CONTROVERSIES IN MEDICINE
Year : 2021 | Volume
: 2 | Issue : 3 | Page : 252--255
Reservations in medical colleges were justified and should continue: Favour
Independent Scholar and National President, Academy of Family Physicians of India, New Delhi, India
Dr. Raman Kumar
049, Crema Tower, Mahagun Mascot, Crossing Republik, Ghaziabad - 202 016, Uttar Pradesh
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Kumar R. Reservations in medical colleges were justified and should continue: Favour.J Med Evid 2021;2:252-255
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Kumar R. Reservations in medical colleges were justified and should continue: Favour. J Med Evid [serial online] 2021 [cited 2022 Jul 5 ];2:252-255
Available from: http://www.journaljme.org/text.asp?2021/2/3/252/333949
Background: Reservation as an Affirmative Action and Political Debate
Within the domain of affirmative action, the common reservation criteria include caste, gender, disability, domicile, terrain (hilly/plain), religion and language in India for higher education as well as for employment. Caste-based reservation is a politically sensitive debate in India as it is the most powerful influencer of electoral politics. Both supporters, as well as opponents, have strong opinions about it. The reservation debate is embedded into the political system of Independent India. Institutions and employers employ different selection criteria to seek the most suitable candidates. The suitability criteria may not be multiple-choice questions (MCQ)-based scholastic performance-derived merit list always. The Indian higher judicial system uses the collegium system that is a unique selection system and is different from open meritocracy. The British empire raised caste-based military regiments in India. However, the present military establishment of India maintains a regional/state-based quota to ensure the geographical representativeness of all states within the services. Many minority educational institutions have religion-based preferential criteria. Private educational institutions have traditionally allowed high capitation or tuition fees and family wealth as entry criteria instead of pure meritocracy. Every domain of human development and activity may have a different requirement for recruiting a suitable candidate. Affirmative action intervention is required in order to promote inclusivity and diversity of the workforce. Affirmative action refers to a set of policies and practices within a government or organisation seeking to include particular groups based on their gender, race, sexuality, creed or nationality in areas in which they are underrepresented such as education and employment. With this background, we have to evaluate the objectives of the government-funded medical education system in India. For any publically funded program within the health sector, the most important criteria should be improving the population health and health of all sections of the society.
Social Determinants of Health
Social disparities have a detrimental impact on health outcomes. The social determinants of health (SDH) are the non-medical factors that influence health outcomes. These are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. According to the World Health Organisation (WHO), the social determinants can be more important than health care or lifestyle choices in influencing health outcomes. Several research papers suggest that the SDH account for between 30% and 55% of health outcomes. It is estimated that the contribution of other sectors of human development to public health outcomes, exceeds the contribution from the health sector. Therefore, addressing SDH is fundamental for improving health and reducing long-standing inequities in health.
A systematic understanding of how SDH impacts health outcomes is essential for continuous improvements in the health of all Indians. Progress in the social sector across India has not been consistent. Indians living in rural areas continue to have worse health indicators. Caste-based inequities are also significant. Gender inequalities affect women from the poorest to the richest households, but especially compound other disadvantages for women of lower castes and from rural areas. Improving SDH in India is critical for improving population health in India.
Social Representativeness among Health-care Professionals is Essential for Positive Health Outcomes
Looking at the health-care workforce through SDH criteria gives interesting insights. Analysis has shown that for the health professional the representativeness for each social group is highly negatively skewed for the scheduled castes (SCs) and scheduled tribes (STs), the deficits being between 50% and 80% for the given population. Moving down the hierarchy to nurses and paramedics the variances become narrower with a few excess ratios for SC and ST, notably for the category of sanitary workers. Thus despite affirmative action/reservation policies of the government, the SC and ST have been unable to break the glass ceiling of the health professions, especially to the physicians of all types. The physician's workforce in India is not representative of societal stratification.
Eligibility, Capacity, Merit and Suitability: Entrance Examinations
The Indian education system conventionally has focused on entrance examinations. In that process, entrance examinations are becoming a competition and parallel system to the conventional education system. The scholarship achievements of students during schools and universities become redundant when faced with entrance examinations as part of career progression. Success at entrance examinations requires special and expensive coaching classes. The objective of the coaching class is not to develop scholarships but to teach special tricks for candidates to achieve high scores in the merit list. The merit score of the entrance examination is not the true reflection of knowledge, scholarship, competency and suitability. Success at entrance examinations is a reflection of access to better schooling and coaching classes. It is not uncommon for students of certain schools to have a high success rate at entrance examinations. The study of medicine has special requirements: The trainees are not only expected to work within the structured environment of a hospital but also within the communities directly. It is public dealing and healing in the day today's life that makes the medical profession different from other technical courses and disciplines of higher education. It is a vocation training also where one learns the nuances of the work under direct supervision in a clinical and patient care environment.
Even in the most developed countries, research has shown that a very high academic score is generally required for medical college entry may have the unintended consequence of selecting fewer graduates interested in a rural practice destination. Increased efforts to recruit students from lower socio-economic backgrounds may be beneficial in terms of an ultimate intended rural practice destination.
Meritocracy: Career Choices of Best Medical Graduates from India
India has the largest medical education system in the world with more than 500 medical colleges and 100,000 undergraduate medical seats. However, we observe that the doctor population ratio in most of the parts of India is skewed. Three-fourth of the medical colleges are located in the four southern states of India. The situation remains challenging in rural, remote, tribal, hilly areas despite the pressing healthcare needs. More than 50% of the medical colleges in India are operated by the private sector. It is the wealthier and financially well-off section of the society who are able to afford it. The recent policy to address the geographical disparity of medical education across India, it has been decided to convert each district hospital into a medical college. Hopefully, by 2030, all districts of India will have a medical college. However, it would not ensure the representativeness of the local population due to the existing entrance policy. In the present system of selection, only the students who have received better schooling and coaching classes are best positioned to be successful.
