Saturday, August 28, 2010

Subsidising medical education - is this a good idea ? Chap 7 from Dr Nadkarni's book

Now let us look into the pattern of charging fees to the medical students during their entire curriculum. When I joined the medical college in 1951 just one year after India became Republic of India, we paid Rs. 175/- per term i.e. Rs. 350/- per annum as our tuition fees. There were, of course, other ancillary fees so that effectively our term fee was about Rs. 250/- per term. The brochure then mentioned that he government subsidized the medical education to the extent of nearly 50% of the actual expenses. When my son and daughter entered the medical education somewhere in the early eighties i.e. more than 30 years later, the fees levied were exactly the same. But now they formed hardly 10% of the actual expenses incurred on medical education. Subsequently the fees were raised but the fees were most appreciably raised only after the private colleges came up. While medical colleges run by public sector are subsidized so heavily by the government, the private colleges have to bear the entire expenses as they do not get any government aid / subsidy. It is but natural that the students/parents must bear all the expenses in these colleges.

The private medical colleges took advantage of this logic and started to charge exorbitant fees and the Court had to intervene again to regulate the fees for the medical students. Now a committee is supposed to supervise and determine the legitimacy of fees to be charged to the students. It is not clear what principles are used to determine the legitimacy of the expenses and, therefore, the legitimacy of exact fees charged but the formula appears to be obviously faulty.

The medical colleges continue to charge very heavy fees, in these colleges. A medical student pays anywhere between Rs. 1.5 lac to Rs. 3.5 lac per year at present. The government too has raised the fees because of the financial pressure; yet the fees are around Rs. 18,000/- to Rs. 20,000/- per year. The students prefer government or public sector medical colleges because the training in these is qualitatively much better and not non-affording because the training is so cheap, except in the case of a few minority of the students. Naturally the students who get highest marks enter the government medical colleges while the students getting a little less marks are forced to take admission in the private medical colleges and medical colleges of deemed universities. The paradox of the present situation is that students getting very high marks get subsidized education and, therefore, in a way are supposed to be economically handicapped whereas those students who have secured marks less by a few percentage have to pay exorbitant fees and, therefore, in a way they are supposed to be belonging to the rich or economically affording class. Between students of equal caliber of intelligence, it is the rich or affording class who can provide better facilities-special tuition class and internet facility etc. to his ward, whereas it is the middle class parent who may not be able to provide such facilities and may depend on ordinary tuition classes at the most for his ward. Between them, therefore, it is the affording student who is likely to secure more marks than the unaffording student. Yet as mentioned above, it is the student who gets less marks who has to pay very high fees and the student who gets more marks pays lesser fees irrespective of the affordability of their parents and, in all probability, the affordability being quite the reverse. During my time in 1951-56, 15% of students were given partial freeship i.e. they paid only 50% of the stipulated fees, while another 10% were given full freeship; It means that they did not pay any tuition fees at all, except the ancillary fees. The criteria for giving partial or full freeship were purely economical. The parents had to submit a form and documentary proof to confirm their income and only the deserving candidates got such relief of not paying part or full fees. I myself might not have been able to complete my medical education but for the partial freeship which I obtained during the course of my education. It is ironical, therefore, that now when the fees have been raised so high, there is not a single seat with partial or full freeship in any of the colleges – government or private. Even in the government medical colleges, the fee structure, though reasonable, may not be quite so reasonable for many of the very poor students and, therefore, today, they are forced to give up the ambition of becoming medical professionals. The situation would be even worse for those who aspire to get admission in the private colleges. Thus, it can be seen easily that more and more percentage of students in medical colleges both in government & in private colleges are now belonging to the higher income group and the percentage of students from lower income group in medical colleges is steadily decreasing. Apart from the fact that deserving students are being denied the opportunity despite their merits, this has even more repercussions on the very pattern of healthcare. Both the students and teachers belonging to the rich class cannot easily think of simpler or cheaper substitutes in healthcare for the poor. They easily accept the costly modern technology as but natural and as a sign of real progress in medical management; thus contributing to the medical expenses rising by leaps and bounds. Should the expenses for medical education be subsidized at all? The subsidy in medical education is justified, if the doctors coming out from the colleges are sure to be absorbed in the national health services and that the people at large are served by them and in return they are given a reasonable remuneration.

In countries like England and Sweden, highly subsidized medical education may be fully justified as their entire health care system is nationalized. But in our country, where the student has a total freedom to select his field of practice-even go out of the country to the greener pastures in the foreign countries-the subsidy coming from the tax payer's money cannot be justified. Alternatively some provision has to be made to recover the entire subsidized fund with interest, if and when, the doctor leaves the country or enters into private business (I have deliberately used the word business instead of practice). Therefore the question of subsidy in medical education has to be very carefully looked into. The best solution for this is easy availability of educational loan at fairly low interest rate, say 6% which can be repaid by the student after he enters into regular professional field. Certainly some students-to the extent of 15% and 10%, from the poorer sections of the society-deserve partial and total free ship respectively as was the practice in the fifties and the sixties. The government would be fully justified in compelling these students to serve in the public sector for a stipulated period-say 10 years on a subsidized salary. On the other hand, the insistence of the government of compulsory service in the public sector by each and every student does not appear to be justifiable, if he/she is paying fully for his/her education. Similarly the fee of only Rs.18,000/- to Rs. 20.000/- in government medical colleges versus average fees of Rs. 2,00,000/- in the private colleges is too weird as explained above. At least 50% of the students getting admission in government/municipal colleges belong to high/very high income families. A few of them could buy the hospital. For example if the son of Ambani or Godrej or Kirloskar secures 98% of marks and gets admission in G.S. Medical College (K.E.M.) in Mumbai or B.J. Medical College in Pune, he pays the fee of only Rs. 18,000/- but the son of the poor accountant or head clerk working in his own office who secures 92% marks pays a fee of Rs. 2 lacs, if at all he aspires to become a doctor. The question of proper subsidy to proper students will be correctly approached and this paradox will be totally abolished, if the fees in the government colleges are also raised on par with the private colleges and, therefore, the subsidy is totally abolished. Now subsidy should be given only on the basis of the economic status of the family in two or three grades ot students in all colleges, government or private. The students with family income of Rs. 75,000/- per month or more will pay full fees. those whose monthly income ranges from Rs. 60,000/- to Rs. 75,000/- per month may get 25% subsidy. The families with income between 40,000 to 60,000 will get 50% subsidy. Those below this income up to Rs. 25,000/- per month may get 75% subsidy. and those below Rs. 25,000/- p.m. will get full freeship. These figures are mentioned somewhat arbitrarily but the actual figures could be worked out very easily taking into consideration family liability and their capacity to pay for the education OF THEIR TWO CHILDREN ONLY. The government need not consider even remotely the financial burden of the family beyond two children as in Singapore. In short the pattern of subsidy would ensure that the poor should get 100% subsidy, lower middle class may get 75% and the middle class may get 50% For the highest strate, there is no need to give any subsidy irrespective of which college he joins, government or private. Such subsidy, therefore, will be available to the students whether he joins a government college or private college or a deemed university college. The subsidy means that an equivalent amount will be paid to the respective colleges by the government so that their budget is not disturbed. Every student who gets subsidy will have an obligation to serve in government service or in public sector for a reasonable number of years as per the subsidy he has received or else he will have to return the amount of subsidy with interest to the government. A large number of doctors will then become available to serve the poor at various primary health centres or other public sector health care organizations. Otherwise the government will receive back the money they had spent on these students-money which can be now re-used for future students.

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