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India's medical education system hit by scandals
World Report
India’s medical education system hit by scandals Recent cases of corruption in India’s medical school entrance exams are part of wider problems in the country’s system for educating its future doctors, say experts. Dinesh C Sharma reports.
www.thelancet.com Vol 386 August 8, 2015
qualify for taking the course can by no means be compromised”.
“A police investigation found that a criminal network had gotten hold of a leaked copy of the question paper and sent the answers to candidates via messaging app WhatsApp during the exam.”
Fake candidates Although the full ramifications of the AIPMT scandal are still unfolding, on July 15, the Central Bureau of Investigation began probing a much deeper medical school entrance exam scandal in Madhya Pradesh state after a public outcry over slow investigations by local police. Whistle-blowers alleged that some students gained admission into government medical colleges without actually sitting the entrance test. The candidates had paid huge amounts of money to middlemen who arranged for medical students or doctors to sit the test. The middlemen also arranged fake identity documents with the help of insiders from the government agency—Madhya Pradesh Professional
Examination Board (MPPEB)—which oversees the test. Anand Rai, a Madhya Pradesh government medical officer and whistle-blower, told The Lancet: “I got a whiff of wrongdoing when I appeared for MD entrance test in 2005. I noticed that top rankers in my class did not have good academic background, had influential or rich parents, and came from one hostel block of a particular medical college. From then onwards I started tracking medical entrance tests and giving tip-offs to police, and finally in 2009 I filed a public interest petition in the Madhya Pradesh High Court seeking an enquiry.” Under pressure from judiciary and the opposition parties, the Madhya Pradesh Government began probing the scandal in 2013. So far, it has led to the arrest of more than 1000 medical students and doctors named in dozens of criminal cases filed by the state police. Investigators have confirmed that 295 students who did not sit the entrance test were admitted to government medical colleges and 721 to private medical colleges between 2011 and 2013.
This online publication has been corrected. The corrected version first appeared at thelancet.com on August 11, 2015
Hindustan Times/Contributor
More than 600 000 students in India retook the All India Pre-Medical and Pre-Dental Entrance Test (AIPMT) at the end of July after the test they originally sat on May 3 was scrapped by the Supreme Court following evidence that large-scale cheating had taken place. A police investigation found that a criminal network had gotten hold of a leaked copy of the question paper and sent the answers to candidates via messaging app WhatsApp during the exam. The network had provided several candidates (who had each paid up to 2 million rupees) with tiny Bluetooth devices, vests tagged with microSIM cards, and wristwatches fitted with cameras, so that answers could be relayed in real-time to them via wireless devices. Medical students and doctors were hired to solve the multiple-choice questions. Acting on a tip-off, police caught seven of the people involved while the entrance test was being sat. Police investigations revealed that the head of the network operated from Behror, Rajasthan state, while his clients were spread across several states. The gang responsible had previously leaked admission test papers for postgraduate medical courses of the All India Institute of Medical Sciences and some state medical colleges. The Central Board of Secondary Education, which undertakes the AIPMT, has permanently debarred 46 students from taking the retest. “The disclosures, to state the least, are startling and alarming”, the Supreme Court stated in its order that cancelled the rigged test. It justified the retest saying that the examination involved “future generations of doctors who would be in charge of public health, [therefore] their inherent merit to
Candidates leave the exam centre after the AIPMT retest on July 25
517
World Report
The state government scrapped the MPPEB test in 2013. AIPMT scores are now being used by government colleges to fill all their seats and by private colleges to fill 42% of their seats; the rest are filled through a separate admissions test overseen by the Association of Private Dental and Medical Colleges. However, this test has also come under suspicion of corruption in a petition filed in the Supreme Court on July 17. Rama Baru, professor at the Centre of Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi, and a former member of Medical Council of India’s (MCI) ethics committee, said: “What we are witnessing are the results of the criminalisation of medical education, which begins with licensing of colleges by the MCI. Besides the MCI, this criminal nexus includes promoters of private colleges, real estate lobbies, local politicians, and serving or retired doctors from government colleges. Large amounts of money changes hands at every stage of the medical education chain.” The admission scandals not only affect the quality of medical education but also the practice of medicine, noted experts. “Candidates willing to adopt fraudulent means to get into medical colleges are not just denying meritorious students a chance to study but are subverting the system with money. They can try similar means to clear exams during the medical course as well”, Anant Bhan, a bioethicist and adjunct visiting professor at Yenepoya University in Mangalore, told The Lancet. “Equally appalling are medical students who agree to sit in entrance tests as imposters to help candidates join medical courses. Willingness to be part of a medical education scam does not augur well for their future in the medical profession.”