According to research nearly 44% of AIIMS graduates during 1989–2000 now reside outside India. Students admitted under the general category are twice as likely to reside abroad as students admitted under the affirmative-action category. Recipients of multiple academic awards were 35% more likely to emigrate than non-recipients of awards. Graduates from higher-quality institutions account for a disproportionately large share of emigrating physicians. Even within high-end institutions, such as AIIMS, better physicians are more likely to emigrate. Interventions should focus on the highly-trained individuals in the top institutions that contribute disproportionately to the loss of human resources for health. It is therefore suggested that affirmative-action programmes may have an unintended benefit in that they may help retain a subset of such personnel. Many Indian nationals who immigrate to developed countries are beneficiaries of the affirmative action provision of those countries. The beneficiaries include medical graduates from India who opt to immigrate abroad. No doubt they are meritorious however they benefit from the opportunities integrated into the society and the health system through the diversity and inclusive provisions of the governance. All school students who have achieved eligibility for medical entrance through the schooling system have the capacity to undergo medical education irrespective of the merit ranking. The reforms of the common entrance (NEET) and exit examination (NEXT) have put to rest the debate on the quality of services provided by qualified medical graduates. Both at entry-level as well as exit level the minimum standards are now ensured.
Reservation is not Unique to India: Provision Affirmative Action Globally
Many of the opponents of reservations see caste reservation as an unique phenomenon existing in India and argue it as a cause for the brain drain of meritorious students and professionals from India. However, globally affirmative action is seen as a tool towards building inclusive and just societies. The affirmative action provisions are more stringent in the United States of America (USA) than in India.
You do not wipe away the scars of centuries by saying: 'now, you are free to go where you want, do as you desire, and choose the leaders you please.' You do not take a man who for years has been hobbled by chains, liberate him, bring him to the starting line of a race, saying, 'you are free to compete with all the others,' and still justly believe you have been completely fair... This is the next and more profound stage of the battle for civil rights. We seek not just freedom but opportunity—not just legal equity but human ability—not just equality as a right and a theory, but equality as a fact and as a result'.
•President Johnson, to graduating class at Howard University, United States of America.
President John F. Kennedy's Executive Order (E. O.) 10925, 1961 used affirmative action for the first time by instructing federal contractors to take 'affirmative action to ensure that applicants are treated equally without regard to race, color, religion, sex or national origin'. Created the Committee on Equal Employment Opportunity. In 1964, the Civil Rights Act of 1964 was signed into law. This was landmark legislation prohibiting employment discrimination by large employers (over 15 employees), whether or not they have government contracts. This act established the Equal Employment Opportunity Commission. According to the US Department of Labor 'for federal contractors and subcontractors, affirmative action must be taken by covered employers to recruit and advance qualified minorities, women, persons with disabilities and covered veterans. Affirmative actions include training programs, outreach efforts and other positive steps. These procedures should be incorporated into the company's written personnel policies. Employers with written affirmative action programs must implement them, keep them on file and update them annually'. Therefore, we see that the provision for reservation or affirmative action is more stringent in the United States of America than in India.
Sir Joseph Bohre and Dr. BR Ambedkar: Public Health and Social Justice
Bhore committee report is considered unequivocally a fine blueprint for the development of a comprehensive healthcare system in India. This committee, known as the Health Survey and Development Committee, was appointed in 1943 with Sir Joseph Bhore as its Chairman. It emphasised the integration of curative and preventive medicine at all levels. It made comprehensive recommendations for the remodelling of health services in India. In its final report in 1946, the Bhore Committee noted 'If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about'.
Dr. BR Ambedkar, the architect of the modern Indian constitution crossed paths with Sir Bhore at an earlier opportunity. In November 1927, the British government appointed the Simon Commission to report on India's constitutional progress for introducing constitutional reforms, as promised. The Commission was strongly opposed by many Indians because it contained seven members of the British Parliament but no Indians. However, Dr B R Ambedkar took this opportunity to argue for the rights of depressed classes of India. The evidence of Dr. Ambedkar before the Indian Statutory Commission (SImon Commission) formed the foundational work on which the caste-based reservations evolved into the Indian parliamentary democratic system. Coincidentally, Sir Joseph William Bhore of the famous Bhore's committee was the secretary to the Simon Commission. It is an interesting piece of history on how the argument for social justice and a good public health system evolved within the politics of India. Social justice and public health outcomes are inseparable.
Reservation in medical education as a way of affirmative action is a decision of the government of India. Such policies exist in several states across India for decades. In the background of the above discussion, we can confidently say that to address SDH, representativeness within the health-care workforce is one of the primary requirements. Currently, it is enforced only on the government-operated medical colleges in India, whereas more than 50% of the colleges exist in the private sector. The government as the representative of all sections of the society has taken the right decision through affirmative action to ensure inclusivity and diversity of the medical personnel. Suitability to admission to medical colleges can not be solely judged through merit prepared through MCQ-based entrance examinations. Majority of Indian students who did not get ivory class school education and expensive coaching classes, especially from the rural background are at most disadvantaged situations. Family wealth should not be the most important determinant of selection to the medical profession in the name of merit. Reservation to the local students should be given at the district medical colleges otherwise the purpose of developing inclusive workforce and geographical representation of doctors across would be defeated. School students from rural backgrounds should be given special consideration. NEET and NEXT have put to rest the debate of the quality of medical graduates produced by the government of private medical colleges. One should rise above one's own biases for national building and developing an inclusive society.
The presented viewpoint is not the representation of any organisation or organisations that the author has been affiliated with in the past or present.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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