Indian Student Migration for Medical Education to Central and East Asia: Understanding Demand, Supply and Roles of Market and State
By V Santhakumar
Introduction
The literature on international student migration1 focuses mainly on two trends: (a) students from developing countries migrate to developed ones to get jobs and live there; This is the case for the majority of Indian students who go to countries such as the USA, Canada, the UK, and other European countries, Australia, New Zealand, etc. (b) migration for better quality education which may not be available in their own country and some of them may come back to their own countries. In both these cases, the movement of students is from developing countries to developed countries (or to countries with better quality education).2 However, international student migration for medical education from India, which is sizeable in terms of the number of students, to countries in Central and parts of East Asia is an outlier in this regard.3 A number of these countries (say, Tajikistan, Kyrgyzstan, etc.) are only at par with India in terms of human development. The quality of education in these is not perceived as better than that available in India. Hence, the motivations and dynamics of this migration of Indian students need to be analysed differently from that of student migration in general. This paper analyses the underlying features of demand and supply and the role of markets and the state in the case of international student migration from India to Central Asian countries.
Though the exact number of Indian students who go abroad for medical education is unknown, it could be around 20000-25000 per year currently.4 Their destination countries include China, Ukraine, Uzbekistan, Tajikistan and the Philippines. Though China and the Philippines are also somewhat similar to Central Asia in this regard, the focus of this paper is on Central Asia. Some countries in the Caribbean Islands also attract medical students from India, these students may be motivated to migrate to the US and other countries in the region and are therefore, not considered here.)
Destination Central Asia: Different motivations
The majority of students who go from India for higher education to other countries (Canada, UK, USA, Australia, Europe, and so on) go with the intent of finding employment and residence in these developed countries.5 However, such an aspiration is not strong among those who move to Central Asia for medical education. Central Asian countries are not desirable destinations for Indian students to migrate. Employment and migration opportunities in these countries are not very attractive to most Indians. The salary of a medical doctor in Central Asia could be around 1000 Euros, which is not much higher than that of a school teacher in that country, and salaries in the region are, generally, not higher than those in India. The quality of medical education in Central Asia is not perceived as better than that in India, as evident from the fact that those who can get admission in India to government colleges are less likely to migrate to Central Asian countries for this purpose.
Hence, the main goal of those students who go to Central Asia for medical education is to return to and practice in India. Even if some of them want to move to other countries, this trend may not be that different from those who get medical education in India.6
Excess demand for medical education in India
The attraction towards medical education in Central Asia is based on two factors: first, there is a surplus demand for such education in India. Even those who get a reasonable score in the all-India National Eligibility cum Entrance Test (NEET) do not get admission in India. Secondly, the cost of medical education in Central Asia is much less than that of private self-financing colleges in India.7 Both these factors prompt medical education aspirants to study in Central Asia. The emotional costs of staying far away from home and uncertainties regarding the outcome of education may be moderating the outflow of students despite the advantages mentioned.
In fact, the need to get a very high score in the entrance examination to get admission to a medical college in India is an outcome of this excess demand, and may not be connected to proficiency in secondary school education (which is the basic qualification for entry to medical education) as evident from the fact that even those who score well in higher secondary grades may not get this admission.8 In fact, a tough national-level entrance examination (in addition to success in higher secondary education) is necessary to filter out students transparently in contexts of excess demand.
There are three price-quantity points in the supply of medical education in India since the number of seats and fees are by and large fixed due to regulation. First, seats in government (and aided) colleges; the second category is government-regulated seats in private self-financing colleges; and the third category comprises open seats in these private colleges. In about 30 percent of seats, the cost of medical education could be more than INR 10 lakhs per annum in India.9 It is obvious that the cost of education in almost all colleges outside India is less than that of the third category of seats in Indian colleges. The cost of medical education in Central Asia (which may be around 15-20 lakhs) could be less than that of the second category of seats in India. The investments to increase the number of colleges in India are not enough to meet the higher and growing demand for medical education.10 This is driving the use of medical education in Central Asia by Indian students.
