The BMJ calls for action over illegal payments to India's private medical colleges
Known as "capitation fees" these effectively compulsory one-off donations may exceed 10,000,000 rupees.
Despite the Supreme Court declaring the practice illegal, capitation continues because of high demand for medical degrees. It is estimated that capitation fees paid to professional colleges last year totalled some 60bn rupees.
One undergraduate student told The BMJ that "it is almost impossible to get admission into government colleges. And in many private colleges it is difficult to get a seat without paying huge sums of money." The situation is worse for postgraduates, she added, where the number of seats are very limited, "and almost all the government seats go to reserved candidates."
The situation seems to have deteriorated recently as the regulator of medical education, the Medical Council of India, did not renew permits for at least 10 medical colleges, with 6390 seats lost, explains D'Silva. This decrease coupled with an increase in the number of students applying to medical colleges has reportedly resulted in a sharp rise in capitation fees.
"Except for a few who get into premier institutions of their choice purely on merit, many students face Hobson's choice - either pay capitation to secure admission at a college or give up on the dream of a medical degree," she writes.
And while India is in desperate need for more healthcare professionals, a global report, Education For Health Professionals for the 21st Century, states, "In India, the growth of private medical schools raises concerns about the quality and transparency of one of the world's largest medical educational systems."
Ravi Narayan, community health adviser at the Centre for Public Health and Equity, Bangalore, has consistently questioned the commercialisation of medical education in the country. He said that the big concern is that many of the newer institutions are set up with substantial political backing. "This resulting culture of having to pay your way through the system introduces financial pressures which may be in conflict with the values and ethics of medicine, which are steadily getting eroded."
Samiran Nundy, chairman of the department of surgical gastroenterology and organ transplantation at Sir Ganga Ram Hospital, Delhi, agrees. "With an increasing number of candidates paying to get into medicine, merit has taken a back seat," he says. "As a result, the overall quality of graduates is very poor."
Although officials at private medical colleges that The BMJ contacted stated that they follow all norms and regulations that govern admissions, many colleges are alleged to have developed covert methods to collect capitation.
And with such great investment in their education, students are keen to start earning as soon as possible, writes D'Silva. "As a result, we see a growing inequity in healthcare standards between the rural and urban areas. Few private colleges have mandatory rural postings."
Many experts, including Samiran Nundy, think that the admission process into medical colleges needs more stringent monitoring "to ensure complete transparency in the admission process" and "leave no room for corrupt practices like capitation."
In an accompanying article, Sanjay Nagral at Jaslok Hospital & Research Centre in Mumbai says Indian citizens need reminding that growing commercialisation in healthcare and medical education is linked to the corruption they experience in their healthcare encounters.
In 1983, he helped lead a strike by junior doctors in Maharashtra to oppose a government proposal that would permit private medical colleges, which would accept "capitation" fees. Today Maharashtra has 21 private medical colleges, he writes. So what was once perceived as unacceptable is now a gigantic and legitimised industry.
He argues that India's medical profession "is too entangled in these institutions to offer substantial resistance to their growth and sleaze" and suggests the international medical community help "by barring students from such colleges from taking training jobs abroad."
"While unpeeling the layers of corruption in Indian medicine we must look at the private medical college industry, he writes. "Besides establishing a poor benchmark for fairness and honesty, they also push students to recover their enormous investment after they start practice, fuelling unethical practices in an already monetised and competitive scenario."
D'Silva paper: www.bmj.com/cgi/doi/10.1136/bmj.h106
Nagral paper: www.bmj.com/cgi/doi/10.1136/bmj.h237