Admissions to medical colleges in Tamil Nadu have long been an area of contention. Unfortunately, the debates have not been about securing the best outcomes for patients, which one presumes is the natural focus of medical education. It has instead been focussed on giving a fair deal to the candidates, using medical education as one form of social justice etc. Even here the debates are flawed.
In the early days after Independence, selection to medical colleges in Tamil Nadu was made by interviews. Anyone with over 50% in the relevant subjects could apply. The system encouraged nepotism. Many children of doctors, and other influential people were selected. There was a very large caste bias. After the Dravida Munnetra Kazhagam (DMK) captured political power, the only thing that changed was the castes that now entered medical college. The method of selection continued to be opaque. Public pressure forced the All India Anna Dravida Munnetra Kazhagam (AIADMK) government of MG Ramachandran to introduce an entrance examination in 1984. This was the first transparent method of selection to medical colleges in Tamil Nadu, as the rank list was published. Subsequently in 2006, the DMK government of M Karunanidhi abolished the entrance examination and made the marks in Class 12 the criterion. The reason given was that entrance examinations favoured the urban student, who could afford coaching.
Medical education: High social value and guaranteed financial security
Medical education is highly prized in India. The social value bestowed on doctors by society makes even newly wealthy business families aspire to medical education. In addition, sections of the upper middle class, like doctors, bureaucrats and the judiciary, see medical education as not only of high social value, but also a means of guaranteed financial security.
Rise of commercial colleges
The introduction of a transparent means of admission to medical colleges meant that these sections of society could no longer be absolutely sure of admission. The way around this problem was to permit commercial medical colleges, which were allowed to admit students of their own choice. Here it is important to emphasise the difference between these commercial colleges and private colleges in the West (and a few in India). The reputable private colleges in the West are not-for-profit institutions. In India, nearly all private colleges are commercial entities which earn large profits, much of it outside the legal system. Politicians saw a business opportunity and seats in these private medical colleges are sold for huge amounts. The commercial sector in medical education in Tamil Nadu now has more seats than the government sector in undergraduate education. In post graduate education, in several specialities which are considered lucrative (for example radiodiagnosis and orthopaedics), there are far more seats in the commercial colleges than there are in government colleges.
Up to the introduction of the National Eligibility cum Entrance Test (NEET), these seats were sold at over Rs one crore. By this ploy, the supposed champions of social justice achieved several objectives; they could retain their credentials as supporters of the underprivileged, while simultaneously satisfying the demands of their political funders. There was the added advantage that these colleges generated large amounts of black money. No major enterprise in Tamil Nadu can survive without paying rent to the political parties. Private education is no exception.
School education in Tamil Nadu
Government schools in Tamil Nadu are in poor shape. In two articles in Scroll in November 2016, M Rajshekhar reported on findings of the National Achievement Survey of the National Council of Education Research and Training Training (NCERT). Students from Tamil Nadu who perform very well at Class 5 level, perform very poorly at the Class 10 level. The reasons are clear. Poor funding, nepotism in appointments of teachers and general neglect have ensured that students get a raw deal. Only the very poor utilise these schools. The chances of a student from these schools pursuing university education is low, and that of following a professional course for which competition is fierce, is lower still.
In response to a query under the Right to Information Act, the MGR Medical University revealed that government school students could secure only 213 of 29,925 medical seats between 2006 and 2016 (0.7 percent). In the private colleges only 65 of 6,132 students were from government schools. Most private schools all over Tamil Nadu are run by persons with close affiliations to political parties. Several centres, most notably in Namakkal sprang up to coach students for the Class 12 examination and were very successful in getting their students into medical colleges.
In his article in Scroll, M Rajshekhar scrutinises the examination system and suggests that it is being manipulated to ensure high scores. It is clear, therefore that the deleterious effect of NEET on government school students is very small. The real effect will be on the commercial schools and commercial medical colleges all of which are under the patronage of the politically powerful. The effect of NEET on the caste composition of medical students will be negligible, because the rule of reservation is applied for selection once the NEET scores are obtained. This year, not a single seat in government medical colleges, distributed following rules of reservation, went unoccupied. It suggests that students from the underprivileged sections are capable of crossing any entry barrier, provided they are given the opportunity.
Medical Care in Tamil Nadu
One of the arguments being put forth in the campaign to protect the present system of medical education is that Tamil Nadu has an excellent public medical care system, and, therefore it is obvious that its medical education system is working very well. In a couple of articles in Scroll (December 12 and 13 ) M Rajshekhar describes the real situation in Tamil Nadu. It is only in comparision to the abysmal situation in some other states that Tamil Nadu looks good. The public medical system is overcrowded and underfunded. Faced with a tidal wave of seriously sick patients with not enough resources to manage, the staff lose morale and become apathetic. The state of Tamil Nadu is no different from the rest of India, in steadily pushing the commercial sector in medical services. Many politicians own hospitals and diagnostic centres.
Looking at the data from the Indian Human Development Survey 2011-2012, Tadit Kundu pointed out in Live Mint that intergenerational job mobility is very low in India. In an earlier article, he had pointed out that Intergenerational educational mobility is also low. In other words, the chances of the less privileged to better education and jobs, is low. Thomas Piketty and Lucas Chancel suggest that income inequality in India, which had declined between 1951 and 1980 has been growing steadily since 1981. In short, the rich are getting richer despite all the political rhetoric about social justice.
The protests against NEET
With this background, one can understand that the protests against NEET offer a rare opportunity for political parties in Tamil Nadu. They can simultaneously pretend to be fighting for the dispossessed, while actually protecting their huge investments in private education and private medical care. It has the double advantage of giving the appearance of being pro-poor while actually changing nothing significant and protecting the interests of the rich. The status quo in school education, medical education and medical care remains. NEET, a negligible entity in making any large-scale changes is a convenient villain.
What needs to change?
In the short-term, we need to eliminate commercial medical education. Pricing should be sensible and government must pay the fees of students from socially disadvantaged sectors.
Medical admissions must use a criterion which eliminates any advantage of coaching, whether at the Class 12 level or any entrance examination.
In the long-term, we must improve government schools and eliminate or reduce private schools. In the world champion of private enterprise, the United States of America, there are hardly any private schools.
If we want better outcomes for patients we must work towards introducing a system like the medical care systems of Western Europe.
Dr George Thomas, an orthopaedic surgeon, is also part of the Editorial Board of the Indian Journal of Medical Ethics.