Ethics in Tangents – Part 5: Do Doctors coming out of Government-Run/Aided Institutes Need to ‘Pay Back’?


This in response to a very narrow aspect of Vidyut’s blog post – Globalization – Brain Drain (click).

Expense of education borne by less developed country, while fruits of the person’s service are reaped by developed countries.  Today’s outrage on Twitter was the government making it mandatory for doctors going abroad for further education to return to work in India after completing their education and reserves the right to enforce it by not issuing No Objection Certificates to doctors who don’t comply. The government of India estimates some 3,000 doctors who studied in government subsidized hospitals have left the country in the last one year. The annual cost of each student is about 31.31 lakh rupees, while fees charged are Rs.850/- per annum. The government is paying the difference per student that results in no gain to the citizens. 939 crores is no amount to sneeze at. In a country with high poverty, scarcity of medical professionals and tight budgets, this money should be better utilized or recovered.

What Vidyut says makes sense, but what about the underlying presumption that the Government actually spends Rs. 31 lakhs over each student per annum? Can that claim stand scrutiny? Using emotional blackmail, the insinuation that doctors (as against other professionals), by default, need to be altruistic (there is a difference between being humane and altruistic) and citing that doctors anyway “make loads of money” later in their lives, doctors-in-training, in my opinion, are meted out with perhaps the most inhuman treatment of all the students, and that position seems to find even accent of the society at large. The inhuman treatment I am talking of involves working hours bordering on ordeal faced in rigorous imprisonment, and the ‘bonds’ to be fulfilled because the government would have purportedly “spent” huge amounts of money on ‘making’ doctors. Hence, this topic has been very dear to me.

Though I must again clarify, I have not read Vidyut’s entire blog post. I am only responding to a very narrow aspect of the basis of reasoning in her blog post, that the government indeed spends more on ‘making doctors’ than what doctors ‘give back’.

The figure of Rs. 31 lakhs on a 5.5 years per student is a total hyperbole. I don’t think there is any way to account for that kind of spending. I have, needless to say, completed an MBBS course in a government sponsored seat (in a private college), and my annual fee for a period of 4.5 years was Rs. 15,000.

Now, the issue of “bond” has been a huge one with most young medicos, so I have pondered very much on the entire issue. I fail to see how exactly the government spends the humongous amounts on medical students it claims to spend.

Let us do a rough break up for a government/aided institute with an **attached** hospital (having which is anyway mandatory to get MCI recognition). In an average batch there are 100 students in most colleges. It is mainly only in the first year that the teachers are purely of ‘academic’ kind, meaning, they do not do anything in their routine course of work that would contribute to public health care duties [anatomy, physiology and biochemistry], of which the biochemistry staff would be involved in conducting tests on lab samples of patients from the attached hospital. Now because this a government/aided institute, the attached hospital would be also of government/charitable? So, whatever duties the biochemistry staff discharges towards the patient welfare by conducting tests on and reporting on those tests on the patient samples, is **not** in service of the undergraduate medical students? So, at least part of the biochemistry staff pay ought to be borne by the government, because it is the government that has promised universal health care for all, and not the medical students? But yet, let us for the time being forgo the duties discharged by the biochemistry staff towards patient welfare. Let us presume that undergraduate medical students be **made to** pay for patient welfare towards which they actually have no obligations. Let us assume there are approximately 4 teachers per department in the first year. So, that comes to 12 teachers. And, then there would be assistant staff also equal in number. That comes to approximately 24 employees in all. Their mean salary can be computed to around Rs. 25,000 per month (pays of teachers are pretty high, but that of non-teaching staff are very low), which comes annually to 72,00,000 for the pay of all the employees. But, let us assume that of whatever the government pays to the employees, at least 10% will come back to it as income tax, for which students must not be made to pay? So, let us take the total pay borne by the entire batch to be Rs. 65 lakhs per annum. I’m presently discounting other staff like office clerks, administrative officers, security personnel cuz the onus of their upkeep falls on students of all the years and also on the employees. Also, now let us think of the lab equipment that might have required to be spent on training of the students, electricity expense (including that of hostels), cadaver maintenance, microscopes, glass slides, cover slips, etc (most of these instruments are bought for years together and not every year; average light microscope costs like Rs. 20-40 thousand). At the outset, I would like to point out that none of these facilities were truly ground breaking or exquisitely expensive. None of these facilities were extraordinarily more expensive than would be spent on someone pursuing their Masters in some other field of science like biochemistry, microbiology, physics or organic chemistry.Yet, to **round it off**, let me take that overall expense on a batch of 100 first year students to be Rs. 90 lakhs. How much does it come to per student per annum? Rs. 90 thousand. Now we’ll keep this as template expense for subsequent years. One may quibble about the number of teachers or other staff, but let me assure you, I’ve really taken the maximum possible expense on all of this.