System problems India has one of the largest medical education systems with more than 410 government and private medical 518
schools having an annual intake of 50 000 students for the MBBS course. In the absence of a national admissions test, aspiring doctors have to sit multiple entrance exams, which might cover different curricula. AIPMT is a qualifying test for only a few central government colleges and for 15% of seats in medical colleges run by state governments. States that don’t undertake their own entrance tests opt for AIPMT rankings. “Most entrance tests depend purely on a singular exam (mostly multiple-choice questions). Entrance examinations need to be set with standardised quality parameters, and supplementary processes that can gauge the candidate’s suitability, inclination, attitude for a medical career, and other factors like ability to work in teams”, said Bhan.
“‘What we are witnessing are the results of the criminalisation of medical education, which begins with licensing of colleges by MCI...’” The MCI introduced the National Eligibility and Entrance Test in 2013, but it was scrapped by the Supreme Court on the grounds that running an admissions test was not in the scope of the MCI. “The big challenge is not whether we have the capacity to conduct a national examination but whether states will agree. States have some legitimate concerns. School curriculum varies from the CBSE [Central Board of Secondary Education] syllabus in several states and state governments are keen on conducting their own MBBS entrance tests. However, there is really no reason why states or private medical colleges should oppose a national entrance examination for postgraduate seats, as long as state quotas are maintained”, said K Srinath Reddy, president of Public Health Foundation of India. To prevent scams such as the one in Madhya Pradesh, he suggested customised state level
entrance tests run by an autonomous central organisation instead of local agencies.
Regulatory reform Experts say that merely adjusting the admissions process without reforming the regulatory system is not enough to improve medical education. “We have to relook at the way the MCI works. We need to break the stranglehold of corrupt medical mafia with alternative models of medical council, such as that of the GMC [General Medical Council] in the UK, by ensuring wider participation from all stakeholders, including the community and patient groups”, suggested Baru. At present, MCI and state medical councils are elected by doctors themselves. “These councils have proved incapable of providing good governance or protection of professional standards. While the principle of self regulation is generally good, it has been extremely vulnerable to unsavoury influences that make it untenable for the foreseeable future”, said Reddy. Lax regulation by the MCI affects the overall quality of medical education. For example, the media have uncovered cases in which private medical colleges have hired fake faculty and even patients to pass inspections for the approval or renewal of licenses by the MCI. Clinical exposure of students graduating from such colleges is likely to be below par. MCI also has no policy on licensing new medical colleges based on regional needs, which has caused disparities, with concentration of nearly half of India’s medical colleges in a few regions in the south and west. The system needs urgent reform but an official response has been slow. In 2011, the ministry of health proposed an overarching National Commission for Human Resources for Health to regulate the standard of health education but it is yet to be established.
Dinesh C Sharma www.thelancet.com Vol 386 August 8, 2015
India’s medical education system hit by scandals Recent cases of corruption in India’s medical school entrance exams are part of wider problems in the country’s system for educating its future doctors, say experts. Dinesh C Sharma reports.
www.thelancet.com Vol 386 August 8, 2015
qualify for taking the course can by no means be compromised”.
“A police investigation found that a criminal network had gotten hold of a leaked copy of the question paper and sent the answers to candidates via messaging app WhatsApp during the exam.”
Fake candidates Although the full ramifications of the AIPMT scandal are still unfolding, on July 15, the Central Bureau of Investigation began probing a much deeper medical school entrance exam scandal in Madhya Pradesh state after a public outcry over slow investigations by local police. Whistle-blowers alleged that some students gained admission into government medical colleges without actually sitting the entrance test. The candidates had paid huge amounts of money to middlemen who arranged for medical students or doctors to sit the test. The middlemen also arranged fake identity documents with the help of insiders from the government agency—Madhya Pradesh Professional
Examination Board (MPPEB)—which oversees the test. Anand Rai, a Madhya Pradesh government medical officer and whistle-blower, told The Lancet: “I got a whiff of wrongdoing when I appeared for MD entrance test in 2005. I noticed that top rankers in my class did not have good academic background, had influential or rich parents, and came from one hostel block of a particular medical college. From then onwards I started tracking medical entrance tests and giving tip-offs to police, and finally in 2009 I filed a public interest petition in the Madhya Pradesh High Court seeking an enquiry.” Under pressure from judiciary and the opposition parties, the Madhya Pradesh Government began probing the scandal in 2013. So far, it has led to the arrest of more than 1000 medical students and doctors named in dozens of criminal cases filed by the state police. Investigators have confirmed that 295 students who did not sit the entrance test were admitted to government medical colleges and 721 to private medical colleges between 2011 and 2013.
