In the first post of this series about demystifying higher education, we looked at universities in India and the administrative bureaucracy around them. In the second post, we built on the first post by adding information about Institutes of National Importance. With today’s post, we move away from universities to the components that make up the second tier of higher education – colleges. We’ll also start discriminating between subjects and courses so that we can get deeper in and focus on colleges offering an MBBS, the basic medical degree.

The entire institution of medicine, like the institution of education, is widely seen as a public good. Medical education is therefore doubly burdened with noble responsibility. It bears this responsibility to educate well and wisely to both the student and to the student’s future patients whose very life might depend on it. So to safeguard against dilution of standards, the criteria for imparting a medical education have always been stricter and more demanding than other streams.

But in a country such as India where the demand for health infrastructure far outstrips the supply, a compromise of commercialisation might be unavoidable. The assumption being that any medical attention is better than none, something which does not always have to be true. There is also a powerful case to be made for the quality of private healthcare being higher – which is great, if you can afford it. And affordability of health care is a matter of life and death as P. Sainath has reported, chronicling the rise in medical debt and related suicides in rural India. And since the price of medical care cannot be separated from the price of medical education, it becomes imperative to have greater understanding of what’s driving this sector.

There are currently 370 medical colleges in the country that offer 49,840 MBBS seats between them. This makes India the largest creator of doctors in the world. In comparison, the United States only produces 18,000 doctors a year. Roughly half of India’s medical seats are in private colleges whose habit of collecting capitation fees is an open secret. According to an interview by a senior member of the Medical Council of India—the apex regulatory body for medical education—gave to the Business Standard, no one has ever formally filed a complaint. Here’s a statistic for you though: doing a back of the envelope calculation, if 24,260 seats are allotted with a Rs 50 lakh capitation each, that totals up to 12,130 crores a year in shady fees.

And the Medical Council of India hasn’t had time to look into this?

In fairness to them, they are a relatively effective organization. The Council frames rules, regulates the formation and continuation of medical colleges and maintains the Indian Medical Register (IMR). The IMR is a database of all licensed medical practitioners in the country. It is accessible online and you can use it to verify whether your doctors have the credentials they claim. Just a caveat, it might be out-dated so don’t be too quick to pull the trigger. Each state also has its own medical council and state medical register from which information is aggregated to form the IMR. But probably the most interesting part of the MCI’s duties is the yearly inspection that they do of every single medical college in the country. This inspection settles whether the college is given permission to continue taking admissions or not – so it’s a pretty big deal. These inspections are no rubber stamp though. The MCI has been known to brutally slash seats if standards of quality are not maintained. For the year 2014-15, the Council denied permission for renewal to 45 colleges offering 3,820, seats citing lack of infrastructure and shortage of staff. We should be relieved; they initially threatened to cancel 15,000 seats.

The lack of qualified staff seems intuitively correct but the MCI lists almost 1.2 lakh registered teachers on its website, and with only about 75,000 MBBS and post-graduate seats, the problem seems to be one of distribution or pay-scales rather than straight out lack of supply. Or the website is wrong or contains repetitions, which is also possible.

The information in this post is taken from the latest data available on the MCI website, after removing the colleges that failed inspections this year. The geographic distribution of these colleges shows a noticeable southward slant with 44% of all medical seats distributed between the states of Karnataka, Andhra, Telangana, Tamil Nadu and Kerala. Undivided Andhra Pradesh had the most number of seats in the country but after division, Karnataka holds that title. Maharashtra has the most colleges but has a lesser number of seats when taken cumulatively.

But despite having the most number of seats, when averaging over population data from the SECC 2011, we see that the South Zone has a worse ratio than the North Zone (UP falls in the Central Zone). Both the East and West zones do worse than the North East and Central zones, which is very surprising.

(Y-axis: fraction of share of government and private colleges.)

The national distribution between government and private colleges is almost exactly 50%. There are 187 government and 183 private colleges. Looking at the breakup across states, the states with more than 20 colleges are biased towards private entities. The notable exceptions being Tamil Nadu and Uttar Pradesh that almost mirror the national distribution. On the flip side, states that possess less than 20 colleges tend to be heavily biased towards the government institutions. The notable exceptions here are Pondicherry and Punjab, both of whom possess nine colleges but of which only two and three respectively are government-operated. Government colleges usually charge fees as low as 11500 per year as against 7-9 lakhs at a private college. That’s not taking into account capitation fees that range from 50 lakhs to 1.5 crore. (Remember my Rs 12,130 crore calculation?)

