMCH, Faridkot.

“If the government wants to attract talent, it must offer better salaries,” he added. “Also, higher salaries should be paid to doctors posted in rural or backward areas [compared to those in urban areas].”

Handsome salaries and perks are not the only reasons for doctors to join private hospitals, however. Private hospitals have better diagnosis facilities where doctors gradually improve their skills and have a better learning experience, said Rajesh Dhir, president of the Chandigarh chapter of IMA. “On the contrary, the government’s spending on healthcare is meagre. They must improve their delivery system and incentivise doctors if they want to retain them.”

Comfortable working conditions in private hospitals attract more doctors there, reiterated Navjot Singh, state president of IMA.

“The state government should reduce its MBBS fee with a rider that those passing out from its medical colleges will have to work mandatorily for two years in rural or semi-rural areas to strengthen the grassroots of government health care system,” he suggested, adding that the fee structure of private colleges should be evaluated scientifically by the Director Research and Medical Education, Punjab.

The writer is an independent journalist based in Chandigarh.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.