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Improving the quality of healthcare in resource-constrained settings: is improving undergraduate medical education quality the way out?
  1. Vikram Datta1,
  2. Ajay Shukla2,
  3. J L Meena3
  1. 1Neonatology, ABVIMS & Dr RML Hospital, New Delhi, Delhi, India
  2. 2ABVIMS & Dr RML Hospital, New Delhi, Delhi, India
  3. 3National Medical Commission, New Delhi, Delhi, India
  1. Correspondence to Professor Vikram Datta; drvikramdatta{at}

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We understand that the future of the health system of any country rests on the skill and knowledge set of its medical students. These individuals will eventually take over the reins of their countries’ complex and adaptive health systems. Poor quality of care and compromised patient safety in LMIC settings often has its origins in skill and knowledge transfer during the undergraduate medical curricula. It requires an in-depth understanding of the various challenges in delivering quality medical education in such settings to identify high priority areas for remedial actions. There are numerous policy, place and process related factors which affect the quality of medical education. India is one of the largest and most populous countries in the world, with a diverse and complex health system. The quality of undergraduate medical education (UME) in India is crucial for ensuring the competence and professionalism of future doctors, who will serve the health needs of millions of people. The potential factors affecting the quality of medical education in India can be grouped under the following subheads.

Competition and the cost of medical education

Students enter the medical school after facing a stringent entry-level assessment system in India called the NEET Examination. This year over 2.1 million medical aspirants applied for the NEET to seek admission1 to state-managed and private medical institutions across India for seats which number a little over 0.1 million.2 Besides the ever-increasing number of students vying to enter medical schools, the next aspiration of the candidates is to secure a seat in a government medical college. The competition becomes, even more, tougher as the seats in government medical colleges are nearly 50%–60% of all seats available. A total of 56 383 MBBS seats in government medical colleges and 52 465 MBBS seats in private medical colleges are available for the year 2023–2024. For students who do not succeed to make it to government medical colleges, the cost of medical education is expensive. Often the costs in these private institutions range from 7 to 10 million INR for the entire course duration.

Infrastructure challenges

There has been a rapid expansion in the infrastructure to increase the number of medical schools in India. The numbers have increased from 387 to 706 as of now.3 The country has seen a phenomenal increase in medical seats, which have gone up from 51 348 in 2014 to 108 848 in little over 9 years.4 Many states in India have upgraded the existing district hospitals to medical colleges. This has been made possible by a centrally sponsored scheme in which the central government contributes nearly 60%–90% of the total expenditure incurred in setting up of such medical colleges. Till date over 101 such medical colleges have been started. There has been a change in policy allowing public-and-private partnerships to set up new medical colleges. Existing medical colleges of eminence can set up campuses with permissions to start immediate admissions as against a 3-year holding period as per the previous policy. Many states have been providing land on subsidy and facilitating the setting up of medical colleges by private players in a bid to meet the gap in the numbers of medical seats in remote and rural settings across India. Despite these facilitatory factors, medical colleges face significant challenges. Operating and maintaining a medical college according to the contemporary National Medical Commission (NMC) guidelines has become a major challenge for many institutions. Institutions located in tier 1 and tier 2 cities and rural settings face deficits in the numbers of experienced faculty, staff nurses and above all requisite footfalls from patients. As a result, they often struggle to provide high-quality learning and training environments in these setups.

Quality of medical education

With the recent introduction of the competency based medical education curriculum and the attitude, ethics and communications modules greater emphasis is now placed on hands on skills, soft skills and communication in undergraduate medical curriculum. To impart these skills to a medical student there is a need for a well-trained team of faculty who are conversant and trained in these processes of teaching training. Till date many medical teachers in recently opened medical colleges are not fully trained in implementing these modules to the undergraduate medical students. Besides this, factors such as availability of skills and simulation lab, clinical material and strict compliance to implementing these modules can act as confounding factors to the overall impact of these modules.5

Financing for medical education

Setting up a medical college for 150–250 medical students can be a very cost intensive exercise. It often costs upwards of nearly US$70 million. The major chunk of this cost is towards sustaining human resources (doctors and nurses) who are vital for the operational system of the medical college. For a private sector investor, the recovery of the capital invested can take as long as 7–10 years. In absence of governmental subsidy, these colleges often compromise on the numbers of full-time faculty, human resources or look towards meeting this expense by increasing the cost of services both in service provision (hospital side) and teaching side (medical college fees). The Increased costs often do not translate to high quality education or patient care in these understaffed set ups.

Numerous other bottlenecks also afflict the system which are beyond the scope of discussion in this editorial. The readers are referred to relevant sources on these important aspects.6

Multiple factors need to be addressed as priorities to improve the quality of UME in the region. Efforts to strengthen infrastructure and provide adequate resources are essential. Governments and educational institutions should prioritise investments in modern facilities, equipment and technology. Collaboration with international partners can facilitate knowledge exchange and resource sharing. Embracing virtual learning platforms and telemedicine initiatives can help overcome resource limitations and ensure access to quality education.

Curriculum reform is crucial to align medical education with evolving healthcare needs. Regular review and updating of curricula should incorporate the latest medical advancements, technological innovations and societal considerations. Emphasising problem-based learning, case-based discussions and simulation exercises can foster critical thinking, clinical reasoning and practical skills among students.

At the policy level, the NMC Bill, 2019, with the goal of boosting visibility, accountability and quality in the governance of medical education paves the way for quality medical education in India. The commission intends to improve the number of medical seats and lower the cost of medical education to encourage more students to pursue careers in healthcare. Numerous other reforms like restructuring of medical licensing systems, ranking of medical colleges and standardising entry requirements at medical schools across the country are under the purview of NMC.

The union government has modified appointment rules which now allow national board-trained doctors to be appointed as faculty in medical colleges to offset the deficit in faculty numbers.7 Investing in faculty development programmes is essential to empower educators and enhance teaching quality. Offering competitive remuneration packages and career advancement prospects can attract and retain experienced educators, ensuring a stable and competent teaching faculty. Collaborative practice and effective communication are essential for delivering comprehensive patient care. By incorporating interprofessional education, medical schools can prepare students to work as part of a multidisciplinary team, enhancing the quality and coordination of healthcare services.

In conclusion, improving the quality of UME is pivotal for overcoming the bottlenecks that hinder healthcare advancements in Indian settings. By addressing the challenges related to infrastructure, curriculum, faculty development, financing and interprofessional education, we can nurture a generation of competent and compassionate healthcare professionals who can deliver high-quality care to the diverse populations of the region. Governments, educational institutions and stakeholders must collaborate to prioritise these efforts and ensure that healthcare systems are equipped to meet the evolving healthcare needs of the population. Investing in delivering high-quality medical education which is relevant, affordable and community centric would go a long way in creating medical professionals who would be equipped with skills and knowledge to face the evolving challenges in the health landscape of South Asian settings.

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  • Contributors All the authors contributed equally to the conceptualisation, research and drafting of the manuscript. All have reviewed and approved of the final presubmission manuscript.

  • Funding Publication of this article is made open access with funding from the Nationwide Quality of Care Network.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.