High capitation fees are one of the reasons that, as per The Hindu’s sources, more than 9,000 Indians are enrolled in medical colleges in China as of 2013. The MCI actually regulates which Chinese colleges are recognised in India and publishes a list of eligible institutions every year. The latest one has 45 colleges with 3,470 seats. Despite being cheaper to study abroad, the odds are stacked against you if you want to work in India. The MCI conducts a screening test for returning graduates that has pass percentages of less than 25%. With 14,476 graduates appearing in 2012, that’s a lot of doctors stuck in limbo. The official reason is to verify their skill level but with the lack of transparency and accusations of excessive difficulty, the screening test does seem suspicious.

An RTI request for a copy of an answer sheet was rejected, but the reply did reveal officially that the questions are the ‘same as that conducted by AIIMS for candidates desirous of admission to post-graduate courses in the Institute’. Considering that most medical graduates in India don’t get into AIIMS, asking every foreign graduate the same questions doesn’t seem fair. The only exception to the test is if the student has completed both a graduate and post-graduate degree from either Australia, Canada, New Zealand, the UK or the US and has been recognized as a medical practioner there.

Part Two – What does it take to start a medical college?

As one of the things I wanted to do in this series was to study the complexity of forming a college or university, I’ve conducted the exercise with medical colleges which is ideal considering they’re probably the most regulated. As I learned, the MCI has come under criticism for both being too strict and too lax with their assessment of applications for the formation of new medical colleges. They only accept applications in the month of August and only recently launched an online application portal. The law that governs the qualifying criteria to form a college is the Establishment of Medical College Regulations, 1999. The main criteria are possession of adequate land, an essentiality certificate, consent of affiliation, an operational hospital and submission of financial guarantees.

The specifications for the land required have undergone the most number of changes. There have been eight amendments since November 2008, some of them drastic modifiers of the previous regulation. Initially, to start a college the applicant needed to have an unbroken 25 acres of land. Then, exceptions to this hard and fast rule begin to crop up, probably because acquiring an unbroken parcel of 25 acres anywhere near large urban centres became practically impossible. But some of the changes are less sensible. In 2011, there was a relaxation in prerequisites for a period of 5 years for the setup of colleges in the states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal. But looking at the numbers, there were 20 colleges formed since 2011, but there were 22 formed in the five year period before 2011. So the land relaxations don’t seem to have had the intended effect and these states still suffer from a glaring lack of service.

An essentiality certificate is issued by the government of the state in which the college aims to be located. It’s a statement by the government that a medical college is required in that area. This is interesting for two reasons: one because they assume a medical college isn’t required in every area, and two, because they think the government is the best arbiter. In 2002, four private medical colleges were started in one year. On further digging, I learned from an article in The Hindu that P. Sankaran, the Health Minster of Kerala in 2002, had issued approvals to 48 applicants that year. Out of which only 4 had received permission from the Medical Council of India. The reason for the large number of approvals? 2000 crores that supposedly left the state as capitation fees to colleges in other states. Now take into account that five medical colleges were started in Karnataka in 1999 under J.H.Patel, and another five in Maharashtra in 1989 under Sharad Pawar, and in Andhra in 2002 under Chandrababu Naidu and you realise that maybe this step can be skipped as states don’t seem to be in the habit of saying no.

Consent of affiliation is a certificate issued by a university affirming that the college can issue degrees in its name. Private parties must submit two bank guarantees: The first is based on the number of admissions, one crore for the first 50 admissions and fifty lakhs more for every additional 50 admissions. The second is based on the number of beds in the hospital starting with 3.5 crore for 400 beds. Governments just have to show that their budgets have the necessary funds allocated, but that doesn’t seem to have helped them. I could go on and on about the legal hoops to jump through to expand a college’s quote of seats.

There’s a Planning Commission report on the steps to achieve universal health care in India that makes for very interesting reading if you can brave the 343 pages. The UN/WHO describe the ideal doctor-population ratio as 1:1,000, and India is approximately at half of that. To attain the ideal ratio, the report lays down the need for 59-187 (depending on strategy) more government institutions before 2022 at an estimated cost of Rs.100 crore per medical college, along with suggestions for new courses like the 3-year Bachelor’s in Rural Health that was started in 2013. We might need 600,000 more doctors and one million nurses along with lakhs and lakhs of primary, community and rural health workers. What are we doing to get there?

As always, please write to me with comments and criticisms at thomas@supportivecities.com.

Thomas Manuel is a freelance writer and playwright based out of Chennai. He curates content at the Urban History Project, where this piece first appeared.