In the second year, there are pathology, pharmacology, microbiology, and forensic medicine & toxicology (FMT). It is again only pharmacology staff that is usually not involved in patient care. FMT people, in many but not all colleges, serve other obligatory duties not directed towards student education, like performing autopsies, being involved in medicolegal cases, serving as forensic experts, sometimes managing cases of poisoning, etc. But pathology and  microbiology staff do indeed contribute significantly to patient care. So, what portion of pay that pathology and microbiology staff get is for training students, and what portion of it is towards caring for the patients that government had promised to care for, and towards which the medical students have no responsibilities? In an average year, there are no more than 200 lectures and demonstrations/practicals per subject. So, one teacher would not be usually engaged in teaching/training activities for more than 100 days (towards that batch), but whereas they are on duty for patient welfare on all (working) days of the year, which means they’re putting in more working hours towards patient welfare than on students. So, what portion of their pay as well as the pay of non-teaching staff be borne by the students, and what portion by the government/patients? Again, to be just harsh on the students, let us say, half would be paid by the students. So, that again comes to Rs. 72 lakhs of pay to be borne by students (of the Rs. 96 lakh salary paid, in all), and after deducting income tax, that comes to Rs. 65 lakhs. We’ll assume other costs to remain the same. So, again per annum each student ought to pay Rs. 90 thousand as fee. But the second ‘year’ is of actually 1.5 years, so make it Rs. 1.35 lakhs.

Coming to the third year. It has ENT, ophthalmology and preventive and social medicine (PSM). In a government/aided college, all the third year departments are heavily involved in patient care activities. So, half of their pay should be borne by the government? Unlike in the first year, there are no elaborate ‘experiments’ to perform for any significant expenditure to occur. So, students should pay for Rs. 32.5 lakhs for staff pay (half Rs. 65,000 that was calculated for the first year)? Rest of the expense we’ll keep nearly the same. So, total spending on the 100-student batch is of Rs. 60 lakhs. Per student per annum that comes to Rs. 60,000.

Coming to the final year: there are four major subjects – internal medicine, general surgery, obstetrics & gynecology and pediatrics. But, there are some ‘allied’ subjects as well – anesthesia, orthopedics, radiodiagnosis, etc. But very, very few lectures and clinics are conducted for allied subjects. So, if we club together the allied subjects as one single subject (in terms of cost of the staff members to be borne by students), then we have five subjects. Total pay of staff comes to Rs. 1.2 crores, of which **half** is to be borne by the students – that comes to Rs. 60 lakhs. After income tax deduction that would be Rs. 54 lakhs. Rest of the expenses remain constant, so that comes to around Rs. 80,000 per annum per student.

How much the total comes to? Rs. 3.6 laksh! But, but, but we’ve not included the pay of librarians, cashiers, security personnel, administrative officers – etc., most of who work not only for the students, but also for the employees’ and patients’ benefit. We’ve not included the costs of library – new books, subscription to periodicals, etc (which are used by the teachings staff as well and not just the students). Still, to make the students shoulder some of that burden, we will ask the students to pay one more lakh rupees? How much that comes to? Rs. 4.6 lakhs. But in this country where we like no accountability and answerability, we can throw around figures the way we like. So, we make the **total** expense of four-and-a-half years of academic component of the MBBS course to be Rs. 10 lakh! How does this compare with that figure of Rs. 31 lakhs?

Even if I were to assume that I’ve forgotten some significant costs (which I’ve not because I’ve been in this course, and observed these things myself) and also because I’ve actually been on the ‘lavish’ side of making students pay, how much at the most the max expenditure come to? Rs. 10 lakh per student? So, what is the need for a more than seventeen-fold exaggeration? Why 10 lakh be made 1.7 crore? What does this state about the possible intent of the minister/officer making such a claim? And then, why not say that the government spends Rs. 15 lakhs on each student passing some commerce or science or humanities degree? What does the government do to the MBBS course to be spending so much?