Relatively cheaper supply of reasonable quality medical education in Central Asia
Historical investments by governments in these countries, when these were part of the Soviet Union, led to the creation of public colleges for medical education. The features of medical education in professional schools in the Former Soviet Union (unlike in universities in the USA) were somewhat similar to those of India.11 In order to understand the investments in medical education in the Soviet Union, the following data may be useful. In 1968, there was one medical doctor for 450 people and the annual production of doctors was around 20000.12 (It may be noted that this number in India even in 2020 could be less than 1 doctor per 1000 people13). These colleges in Central Asia have basic facilities and a reasonable number of trained teachers. There were changes after the collapse of the Soviet Union and international efforts to standardise and reform medical education in Central Asian countries afterwards.14 A notable impact of the collapse of the Soviet Union is the dwindling budget for healthcare organisations and the system as a whole.
The capital costs for these colleges were invested historically. They have a certain level of facilities and teachers. They were meant for the education of domestic students. However, fees from domestic students was not adequate to meet the recurring costs. There was a scarcity of funds due to the inadequate allocation of public resources for these purposes. There was a scope for enhancing the number of students, and hence, they took in students from countries such as India and Pakistan. This is seen as a way to get additional revenues for these colleges. International students are charged a higher fee but it is less than that in private self-financing colleges in India since the latter attempt to recover both capital and recurring costs from their students.
There is a public-private partnership in this education in Central Asia. These medical colleges have agreements with private contractors to get students from other countries. These contractors have sub-agents who operate in different parts of India. They attract students who have cleared NEET, scored a minimum of 50 percent marks in higher secondary and can afford to pay the fees. The main contractors also arrange/operate residence facilities for students in these destinations. They are also trying to bring in additional medical teachers from India who can teach courses in English. Many universities in the region see this as a way of resource mobilisation.15
There is no point in taking a negative view of this exodus from India for medical education. The cost of medical education is prohibitively high in India. Entry barriers are unreasonable.16 India needs many more doctors, especially those who are willing to serve in its rural areas. As noted earlier, India has only 4.1 doctors per 10000 population17 and is yet to have one doctor per 1000 population – the norm suggested by the World Health Organisation (WHO).
On the other hand, the quality of medical education in Central Asian countries is not inferior to that in India considering the healthcare achievements of these countries.18 The health indicators of these countries are relatively better than those of India. Health care was accessible to all people in Central Asia though there could be problems of under-investment by the government over time.19 If colleges in the region use the enrolment of Indian students to enhance their capacity utilisation and get additional revenue, that is good for their functioning and sustainability. If this can help a set of Indian students to become doctors, that is broadly a win-win situation.
The demand and supply factors which are discussed here may determine the use of medical education in Central Asia. There may be one category of students who use medical education in Central Asia because they cannot get admission in India. For them, the expected gains from medical education in Central Asia, despite all uncertainties and emotional costs may be higher than the gains from alternative educational opportunities in India. There may be others who may get admission in a self-financing seat in a medical college in India, but it may be costlier than the education in Central Asia, and hence, they opt for the latter.
Internationalisation of higher education: Some reflections
The relationship between migration for higher education and the quality of such education within the host countries needs to be understood. The migration for medical education from India demonstrates that it is not the poor quality of such education in India (or the better quality of it in Central Asia) that leads to this migration. To some extent, this can be seen in other cases of education too. For example, most proficient students in India may opt for Indian Institutes of Technology (IITs) for engineering education in India. They may attempt migration only after getting this undergraduate education in India. This is a rational decision since IITs provide quality education at reasonable costs, and getting an education from an IIT is not a disqualification for migration to a developed country. If one can get cheaper but good quality education in India that is valued internationally, then the most preferred option would be to use it even if the motivation is to migrate and work abroad. This is also visible in other occupations, like nursing. Many students who get training in good quality hotel management institutes in India also seek jobs in other countries.
The migration for education can be seen as the outcome of a matching process. There is a matching that happens within the country based on the entry requirements of each institution, and the student’s proficiency and willingness (affordability) to pay fees. There is a trade-off between the proficiency of students and the fees in India since most of the better-quality colleges are in the public sector, where the fees are lower but the difficulty to get admission is higher. On the other hand, the difficulty of getting admission to a private college is less whereas the fee is higher. Hence, highly proficient students may get admission to low-fee, but higher-quality public institutes and less proficient ones may opt for higher-fee but lower-quality private institutes. Since the number of seats in public colleges is limited, a large number of students have to seek admission in not-so-high-quality private colleges. There can be spectrums of quality of education, proficiencies and fees, and the admission of a specific student in a college could be based on a matching process.
