India’s medical education regulator, the National Medical Commission recently released a draft regulation that will govern the eligibility and acceptability of foreign medical graduates to practice medicine in India. Other than mandating these foreign graduates to have qualified the National Eligibility cum Entrance Test (Undergraduate), or NEET (UG), the draft regulation proposes that applicants must have had English language as the medium of instruction in their foreign medical school of graduation, completed an internship of 12 months, be registered to practice in the country of education for 10 years, and qualify the Foreign Medical Graduates Examination until the Indian exit exam, NeXT, comes into force.
While a minimum standard of uniform competence should be expected of any MBBS graduate who wishes to practice in India, overtly stringent rules suggested in the NMC’s draft Foreign Medical Graduate Regulations, 2021 will end up creating a new set of barriers, resulting in a loss of opportunity to improve the healthcare worker pool in the country.
As per the current rules, anyone who has completed MBBS in countries other than the US, the UK, Australia, New Zealand, and Canada, is required to appear for an entrance exam, the FMGE, to get a license to practice in India. There are approximately 40,000 Indian students enrolled in such medical colleges abroad and nearly 70,000 such graduates in India. The rate of passing this exam has been abysmal, thus allowing only a limited subset to be able to practice medicine in India. Between 2015 and 2018, more than 60,000 students appeared for FMGE and a mere 14 per cent of them passed the exam. Since the NMC has introduced plans for a two-part exit exam called the National Exit Test (NeXT), these students will be required to pass that when it comes into force.
NMC draft regulation misses a lot
The reason Indian students choose to study in foreign medical schools is two-pronged: the inability to qualify for government medical colleges or the few government quota seats in private medical colleges, and the exorbitant fees in private medical colleges.
While the NMC’s draft regulation makes some hits in scrapping a separate eligibility exam in the future as it makes NeXT the only qualifying exam, it misses a lot, ending up over-regulating, and not necessarily protecting the quality of healthcare provided or ensuring patient safety.
Restrictions in terms of requirement of 12 years of schooling with subject combination of Physics, Chemistry, Mathematics, and Biology, and with practical courses in these subjects, is uncalled for. The mandatory requirement of NEET for students wishing to study abroad is unnecessary too. Why should a student who has had a different combination of subjects, and who has not appeared for NEET and decided to take a plunge into medicine after a break of a few years, be denied the opportunity to seek the exit exam in order to practice in India as long as they have qualified in medicine?
The Covid-19 pandemic has brought forth the dire situation of lack of doctors and other healthcare workers in India and more particularly the inequitable distribution of such human resources. Various foreign medical graduate representative bodies have been demanding that they be taken into the workforce to serve in the pandemic. In fact, few states such as Gujarat planned their deployment in Covid teams, albeit temporarily. While the activities of informal providers (colloquially called ‘quacks’) during Covid has grown manifold and states such as West Bengal have planned to rope in quacks for Covid management in rural areas without qualified doctors, the plea of foreign medical graduates (FMGs) to be offered an opportunity to help enhance the Covid-19 response health workforce through temporary licences or short training programmes for inclusion have not been heard by Indian healthcare mandarins, despite senior politicians arguing their case.
Criteria NMC can adopt
Medical graduates from many low- and middle-income countries (and some high-income countries) move to high-income countries like the US and the UK after their primary medical qualification (MBBS) in India for reasons like better pay, good working conditions, and career progression among others. To be able to practice in the US, graduates have to qualify the United States Medical Licensing Examination (USMLE) and the Professional and Linguistic Assessments Board (PLAB) in the UK. One can appear for USMLE if they have studied in colleges approved by Educational Commission for Foreign Medical Graduates (ECFMG); for PLAB, it’s the colleges listed under the Foundation for Advancement of International Medical Education and Research (FAIMER)’s World Directory of Medical Schools or in World Federation of Medical Education.
For USMLE, until now colleges were approved by the ECFMG, but from 2024, they plan to accredit the regulatory bodies of the countries the students belong to. This makes sense because if the regulatory body has good standards, the colleges under it will be expected to maintain those as well. The NMC and the Indian medical fraternity largely have had long associations with the ECFMG given the vast number of Indian doctors in the US and Europe and with FAIMER in running regional centres and training hundreds of medical teachers.
The NMC can think of adopting their criteria, which would in turn bring a wider standardisation. While it is true that India does not attract foreign graduates for the very reasons that makes young Indian medical graduates migrate abroad, the option for such graduates to return should not be shunned in the future.
Focus on quality, but be objective
The concerns of the NMC vis-à-vis quality of FMG are genuine. There are several foreign medical schools that could be imparting sub-par medical education. The current system is built on an assumption of poor quality of FMG training, but the metrics of ensuring quality are not necessarily fair, objective and relevant. The NMC should instead be looking at basic metrics of competency and ensuring patient safety as the major qualifying criteria for FMGs to practice in India. These criteria and requirements should be continuously reviewed not just to stay focussed but also to maintain the sanctity of our regulatory process for medical education.
The two prominent points vis-a-vis FMGs in India lies in quantity and quality. The minimum standard of competency allowed for FMGs to practice in India should be equal to what is expected of an Indian medical graduate. Both should be subjected to a fair, objective and relevant test, which hopefully the NeXT will meet criteria of. The quantity issue will be taken care of once the quality issue is addressed through the level-playing field of NeXT as the sole arbitrator.
The rest of the mandate mentioned in the draft regulation is window dressing. It should not matter after passing MBBS whether a student studied Physics; it should not be important for a student who is intending to study abroad that they be required to attempt NEET, which is applicable to India alone. If the government of India, through NMC, wishes to discourage students to study in sub-par foreign medical colleges, it may use existing international approval lists as a filter, and also help students wishing to study abroad to choose wisely by making information on accredited acceptable medical schools widely known, available on websites and updated regularly. The revised regulations by the NMC should aim to build an enabling environment to enhance the medical workforce in India by allowing qualified talented FMGs to join it with a focus on qualification filters, which are meaningful and objective in nature, rather than create further barriers for FMGs intending to practice in India.
Dr Sambit Dash, PhD, is Assistant Professor of Biochemistry in Manipal Academy of Higher Education, Manipal, and comments on public policy & health. He tweets @sambit_dash. Views are personal.
Dr Anant Bhan is a researcher in global health, bioethics and health policy, and Adjunct Visiting Professor in Yenepoya University, Mangaluru. He tweets @AnantBhan.Views are personal.
(Edited by Prashant Dixit)