And yet, I have not taken into account internship. Internship is a period, which in most government college hospital entails that the intern work for inhuman hours. They do **real** work. They get paltry sums for that because they are **training**. The fact is almost every district/government hospital would totally collapse if it were not for the interns and junior residents (pursuing their postgraduation). How much is the stipend paid for internship? I don’t think it is on an average more than Rs. 5,000 per month in most states for internship. Can the government defend putting real patients’ health at risk by letting their care fall in hands of ‘trainees’ as part of ‘education’ of MBBS interns (that they’re trainees is the reason they get such dismal pay, right?)? I hope the reader must have got the point! Government cannot indulge in farce of saying that it is providing public ‘health care’ by opening up government hospitals for the tax payers and then also claim that the tax payers are experimental subjects for trainees? Either the government has opened these hospitals for patient welfare or for training. It cannot be both at the same time. If it is for patient care, then, the real work done by interns for real patients (not dummies, as ‘training’ would ideally entail), then the interns’ work should be recognized as real labor and be compensated appropriately by paying close to what they would pay to a medical officer, which would come to around Rs. 40,000 per month. But if the government is not treating the work done by interns as real work, but only a part of their hands on training, then the same should be displayed openly on the notice boards outside government hospitals that the patients are getting subsidized treatment because they have consented to be experimental subjects of interns who’re getting ‘trained’. Would the government ethically and legally be able to do that? No! But, because the interns need to be under ‘supervision’ (they get a provisional medical license to ‘practice’ medicine and surgery under supervision) for a year, so let us say that they ought to be paid only half of what a medical officer gets paid, which comes to Rs. 20,000 per month. I think this is reasonable. If there are any contentions to this point, they’re invited. Which means, on an average, the government is already taking away some Rs. 15,000 from each intern’s pocket! That comes to some Rs. 1.8 laksh. But the government officials are ever so ready to point out the ‘free’ electricity that they provide to students and the accommodation (which trust me, hardly ever actually gets provided, and of course is not of that tune. I mean, how can a student in a hostel where no refrigerators or air conditioners are allowed end up spending Rs. 1,000 worth of electricity every month?).

So, in the end, of some odd Rs. 10 lakh the government **at the very most** could be spending on a medical student, which certainly it does not, the government is already taking away some odd Rs. 1.5 lakhs from the student.

Most of the above calculation was actually farcical. I personally feel, the most that the government spends on an MBBS student in the entire course is like Rs. 2.5 to 3 lakhs. Of which the government anyway takes away Rs. 1.5 laksh during internship. And furthermore, in states like Maharashtra, as far as I know, the present annual fee is Rs. 40,000, though I’ll have to confirm (which comes to Rs. 1.8 lakhs for the entire course). So, if one is reasonable, an MBBS student from Maharashtra, by way of simply completing the MBBS course, is already paying the government some Rs. 30-40 thousand! So, this talk of student having to ‘pay back’ the government is total crap!

Likewise, if we give same consideration to the postgraduate courses, most of the junior residents are on round-the-clock duty and for all days of the year. Is a stipend on scale of ~ Rs. 30,000 per month justified for the kind of labor extracted out of them [it is mandated that no Indian worker (there is no reason why trainees/interns wouldn’t fall in the ambit of this provision) should work more than 48 hours per week, and absolutely not more than 60 hours a week. Any hours in excess of 48 have to be considered ‘overtime’, and paid for at higher rate than routine pay accordingly]? So, even through a post graduation course (PG) the government is actually extracting more out of the PG students than it is ‘spending’ on them. In fact, in PG courses, there are hardly any official lectures or ‘practicals’. There is virtually no ‘lab equipment’ for ‘experiments’. ‘Training’ involves **routine** work of a government-managed hospital **meant for patients’ welfare** getting done in which PG students are observers/supervised laborers. Other costly machines like CT scanners, MRI, PET scanners, PCR facility, automated assays are **for patients** and not for students to **learn** by treating patients and data generated from them as **experimental subjects**. So, if at all, all ethical and legal issues are considered, I feel, it is the government that would end up feeling obliged to significantly raise the pay of the PG students and also reduce their working hours, rather than throwing tantrums and asking for ‘money back’.

In fact, medical and related courses are unique in that just by the process of undergoing training, the students end up doing lot of service to the society at large. I do not know, for instance, if as part of their routine ‘service to the society’, law students are expected to help fighting of cases for ‘underprivileged’ suitors/defendants. Or if electrical engineering trainees have to do maintenance work for a thermal power station operated by the government.

But even if we were to assume that the government indeed incurs the cost that it claims to do in training of medical students, and that by way of that, it is ‘indebting’ the medical students in certain way, then there should be the option of student not getting indebted? Why subsidize the education compulsorily? Why should the student not ought to have option of taking an education load and not taking ‘favors’ from the government,and actually paying the fee **while** undergoing the course?

The fact is: this is an elaborate scam! Please read my comment on Wise Donkey’s blog post on dismal health care facilities in village here for maternal health here: Roots (click).

Coming to the more practical issues. As long as the government does not incentivize medicos going to the rural areas (e.g., by providing tax benefits, higher pay and good infrastructure), there is no point in sending highly trained doctors to places where their training would go waste because of lack of equipment and something as basic as electricity! The foreign-trained doctors coming back to India would anyway end up serving only the affluent class (where actually lot of competition already exists to ‘serve’ them), unless the government shows some more imaginary expenses in having subsidized those doctors’ flight tickets and makes it mandatory for them to join district hospitals or primary health centers!

