Equity at the cost of capacity

Should the Government of India or national regulators think that penalising one section of the country is necessary for the improvement of another? This is not just contradictory in theory, but has in practice proved detrimental to India’s economic development in the past. And yet that seems to be the instinct behind some recent decisions — in particular the restrictions freshly imposed on the expansion of medical colleges.

The National Medical Commission oversees various facets of medical education in India. A recent and controversial regulation from the Commission shut down further expansion of the medical college network in the country unless certain requirements were met. The controversy was caused by requirements that were not enhanced quality standards but essentially geographical in nature. They were meant to address an apparent and growing inequity between various regions of the country in the local availability of medical training seats. The Commission also believes, possibly, that the inequitable geographical distribution of medical training seats has led to an unequal distribution of doctors regionally as well.

The material consequence of the Commission’s directive was that new colleges would not be allowed to open in certain states. Existing colleges will not be allowed to add seats, either. The states affected by this de facto ban would be those which already have more than 100 medical education seats for each million of their population. In effect, this has shut down expansion plans for the medical college network in multiple southern states as well as some others in the rest of the country.

No reasonable person would look at the state of the health system in India and conclude it has enough doctors. The only way that the Government of India can claim it meets the World Health Organization recommendation that there be one doctor for every 1,000 people is by inflating the number of real doctors by including those with certifications in “traditional” systems from the AYUSH ministry. There are 1.3 million registered doctors in India and over 500,000 such AYUSH-certified practitioners.

The inequity in the distribution of the actual doctors is particularly pernicious not in terms of a divide between states but between rural and urban areas. Community Health Centres are particularly understaffed. They suffer from a 50 per cent deficit in the availability of doctors, according to Rakesh Kochhar, a former president of the Indian Society of Gastroenterology, who quoted the Rural Health Statistics of 2021-22 in an article in The Hindu. Naturally, reducing the number of doctors produced in the southern states will do nothing to increase the availability of doctors in the rural north.

If there are credible reasons that the number of doctors of a northern background is less than it would be because of discriminatory practices in admissions in medical colleges located in southern states, that should be addressed. In fact, the South Indian media regularly reports on the problematic treatment of students from the region who have migrated north to study in medical colleges in the northern states. A series of suicides from 2016 onwards had made this a live and emotive issue in the south.

However, the actual geographical location of seats should not matter in a country where people can largely move freely for further education in the private sector. There is certainly a problem in that many seats under the government quota are reserved for local students in private colleges. Some states, such as Telangana, have moved to reserve far too many of these seats for in-state applicants. This in Telangana’s case is clearly directed at students from Andhra Pradesh. In general such practices should be discouraged. But a blanket ban on new colleges is hardly the way to go about it.

Thinking that reducing prosperity or growth in a sector in one part of the country will enable development in another is foolish. In India’s grey socialist past, policies such as freight equalisation were carried out in the name of equity. These merely caused deindustrialisation in the areas of India which were the most efficient locations for heavy industry.

The ultimate required outcome surely is more doctors in rural India across the board. Other methodologies should be tried for this. Ideas for compulsory rural service for those receiving government subsidies and for a national medical corps with preferential access to education have been floated in the past. These are how other countries have tried to increase health access and capacity. India is hardly at the point in its development where it needs to reduce the availability of education instead of increasing it.