A similar matching may happen with the internationalisation of education. Sections of those who may not get admission to good-quality colleges in India may opt for colleges outside the country. Such colleges can be costlier in certain cases (say, for liberal arts and science education in the UK or other European countries). There are those who cannot get an education within India that is valued in international labour markets, and they may see education abroad as a way to be part of national labour markets of the developed world and international labour markets. They may be willing to bear the (higher) cost of education abroad as a way to break the entry barrier in these labour markets. There may be others who seek education abroad since they cannot get admission to Indian colleges and/or because of the reduced cost of education elsewhere. The increase in student migration for higher education can be seen as an outcome of a process of international matching.
Possible failures
There can be possible failures in the migration for medical education. Some students may overestimate their ability to complete this education (and associated troubles). There is a perception that the majority of students fail in the Foreign Medical Graduates Examination (FMGE) of India and part of this could be due to overestimation of their abilities. (Such an overestimation may happen in India too since some students who join Indian colleges may fail to complete the programme.20) Hence, the major concern of these foreign graduates is whether they can pass the qualifying examination in India (or whether the government will do away with it and replace it with an examination for all students irrespective of whether the degree is from India or abroad). This is a problem if the expectation from these students is a lot more than those who complete medical education in India (and this issue is discussed next).
There may be some private intermediaries or their sub-agents who may not reveal all relevant information to attract more students.21 Developed countries may have an incentive to regulate these education agents to see that student migration does not lead to problems such as the misuse of visas22 but such an incentive and regulation are yet to evolve in developing countries.
There could be crisis situations, like the one in China during COVID23 or in Ukraine due to the war. These may lead to severe losses for these medical students. Are students prepared to handle these situations? What are the possible ways to mitigate losses if such emergencies arise? These may depend on the role of markets and the state. This is discussed in the following section.
Role of markets and the state
For Indian students, the admission process in medical colleges in Central Asia is driven by the market. Intermediaries or agents charge commissions and facilitate admissions. There are no regulations over these intermediaries to ensure that they provide all relevant information or do not indulge in malpractices. One can argue that it is also in their interest if they want to remain in this business to maintain a good reputation by being truthful and reliable.24
The Government of India does not (or cannot) have a major role in this. Its ability to help students even during exigency situations is not high.25 The only step that the Government of India takes regarding medical education abroad is to tighten the qualifying examination to practice within India. Only a small percentage of foreign medical graduates could pass this qualifying examination.26 Is this due to the toughness of this examination driven by the urge to discourage the seeking of medical education abroad or to ensure the quality of medical practitioners in India is not clear? There is a perception that the qualifying examination is working as (an unreasonable) entry barrier27 to the practice of medicine in the country. If it is so, it may be harmful given the need for more doctors within the country and also the inability of the government to open more government medical colleges. In that sense, moving to a common examination, like National Exit Text (NExt), to give licenses for medical practice to all graduates (whether they have received their degrees from India or not) may be a useful step.
If India accepts that enrolment in medical colleges in Central Asia is a normal (desirable) option for Indian students, given the excess demand for it in India, the central and state governments can play an enabling role in this regard. Since India is interested in the internationalisation of higher education and attracting foreign students to its universities,28 the Government of India cannot have a negative attitude towards Indian students seeking education abroad. A collaborative approach is possible that may enable Indian regulators to understand the real strengths and limitations of these foreign medical colleges. These colleges can be seen as instruments to meet the excess demand to be, and to create additional, medical doctors in the country. A close collaboration with these colleges may enable the regulation of intermediaries. There can be public information campaigns about the pros and cons of medical education in these countries enabling students and parents to make informed decisions. Moreover, the government can collaborate with these colleges to see that their education is appropriate for medical practice in India.
AUTHOR
V Santhakumar is Professor, Azim Premji University, Bangalore
Featured Photo by National Cancer Institute on Unsplash
