If doctors picked from under-served areas are more likely to inhabit and practise there than others, there arises a case to strategically reserve a proportion of seats for such aspirants
By Soham D Bhaduri
In an eloquent account of general practice in the UK, Julian Tudor Hart, in a famous paper published in 1971, captured how quality medical services tend to accrue in regions that already have them. Industrial areas in the UK—which witnessed a higher case load, lesser physician time per patient, and consequently poorer quality of clinical care—attracted not only fewer doctors but also those with a lower morale. Pecuniary incentives to attract doctors to under-served regions did little to improve things, and many of those who populated industrial areas had kinship ties therein. This has relevance for contemporary India which sees a reignited debate on reservation in medical education.
The recent announcement of a 27% and 10% reservation for the OBC and Economically Weaker Sections (EWS) categories respectively in the All India Quota for NEET has ruffled many feathers. Seen closely, it is not the kind of dramatic move that should catch somebody off guard. Rather, it is an extension of what has been applicable across central educational institutions since quite some time now. Nonetheless, it has engendered a renewed debate on merit versus reservation, with many speculating that it could worsen medical brain drain. But, this is not the saddest part.
The fundamental deformity in the current discourse is that medical education is seen merely as an opportunity for certain individuals to prosper in life, just as in the case of jobs. It is therefore that it becomes a playground for different sections to joust for privileges, and thus also for ‘vote-bank’ politics. The large subsidies flowing into medical education seem incapable of conjuring into common consciousness the fact that the purpose of medical education is to serve national health goals. This entails that reservation must also be aligned to achieving these national goals. Had this been realised, we might have already had in place a more effective model and a more salubrious discourse on medical reservation.
If doctors picked from under-served areas are more likely to inhabit and practise there than others, there arises a case to strategically reserve a proportion of seats for such aspirants. Time and again, enrolment of students along domiciliary and vernacular lines has been advocated by experts and thinkers. This can be topped up with measures like strategic construction of medical colleges in areas of deficit. Compounded with reforms such as an enhanced community focus in medical education, these can be useful tools towards achieving an important national goal—that of ensuring a relatively equitable distribution of physicians and quality health care. Such a strategic reservation framework would however involve multiple subtleties requiring thoughtful planning, research, and coordination, something that continues to elude the country in favour of simplistic and expedient paradigms.
Between 2014 and 2019, there has been a 47% increase in the number of government medical colleges. Between 2014 and 2020, MBBS and PG seats have increased by 56% and 80% percent, respectively. Along the course of this commendable expansion, how much attention has gone into strategic regional distribution of medical colleges? How much effort has gone into exploring the distribution of both medical students and emergent doctors between domiciliary and social categories, so as to rectify possible disparities? Despite a long established rural-urban maldistribution of physicians, our only conceivable tool continues to be the cliched mandatory rural service clauses. Reservation along social and economic lines indeed forms a subset of addressing the wider problem of maldistribution, but is by itself neither adequate nor intended to address this problem. Not to mention that such reservations continue to operate in a medical education ecosystem that is being increasingly geared towards privatisation, and thus, increasingly removed from the principle of equitable distribution.
For medical reservations to be strategic, their guiding philosophy has to change—from one where reservations mainly uplift specific sections to one where national interests are best served. Lately, government provisioning of healthcare has increasingly espoused the principle of strategic purchasing. This is only fair since taxpayers’ money should only be efficiently utilised. It is high time we understood that so is the case with reservations.
The author is Physician, health policy expert, and chief editor of The Indian Practitioner