Sunday, July 15, 2007

Medical Education in Maharashtra – 2

A path to resolution.

Now that the stewards of state (of “commanding heights” fame) have completely botched things, how do we reform? Where do we begin? What do we do?

To answer that question, it may be useful to remember the Cheshire Cat from Alice in Wonderland, “[what you need to do] depends a good deal on where you want to go.”

To understand what we need to do, we need to have a suitable vision of where we want to go. We may, for instance, want to “Establish a system to produce world-class physicians and health care leaders to meet Maharashtra’s and India’s demand for talent, while creating economic value via high-quality patient care, research and accelerated job creation.”

Translated into plain English, this means more and better hospitals -- say three times as many, with vastly improved teaching skills and capabilities that directly meet India’s healthcare needs.

It is tempting – but wrong – to conclude that all it will take is more money. If that were the case, the thousands of crores of taxpayer money the government has spent in shoring up Air India and Indian Airlines again and again would not have been as completely wasted as they have been.

No – it’s not more money that is required. What is required is an entirely new system for channelling cash, most of it from private pockets, to create an all new educational system.

There are three big changes the government must drive to make this happen:

1.Create competition in the delivery of medical education by liberalising norms governing setting up of medical institutions

The only way we can have more medical schools is, well, by allowing more people to start medical schools.

Transparent, simple yet stringent norms should be established – and anyone meeting those norms should be allowed to start a medical school. The norms could well cover requirements such as financial stability, experience in running medical schools – perhaps even globally. This is a good way of getting schools like Harvard and Hopkins interested. Incidentally, Singapore adopted a similar strategy to attract Insead Business School and Duke Medical School to Singapore.

Going beyond the school itself, medical institutions should be allowed to select the university with which they choose to be affiliated. Ergo Medicine programs should be repatriated to their parent universities, completely reversing the current trend for sameness. Creating competition – where universities strive to be affiliated to the best schools – is a far more powerful means of creating quality than by obsessing over standardising curricula across the state.

2. Create payment security in Education to attract the best medical schools

While (1) will grab the interest of leading healthcare educational institutions, it is unlikely to keep them from having bouts of attention deficit. To make sure the Harvards of the world come – and stay – the Government will need to assure them of a good return on their investment.

Discussing “returns on investment” in education is typically considered inapplicable – heretical even.

I disagree.

An education – in particular, a degree from a reputed college – is highly monetisable. When an average IIM-A student gets a starting salary worth 10 lakh, the market deems the worth of that “student+degree” combination to be worth at least as much. So, if an IIM-A student is charged Rs. 5 for a degree, s/he should not really be bothered – s/he will still be, economically speaking, better off.

So, in a nutshell, the government must give full freedom to medical schools to charge market rates for their fees.

And, instead of controlling fees, mechanisms should be established whereby the poorest of the poor have access to the capital required to fund this education. A cornucopia of solutions – from student loans to vouchers as suggested by Friedman – are possible. The government can, in fact, “fund” the education of students from whichever caste/creed/demographic/electorally useful group of people it wishes to pamper by directly paying the school the full cost of their education.

Such a move will have an altogether salubrious effect on the schools themselves. Forced with having to compete for the student’s rupee, colleges will have to offer better facilities, higher teaching standards and resources to attract students and value –added services – like career counselling and placements. The motivation for becoming distinctive will also incentivise them to establish tie-ups and alliances for research and development.

Existing shackles that prevent these relationships from emerging should also be removed.

3. Ensure public safety by establishing an independent regulatory authority.

While (1) and (2) may be adequate in other sectors, it is certainly not enough in medical education. After all, is it safe to leave the licensing of physician to a bunch of colleges that is interested in a 100% pass rate?

This is a legitimate concern, but effectively solved by establishing an independent regulator.

In the United States for instance, all physicians – even those from the best schools –must pass stringent licensing examinations administered by an independent licensing authority.

India too has successfully established ombuds and regulators such as the TRAI, indicating the viability of the concept. This regulator should be kept independent of the government (which means the Ramadoss or Grand poobah of the time should not be allowed to meddle in its operations). It should also be made financially secure by providing it with ring-fenced government funding and “licensing fees” collected from students and medicall colleges.

This independence and financial stability is crucial to staff the regulator with high quality experts – and not some spineless lackeys beholden to the present Minister.

Details about how we can make this regulator – indeed any institution – at arms length from political vicissitudes is matter enough for a separate post.