So, while the issue of dismal health care delivery system for poor and rural classes is a real issue in itself, ethically speaking, it is unacceptable to make doctors a scape goat by pointing to imaginary costs borne in their training. Let the legislators come out in open and say, “We’re exploiting you doctors, not cuz you owe us anything, but simply cuz we **can** and we **need to** cuz we don’t have it in us to fight the market forces, to provide you with good infrastructure in rural areas, good facilities and humane working hours in facilities erected and managed by us, and because we cannot pay you well enough to lure you away from corporate sector or private practice, and we cannot tempt you with good research facilities. And we need to do that cuz in every election we promise the people that we will do good to them, and on that pretext we collect various kinds of taxes. Kya ukhaad loge humaara?” And, that would be closer to truth. 🙂

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6 thoughts on “Ethics in Tangents – Part 5: Do Doctors coming out of Government-Run/Aided Institutes Need to ‘Pay Back’?

  1. You have written a thoughtful post. thank you for taking this effort. I wish we had more access to the actual numbers from the goevernment the would make all these assumptions unnecessary. Time to file RTI applications I suppose! And I will not be surprised if the actual numbers are closer to your calculation.

    Incidentally, what you have done here is done more systematically under the umbrella of cost effectivenesss research which includes evaluating the costs needed for a particular service or project and whether those costs are yielding the desired outcomes. I daresay that this topic if pursued could yield surprising results for policy and even get you some publications. If you are interested, some institutes provide free course material to learn the methods of cost effectiveness. a quick search revealed these:

    http://ocw.jhsph.edu/courses/UnderstandingCostEffectiveness/
    http://ocw.jhsph.edu/courses/ConceptsEconomicEvaluation/

    Regards

  2. excellent work. I would also like to point out the fact that there are hundreds of private colleges recognized by MCI where students pay insane amount of money to get a medical education ( n I mean really insane) who have the right to earn back the money they spend, which unfortunately is not possible in India with the attractive salaries doctors without a post grad degree get. By having this compulsory bond, we are being deprived of a very very fundamental right.. called FREEDOM.

  3. Well, there is the opportunity cost. The govt trained this person with the intent of meeting some societal needs. And now it will take another 6 or 7 years to find a replacement.
    You might be aware that only a fer years back, the IMF folks suggested an Exit Tax on educated folks leaving Third World countries. Yes, the original proposal was not from our govt.

  4. Hello!
    Its very accurate to say that govt does not spend the amount it claims on each student. But what are we young doctors supposed to do! Im regretting getting into this professional line now. I just passed out of medical college. Im a foreign medical graduate, did my MBBS from mauritius, writing MCI this year. Having lived abroad its a nightmare living in india! Especially in our great capital, Delhi!! Crime against women is rising day by day! I dont even want to leave my house, fearing thr fact of being picked up from the road, or being gang raped! I cannot dress up the way i would like to just because of the fact that i will attract inappropriate attention from inappropriate people, as in rickshaw wala, auto guys etc etc. I dont remember a single day walking on the road and not being eve teased. Im actually scared for my life here. I have been groped at public places!! An acquaintance of mine, was walking down the street at 8 at night, and two guys on a bike went past her, squeezing her breast!! Having said all of this, i think you get my point. How can one live in a society like this. As i have stayed in mauritius for the past 5 years now, i cannot have a life in india now. And we cant even talk about the salary here!! Its shameful what our govt pays us. A person working at a call centre with just a 12th board degree, with no tertiary education, draws more salary than a doctor. A massage therapist withdraws more salary than a junior resident doctor. A doorman at the mall makes equivalent money as an intern.
    Where is the fairness?? Our govt should not even be opening their mouth when it comes to health services in india! Why are hosting common wealth games? Why arent we giving jobs to billions of enemployed in the country. Why arent we providing better to the general population which runs the country? Who pays the taxes! We do all the work, take all the blame, and are treated the worst. India is in a need for revolution. We are stuck in dark ages, and India is no place for anyone to lead a fair life.
    It really is a mourning period for our country… Its depressing to see where our country is headed, n im remourseful about the fact that im an “INDIAN” doctor!

    • Iagree with the Quality of Life part of your comment but the call center guy getting paid as much as a doc and a guard as much as an intern is just out of proportion. A doc in a poor state like Himachal gets 45k, 52 in tribal areas. A doc with Central institute gets 55+ just after MD. An MD Doc with a state govt contract for three years gets 40k fixed.And I blv things are better in good states which are not as poor as HP. But yes Decs are less in number and thats why they want to move to better avenues. So may.

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