This online publication has been corrected. The corrected version first appeared at thelancet.com on August 11, 2015
Hindustan Times/Contributor
More than 600 000 students in India retook the All India Pre-Medical and Pre-Dental Entrance Test (AIPMT) at the end of July after the test they originally sat on May 3 was scrapped by the Supreme Court following evidence that large-scale cheating had taken place. A police investigation found that a criminal network had gotten hold of a leaked copy of the question paper and sent the answers to candidates via messaging app WhatsApp during the exam. The network had provided several candidates (who had each paid up to 2 million rupees) with tiny Bluetooth devices, vests tagged with microSIM cards, and wristwatches fitted with cameras, so that answers could be relayed in real-time to them via wireless devices. Medical students and doctors were hired to solve the multiple-choice questions. Acting on a tip-off, police caught seven of the people involved while the entrance test was being sat. Police investigations revealed that the head of the network operated from Behror, Rajasthan state, while his clients were spread across several states. The gang responsible had previously leaked admission test papers for postgraduate medical courses of the All India Institute of Medical Sciences and some state medical colleges. The Central Board of Secondary Education, which undertakes the AIPMT, has permanently debarred 46 students from taking the retest. “The disclosures, to state the least, are startling and alarming”, the Supreme Court stated in its order that cancelled the rigged test. It justified the retest saying that the examination involved “future generations of doctors who would be in charge of public health, [therefore] their inherent merit to
Candidates leave the exam centre after the AIPMT retest on July 25
517
World Report
The state government scrapped the MPPEB test in 2013. AIPMT scores are now being used by government colleges to fill all their seats and by private colleges to fill 42% of their seats; the rest are filled through a separate admissions test overseen by the Association of Private Dental and Medical Colleges. However, this test has also come under suspicion of corruption in a petition filed in the Supreme Court on July 17. Rama Baru, professor at the Centre of Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi, and a former member of Medical Council of India’s (MCI) ethics committee, said: “What we are witnessing are the results of the criminalisation of medical education, which begins with licensing of colleges by the MCI. Besides the MCI, this criminal nexus includes promoters of private colleges, real estate lobbies, local politicians, and serving or retired doctors from government colleges. Large amounts of money changes hands at every stage of the medical education chain.” The admission scandals not only affect the quality of medical education but also the practice of medicine, noted experts. “Candidates willing to adopt fraudulent means to get into medical colleges are not just denying meritorious students a chance to study but are subverting the system with money. They can try similar means to clear exams during the medical course as well”, Anant Bhan, a bioethicist and adjunct visiting professor at Yenepoya University in Mangalore, told The Lancet. “Equally appalling are medical students who agree to sit in entrance tests as imposters to help candidates join medical courses. Willingness to be part of a medical education scam does not augur well for their future in the medical profession.”
System problems India has one of the largest medical education systems with more than 410 government and private medical 518
schools having an annual intake of 50 000 students for the MBBS course. In the absence of a national admissions test, aspiring doctors have to sit multiple entrance exams, which might cover different curricula. AIPMT is a qualifying test for only a few central government colleges and for 15% of seats in medical colleges run by state governments. States that don’t undertake their own entrance tests opt for AIPMT rankings. “Most entrance tests depend purely on a singular exam (mostly multiple-choice questions). Entrance examinations need to be set with standardised quality parameters, and supplementary processes that can gauge the candidate’s suitability, inclination, attitude for a medical career, and other factors like ability to work in teams”, said Bhan.
“‘What we are witnessing are the results of the criminalisation of medical education, which begins with licensing of colleges by MCI...’” The MCI introduced the National Eligibility and Entrance Test in 2013, but it was scrapped by the Supreme Court on the grounds that running an admissions test was not in the scope of the MCI. “The big challenge is not whether we have the capacity to conduct a national examination but whether states will agree. States have some legitimate concerns. School curriculum varies from the CBSE [Central Board of Secondary Education] syllabus in several states and state governments are keen on conducting their own MBBS entrance tests. However, there is really no reason why states or private medical colleges should oppose a national entrance examination for postgraduate seats, as long as state quotas are maintained”, said K Srinath Reddy, president of Public Health Foundation of India. To prevent scams such as the one in Madhya Pradesh, he suggested customised state level
entrance tests run by an autonomous central organisation instead of local agencies.
Regulatory reform Experts say that merely adjusting the admissions process without reforming the regulatory system is not enough to improve medical education. “We have to relook at the way the MCI works. We need to break the stranglehold of corrupt medical mafia with alternative models of medical council, such as that of the GMC [General Medical Council] in the UK, by ensuring wider participation from all stakeholders, including the community and patient groups”, suggested Baru. At present, MCI and state medical councils are elected by doctors themselves. “These councils have proved incapable of providing good governance or protection of professional standards. While the principle of self regulation is generally good, it has been extremely vulnerable to unsavoury influences that make it untenable for the foreseeable future”, said Reddy. Lax regulation by the MCI affects the overall quality of medical education. For example, the media have uncovered cases in which private medical colleges have hired fake faculty and even patients to pass inspections for the approval or renewal of licenses by the MCI. Clinical exposure of students graduating from such colleges is likely to be below par. MCI also has no policy on licensing new medical colleges based on regional needs, which has caused disparities, with concentration of nearly half of India’s medical colleges in a few regions in the south and west. The system needs urgent reform but an official response has been slow. In 2011, the ministry of health proposed an overarching National Commission for Human Resources for Health to regulate the standard of health education but it is yet to be established.
Dinesh C Sharma www.thelancet.com Vol 386 August 8, 2015