So there we have it – a framework to pull Maharashtra back from its state of self-inflicted medical decline and place it firmly onto a growth trajectory.

Of course, several operational issues remain unanswered – such as how do we ensure that these medical colleges have the right kind of teaching hospitals available? This one is easy: allow hospitals to forge alliances with existing hospitals to upgrade them into teaching institutions. Give incentives for adopting and transforming poorly run government hospitals and so on.

Some questions are harder – such as how do we get the best here? How many medical schools are enough? How expensive is too much?

They are all valid and important.

However they are also amenable for resolution under the umbrella framework of the three shifts listed above: competition, payment security and outcome regulation.

So, why have we not started as yet?

Unfortunately, like most changes – this change too has to start from the government. Babus have to go from thinking of themselves as thekedaars and maay-baaps of the sector to facilitators and nurturers.

They have to realise that this sector is too important to be held ransom to their petty egos.

Alas, the recent fracas with Ramadoss and the AIIMS demonstrated how far the sarkar is from this realisation.

Einstein had once said that a problem can only be solved at a level of consciousness higher than at which it was caused.

Our netas and babus need to raise their levels of consciousness pretty significantly to embrace such radical change.

Cold comfort, that we need to wait for our Netas and Babus to think differently.

Perhaps they should begin their journey by reading Alice in Wonderland.


Mukul said...
This comment has been removed by a blog administrator.
Soniya said...

Although I agree with your larger argument about opening up the education sector, I am still not convinced it is the ultimate panacea for the problems that continue to plague our system.

Considering the babudom does manage to wake up in the next few years and implements large-scale reforms, would it still be enough to ensure that there will be adequate doctors to cater to the non-urban sector? The dismal state of primary healthcare centers all over India is well-known, as is the large-scale corruption that continues to go unnoticed. The only doctors who work in these areas are ones in Govt. jobs who have no say in where they are posted.

Reg. increasing supply of medicos, what is your opinion on the plethora of homeopathic and ayurvedic medical colleges that have mushroomed all over the place? I had friends who went to some of these institutions, and although the students are almost nearly as competitive as those who get into mainstream medical schools, these fly-by-night places grossly underserve them by offering a vastly inferior curriculum. Their degrees have no recognition anywhere, and the rules on whether they can qualify for graduate studies keep changing all the time. One way of bridging the demand-supply gap would be to start making their degrees more recognizable through stringent licensing exams.

So I believe the larger issue of how much control the Govt should have in matters of healthcare. The American system based on insurance and drug company driven is at a near-collapse. (On a related note, would you review Michael Moore's Sicko on your blog ?) But India is in no position right now to offer universal free healthcare as some developed countries do.

Ok, that was my long and rambling comment. Would love to hear back from you.

Ashutosh said...

I have read many of your posts; sometimes with dismay and sometimes with shear amusement.Please let me know your comments regarding this piece that I came across:

Patna: It's a classic tale of small towns and big dreams -- only this time round, the dream almost came true for Sushila Mishra, a resident of Nadda Village in the Bangah District of Bihar.
She scored 91 per cent in her class XII boards and also cleared the IIT-JEE exam, but Sushila wasn't able to get a seat at IIT because her father couldn't afford to pay Rs 40,000 as admission fee.
"It was my dream to study at IIT. I heard from somewhere that the state government is helping poor students. I was hopeful, but I didn't get any help," says the dejected girl.
Sushila's father approached various banks for a loan, but failed to get any because of his weak financial status.
"My daughter is really bright and with a little help she could have really done well. We went to everyone for help, even the Chief Minister but nobody helped us," says her father, Surinder Mishra.

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Meanwhile, Chief Minister Nitish Kumar says an inquiry is on to find out why Sushila was denied financial help.
"An inquiry is on. For students from Bihar who clear IIT entrance, usually the government spends Rs 50,000 from the Chief Minister's Relief Fund," said Nitish Kumar.
However, all that matters little to Sushila for now that the last date for submission of admission fees has expired, her dreams of making it to IIT might just remain that -- a dream!

AGworld said...


Suggest you think of the hundreds of sushilas who do not get an education AT ALL due to the government's monopoly on education.

Since you find this rather amusing, do you have a better solution?
Oh.. perhaps you're saying the government should spend another 100 crore in making 10 more (white elephant) IITs.

After 50 years of the IITs, why are we still behind so badly?