The draft National Education Policy’s call for abandoning all regulation of fees in professional courses marks the latest in a series of steps that have aggressively pushed commercialisation of medical education over the last decade, say public health activists.
Till 2009, the official stance was that education could not be for sale or a for-profit venture. So on paper, all private colleges were run by trusts or charitable societies. Yet, the fact that many made illegal profits through capitation fees, hugely inflated tuition fees and other charges was an open secret. In February 2010, the then UPA government allowed companies registered under the Companies Act to open medical colleges though with the ironical caveat that “permission shall be withdrawn if the colleges resort to commercialisation”.
Even this fig leaf was dropped in August 2016, when then health minister JP Nadda approved an amendment in the eligibility criteria to allow companies to set up for-profit medical colleges. The government argued that no companies were coming forward to set up colleges because of the no-profit stipulation. It also argued that profits were in any case being made in nontransparent ways and that legally permitted profits would at least yield some income tax for the exchequer. There was little or no discussion about how students would be able to afford the huge fees charged in these colleges.
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Following a huge outcry over spiralling fees in private medical colleges, a constitution bench of the Supreme Court had directed in 2003 that each state must have an independent fee fixation committee headed by a retired high court judge. A July 2018 Supreme Court judgment again upheld the 2003 judgment.
Mining giant Vedanta was one of the first companies to set up a college, in Palghar, Maharashtra. In a move that shocked the medical fraternity, students and activists, the state government gave it a free hand to decide fees. However, just a couple of months later, the college was found deficient and the Medical Council of India (MCI) refused to allow further intake in July 2018, a decision challenged by the company in Bombay High Court.
Allowing the entry of for-profit companies also led to those running societies or trusts asking why their own colleges could not to be converted into profit-making entities. In January 2017, the government acquiesced and notified that any medical college set up by an autonomous body, society or trust could be converted into a company, thus ending all pretence of medical education being a not-profit venture.
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Going a step further, last month, the MCI Board of Governors amended the Establishment of Medical College Regulations, 1999 to allow consortia to set up medical colleges. A consortium, it clarified, could be a group of two to four eligible organisations including a society, trust, company, university or deemed university who have entered into a Memorandum of Understanding. The notification claimed that the object was to invite greater participation from the private sector in establishing medical colleges and “imparting high quality medical education and training facilities… without compromising the standards of medical education”.
However, this move is viewed by many health activists as a way for private entities to use public hospitals to start medical colleges through MoUs with a “consortium”. Even before this, in several states including Maharashtra and Gujarat, public facilities had been utilised by private entities to set up medical colleges under the rubric of PPPs (public-private partnerships).
“All this is only about producing more doctors and not about the quality of doctors suited to our needs. Doctor shortage is in rural areas, but with no fee regulation only the affluent will become doctors. Will they serve where the shortage is?” asked Chhaya Pachauli, a public health activist from Rajasthan.
Dr T Sundararaman, former dean of the TISS School of Health System Studies, pointed out that over-production of doctors will suit corporates but not for the country. “Doctors will accumulate in urban areas leading to unhealthy competition and they will try to milk patients as is already happening in Mumbai. We need a policy that will get people to under-served districts of North and North East India,” he said.
While public health activists worry about the implications of a private sector without fee regulation, there is also the question of standards of medical education. India’s experience has been that regulation of private colleges has failed miserably, as both a parliamentary committee and the Supreme Court observed. What reason is there to believe things will get any better, ask the activists.