Doctors For The World: Indian Physician Emigration

Fitzhugh Mullan

Health Affairs. 2006;25(2):380-393. 

In This Article

A Popular Profession

Medicine is a popular profession in India. It is widely respected, seen as a remunerative career, and, for some, presumed to be a ticket to emigration. More than 100,000 students in the final year of secondary school take examinations, administered by government, for entrance into medical studies each year. This system, as originally conceived, allots the tuition-free seats in government medical colleges based on the examination results.

Growth of Medical Education

Medical education has grown rapidly in India, from 11,800 admissions per year in 1990 to 24,000 in 2005. Much of this growth has been attributable to the opening of private, for-profit medical schools, which now account for 42 percent of medical student seats.[16] The new private schools are expensive, charging "capitation fees" (also called "donations") of $40,000-$50,000 at the time of admission followed by tuition payments in the range of $3,000-$6,000 per year. Admission to private schools is determined by the ability to meet cost requirements as well as academic achievement. This picture is complicated by a government requirement that private schools award a designated number of seats to merit candidates from the government list at low tuition rates. Additionally, some government medical colleges have initiated sharp tuition increases of their own.

The 242 medical schools currently listed by the Ministry of Health and Family Welfare are mostly urban and are located in twenty-seven of India's thirty-five states and territories.[17] The continued growth of medical colleges is testimony to the popularity of medicine and the belief by large numbers of students and families that the combination of growth in the Indian economy and opportunities abroad will guarantee future medical employment. Although private colleges do not explicitly educate for emigration, multiple observers told me that the rationale for the development of more private schools was continued high interest in emigration. The quality of education at these institutions was also a subject of concern—in particular, the shortages of trained faculty and clinical learning opportunities.

Community Service Requirement

The requirement of a period of community service in return for receipt of medical education has been attempted at some schools. Government medical colleges in certain states have instituted mandatory two-year rural service following graduation to be eligible for postgraduate training. Reportedly, service requirements are frequently ignored by physicians and have effectively been abandoned by a system that lacks enforcement ability. Medical colleges with a religious base, such as St. John's Medical College in Bangalore and Christian Medical College in Vellore, ask their graduates for two years of clinical service in village clinics or mission hospitals. More of their graduates do fulfill these stipulations, but large numbers are reported to go abroad or find other training or work opportunities without fulfilling the obligation.

Postgraduate Specialization

Although the medical school exiting degree (bachelor of medicine/bachelor of surgery, or MBBS) is sufficient to obtain registration and to practice in India, most medical graduates desire postgraduate training. Specialization is uniformly seen as desirable for reasons of competence, stature, and income. The total number of residency positions is uncertain but appears to be in the range of 10,000 annually for the 24,000 students now graduating each year.[18] This means that postgraduate training in India is available to fewer than half of all graduates. Many postgraduate programs (especially those in private institutions) require a capitation fee of as much as $50,000 for entrance into postgraduate studies. The dearth of positions as well as cost are factors that contribute to travel abroad for medical specialization.

Status of Primary Care

In contrast to this emphasis on specialization, multiple national committees and commissions since the time of independence have promoted the concept of the primary care physician as the basis of health care in India.[19] Despite such pronouncements, curative medicine, interventionism, and specialism are strong cultural values in medical education in India, and postgraduate positions are entirely specialty oriented. Family medicine as a discipline is virtually nonexistent, and preventive and community medicine are considered second-class specialties. One commentator characterized the position of general practice in Indian medical education as "devalued, degraded, and distorted."[20]